After my graduation from medical school, I took two weeks off before starting my obstetrics and gynecology residency. In hindsight, I wished I spent those weeks doing something more memorable than studying and looking at the June call schedule. My training program was a small one, only four residents per year, which meant we took call every other night to every third night, unless someone was on vacation and then we basically lived in the hospital. As residents, we worked punishing hours; I recall driving into work at 3 a.m. and leaving at 8 p.m. the next day. First-year residents were not allowed to sleep at all on call nights, and there was no time for that anyway. We manned the emergency room, the labor and delivery room, and the obstetrics triage clinic in a very busy metropolitan city in Florida. There were emergencies constantly: women with uterine bleeding, fetal distress during delivery, a triplet pregnancy in preterm labor. I recall one heartbreaking case in which a mother to be, 32 weeks pregnant with her first child, presented with concerns as she had not felt her baby move for over 24 hours. We diagnosed a fetal death in utero where the mother was then was required to deliver her deceased baby.
Going into medicine, the expectation is there will be difficult moments with patients, families, and co-workers. The workload is known to be intense, and the amount of information to consume grows daily and requires superhuman efforts to manage. We take out hundreds of thousands of dollars in loans that require 20-30 years to pay off, while earning very low salaries during training. And training can be brutal: sleeplessness, high stress, and life-and-death stakes are constant companions.
I thought it was interesting that my intern year was the year residency programs were required by regulation to implement the “80-hour rule.” This rule meant that residents were limited to only working 80 hours a week. Imagine my surprise when I worked 110 hours or more every week and my training program required me to sign a form stating those 110 hours were really only 80.
Taking all these factors into account, is it any wonder that health care workers are struggling with mental health issues? COVID simply amplified the atmosphere creating a battlefield medicine environment for doctors and nurses, especially those working in ERs, ICUs, and nursing homes. Staff shortages, supply shortages, and increased patient loads all contributed to increased demands during COVID. Add to this the grief of losing patient after patient at the height of the pandemic.
What does the research show?
Data reviewed by the Centers for Disease Control and Prevention, in their Morbidity and Mortality weekly report Nov. 3, 2023, detailed that health care workers in 2022 suffered more from burnout, depression, and even suicide compared to 2018. Stats show burnout between 2018-2022 increased from 11.6% to 19% and health care workers reported 4.5 poor mental health days a month, versus 3.3 poor mental health days per month in 2018.
May is Mental Health Awareness month and it comes on the heels of the anniversary of Lorna Breen’s suicide in April 2020. This year marks five years since the ER physician, practicing in New York City in the early days of COVID, struggling with mental health issues, eventually took her life. Since her death, her family has pushed for reform of mental health regulations, working to change laws that have posed as barriers for health care workers to obtain mental health treatment and support. Corey Feist, her brother-in-law, echoes the sentiment in this post-COVID world that even just having a conversation about the mental health of health care workers is groundbreaking.
These conversations are becoming more welcome and accepted within our healthcare system. Psychiatrist, Dr. Jessi Gold, Chief Wellness Officer for the University of Tennessee System, details how to recognize burnout and how important it is for healthcare workers finding meaning and value in the work they do, in her new book, How Do You Feel. She outlines her own struggles with mental health wellness while practicing in a broken healthcare system.
Doctors still in training face higher risks of suicide, as well. In fact, suicide is the second highest cause of death among residents in training programs in the United States, with the risk being higher earlier in training. Nurses have high rates of suicides, as well. Prior to and sustained through COVID, female nurses had twice the rate of suicide versus the general population, reaching 41% higher than the general population in 2019. More recent studies show that nurses, health care techs, and behavioral health support workers all had higher rates of suicide than their general population counterparts.
Nurses particularly have been hard hit by the COVID pandemic. They were on the frontlines, and often at the grim last moments with patients who were not allowed to have families visit. I recently treated a nurse who worked the ICUs in a NYC hospital during COVID. She had experienced a flashback during a shift on a medicine floor a few months ago, triggered by alarms going off on a critically ill patient. No one had ever diagnosed her with PTSD and she was self-treating with alcohol when she came to me for help. On recollection of her COVID experience, she told me, “it was death every day, sometimes every hour.”
What can we do?
Recent studies indicate that there are good things we can advocate for to whittle down the mental health burdens on health care workers. These include humane work schedules and easier access to mental health care.
Reducing the stigma associated with asking for help can also play a huge role in turning the narrative: The Lorna Breen Foundation has been instrumental in getting 30-plus state licensing and credentialing boards to remove questions about past mental health diagnoses or treatment from licensing applications. These questions have been shown to have a negative impact on health care workers seeking mental health treatment for fear of losing their license and livelihood.
Other interventions include living wages for residents who are often faced with tremendous financial burdens from loans and support from medical leadership. Interestingly, as part of the CDC study done in 2023, if the health care worker felt trust from their leadership as well as time and help to complete their work, burnout was lower.
During my third month of training in OB-GYN, I approached my chief resident to tell her I was exhausted, depressed, and was considering leaving the field. She urged me to stick it out, telling me things would get better eventually. I shared that I had fallen asleep while driving home on the interstate after a 40-hour shift and when my parents visited the weekend before, I was only able to spend a total of 90 minutes with them due to the call and work schedule. My dad had just been diagnosed with a serious heart condition and I felt every moment with him was precious. Listening to me, as empathetically as I think she could, she pulled out her prescription pad and wrote a 30-day supply for Effexor, an antidepressant. “Just don’t quit before our licensing visit with ACGME next month.” she pleaded.
I left OB-GYN the following month and took six weeks off. I felt I had to ask forgiveness from everyone I thought I was letting down. Fortunately, my mentor, a psychiatrist, reminded me this was my life and I deserved to advocate for something better for myself. He encouraged me to enter into a psychiatric residency off-cycle, where I thrived. I now help other medical professionals, doctors, nurses, and even non-medical professionals, such as attorneys, obtain healing from mental health and addictive disorders. Being a physician is a tremendous privilege and one I have never taken for granted. But as I look back, I consider myself one of the lucky ones.
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