JAMA and Jammies: The Work-Life Balance of an Intern

To the Editor: A growing body of evidence has shown that the grueling hours and expectations of residency in general, and internship in particular, lead to poor quality of life and a wide array of mental health issues including depression, anxiety, and emotional burnout. For instance, a 2008–2009 survey study of internal medicine residents [1] showed that 14.8 % of respondents reported quality of life that was “somewhat bad” or “as bad as can be,” 22.1 % reported emotional exhaustion a few times per week, and 28.9 % reported feeling depressed at least once a week. A prospective cohort study, part of the Intern Health Study led by Dr. Srijan Sen [2], followed medical interns and estimated that the prevalence of a major depressive episode during the intern year is at least 19.5 %. An increased awareness of these issues was instrumental in the decision of the Accreditation Council for Graduate Medical Education to implement stricter duty-hour restrictions in 2011. However, these implementations do not appear to have improved residents’ quality of life. For instance, Sen et al. [3] followed a new cohort of interns training after the initiation of the new duty-hour restrictions and found no significant improvement in hours slept, depressive symptoms, or well-being. Similarly, a survey study of general surgery interns training after 2011 [4] found that less than half believed that duty-hour restrictions had reduced fatigue, whereas 28 % reported weekly feelings of emotional exhaustion, 28 % reported weekly experiences of depersonalization, and 32 % felt that their personal-professional balance was “very poor” or “not great”. Among the interns surveyed, 67 % reported reflecting on satisfaction from being a surgeon on a daily or weekly basis, and 1 in 7 considered leaving their residency at least once a week. Why have the quality of life, rates of depression, and other psychiatric consequences of internship not improved with the new duty-hour restrictions? Inmy experience as an intern with a wife and two daughters under the age of 2 years, the interpersonal and psychological issues inherent to work-life balance were more stressful than residency itself. It is not just the long hours and fatigue that makes internship difficult. The feeling of constantly being supervised and evaluated, being at the bottom of the medical hierarchy, and having a tremendous responsibility for patient care that sometimes exceeds one’s experience can make internship incredibly stressful. The all-consuming nature of the job can be depleting, making one less able to perform social roles outside of work. Even with the work-hour reduction, an 80-h workweek forces most interns to radically alter the roles they play as romantic partners, parents, children, and friends. These factors havemore to do with the inherent nature of internship and its psychological effects than with the absolute number of hours worked. Reducing work hours without addressing these fundamental psychological issues will likely be ineffective for many interns. By sharing my personal experience, I hope to highlight some of these psychological difficulties and to offer specific recommendations to institutions for how to address them. Duringmy intern year, I faced overwhelming stress, a steep learning curve, and an entirely new set of expectations—and that was just from being a father. My wife and I have been blessed to have two wonderful daughters, born at the beginning of my fourth year of medical school and halfway through my intern year. The clash between my personal and professional lives came as quite a shock. As a medical student, I prided myself on my ability to balance school and family. In mymind, as well as inmy apartment, diapers and stethoscopes * Jason Dean jdean2@partners.org