Combating Depression in Medical Trainees

Following-up quickly on the previous post, because identifying a problem is fairly meaningless if you can't do anything about it. I said in that post that there are no simple answers and that's definitely true. Equally important to note is that whatever responses to this problem I present (or that anyone else presents) will likely not have much of an evidence base behind them, as there isn't much good research on this problem in particular. Reasonable theories is about all we have at this stage. In any case, if I had some all-powerful influence over medical education policies, here's what I'd try.

1) Reduce Hours

Physicians work a lot. Residents work a lot more. Medical students work less, but still quite a bit. All work more than a standard 40-hour week. Heck, a 40-hour week ever is practically luxurious. A fair bit of unofficial work is also effectively required, whether that's administrative work, reading, teaching, or research. At the extreme ends, typically residents in high-intensity fields, 100+ hours per week is commonplace (out of a total of 168 hours in a week).

While many people avoid depression despite these long hours, it's hard to see how the rate of depression and depressive symptoms goes down without some relaxation in work hours. There are many ways to treat or prevent depression, but many of them take time, time which is not available when working 100+ hours per week. Basic self-care suffers under such schedules, let alone the extra care needed to maintain or improve mental health. The correlation between resident work hours and sleep is pretty clear, for example - more hours at the hospital means less sleep overall.

Simple work hour limits have been put in place in the US to some effect, but with significant limitations. Part of the problem with straight work hour limits is that programs still need the same amount of work done by the same number of people, just with fewer hours. So, residency programs find inventive ways to get the same work done by the same number of people through creative (often undesirable) scheduling, increasing workloads during worked hours, or straight-up lying about hours worked (particularly common in surgical specialties in the US).

Another concern with reduced working hours is that it may require extension in the number of years of residency in order to maintain the number of total hours worked and allow residents to gain the necessary experience to become competent. A certain amount of exposure to a given pathology or procedure is necessary to be able to work independently, of course. The argument here is that if residency is going to be terrible, it might as well be as compact as possible to allow physicians to move onto independent practice.

All things considered, I don't believe reducing work hours alone will be particularly effective in reducing depression among residents, but I do believe it is a necessary component to any solution. I believe it needs to come in conjunction with efforts to make residency training more effective in terms of educational outcomes, and more efficient in terms of workload completion. I see substantial room for improvement on both these fronts.

2) Orientation and Role Definition

One thing that's always struck me about medicine is how little orientation people get to their surroundings. Physicians-in-training are thrown into situations without any idea as to what their responsibilities are or how to carry out those responsibilities. I had a better orientation when I worked at McDonald's in high school than I have at any point during my medical training.

The disjointed nature of medical training does not help this process. During my clerkship, I had one rotation that lasted 6 weeks, one rotation that lasted 4 weeks, and one rotation that lasted 3 weeks. Everything else lasted for 2 weeks or less. By the end of a 2 week rotation, I would usually have a decent idea as to what I was supposed to be doing and how to start doing it somewhat effectively, but by that point, it was onto the next rotation and the whole process started over again.

Having a clear role, and having that role understood by those around you (especially superiors) is an important factor in overall job satisfaction. I see little reason to think this doesn't apply equally to physicians-in-training.

Ideally this would be accomplished with dedicated time for orientation combined with a degree of standardization of roles for learners between all rotations, but that may be overly ambitious. An easier change to implement could be simply having instructions for trainees put down in writing and communicated to both learners and instructors. This would not take much effort to accomplish, yet I found this simple document was not present for most of my rotations.

3) Allow Greater Flexibility in Education

Working hard, long hours sucks. Working hard, long hours you have some say over sucks a whole lot less. People who have control over their schedules tend to have much higher satisfaction with their work and their lives.

Realistically, students and residents are never going to have complete autonomy over their schedules. Yet, they could have a lot more control than they currently have. When talking about long hours, while many would prefer intensive, shorter residencies, some may want longer residencies with more favourable hours - yet this is an option only at a small handful of residency programs (usually Family Medicine programs).

Likewise, there are a lot of aspects to medical training which are mandatory across-the-board without having across-the-board value. My school has 12 weeks of required surgical training, yet the majority of students will never step foot in an OR after finishing residency. Likewise, of those who are going to be in the OR, do they need the full 6 weeks of training in both Family Medicine and another 6 weeks in Psychiatry? Would half the training in each make that much of a difference in overall competence once training is completed? Could that time be better spent if freed up for more electives or selectives? Some training in surgery, psychiatry, and family medicine seems necessary for all physicians, but additional exposure comes with diminishing returns.

Similarly, having some control over productivity within the day-to-day schedule may be beneficial. Pretty much every residency program has academic half-days and function well enough with residents missing for a period of time to attend mandatory lectures. Would it be possible to give residents a half-day to set their own schedules, whether that's working on research, attending specific clinics, or gaining more experience with useful procedures.

