The Misery of a Doctor's First Days

For many new physicians, residency brings fatigue, emotional stress, and self-doubt, affecting their ability to take care of themselves and their patients. Is there a way to fix it?

One night in July—the night before her first day of work—a new doctor picked at a container of sushi in her apartment on a sleepy street in Brooklyn. She tried to swallow a few bites as she chatted on the phone with her best friend from medical school, who was also marking the eve of his first day as a working physician. “Break a leg,” she said. “But not really.”

There wasn’t any street noise to keep her up as she tried to go to sleep early for her 5:00 a.m. start—but even in the silence, heavy with midsummer humidity, she couldn’t drift off. For two months, since she’d graduated medical school, her body had registered her mounting stress leading up to her first day in the hospital. She was plagued by insomnia. Food made her nauseated, except plain donuts, which she ordered twice a day from the diner at the end of her block. She’d eat them while studying diagnoses and procedures that she’d learned in school and long since forgotten, crumbs piling up in the crease of her textbook. In the months between graduating and starting work, she lost more than 15 pounds.

Her first week, she worked more than 80 hours on a general-surgery rotation, charting for her attending physician, checking patients’ vital signs, and trying to restart exhausted hearts long after her shifts ended. “There’s no way to get all of our work done in 80 hours,” she says. “Our supervisors can’t make the work go away.” When her pager beeped with a reminder to clock out for the day, she ignored it, she says, while the more senior physicians looked the other way. Like many of her fellow residents, she went entire days without eating. She was so drained that she was halfway out the door one day before remembering that she’d left an IV in a patient’s arm.

Within her first month, she crumbled under the pressure. After she went to visit the hospital counselor—sobbing through the appointment—a few of her fellow residents told her to suck it up. Feeling frazzled and helpless just comes with the first year territory, they said. It’s a rite of passage. In his memoir Intern, the New York cardiologist Sandeep Jauhar describes residency as “brutal, like a kind of hazing.”

Choosing whether or not to share these concerns with supervisors can be difficult, says a resident in family medicine at a New England hospital. She cites a common fear among residents: that their honesty will lead more senior doctors to write them off entirely. “They don’t want you to show any weakness,” she says. “You almost need to be a robot.” Her anxiety is affecting her daily work. “I’m exhausted because of the existential crisis playing out in my head every minute.”

Two centuries ago, aspiring physicians in the U.S. could just hang a shingle and begin cutting people open with little formal training. As the skeleton of America’s medical-education system emerged—medical schools, exams, and residency and fellowship programs—physicians had to follow a standardized procedure to become licensed. And as much as this system teaches them how to be doctors, it also teaches them how to operate within the medical profession—a lesson that can leave new doctors crippled by fatigue, emotional stress, and self-doubt, affecting their abilities to take care of themselves and their patients. Some in the medical community believe that there must be a better way to do it.

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When they graduate from medical school, newly minted physicians are prepared to recall minute details about a litany of illnesses—but not necessarily confident managing the symptoms. In his memoir The Real Doctor Will See You Shortly: A Physician’s First Year, Matt McCarthy describes the “tectonic shift” from laboratories to hospital life: Throughout much of his rotation in general surgery at Massachusetts General Hospital, where he practiced suturing banana peels back together in his free moments, McCarthy felt unprepared to deal with the onslaught of diseased bodies.

If he had been asked to “recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show,” he writes. “But I hadn’t learned much of the practical business of keeping people alive, skills like drawing blood or putting in a urinary catheter.”

Many brand-new doctors are painfully aware of the gaps in their knowledge—and in fact, that recognition can be paralyzing. Jauhar refers to his first year of residency as a “disillusioning time.” He writes, “I spent much of it in a state of crisis and doubt.”

Feelings of hopelessness appear to be fairly widespread among medical students and early-career doctors. The worrying combination of plummeting self-worth, and emotional fatigue has reached “epidemic levels,” according to a survey conducted at the University of North Carolina, Chapel Hill. Researchers found that approximately 70 percent of residents met the diagnostic criteria for burnout.

Burnout is a popular topic of discussion among people who run residency programs, and the feeling of being bone-tired and ragged comes up again and again. A study published earlier this year in the Journal of Graduate Medical Education found that nearly 40 percent of residents experienced difficulty sleeping while on call, and more than 80 percent said that they “never, seldom, or only sometimes” met their nutritional needs while on duty.

