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.