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his month, more than 25,000 medical school graduates will begin working at hospitals and medical centers across the United States. By the end of September, nearly one-third of these new doctors could become depressed and 24 percent could have thoughts of suicide.

First-year interns often move away from family and friends to start the next chapter of intensive training. It is an exciting time, but also a difficult time. A recent study in Academic Medicine confirms that their suicide risk is highest in the early months of training.

The tragic deaths of two interns in New York in August 2014 was a sentinel event, leading to an urgent re-examination of the learning and work environment in academic health centers. Medical educators partnered with other stakeholders, including leaders of the Accreditation Council for Graduate Medical Education, to develop a national response to this crisis in medicine.

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As a result of these efforts, physician training programs that begin on or after July 1, 2017, must now follow new, dramatically improved “core” requirements that provide access to confidential, affordable health care, including counseling and urgent care, 24 hours a day and seven days a week.

The new guidelines also urge improving connections between residents and faculty, reducing the social isolation that is common in young physicians who work 80 hours a week. Senior residents, attending physicians, and others are also asked to watch out for signs of burnout, depression, or significant changes in performance that might indicate a new intern physician at risk for depression or suicide.

We applaud the ACGME’s commitment to preventing depression and suicide in medical trainees and understand this will require sustained commitment and effective interventions at the local level. Oregon Health and Science University, where we work, played a significant role in developing the new guidelines, and we welcome the positive changes that will affect all U.S. interns and resident physicians.

With these guidelines in place, building a comprehensive physician wellness program is now feasible for every academic health center, and we’ve seen progress as hospitals across the country are opening centers focused on physician well-being. Yet significant barriers remain, and many of our physician colleagues continue to avoid seeking professional treatment during their medical careers. The impact can be life-threatening.

Every year, an estimated 400 physicians die by suicide. Most did not receive a mental health evaluation or treatment of depression before their deaths. The most common and powerful barrier to getting treatment is fear — fear that receiving treatment for depression could have a negative impact on a doctor’s medical practice. That needs to change. We have seen hundreds of physicians receive professional care for depression, continue to practice, and thrive in their profession.

OHSU built a Resident and Faculty Wellness Program in 2004. Over the past 10 years, use of this resource has increased from 5 to 25 percent of trainees. This nationally recognized model demonstrates that physicians will access a treatment program when it is safe and effective.

Recognizing the urgency of this public health crisis in medicine, the American Medical Association recently recommended that all state medical licensing boards “refrain from asking applicants about treatment and only focus on screening for current impairment.” We join the AMA in urging the Federation of State Medical Boards to “accept safe haven non-reporting which would allow physicians receiving treatment to apply for licensure without having to disclose it.”

The Oregon Medical Board is at the forefront of a national effort to reduce physicians’ fear of reporting treatment on licensing or hospital credentialing applications. It prioritizes the identification of impaired physicians and encourages licensees struggling with burnout, depression, or substance abuse to seek professional treatment.

The new requirements for all U.S. residency programs signal an important change in medical culture. However, progress will be blocked if physicians’ worries about reporting depression or being treated for it continue to be a barrier. We urge all state licensing boards to follow Oregon’s model and the AMA’s recent recommendations to accept “safe haven.” Only then will the medical community see a paradigm shift that saves lives.

George Keepers, M.D., is professor and chair of the Department of Psychiatry at Oregon Health and Science University and chair of the Accreditation Council for Graduate Medical Education’s review committee for psychiatry. Mary Moffit, Ph.D., is associate professor of psychiatry at OHSU School of Medicine and director of the OHSU Resident and Faculty Wellness Program.

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  • Physician work days need to be strictly limited to 10 hours within a 24 hour time period, with at least 10 hours off before the next shift starts. The physicians can have report just like the nurses and other health professionals. They simply record in a notebook, in a digital or tape recorder or meet with the on coming shift what is happening with each patient. In that way, continuity of care is maintained and the physician can read the complete medical record when he gets back on shift, if he needs to.
    Also, physicians have to stop the nonsense image that they are superhuman. It creates a great deal of stress as well as danger for all health professionals and patients throughout the medical system. Keeping up the image of the superhuman physician is a medieval, narrow minded and ignorant medical tradition, which needs to end.

