Opinion | How Much Anguish Must Residents Experience?

I just completed intern year of my emergency medicine (EM) residency. It was rewarding, but also the most emotionally laborious year of my life. Amidst becoming a family member’s caretaker due to illness, and then working 60- to 90-hour weeks, my emotional anguish experienced as an EM resident has been like a tightly bound coil waiting to unleash. And of course, it did.

It happened during the cardiac arrest of a 50-year-old man. It was one of those days in the emergency department (ED) where if anything could go wrong, it did. I overheard the PA system call the medical team to bay 2 as a patient was coding. I ran into the room, and both his wife and his sons were in distress.

After doing CPR for an hour, my attending called the time of death. The wife’s cry of anguish rang through the bay. Tears formed in my eyes, as the wife threw herself on her beloved’s lifeless body. My tears were not only for the loss of this patient, but for my loss of innocence over the year, all the patients that I had lost, and for the newfound responsibilities that being a physician brought, not only for me, but for my family as well.

I wiped my eyes and dejectedly walked to the doc box. My attending held a decompression session discussing the case. She told me to take the time I needed to decompress, as my emotions ran high. But patients were lining up to be seen, so I went back to work. The shift ended and I walked to my car. I scrolled through Instagram and was stunned to see that a resident in New York had committed suicide. An indescribable feeling of sadness raced through me. Although she was not an EM physician, all of us in residency experience the same feelings of helplessness, burnout, and sorrow at times.

How much anguish and sorrow do residents need to experience for people to realize that residency itself can perpetuate feelings of helplessness and the worsening of mental health and burnout? The New York resident is one of several I knew or knew of that had committed suicide over the past year.

Aren’t there structural protections that act as safeguards to counteract the unusual stressors of training? That day, mixed answers to this question ran through my mind.

What Is the General Mental Health of the EM Physician?

EM physicians have higher rates of burnout, depression, post-traumatic stress disorder (PTSD), and poor mental health outcomes in comparison to other specialties. Burnout is defined as a chronic workplace stress that has not been managed, leading to feelings of energy depletion towards one’s job. While burnout isn’t the same as depression, it can lead to worse mental health outcomes, in particular for those in emergency medicine. Surveys indicate up to 65% of EM physicians feel burned out, compared to a lower physician average. Furthermore, 10% of physicians considered or attempted suicide, according to a 2022 report, with 20% of doctors reporting feeling depressed; EM has one of the highest rates of suicidal ideation at 11%. Lastly, EM residents have PTSD at rates up to 20%, which is greater than twice the rate of the general population.

Why Do EM Physicians Have Such Poor Mental Health Outcomes?

These rates are not surprising to those of us in EM. In our specialty, the stress is heightened by life-or-death situations, missed diagnoses, increased documentation, irregular sleep schedules, and the sheer numbers of patients we are expected to see. Additionally, we see a profound amount of human suffering and death, arguably more than our other colleagues, and significantly more than the average person.

However, we receive little to no training on how to process the grief we witness.

Put these systemic factors in the pressure cooker that is residency — such as the 24-hour shifts, limited free time, missed family events, and the salary as low as $13 per hour — and it is no surprise that EM physicians have such high rates of poor mental health and burnout.

Since there are systemic factors that lead to worsening of mental health outcomes for EM residents, residency programs need to explore systemic solutions to decrease burnout and improve the mental well-being of physicians.

What Can Be Done?

First off, fair wages, appropriate duty hours (no more than 80-hour weeks), and adequate PTO/sick days are the first easy steps to improve the mental wellness of residents. Studies show that improving wages and decreasing work hours is correlated with better mental health. These are simple policy changes for residency programs.

Secondly, the Accreditation Council for Graduate Medical Education (ACGME), the governing body responsible for all residencies in the country, needs stricter regulations regarding the mental health resources residencies provide. The ACGME requires that residencies allow for time for mental health appointments, and provide access to mental health resources, including in emergent scenarios. Unfortunately, the recommendations remain vague regarding specific resources that should be provided. Also, although some residencies provide access to the hospital therapists through health insurance, it is often difficult to actually access a therapist due to the difficult schedule of a resident. A possible solution to this is having residency-specific therapists, as this increases access by increasing availability. Also, having incentives for physicians to attend appointments could increase utilization of mental health tools. However, without ACGME providing stricter requirements on what exact mental health resources should be provided, programs will not be incentivized to tailor mental health resources to their residents.

Other approaches can also help to improve mental health and decrease burnout during residency, such as de-stressing/decompression sessions after traumatic events in the ED and physician coaching. After the code in the ED, I was grateful for the safe space created for us to decompress. Yet, I recognize that by itself, it may not be enough to process grief and promote mental health. A multipronged approach is necessary to address the mental health and burnout of EM residents, and residents as a whole. The onus is on medical education to not only educate physicians but equip physicians with tools to recognize and combat burnout and poor mental health. This will benefit our well-being and the well-being of the patients we serve.

Ogechi Nwodim, MD, is an emergency medicine resident in Philadelphia.