Becoming a doc is a hard road. And it should be. Docs have your life in their hands. If you’ve got it figured early, there’s that time spent in high school making sure you get into a top college. Once there, it’s the grind for grades (in hard classes!) and seeking recognition sufficient to impress a med school admissions committee, provided you’ve aced your MCATs. Should you actually get into one, there’s your classmates who have been doing basically the same thing as you for years. Talk about competition! The pressure eases up a bit – even though the classwork is way harder than anything that’s come before, and then the wards! – as most med schools grade pass-fail, like my own U of C did even in the 70s. But beware, they keep a separate set of books, and the dean always knows where everyone ranks. If you can impress a few professors to get them to write you good letters, you might overcome meh grades and lack of honors to get into a decent training program. You surrender your fate to a machine with that next choice, as the computer takes your rankings and the rankings of the places where you interviewed to come up with the best match. But what comes next is the real crucible: internship and residency. You’re the doctor now, with life-and-death power over patients who may not know the ink is barely dry on your diploma. Yes, there’s always someone more senior to back you up, but the training process remains as it has been for ages: one of graded addition of responsibility. And a good program makes sure you have plenty of opportunities to practice. This involves many hours of hard work and more than a few sleepless nights. I suppose docs have always realized that maybe this isn’t exactly a good thing – I sure didn’t like it when I was going through. But recognition beginning in the 90s that overworked, sleep-deprived doctors-in-training made mistakes – sometimes serious ones – spawned a movement to limit house officer’s work hours. Finally, in 2002, the Accreditation Council for Graduate Medical Education (ACGME) established guidelines that limit on-call nights to 24 hr and the work week to 80 hr, implemented long ago (7/1/03) (1). Two and a half decades before, my call nights regularly ran into the next day and my weekly work hours rarely came in under three figures. So when I hang with my buddies from those days, we grunt how easy kids today have it. But do they? Being an intern or resident nowadays is different. Compare the antics of the Beth Israel house officers from House of God (my era) (2) with those at the same place in Man’s 4th Best Hospital (3). Time pressures may have lessened, but hospitalized patients are sicker, pressures from the business people are greater, and there’s that damned EMR (electronic medical record). So interns and residents still get stressed and depressed and burn out. How much that happens, and maybe even why, was addressed by a U of M faculty colleague of mine, Amy Bohnert, a PhD mental health services researcher in the department of Anesthesiology. She assembled a team that assessed cohorts of first-year resident physicians (we used to call them “interns”) from across the country from 2009 to 2020, 17,082 docs in all. Each doc completed a 9 item questionnaire that purportedly could measure features of depression, repeated quarterly. Then, the team kept track of their work hours. Wouldn’tcha know, more hours, more depression! Of those working more than 90 hours a week (where’s the ACGME?!) 33.4% met criteria for depression. Further, the relationship between weekly work hours and depression scores was linear and, of course, statistically significant. The U put out a little 4 minute video summarizing the study (4). As you might imagine, this all got a lot of press, even if it was a mere letter to the editor (“correspondence”) in the New England Journal (5). Watch it be quoted by those pushing for a ratcheting back of the work week everywhere. Since Professor Bohnert and friends looked only at two factors, they may have missed some others that could be contributing to house officer dissatisfaction. I wrote her to point this out, as follows:
Dear Professor Bohnert
I read with interest your recent NEJM letter after having it brought to my attention in the online University Record. I commend your ambitious work in a very important area, and am sure the accolades and attention you are receiving are well deserved. From a mention I read today in an Asian publication (6), I see you are being recognized internationally and your findings are being extrapolated to the general workforce. Please allow me, then, to raise a question and take issue. Is it possible that work hours are not the only contributors to the stress and depression we see in today’s house officers? After all, work hours, though still substantial, have decreased after the ACGME established guidelines that limit on-call nights to 24 hr and the work week to 80 hr, implemented long ago (7/1/03). The admitted patient now rarely sees the same doctor through the night, instead being signed off to someone else covering. I saw trends beginning 40 years ago. I trained at Barnes Hospital, a pretty freewheeling place then with a proud and confident housestaff. Coming to Michigan in ’82 for my rheumatology fellowship then beginning to round on the wards, I was taken by differences. Medical students and house officers here often seemed timid, unwilling to think beyond their assigned roles or challenge group opinions. Consultations were common, whereas we looked on a consult at Barnes mainly as a way to show off to a subspecialist what a good job we’d done on a patient. Requirements for attending input increased steadily, then came the EMR. Guidelines and protocols proliferated and it became less and less necessary for a doc to think through a diagnostic/treatment plan all the way oneself. Who’s happier, a doc thinking independently on his/her feet or one sitting at a keyboard checking off the elements of a dictated protocol implemented? And hours spent working can be fulfilling and not stressing if spent in an activity that engages one’s talents in a challenging and satisfying way. Check out the work of Csikszentmihalyi (7), who pioneered the description and analysis of the “flow state”, in which a person is completely focused on a single task or activity. Attaining the positive feelings which result is the main reason people scale rock faces or crack chests to do a CABG. Do today’s house officers have chances to enter such a state? I doubt that sitting at a keyboard entering data provides that. Perhaps after 16 or more years of striving and achieving, our new house officers are hit with a little buyer’s remorse when asked mainly to be automatons. Even less of that will still be depressing. I think that better work, not less work, is the answer. Medicine can still be a fun game, if you just let the players play it. Time to loosen up a little and let some autonomy back in. A mind is a terrible thing to to waste, especially of the best and brightest who choose to become doctors.
References
1. Philibert I, Friedmann P, Williams WT; ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA. 2002 Sep 4;288(9):1112-4. doi: 10.1001/jama.288.9.1112. https://jamanetwork.com/journals/jama/article-abstract/195244
2. Shem S and Updike J. House of God. New York: Richard Marek Publishers, 1978. https://www.amazon.com/House-God-Samuel-Shem/dp/0425238091
3. Shem S. Man’s 4th Best Hospital. New York:Berkley, 2019. https://www.amazon.com/s?k=4th+best+hospital+by+samuel+shem&crid=3OA6YBFVEHRZK&sprefix=samuel+shem%2Caps%2C137&ref=nb_sb_ss_pltr-ranker-20mins_7_11
4. Work-hours and depression in first-year resident physicians. YouTube https://www.youtube.com/watch?v=EsgGeDzyi8M
5. Fang Y, Lodi S, Hughes TM, Frank E, Sen S, Bohnert ASB. Work Hours and Depression in U.S. First-Year Physicians. N Engl J Med. 2022 Oct 20;387(16):1522-1524. doi: 10.1056/NEJMc2210365. PMID: 36260798. https://www.nejm.org/doi/full/10.1056/NEJMc2210365
6. Number of hours worked in stressful jobs leads to risk of depression: Study. Hindustan Times 10/23/22 https://www.hindustantimes.com/lifestyle/health/number-of-hours-worked-in-stressful-jobs-leads-to-risk-of-depression-study-101666511016315.html
7. Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. New York: Harper & Rowe, 1990. https://www.amazon.com/Flow-Psychology-Experience-Mihaly-Csikszentmihalyi/dp/0060162538/ref=sr_1_4?crid=18YAOO796T811&keywords=csikszentmihalyi+flow&qid=1666923360&qu=eyJxc2MiOiIxLjA0IiwicXNhIjoiMC40OSIsInFzcCI6IjAuMzcifQ%3D%3D&sprefix=Csikszentmihalyi+%2Caps%2C132&sr=8-4&ufe=app_do%3Aamzn1.fos.006c50ae-5d4c-4777-9bc0-4513d670b6bc
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