America's future doctors look tired tonight. Sixteen medical students, most of them in their third year, sit slumped on the lab-room chairs at Stanford Hospital. Short white coats and stethoscopes are stashed near the eyewash station. Nearly all of them have a coffee cup in front of them. They've been here for 13 hours--their surgery rotation began at 3 a.m.--but there's one more requirement for the day. It's a pilot program called Reflection Rounds, four mandatory sessions designed to improve the abysmal mental health of physicians in training.
Chaplain Dr. Bruce Feldstein runs Stanford's program. Feldstein was a successful emergency-room physician before a back injury forced him to slow down at work. That's when he realized he was burned out. Feldstein knew what depression felt like. So when he noticed the telltale signs creeping up on him, he decided to trade in his white coat for a kippah and tend to the spiritual and emotional needs not just of patients but of doctors too.
In tonight's session, Feldstein wants the med students to talk frankly about what they've encountered in the hospital. (He promises the students confidentiality at Reflection Rounds, and we have respected their privacy by omitting their names.) "Maybe it's something that's really just horrible to watch," Feldstein says to the group. "Who do you get to talk about that with? Perhaps you feel you may be all alone in it."
One student says he got a negative evaluation for playing tic-tac-toe with a child who'd undergone brain surgery. "Needs to prioritize better," he tells the group of his write-up. Another student, who has irritable bowel syndrome, says she got dinged for taking too long in the bathroom. Yet another says his co-workers brag to him about how little they sleep or how rarely they see their children.
This has long been the ordeal of a young doctor: overworked, sleep-deprived and steeped in a culture that demands that you suck it up. Everyone you meet, you think, might be smarter and more capable than you--and you're the only one struggling. One student tells the group that when she was shadowing a medical team as an undergrad, she saw a patient with terminal cancer and it gave her nightmares for weeks. This week, she says, she saw a similar case and felt nothing.
"Who else identifies with that?" Feldstein asks. All hands go up.
Experts warn that the mental health of doctors is reaching the point of crisis--and the consequences of their unhappiness go far beyond their personal lives. Studies have linked burnout to an increase in unprofessional behavior and lower patient satisfaction. When patients are under the care of physicians with reduced empathy--which often comes with burnout--they have worse outcomes and adhere less to their doctors' orders. It even takes people longer to recover when their doctor is down.
Major medical errors increase too. One study of nearly 8,000 surgeons found that burnout and depression were among the strongest predictors of a surgeon's reporting a major medical error. Another study, this time of internal-medicine residents, found that those who were burned out were much more likely to say they'd provided suboptimal care to a patient at least once a month. Those are not great odds for patients, whose safety can be put at risk by a tired or stressed-out doctor; almost anyone who enters an academic hospital will be treated at some point by a resident.
Doctors' safety is also a concern. As many as 400 doctors, the equivalent of two to three graduating medical-school classes, die by suicide every year, according to the American Foundation for Suicide Prevention--the profession has one of the highest rates of suicide. "That's mind-boggling to me," says Dr. Colin West, an internist and physician-well-being researcher at the Mayo Clinic. "It's hard for me to imagine that the public thinks of physicians as being so mentally distressed."
And the stresses are not about to be reduced anytime soon. By 2025, the U.S. will have a shortage of as many as 90,000 physicians. That could translate into even more work for doctors who are already working too hard.
As a patient, you'd never guess that half of all American doctors are burned out, because the culture of medicine dictates that doctors show no weakness. But inside the field, concern is mounting and the calls for action are growing louder. In May, Dr. Ralph Greco, distinguished professor of surgery at Stanford School of Medicine, and Dr. Arghavan Salles, former chief resident of general surgery at Stanford, wrote an editorial in JAMA Surgery about the importance of resident physicians' mental health. Meanwhile, the Accreditation Council for Graduate Medical Education (ACGME)--the governing body for America's 9,600 residency programs--is scrambling to come up with a national program specifically designed to curb the epidemic of physician distress.
If there is a leading expert on doctor depression, it's probably Dr. Srijan Sen, a psychiatrist at the University of Michigan. When he was a medical student, a childhood friend, who was a resident, became paralyzed after jumping off a balcony in an attempt to take his own life. Two years later, another of Sen's friends, also a resident, died by suicide. That led Sen to pay attention to a problem most doctors prefer to ignore. He gathers every conceivable kind of data related to depression--DNA from saliva, blood samples, sleep patterns tracked with a Fitbit--in an ongoing research project he calls the Intern Health Study. Sen now has data from more than 10,000 interns at 55 institutions. "The more biological findings we have, there will be less of a distance between mental illness and physical illness," he says.