4) Just Treat Each Other Better!

Physicians aren't terribly nice to each other. I believe we're largely past the times where physicians used to be outright cruel to each other, but kindness is still often lacking. Encouraging words come far less frequently than they could or should. Gratitude between physicians is less frequent and less genuine than it could be ("Thank you for sending us this consult" isn't really a statement of appreciation as much as a nicety). When someone is sick, or needs to go pick up their kid from daycare, or just struggling to keep up, would it be that terrible to send them home when there's enough people around to do the work at hand - even if it means a little extra effort on the part of those left? All my other jobs managed these situations well enough, including those in health care.

5) Wellness Programs

In general, I'm not a fan of wellness programs currently being rolled out at many medical education institutions. They feel like trying to put a small bandage on a wound after waving around a knife that inflicted the wound in the first place. It's better than nothing, but not nearly adequate and doesn't address why a bandage was necessary in the first place. I find them to be inconvenient for most people and maintains the onus on trainees to help themselves. They often provide resources that are already available in the community in one form or another. As a result, they are often most utilized by those already motivated to improve their situations and willing to make sacrifices to do so - individuals who might have been able to pull themselves up even without a dedicated wellness program.

Still, some of the typical elements of wellness programs have some good evidence behind them. Meditation, yoga, and tai chi do have some benefits to mental health - as does exercise and mindfulness in general. Opportunities to talk through problems, or to reflect on them individually, can both be beneficial. Being able to reframe problems as opportunities, to develop a problem-solving attitude, can be quite useful in forming resilience to challenges. While I dislike the emphasis on wellness programs, they can be part of the solution for a subset of trainees.

To wrap things up, we're never going to eliminate depression or other forms of mental health problems from medicine. There will always be some medical students, residents, and staff struggling with low mood. However, it's clear that the rates of depression are higher than baseline, well higher than they could be given the resources the profession has at its disposal, and certainly higher than is ideal for high-quality patient care. There's a lot we could be doing to minimize this problem.

Depression in Medicine

JAMA recently published a meta-analysis of studies on depression in resident physicians, and it's understandably getting a fair bit of attention. The headlining number approximately 28.8% of residents report depression or depressive symptoms. This is almost certainly a bit of an over-estimate as depressive symptoms aren't necessarily equal to depression itself - particularly when it comes to the somatic symptoms of depression (fatigue, poor sleep, appetite changes), there can be multiple explanations aside from depression.

Still, it's likely not a gross over-estimation. A rate around 20% or so, with approximately half of that being only moderate depression, fits with what the more granular data in the study suggests as well as with my own personal experience. The challenge with depression in medical school is that there is a strong incentive not to let on that you're going through it. The stigma against physicians with mental health problems is lessening, but there are still risks to opening up about it, especially as so much in medical training is subjective. Admitting to dealing with depression wouldn't be met with scorn, but might lose a student or resident the benefit of the doubt when mistakes or misses happen - which they inevitably do for all learners. Showing outward signs of depression can be equally harmful to a trainee's prospects - fatigue, irritability, and disinterest are all significantly frowned upon, even in situations where it might be completely reasonable to feel all three. The outward appearance of strength and tranquility is demanded in trainees, despite having minimal opportunities to get away from medicine and drop their guard. Lastly, taking actual steps to address mental health issues like depression can be very difficult. I have enough trouble finding time to get to see my family physician, I can't imagine what it would be like to get the time to see a mental health professional, especially for the kinds of regular visits that are often optimal for dealing with these issues. Medicine simply doesn't permit that kind of flexibility for trainees. 

As a result, many mental health issues are driven underground, which can give the appearance that it is far less common than reported in the JAMA study as well as similar reports. I've seen a degree of hostility towards even addressing these issues by students or residents who may not recognize the extent of the problem - in some cases, even by those who have trouble recognizing that they themselves are struggling with poor mental health.

There's also an unfortunate notion to dismiss cases of poor mental health in medical trainees as a problem with the trainees themselves. A lack of mental toughness or fear of adversity is often thrown around. Yet I've seen exceptionally strong medical students struggle. They might be doing amazingly well on evaluations or in clinical performance, but be unable to keep up with their social lives, personal interests, or even basic hygiene. Overall, medical students are already being carefully selected to be the most capable, resilient individuals available - if significant groups of trainees are having difficulty with depression, even if we had an outstanding admissions system, I doubt we're likely to get more resilient individuals who are also equally capable.

Addressing this problem is challenging. There are no simple answers as the depression is multi-factorial and any potential solutions to depression in medicine would encounter numerous barriers and trade-offs. I don't believe small changes are going to cut it, however. I think the stats seen in this study will continue until some fundamental changes are made to the way we train our physicians and, likely, the way we organize our healthcare system in general.