CC: “I feel like crap.”
HPI: 29-year old female internal medicine resident. Hasn’t seen sunlight in over three months due to 100 hour work weeks. Crying at work. Always exhausted and irritable. Isolated from friends and family. Feels guilty that she is not effective at work and home. States recent labs were normal.
HEENT: teeth grinding
CV: chest pressure, palpitations
GI: decreased appetite with weight loss
Psych: apathetic, not suicidal
Social: alcohol on golden weekends
What is your diagnosis?
What is your treatment?
- Prescribe SSRI.
- Prescribe a vacation from work.
- Tell her this is normal for residents, and that life will be better after graduation.
During the nadir of my internal medicine residency, I worked for several months in a row of 100 hour work weeks. I did not see the winter sun for months. As a peer leader in our program, my colleagues came to me with familiar complaints of loneliness, overwhelm, exhaustion, and grief. As there was no time to seek medical evaluation, how was I to feel better? Adept at managing septic shock in the ICU, I assumed I could care for my own health. I started myself on an SSRI for depression and had some improvement in my symptoms. I was no longer irritable, but I was still exhausted and unhappy.
My intervention did not address my real issues – a complex blend of burnout and depression in a culture of medicine that did not promote wellness and my own inability to ask for help.
Depression and burnout have common symptoms, but depression is a medical diagnosis, and burnout is an occupational hazard. It is so important to distinguish between the two. You would not hire a scribe to treat your depression, nor would you take an SSRI to solve your work-induced burnout.
Rates of depression among interns entering residency are approximately 4% at the start of training and increase to about 25% within three months. As burnout scores increase, the risk for depression also increases. More than 80% of physicians with high burnout scores meet the criteria for provisional diagnoses of depression. According to the 2020 Medscape National Physician Burnout & Suicide Report, approximately 22% of physicians reported thoughts of suicide, and 39% had told no one.
As an executive coach for physicians who are struggling with burnout, I often joke that my clients’ chief complaint is, “I feel like crap.” After our initial conversation, I refer approximately 10% of my potential clients to mental health providers – psychiatrists, primary care physicians, and therapists – to address their depression or trauma. It is much easier and socially acceptable for physicians to admit to burnout rather than depression. This misdiagnosis (mislabeling of symptoms) can lead to a delay in diagnosis and treatment of depression, a potentially life-threatening illness. Certainly stigma, lack of access and time for mental health providers, and mandatory reporting of mental health diagnoses to state licensing boards compounds this problem.
We know that physicians are most likely to rely on their colleagues for support when they are in crisis. We are uniquely qualified to understand and empathize with our suffering colleagues. If you see that a colleague is suffering, please reach out to them. If a colleague asks you for help, they need it.
I have been depressed.
I have been burned out.
I have been both.
I have been neither.
How do you know if you are depressed vs. burned out when your chief complaint is, “I feel like crap?” It’s time to call a consult. I don’t mean curbsiding your colleagues to fill your medications off the record without evaluation. I mean, ask for real help, from someone who can objectively help you define your diagnosis and the best path forward. If you “feel like crap” and think you may be depressed or burned out, please reach out to a trusted physician, therapist, or coach. You are not alone, and there is hope and help waiting for you.
Kara Pepper is an internal medicine physician and can be reached at her self-titled site, Physician Life Coach: Kara Pepper, MD.
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