Prevention of Depression, Anxiety and Burnout in Resident Doctors – a Systematic Review

Introduction

It is broadly recognized that the hardest step of becoming a practicing physician is the residency. While working their way through the residency, resident doctors must learn to adapt to a drastically different lifestyle from the one they know – an experience which puts the interns through many hardships and proves in many cases to be extremely distressing.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME) established limitation for work and training hours, making the maximum 80 hours per week. In 2011, the regulation was revised anew, and the maximum duty period length was limited to 16 hours. However, in 2017, the ACGME changed their common program requirements policy, and extended the duty period from 16 hours to 24 hours.

In Israel resident doctors work an average of 26 consecutive hours per shift and often have to work without any sleep. It is argued that this stems from the general perception that resident doctors are young and more capable of working under any circumstance, without any regard for their health and their quality of life.

In 2013 a petition was presented to court by a company of residents against ‘Clalit’ Health Services and Israel’s Medical Association in regards to their employment conditions, which break the Israeli law for hours of work and rest. In response, the court decided to change the clause which considers the working conditions of resident doctors. The law now suggests that resident doctors should be allowed two hours of sleep during a shift if such possibility exists. The Israeli resident doctors, on the other hand, claim that this possibility is non-existent due to the high demand of the residency.3

It can be deduced from these findings that the approach towards the working conditions of resident doctors is rather rickety and the possible implications are not being seriously enough.

Reportedly, around 30% of young doctors have shown symptoms of depression, and the numbers are constantly on the rise. The other two main disorders which trail along with depression are anxiety and burnout.

Depressed residents deal with the idea of admitting to having a mental disorder and seeking treatment, which is considered a taboo subject in the medical community. Affected residents don’t seek help due to their belief that it will jeopardize their career. Lamentably, the refusal of these residents to get treatment with the combination of their vast medical knowledge and access to the different medical means – notably drugs – has helped suicide to take up 4% of all physician deaths.

In light of these statistics, it can be presumed that this is a potentially dangerous situation which manages to spread further every year, taking many lives in its path. In order to tackle this problem and eventually obliterate it, it must be taken more seriously by the medical community in particular, while incorporating prevention programs in all hospitals and working towards an environment where asking for help is not considered taboo.

The first purpose of this research is to investigate and understand the main causes behind the onset of these disorders, as well as proving three main hypotheses:

1. That the working conditions of the residency play a considerable role in the onset of depression, anxiety and burnout;
2. That gender, marital and socioeconomic statuses have little to no effect on the quality of life of resident doctors and their susceptibility to these mental disorders;
3. That lack of prevention programs and lack of willingness of residents to ask for help will have a major impact on patient care quality and doctor-patient relationships as well as the residents’ mental health in the long run.

An additional purpose is to evaluate the effectiveness of two programs which work for prevention and an optimization of quality of life in resident doctors.

Research methods

Two main questions are asked: “What are the causes of depression, anxiety & burnout in resident doctors?” and “How can the onset of these disorders be prevented?”

The first step to finding a solution to a problem is identifying what causes it. In this case, determining what aspect of the residency causes its resident doctors to develop depression, anxiety and burnout.

After establishing the causes to the prevalence of these disorders in resident doctors, and in order to eliminate it, it is important to consider a program which aims at finding an effective prevention method.

Inclusion criteria

In order to ensure that this research discusses the topic at hand in an effective manner, the literature used was chosen only if it met the following criteria: only articles which discuss resident doctors who suffered from depression, anxiety and burnout were chosen. The research methods used had to be based on questionnaires or observational studies of consenting resident doctors. The residents in question must have had no antecedents of depression or anxiety before the residency, and lastly the articles had to be in English, Spanish or Hebrew.

Findings

In this research, seven research studies were used in order to identify the causes for the onset of depression, anxiety and burnout in resident doctors around the world: 1 from Nigeria , 3 from Mexico , 2 from the US and 1 from Japan.

The methods of depression, anxiety and burnout evaluation used by the researches were: the Hamilton scale14 (HAM-D for depression & HAM-A for anxiety), the Maslach Burnout Inventory scale16, the Beck Depression Inventory scale12, the CES-D scale17, the IM-ITE test15, A questionnaire based on DSM-IV & ICD-1011, Zung’s auto evaluation scale13 and The Harvard National Screening Day scale16.

The main causes identified for the prevalence of depression, anxiety and burnout in resident doctors around the globe are a high demand from work and long working hours, followed by the changes in their sleeping hours and eating habits. Other factors included overload of responsibilities, uneven work division, lack of time to dedicate to studying, self-involvement with patients (from mostly psychiatry residents), financial debt, aggressive conduct from senior doctors and lack of budget for the health departments (in developing countries).

