Never Let Your Colleagues Worry Alone

Never worry alone. As residents, we've all heard it, whether in med school, from our program directors or chiefs, or said by our attendings when we start a new rotation. And it sounds easy. All of us in medicine can recall the first patient who died despite our best efforts, the family member who got under our skin, the supervisor whose comments cut a little too deep. We also recall those moments of identification with a profoundly ill patient who made us wonder why we were spared; we know the weight of letting a patient walk out of our office and feeling simultaneously responsible and helpless to protect the patient until the next time he or she walks back through your door.

So it should be easy not to worry alone. After all, we have these experiences in common. We know that a career in medicine, even with all the rewards and the fulfillment it offers, has incredibly difficult moments—and that training is especially hard. As psychiatrists, we have been doubly reinforced that becoming depressed is not a character flaw. We know that depression is an illness, not a weakness—that regardless of triggers, it has a biological basis and that there are effective treatments.

But it is easy to forget these things in the whirlwind of training. We get caught up in the rush of multiple admissions in a day, of trying to take time to teach medical students and to learn ourselves. There is often no time to stop and think. It can feel like constantly playing catch-up, and it's easy to attribute exhaustion to never quite getting enough sleep, to feel like disillusionment is just a little bit of compassion fatigue, to find yourself constantly irritable or down or overwhelmed and think that it's just this job.

And the other issue is that depression lies. You may have been told never to worry by yourself and that to be depressed doesn't make you weak or incompetent. You may have learned everything we know about the biological underpinnings and memorized all of the treatments. When depression weaves its insidious way into your mind, none of that knowledge matters. It will tell you that you are stupid and that you are barely holding together the facade of knowing what you are doing. It will say that you are letting everyone down—when your patients don't get better, it's your fault; when you miss your family's holidays for work you are selfish; when you cancel dinner with friends at the last minute, you've failed them yet again. And it can make you believe that there is no hope, that none of the exhaustion or the seemingly insurmountable obstacles will ever go away. These lies make you feel completely and utterly alone.

And when it comes to depression, there is a lot of evidence that we as physicians do worry alone. Our rates of depression, suicidal thoughts and suicide are higher than the general population, and this increase in depressive symptoms is particularly notable early in our careers. Depression early in one's career as a physician predicts ongoing risk for depression as our careers proceed. Among physicians with depression, more than half avoid seeking treatment due to perceived stigma, and among physicians who die by suicide, few are in treatment at the time of their death.

But depression is treatable. And suicide is preventable. So, perhaps an equivalently important instruction is "Never let your colleagues worry alone." If you notice someone struggling, ask what is wrong. Maybe the intern on your service has started coming in late every day or is at the hospital far later than everyone else each night. Or your coresident is drinking more than usual at social functions—or has stopped attending at all. Perhaps someone seems anxious, or irritable, or it feels like they're putting in less effort than before. If you are a supervisor, maybe you notice that a resident's performance has plateaued, or even dropped.

It would be easy to get frustrated with these changes, to notice only their impact on your work. But depression doesn't always look like sadness, especially in those who are trying desperately to keep it together. So ask. Ask them how they're doing and what is going on. And listen. Offer support. Know what resources are available at your institution, and help colleagues in distress access them. Because if we each worry with each other, then no one has to worry alone. ■

References:

1. Schwenk TL, Gorenflo DW, Leja LM. A survey of the impact of being depressed on the professional status and mental health care among physicians. J Clin Psychiatry. 2008; 69(4): 617-620.

2. Rosta J, Aasland OG. Changes in the lifetime prevalence of suicidal feelings and thoughts among Norwegian doctors from 2000 to 2010: a longitudinal study based on national samples. BMC Psychiatry. 2013; 13: 322.

3. Schernhammer ES, Colditz GA. Suicide rates among physicians: A quantitative and gender assessment (Meta-analysis). Am J Psychiatry. 2004; 161: 2295-2302.

4. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014; 89(3): 443-451.

5. Støen Grotmol K, Gude T, Moum T, Vaglum P, Tyssen R. Risk factors at medical school for later severe depression: a 15-year longitudinal, nationwide study (NORDOC). J Affect Disord. 2013; 146(1): 106-111.

6. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry. 2013; 35(1): 45-49.