Medical practitioners are tasked with the unenviable burden of lives resting on their shoulders. Medicine is a fulfilling profession, but one ridden with rigor, intense pressure, the need for intense concentration, dexterity, compassion, and a whole and absolute dedication no matter what.
Training to become a physician is a long and often excruciating challenge. Instances of sheer mental and physical exhaustion or “burnout” are all too common both for physicians and even medical residents and students in training.
This situation is constant across almost all specialties, but one in particular hits close to home: psychiatry.
Burnout and How It Relates to Psychiatry
Burnout arises from a myriad of factors such as the sheer difficulty of the medical field, time demands, challenging interpersonal relationships, and the challenge of reconciling with various patient types and prognoses.
Burnout often translates to depression, fatigue, irritability, and diminished concentration, the latter of which can have a detrimental effect through medical errors in judgment.
Moreover, rates of suicide ideation and attempts are significantly higher in states of burnout (Stockman, 2010). In 2004, administration of the Maslach Burnout Inventory to physicians in training indicated that psychiatry residents have a burnout rate of more than 40% (Martini et al., 2009).
As it turns out, surveys of medical students have often indicated that most students have increased their alcohol intake in medical school, and often particularly cite talking to psychiatric patients as one of the most stressful events of their medical education (Firth, 1986).
Additionally, psychiatry residents have to deal with the same issues as other medical residents: the death of patients and facing disgruntled patients.
However, they also have the added stressors of fear for exposure to verbal and even physical assaults from patients with compromised mental health, as well as the high risk of suicide with which this demographic of patients often presents (Ishak at al., 2009).
As of this year, a large longitudinal study in France investigated mental health status for psychiatrists in training. What it found was not only a greater exposure to violence and sexual assault relative to other specialties, but also a significant prevalence of various substance use disorders.
There were high rates of tobacco, alcohol, and cannabis use, but more concerningly, a large number also reported abuse of drugs such as ecstasy, amphetamines, psilocybin mushrooms, antidepressants, and anxiolytics (Fond et al., 2018).
It goes without saying that we need a sufficient work force of doctors to treat the population, and given the complexity and wide prevalence and impact of mental health, a sufficient work force of psychiatrists is essential.
Already making the situation complicated is the fact that there is a shortage of psychiatrists. However, with an aging and growing population, this shortage is set to worsen. Therefore, at the very least, those who are training to be psychiatrists need to be looked after.
Overworked Resident Physicians- the Libby Zion Case
One notorious instance that comes to mind is the 1984 case of Libby Zion, a college student who died at 18 after suffering cardiac arrest and severe fever (widely believed to be ‘serotonin syndrome’).
Under the partial responsibility of overworked medical residents (who had been well into 30 hours of consecutive duty), Zion was administered pethidine by a resident to control her agitation.
This action turned out to elicit a severe and ultimately fatal interaction with another drug she was taking, an anxiolytic, phenelzine.
The court ruling following her death decreed that the resident physicians’ judgment was compromised from burnout, and led to the Libby Zion Law in New York. This law, going forward, required that residents work no more than 80 hours per week, or more than 24 hours consecutively (Kaplan, 1991).
While the Libby Zion Law has certainly ameliorated burnout to some extent, the same occupational hazards associated with psychiatry (such as fear of violence and abuse, and coping with suicidal patients) still render this specialty as one which has a negative impact on its trainees and practitioners.
Institutional Response to Physician Mental Health Concerns
Beyond the Libby Zion law, one major response to addressing the mental health issues of psychiatrists in training has been that of ‘process groups’ at medical institutions to address the mental health concerns of training doctors.
At the Cedars-Sinai Psychiatry Program, there have been interactive modules developed for residents that focus on time management, relaxation techniques, and meditation. It enables psychiatrists in training to recognize stress and manage it during the work-day rather than after it.
Alongside Cedars-Sinai, the University of South Florida (USF) College of Medicine implemented a USF Residency Assistance Program (RAP), which tends to the mental health needs of its residents. Many more medical schools and hospitals have such resources and personnel on hand to address any concerns or stressors that training doctors have.
What training physicians need to do is not to hesitate to use them as much as they can, whenever they need to (Dabrow et al., 2006). These programs are potentially crucial means of addressing the mental health issues clearly impacting psychiatry residents.
Looking After Yourself Before Helping Others
An essential but understated mantra of medicine is that physicians, to look after their patients, need to be a sound mind, body, and judgment. To realize this goal, doctors need to have their own physical and mental health in order.
The same holds true for psychiatrists. How can you have psychiatrists treating psychiatric and substance abuse disorders if they themselves are victims of the same afflictions on the road to realizing their medical vocation?
Now that more of these intuitive but often ignored mental health burdens on psychiatrists in training are exposed, more medical institutions can and should respond in a way to look after these medical professionals.
Conversely, the medical residents themselves need to reach out to these resources whenever they are overwhelmed or facing stress or strife.
An apt analogy is that of putting on an oxygen mask on a plane: you put yours on first before helping others. Psychiatrists, similarly, need to ensure that their health is in good order before opting to help others address their mental health.
Once they can better manage their own physical and mental stress, they will become better decision-makers, and ultimately, better physicians.
Dabrow, S., Russell, S., Ackley, K., Anderson, E., & Fabri, P. J. (2006). Combating the Stress of Residency: One School’s Approach. Academic Medicine, 81(5), 436-439. doi:10.1097/01.acm.0000222261.47643.d2
Firth, J. (1986). Levels and sources of stress in medical students. Bmj, 292(6529), 1177-1180. doi:10.1136/bmj.292.6529.1177
Fond, G., Bourbon, A., Micoulaud-Franchi, J., Auquier, P., Boyer, L., & Lançon, C. (2018). Psychiatry: A discipline at specific risk of mental health issues and addictive behavior? Results from the national BOURBON study. Journal of Affective Disorders, 238, 534-538. doi:10.1016/j.jad.2018.05.074
Ishak, W. W., Lederer, S., Mandili, C., Nikravesh, R., Seligman, L., Vasa, M., … Bernstein, C. A. (2009). Burnout During Residency Training: A Literature Review. Journal of Graduate Medical Education, 1(2), 236–242. http://doi.org/10.4300/JGME-D-09-00054.1
Kaplan, R. L. (1991). The Libby Zion Case. Annals of Internal Medicine, 115(12), 985. doi:10.7326/0003-4819-115-12-985_2
Martini, S. (2004). Burnout Comparison Among Residents in Different Medical Specialties. Academic Psychiatry, 28(3), 240-242. doi:10.1176/appi.ap.28.3.240
Stockman, J. (2010). Burnout and Suicidal Ideation among U.S. Medical Students. Yearbook of Pediatrics, 2010, 392-394. doi:10.1016/s0084-3954(09)79480-1