New research is studying the effects of stress and long hours on physician intern health, and it’s changing their DNA.
Medical residencies are one of the most stressful and emotionally taxing times for new physicians. But what toll does all that stress and sleep deprivation take on a person’s mental well-being? Researchers are using a popular wearable device to learn more about how stress and sleep affect depression - and how the workplace impacts physicians’ health. Their findings may show the long-term effects of stress on physicians throughout their careers as well.
Researchers at the University of Michigan have been studying physician residents for the past 12 years, and they have discovered clear links between depression and a host of expensive consequences, including lower-quality patient care, lost productivity, burnout and turnover.
“Physician depression has a high cost - one that’s measurable,” says the study’s lead investigator Srijan Sen, MD, PhD, professor of depression and neurosciences and an associate professor of psychiatry at the University of Michigan. “Depressed physicians commit medical errors at almost twice the rate of non-depressed ones. Depression also is clearly linked to attrition. But, if we can provide interventions to retain wellness and reduce work-family conflicts, we can change the system.”
The Intern Health Study, which now includes residents at nearly 60 training hospital sites nationwide, shows that depression rates are getting worse, especially among female physicians, who, as of 2018, now constitute the majority of U.S. medical school students for the first time in history. “Over the past 12 years, depression rates have been increasing by about five percent per year, and as the ratio of female physicians increases, work-family conflict is becoming a big driver,” Sen says.
For the first time, the longitudinal cohort study is using Fitbit wearable bracelets to gather real-time data and self-reporting from all physician participants as they work at their residencies. The smartphone-based app, developed specifically for the study, automatically tracks sleep quality and length, records activity levels and asks the wearer for input on daily mood levels. Algorithms estimate peak fatigue times based on changes in a person’s sleep schedule, length of awake time and other data.
“Now we can gather objective data in real-time, instead of subjective feedback - and that’s a really exciting direction,” Sen says. “For example, we've known for a long time there's a close connection between mood and sleep, but we didn't know that much about how much people slept or how it affected their mood the next day. We found there are really high-risk periods for getting depressed, even becoming suicidal. Being able to get at that fine-grained relationship between these variables wasn’t possible before these sorts of devices were around, and we can collect that data on a daily basis.”
The effects of changes in the sleep schedule aren’t the same across all residents, the study shows. Some residents experience significant mood changes when they work very long shifts compared to shorter ones, Sen explains. Others suffer most when they keep changing from days to nights and back again, preventing a stable sleep/wake cycle.
Among training physicians, depression disproportionately impacts women, especially during the first year of residency, notes a separate study published in JAMA Internal Medicine. Within the study group of 3,121 interns from the academic year 2015-2016, women experienced higher family-work conflict and higher attrition rates than their male counterparts. But, when work-family conflicts were proactively addressed, depressive disparity between the sexes decreased by 36 percent, the article notes.
Sen’s team also is applying advancements in genetic testing to examine how stress and depression affect the genes. Findings show that depression and stress actually accelerate cellular aging by shortening a person’s telomeres, the end portion of the chromosomes. Elevated stress rates make the shortening of the telomeres happen faster. “For most people, as we get older, the telomeres shorten by about 24 base pairs per year,” he explains. “But for the medical residents in our study, the telomeres were shortened by 150 pairs after just one year of residency training, six times the normal rate.”
The study findings open up a culture change conversation, inviting teaching hospitals to change their protocols to contribute to better residency experiences, and ultimately, better doctors. It’s an aspect that hasn’t really been addressed, especially considering the recent shifts in the medical school demographics, Sen says. “Back in the 1800s, most residents were men who worked 120 hours a week and lived in the hospital,” he says. “Now, half the residents are women who might have kids or be married to other physicians, which causes a lot of life-work tension. As a field, we haven’t resolved that.”
But it’s not just about the gender angle, he adds. “The nature of the resident’s work has changed, and that might be another driver of the increase in depression. Hospital patients are admitted and discharged much more rapidly today, so each work hour is much more intense. Then add the new levels of administrative paperwork.” The impact of workflow changes could hold lessons for physician practices long after the residency is over, too, he suggests.
Not being proactive about workplace stress and physician depression could be costing the healthcare industry a lot of money, notes a 2019 article in Annals of Internal Medicine. Mental health is clearly linked to physician burnout and its associated consequences, including medical errors and attrition. More than $4 billion in losses may stem from physician turnover and reduced clinical hours alone, while “at an organizational level, the annual economic cost associated with burnout related to turnover and reduced clinical hours is approximately $7,600 per employed physician each year,” the article states.
Teaching hospitals and private practices have the power to change the tides on physician depression, Sen insists. “We’re showing that stress and depression have real, measurable consequences to the quality of care physicians provide,” he says. “To get healthier employees, we need to work harder to create healthier workplaces. Some of this is about reducing the administrative burdens of being a physician, say, by using medical scribes or office assistants. But it’s also about using creative solutions like work time banks, concierge services and anything that could improve the work-life balance for physicians.”
The lesson physician practice groups can learn from the study? Embrace the family and personal needs of a newly hired physician, Sen says. “There’s a clear link between depression and retention, so working out any family-job conflicts is really important to keeping a good doctor in your office. If you have a practice that is thriving, happy and flexible, you'll be able to attract physicians who will be happy to stay there.”
To learn more about the Intern Health Study, visit the Sen Lab website.
Pamela Tabar, CADDCT, CDP, is a freelance healthcare writer based in Medina, Ohio.