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.