“First, do no harm,” is what medical students in the U.S. declare when they take the Hippocratic oath at the white-coat ceremony symbolizing their entry into the medical profession. It refers to the patients they will be taking care of. But perhaps it should also refer to themselves.
As a psychologist embedded in the department of pediatrics at a major medical center, I have worked closely with pediatric residents since 1995. In addition to meeting with first-year residents during the first week of orientation, I facilitate a monthly support group where residents have protected time to share concerns in a nonthreatening confidential environment.
These monthly groups have spurred many positive changes, including trying to ensure that rotations with the most demanding schedules are now staggered with rotations that have less demanding schedules.
Yet, many health care professionals don’t often discuss a major occupational hazard in medical training: the high suicide rate among medical students, residents and physicians.
The rates of death by suicide in the general public in the United States are on the increase. The National Institute of Mental Health reported in 2017 that suicide was the 10th leading cause of death for males and the 14th for females. It was the second leading cause of death for young people aged 10 to 34, a common age bracket for medical students and residents.
When compared to the general population, however, the rates of death by suicide are much higher in physicians, and especially physicians who are women. In the U.S., an estimated 300 to 400 medical students, residents and practicing physicians die by suicide annually. Physician deaths not only impact the families and friends of the doctors who end their lives, but impact thousands of patients, nurses, support staff and others.
In January of this year, the Accreditation Council for Graduate Medical Education sent out an e-communication to members wishing everyone a “joyous, happy and healthy New Year.” The note also included a reminder that the third quarter of the academic year, beginning in January, is the second highest period of risk for resident and fellow suicide.
For 2020, the third quarter for the academic year begins shortly. Recognizing that physicians are at increased risk for burnout and depression, the council introduced new standards and in their updated Common Program Requirements defined “well-being” of physicians to include that they “retain the joy in medicine while managing their own real-life stresses.”
The ACGME guide states: “Residents and faculty members are at risk for burnout and depression. Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as other aspects of resident competence.”
Historically, there have been many mixed messages in residency training, noting that it is insufficient to provide a wellness curriculum without including, as I wrote about the problem in 1992 "the larger working environment …involving the hospital and/or training programs, and the constantly changing health care system.”
Medical schools, residency training programs and hospitals throughout the country are implementing “wellness initiatives” of varying degrees. And many medically affiliated organizations have programs dedicated to addressing wellness, such as the American Medical Association’s Steps Forward: Preventing Physician Burnout; the Mayo Clinic’s Program on Physician Well-Being; Stanford’s WellMD; and the Pediatric Resident Burnout-Resilience Study Consortium.
Indeed, many of the concerns and challenges of residency—debt, moving to a new location, time management, impostor syndrome—have not changed over the past two decades. However, many concerns have intensified, such as the demands of electronic record keeping, increased burden of non-MD chores such as insurance pre-authorizations, and the intrusion of 24/7 access.
The American Academy of Pediatrics emphasizes the need to address the social-emotional lives of physicians, as well as need to help them sustain work-life balance and avoid burnout. In 2015, six institutions founded the 2016–2019 Pediatric Resident Burnout-Resilience Study Consortium.
The World Health Organization defines burnout as an “occupational phenomenon.” According to the WHO, burnout is a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” and refers specifically to the occupational or workplace context and not to experiences in other [personal] areas of life.”
Some leading institutions are addressing and recognizing the need to address the issues of burnout and work/life balance at the institutional level. In 2017, moving from the Mayo Clinic to Stanford Medicine, physician Tait Shanafelt became the first chief wellness officer at a U.S. academic medical center. At my own institution, in December 2018, physician Bryant Adibe moved to Rush University Medical Center as its first chief wellness officer.
To reduce rates of burnout at Rush University Children’s Hospital, a four-week wellness rotation was launched in 2017 for the second year of training. Many were skeptical about this four-week rotation, yet the most salient component of this rotation provides residents with the time to schedule appointments with their own health care providers, in addition to covering their peers, so that they too may schedule health care appointments. Residents are also encouraged to eat healthy meals, exercise, check in with the staff psychologist, catch up on sleep and socialize with friends and family.
Prior to the launch of the four-week wellness rotation in 2017, the burnout rate reported by Rush’s second-year pediatric and internal medicine/pediatric, or med/peds, residents was 80 percent. In 2018, residents reported rates of burnout fell from 80 percent to 30 percent, and remained there in 2019.
To be sure, a four-week wellness rotation is not the answer to the epidemic of physician burnout, depression and suicide. However, it is a start.
Burnout is a symptom; it is not the problem. Medical students and physicians need time to engage in self-care activities and seek mental health assistance without jeopardizing their license, reputation and ability to practice medicine.
Yes, residents learn that to be ethical doctors, they must first do no harm. They can also learn to first help themselves.