As a consequence of the negative effect of these factors on their mental health, depressed residents were found to make six times more medical errors than their non-affected colleagues. Therapeutic decision making and the diagnosis given were also damaged by these factors, leading to a decline in the quality of patient care (which leads to patient mortality in many cases and patient-doctor relationships). The personality of these residents was also deeply affected, causing them to become more apathetic and cynical. These qualities manifested in the way they approach patients, adding to the quality of patient care decline. In many instances, resident doctors went as far as contemplating suicide, and in some cases they went through with the plan, and took their own lives.

In the majority of events, it was found that women were more prone to developing these disorders, followed by 1st and 2nd year residents. Other contributing factors to the susceptibility were the specialization; psychiatry, anesthesiology and primary care residents were most likely to show symptoms, the existence of debt which was over 200,000$and a low budget given by the government for health care11; mostly in developing countries like Nigeria. Marital status appeared to have little to no effect, but generally single residents were more likely to be susceptible.

While in all of the researches it was established that there is a correlation between the residency and the onset of these disorders, some suggested that the symptoms of depression, anxiety and burnout did not affect the residents in the long term, but rather subsided after the first couple of months. Nevertheless, symptoms of depersonalization lingered and affected their personality, mostly manifested in cynicism, harsh attitude and apathy.

Two programs were evaluated in order to identify the most effective methods of prevention.

Program #1

1. 1. Consists of two main steps:

a. The 1st step focuses on a web-based anonymous survey which was distributed among the participants. Out of the 63 participants that completed screenings; 33% were referred to a counselor, 14% received a personal evaluation and 22% were referred to a psychologist or psychiatrist.

b. In the 2nd step the residents were invited to participate in a campaign consisting of workshops on physician burnout, depression and suicide and de-stigmatizing help-seeking.

1. 1. Two main challenges were identified:

a. Not many residents responded to the invitation to participate

b. More disquieting, different facilities refused to participate under the claim that there was no possibility that they had such problems in their establishments

1. Overall, this program showed to be successful. The responses were positive and 1/3 of the departments invited them for a second time.

Program #2

1. This program worked alongside psychologists and psychiatrists. The staff’s main focus was on enhancing the existing strengths that the resident doctors may have as well as helping them develop resilience.
2. Treatment and “booster sessions” were available throughout the program, as well as direct care & consultation and educational workships that focused on wellness promotion.
3. Overall, a high level of satisfaction was reported from residents and directors, and the demand for this program increases every year.

Discussion

In light of the findings noted above, it is safe to say that the main hypothesis of this essay that believes there is a direct correlation between the residency and the outbreak of depression, anxiety and burnout symptoms in resident doctors is definitely true. However, some studies suggest that these symptoms are only transitory and will pass after the first months of adaptation are over and not be present in the long run.

Another hypothesis that was proved to be wrong by these articles was that gender would have little to no effect on the susceptibility to these disorders. It was proved that women actually do have a higher probability to develop depression than men do because of factors related to the fact that they have to make their way in a mostly male-dominant field, as well as the desire to bear children.

Even though single residents had a higher chance of developing depression, the statistical gap was rather small and proves that, all in all, marital status plays an insignificant role.

One interesting finding was that specialization may affect the residents. Psychiatry residents were proved to be more prone to burnout and depersonalization due to the self-involvement in their patients’ lives. Neurosurgery residents were also prone to burnout and anxiety since most of their patients require surgery due to a malignant tumor. The direct connection of their specialization to cancer and self-involvement with the patients’ lives and families makes them more susceptible to emotional exhaustion.

It was proved that depressed residents had a higher probability of committing medical errors, but this finding is still questionable since the residents themselves admitted to committing the medical errors and it is unknown whether they indeed committed any errors or the fact that they suffer from burnout lead them to that belief. It was settled, though, that depersonalization caused by burnout lead them to become more apathetic and cynical towards their patients, causing deterioration in patient-doctor relationships as well as with their seniors.

In regards to the programs evaluated above, it seems that generally the best way to prevent this kind of diseases is through education and counseling. These specific programs can be used as successful examples. Workshops that work for awareness, de-stigmatization of help-seeking and building qualities of resilience proved to be the most effective.

In conclusion, it can be argued that this is a very important and delicate matter and that the residency programs all around the world should be re-evaluated and changed in order to guarantee the safety of their resident doctors. Unfortunately, some facilities refuse to admit that this is a real problem which is taking numerous lives every year just to keep an impeccable reputation. The truth is that this issue is very much real and as medical professionals, and mostly as human beings, we should put all the effort into eradicating it. It is crucial that facilities take action to make sure that their residents have access to a psychologist, psychiatrist or any other consultation service whenever needed.