A study of interns showed that up to 25% develop depressive symptoms before their internships are over. How might medical education be changed to make this less likely?

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.