Before their intern year, only about 4% of doctors have clinical depression--the same as the rate for the rest of the population. During internships, those rates shoot up to 25%. The first year after med school is of particular interest to Sen. Interns are paid very little, yelled at a lot and often earn none of the credit when things go well and all of the blame when mistakes happen.
"You move immediately after medical school, you don't know anyone there, you're $200,000 in debt, and then all of a sudden you start working 90 hours a week," says Dr. Douglas Mata, a researcher for the Intern Health Study who struggled with depression as an intern. "It can be a big shock."
In the 2013 Stanford Physician Wellness Survey, sleep-related impairment was the single strongest predictor of burnout and was highly associated with depression in physicians, says study author Dr. Mickey Trockel, a psychiatrist at Stanford whose patients are almost all physicians."In time, we'll look back and see this was insane, requiring physicians to do what they do on no sleep or very little sleep," Trockel says. "It's just dumb for everybody involved."
In hospitals all across the country, administrators and doctors are grappling with the issue of physical burnout at every stage of the profession. (As the Washington Post reported in August, Stanford also has a pilot under way to improve work-life balance for emergency doctors that includes providing meals, housecleaning and babysitting in exchange for long hours.) But sleep deprivation is still a rite of passage for residents, who work overnight and for days in a row to earn experience. The relentless pace may sound like the result of modern workaholism, but in fact it was baked into the idea of a residency, first introduced in the U.S. in 1889, says Dr. Kenneth Ludmerer, distinguished professor of the history of medicine at Washington University School of Medicine. Doctors wanted to formalize the graduate study of medicine through rigorous training standards. Residents, virtually all of them unmarried men, lived at the hospital.
It was a good financial deal for hospitals; residents worked long hours for free under domineering doctors they revered as gods. But the promise to these young doctors was clear: after residency, they'd be at the pinnacle of their professional skill level with a job that was societally revered.
The reality of being a doctor has changed dramatically since then. Doctors are no longer guaranteed the high-paying job of their dreams, and the profession doesn't earn the automatic respect and clout it once did. The workforce has changed too. Quality of life and work-life balance have become important to American professionals. And workplace hazing, in most professions anyway, is now more the exception than the rule.
But residency programs remain partly the same: long hours, low pay. On top of that, today's doctors have even more material to learn, more paperwork to fill out and far more patients to see. "These kids have a lot more to learn than what I had to learn," says Stanford's Ralph Greco. "There's so much more technology, interventions and tests we need to know about."
In an attempt to correct course, the ACGME, the residency governing body, made a landmark move in 2003: the group declared that the workweek for residents must cap at 80 hours per week, averaged over four weeks. In 2011 it added that first-year residents could work a shift no longer than 16 hours. Unfortunately, the move didn't improve physician well-being. According to a 2013 paper Sen published in JAMA Internal Medicine, young physicians were getting depressed at the same rates after the rules kicked in.
"In the mad rush to limit resident work hours," Ludmerer writes in Let Me Heal, his recent book about residency education, "the importance of the learning environment was generally overlooked, as if nothing else mattered but the amount of time at work."
Long hours alone aren't to blame for the mental-health crisis afflicting doctors. The stigma against signs of weakness within the profession plays a role too. "Part of it is thinking about wellness as something for wusses," says Trockel, the psychiatrist.
That means that many who need help don't ask for it. Only 22% of interns who are depressed get any help, according to Sen's findings. That's troubling to Sen because depression, if monitored and treated, can actually add to a doctor's arsenal of skills. "Traits that can be seen as predisposing to mental illness are also ones that we really want in our doctors," he says. People prone to depression are more likely to be empathetic, for instance, and are more open to different experiences and willing to be vulnerable, he adds.
But that vulnerability is not welcome in the culture of modern medicine, where doctors at the bottom are often bullied by their superiors. Salles of Stanford says attending physicians, who are in charge of residents, may be kind to residents outside of a case, but they are less cordial in the operating room. "They're like some other monster," she says. "'What's the point of you? Why are you here? Can't you do something? If you're not going to help me, why don't you leave?'"