In a 2009 survey of more than 2,000 medical students and residents, nearly 6 percent reported experiencing suicidal thoughts in the past two weeks; among fourth-year medical students, that number was around 9 percent. Last summer, two new doctors committed suicide in New York City in the same week. Both young physicians jumped to their deaths—one from a New York Presbyterian Hospital facility, and the other from the roof of his former dorm at New York University.

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Three decades ago, Liz Gaufberg slogged through night after night of shifts as a resident in the intensive-care unit of an East Coast hospital. Then she came down with a cold, and the mucus dripping down her throat kept her up at night hacking and gagging. After a few near-sleepless nights, “I was almost delirious,” she says. She recalls standing in the hallway of the hospital and overhearing a page indicating that someone was coding. If the patient died, she could go home and get some rest. If the patient lived, she’d have to stay on. “[I] prayed that they would die so that I wouldn’t have to stay up for two more hours,” says Gaufberg, now a faculty member in the Cambridge Health Alliance Internal Medicine Residency Program. “I remember being so tired that when I looked at patients in beds, I’d think, ‘They’re so lucky that they get to lie down.’”

Duty-hour reform is one way to approach the problem of exhausted residents. In 2003, the Accreditation Council for Graduate Medical Education mandated a maximum 80-hour workweek for resident physicians. The recommendation was modeled, in part, on a 1989 New York law known as the Libby Zion Law, named after an 18-year-old woman whose death was initially attributed to overworked residents. The ACGME also caps individual shifts at 30 hours and requires accredited institutions to give residents at least 10 hours of respite between shifts.

Not everyone believes that these reforms are in the best interest of patients—or even doctors. Hospitalized patients may deal with a number of different physicians who cycle on and off duty, as opposed to having more continuous attention from a single physician who is deeply familiar with the particular case. Moreover, some older physicians feel that contemporary medical education lacks the rigor that they soldiered through. “I think the pendulum has swung too far in one direction, toward making the experience too soft,” the Manhattan internist Robert Press told The New York Times in 2009. “The inmates are running the prison, and it’s a huge challenge.”

Gaufberg disagrees. As the director of the Arnold P. Gold Foundation Research Institute—an organization dedicated to promoting humanism in medicine—she endorses the cap on hours, but thinks it only addresses one layer of a deeper systemic problem. “We all advocate for a humane work environment for our trainees, but I think we hyper-focus on duty hours as though it’s the solution,” she says.

Many medical schools are adopting more humanistic curricula, encouraging future physicians to consider the patients as full-fledged people, not simply constellations of symptoms or puzzles to solve. But that sensitivity to a life outside of the hospital doesn’t necessarily extend to the residents themselves. Gaufberg attributes this, in part, to a discrepancy between what schools and training programs hope to teach, and what they actually convey through institutional culture. “The process of becoming a physician is one of socialization,” she says.

Learning a place’s so-called “hidden curriculum” often involves constructing or adhering to a pre-set personae. Residents “feel that they are evaluated on their ability to fit in and learn the culture,” Gaufberg says. A robust body of research has emerged focusing on how to help physicians navigate professional identities that feel authentic to them, as opposed to a caricature of what they’ve been told a doctor should look like.

Gaufberg suggests that mindfulness exercises are one way to decrease the cognitive dissonance that can arise when workplace expectations—namely, compassionate, patient-centered health care—don’t jibe with the institutional culture or the volume and pace of the workload. She facilitates a monthly meditative reflection session outside of the hospital environment, and sometimes brings cohorts of new residents in her program to museums around Boston to look at works of art and get to know each other. Gaufberg also invites interns to draft an oath, outlining how they hope to embody their work and take care of their patients, one another, and themselves.

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That feeling of being watched, of being constantly judged and evaluated by superiors, isn’t paranoia, says McCarthy. It’s justified. “We’re all watching residents incredibly closely,” he explained. And he agrees that residents are being pulled in lots of directions, trying to scale a mountain of projects that keeps growing. “You’re going to be asked to do more things than one person could possibly do,” he notes. “Your pager will go off five times in the span of 10 seconds. Each of those people is very important and has important things to tell you, and you can’t call five people back at the same time.”

But now, as an attending physician, he’s trying to make the process more humane for the new doctors he supervises. On his white coat, he wears a pin that reads, “Walk the dog.” It serves as a reminder to take periodic breaks, even ones that last just a few minutes. “We have interns who are so busy that they’re coming to us after a 17-hour-day saying that they haven’t even gone to the bathroom yet,” he notes. “The people who keep it bottled up eventually crack. You should feel free to have 10 minutes to grab a coffee, so you’re not spending 17 hours a day grinding away just to do it again the following morning.”