  • i strongly recommend to start with Martial arts training under a reputed instructor who can mentor the students (dr. and other paramedics) to relate training to better working and socialising skills. it will channelise the pent up energy in the right direction and motivate each one to inspire self and others. a goal in life is important but way of life is something a good martial arts instructor teaches and mentors

  • This article provides both a sense of the problem and elements of a solution. But we need broadly comprehensive reforms. The highly competitive selection and training process for medical students and residents reinforces a perfectionism that makes it particularly difficult to seek support. And this problem doesn’t end with completion of residency — depression and suicide rates continue to increase across physicians’ careers. Perhaps reforming residency will help alleviate some of the later emotional stresses, but we need to be thinking of how to support practitioners across training and career. I wrote about this issue for the LA Review of Books, in the context of Paul Kalanithi’s WHEN BREATH BECOMES AIR. While readers and reviewers are very moved by Kalanithi’s account of his final months before dying of a rare lung cancer in his mid thirties, few notice the other death that is literally at the center of the memoir: the death by suicide of Kalanithi’s best friend in residency. In researching my article, I communicated repeatedly with the family of that young man, a stark reminder of the many, many lives that are devastated every time we lose someone to suicide. (The essay is available for free here: https://lareviewofbooks.org/article/the-hidden-dying-of-doctors-what-the-humanities-can-teach-medicine-and-why-we-all-need-medicine-to-learn-it/ )

  • “The new guidelines also urge improving connections between residents and faculty, reducing the social isolation that is common in young physicians who work 80 hours a week. ”

    That last bit, 80 hours of work per week, is also a HUGE contributing factor. Time and again evidence shows how lack of sleep can contribute to, precipitate and exacerbate anxiety and depression. Speaking from my own experience, the times I have had symptoms in line with clinical depression have all also been times when I was most sleep deprived. We say that in the medical profession we want to practice “evidence based” medicine – but we need to start with ourselves! The days of doing things simply because that’s the way they have always been done are long gone.

    (As an aside – I am a non-traditional pre-med student. Even though my own experience with mental health issues is a HUGE driving force behind my motivation to pursue medicine – specifically to pursue holistic primary care to include physical and mental health and their interactions – I have been actively discouraged from sharing ANYTHING about this during the application process. While other applicants can freely share their experience with cancer or surgery or a car accident and how their first hand experience motivated a passion within them to pursue medicine, I am not able to share my own experience because of the on-going stigma around mental health even – and perhaps especially – within the professions which supposedly exist to promote health and well-being.)

    • Amy, thanks for your insight. I too find it odd that the wall between mental and physical illness seems to be impenetrable to crossover. Similar to what you said, it is interesting that at my school, if someone gets cancer or any other serious physical illness, the admins rush to his or her side; yet when someone has a mental illness, the admins all high-tail it as quickly as possible to get away. I was treated very differently when I had to take a leave for a severe illness than I was when I had a relapse of my major depressive disorder…

  • Let’s be clear … a mental health crisis hotline is NOT a wellness program. Depression, alcohol and drug abuse, suicide are complications of burnout. The crisis hotline is necessary and insufficient to address the burnout epidemic. These crises are literally the tip of an iceber.

    The key is to have an active burnout prevention program and a faculty leadership team that understands the Quadruple Aim.

    In our work with med schools and residency programs we find that the faculty often is a great model of chronic burnout rather than a mentor in establishing and maintaining a long term wellness strategy in their students/residents. And faculty will often exempt themselves from wellness retreats when they are the ones most in need.

    Burnout Prevention / Wellness / Resilience or whatever word you would like to use will always live and die by three components of your particular med school or residency:
    – the CULTURE of the institution and faculty – are they empathetic and supportive or abusive and bullying
    – The LEADERSHIP SKILLS of the faculty.
    – the BURNOUT PREVALENCE in the faculty

    Needless to say – an abusive culture, absent leadership skills and burned out faculty will lead to the medical education being a running of the gauntlet and a simple survival exercise.

    And it does NOT have to be this way by any means.

    My two cents,

    Dike
    Dike Drummond MD
    Founder & CEO http://www.TheHappyMD.com

  • Agree strongly with Jennifer Bollen, MD that ” The problem isn’t the lack of access to mental health treatment … but the way we train our physicans.”

    If doctors were trained more humanely and stressed less, it would do far more to lower suicides than making counselling available and unstigmatized.

  • Although the few resident sucides were horrific just like in the non-physican community the majority of deaths are among older physcians not young medical students or residents. The 400 number sounds high but there are almost 1 million active physicans in the US. We need to identify and treat depression and suicide but as physicans we also need accurate information in order to diagnose, treat and prevent depression and suicide. In looking at our state records for example there is no little evidence of any deaths by residents and very none of active physicans in the last 10 years ( there are a few cases of murders). The problem isn’t the lack of access to mental health treatment (lots of kids go off to college) but the way we train our physicans.

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