It's not just at certain schools. The mistreatment of people at the bottom part of the clinical team--third-and fourth-year medical students, interns and residents--has been a topic in medical literature for decades, and research by Sen and Mata confirms that it's still a problem. When asked about the toughest part of their first year as doctors, 20% of the interns in Sen's study mentioned the "toxic" culture of their program. Some people said the memory that stuck with them most was when an attending physician screamed at them and belittled them in front of their peers and made them cry.
"Hazing is real," says Greco, who says he was part of the problem. "I'm not proud of it, but it's true." Once a tough, unforgiving surgeon prone to bullying his residents, he now calls himself a repentant sinner.
His turnaround came with a phone call in 2010, when he learned that Greg Feldman, who'd just graduated from Stanford as chief surgery resident, had killed himself. "He was a star," Greco says. "It was just a matter of how high he'd go." Talking about Feldman still moves him to tears.
In 2011, Greco, Chaplain Feldstein and a few other colleagues, including Salles, got together to discuss how to change things. "When people go somewhere new, they lose everything that was around them that supported them, and it's very natural to doubt themselves," says Salles. "I had this idea that we could have sessions where people talk to each other, and then it wouldn't be so lonely."
They put together a program at Stanford to promote psychological well-being, physical health and mentoring. Every week, one of the six groups of surgery residents has a mandatory psychotherapy session with a psychologist. Each senior resident mentors a junior resident, and residents are given time for team bonding. Young doctors rarely have time to go see a doctor of their own, so the wellness team issues lists of doctors and dentists it recommends. And there's now a refrigerator in the surgery residents' lounge, stocked with healthy foods. They call the program Balance in Life.
"We knew we couldn't necessarily prevent suicide--too complicated for us to solve it," Greco says. "But we needed to feel we did everything we could do to prevent it, if we could."
Greco didn't think that his little grassroots program could possibly be the best thing out there, so he emailed 200 surgery-program directors across the country and asked if they offered anything similar. "Not one answered me," he says. "And some of these people are my friends."
The fact that this is one of the most innovative resident-wellness programs anywhere in the country is "kind of pathetic," says Salles. And still, there isn't institution-wide support for the program at Stanford, she says. "There are definitely faculty members who think this is all a bunch of crap." She and Greco say they have to fight for every dollar allocated to Balance in Life. "I find it disturbing, although not surprising, that every time we talk about this program we have to say, 'There was someone who died, and that's why we need this.'"
Balance in Life, while rare, is not the only program of its kind. Dr. Michael Myers, a psychiatrist at SUNY Downstate Medical Center who for 20 years counseled medical students and physicians exclusively, used to run a program in which senior psychiatry residents give medical students free therapy as well as medication counseling, should they want or need it. That kind of peer-to-peer support goes a long way toward diminishing the stigma that asking for help is a sign of weakness.
"We have to keep reassuring them about there being a firewall between the counseling service and the dean's office," says Myers, who, like Sen, devoted his life to the topic because someone close to him in medical school killed himself. By the time SUNY psychiatry residents graduate, they will have looked after one or two less-experienced medical students.
The ACGME is looking to Balance in Life, among other programs, as inspiration for a new initiative it plans to implement across the country.
"There are a whole host of ways that we, as the ACGME, can influence the direction of things, and we just haven't done it," says Dr. Timothy Brigham, chief of staff and senior vice president for education for the group. No one knows exactly what the initiative will look like, but new rules could go into effect across all 9,600 U.S. residency programs as early as 2016.
"I want us to be able to deal with it, to have some constant attention on this and to do it so well that we don't have to have attention on it anymore," says Brigham. "We can look back and say, Why didn't we do this before?"
in a darkened room at Stanford, a bunch of first-year medical students are sitting in a circle, passing around a tall purple candle. Chaplain Feldstein opens the class--called the Healer's Art--by clinking together meditation chimes three times.
The students have just told the group, one at a time, about the first time they knew they wanted to be a physician. Now they've moved on to something a little more personal: they're telling the group which parts of themselves they don't want to lose as their work wears them down.
"Help me become a stronger and happier individual, because before I can truly focus on helping others, I need to be comfortable with myself," says one young man.
"Strengthen me so that I have the courage to be vulnerable," says a woman. "Help me to not forget that we are all human."
While administrators and doctors at the ACGME try to figure out what they can do to make the world of medicine a happier and healthier place to work--improving well-being for physicians while also making the profession safer for patients and appealing to more doctors--these are the lives on the line.
"I'm determined to do one thing: to make it the rule of the land," says Greco. "If there's another suicide and we're sitting here twiddling our thumbs, it's going to be brutal."