Emotional Distress During Internship: Causes and Support Systems
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J Gen Intern Med DOI: 10.1007/s11606-020-06283-2 © Society of General Internal Medicine 2020
physicians experience emotional distress during M any medical training. In this issue of JGIM, Moore and
colleagues1 expand our understanding of the problem with a thoughtful study of interns’ emotional distress and the support they do or do not receive. We know from prior research that emotional distress and burnout are common early in medical careers.2, 3 Physician distress has real consequences that are not limited to the distressed physician. Studies of burnout have shown higher rates of unprofessional behaviors,4 lower markers of achievement,5 and the self-perception of delivering poorer patient care6 in affected physicians and trainees. Using qualitative methods, the authors outline the causes of interns’ distress. First, they define chronic, “contextual factors,” many of which are systems issues. These markers of dysfunctional work environments remain pervasive in medical education, in spite of efforts to reform the internship experience, and they can gradually wear down the interns. Then authors describe how interns are then hit with “acute triggers” encountered during patient care. These triggers include caring for very ill or difficult patients and dealing with patients’ deaths. This “double hit” combination can push an intern over the emotional brink and into a distressed state. Having examined the causative factors, the authors then describe efforts made by senior residents to mitigate the suffering they observe in their junior colleagues. Often, these are small gestures, such as a kind word or holding a pager. We do remember these acts of kindness. While writing this, I recalled as an intern arriving beleaguered to a general medicine ward rotation after a hard month in the cardiac intensive care unit. My resident, now a prominent academic, looked me over and then wrote all my notes as I acquainted myself with the patients on the service. He then took me out for beers and a game of darts after sign out. Refreshed, I charged into the service on the following day. These gestures may be the most memorable and easiest to articulate, but one wonders what else the residents are doing to support interns they see as struggling emotionally. Some actions, no matter how well intentioned, may not be helpful. Furthermore, by acting alone, residents
may neglect to refer a struggling intern to someone better prepared to assist. That interns receive emotional support from their residents is understandable, since the residents are physically present and support the interns in numerous other ways. Residents serve as role models, define expectations, establish the learning environment, provide experiential learning, give feedback, and stimulate independent learning.7 What remains predictably disappointing is the lack of institutional support. The interns and residents are struggling through crises using ad hoc solutions. Many of the residents’ actions were based on the idiosyncratic experiences that the residents themselves had
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