Thirty-one-year-old Rodolfo Silva, a second-year pediatric resident, thought he was prepared to handle death. In his first year of residency at Loma Linda University Medical Center, he felt he was prepared.
"This is part of the disease process. I think I’ll be okay," he told himself. But then Silva watched as a terminally-ill 4-year-old died and realized it was harder than he thought.
"It’s completely different when you’re actually in the moment and seeing the reactions of the family. I think that’s probably the harder part," said Silva.
Death isn’t the only challenge young doctors-in-training face.
"You have to deal with difficult families. You have to deal with you not being as available to your own friends and family, or missing out on things that other people who are not in medicine that are your age would be able to do," said Silva.
In light of the many pressures on young doctors, the Accreditation Council for Graduate Medical Education, the accrediting organization that oversees teaching hospitals, now requires residents have 24/7 access to a mental health professional.
It's part a new set of guidelines that went into effect on July 1. The rules also include a change in the number of hours first-year residents can work and more flexibility in their schedules.
At Loma Linda, Barbara Hernandez, the director of physician vitality, works to address physician stress before it becomes a bigger problem.
"If many of our physicians saw the kinds of things on the street that they see in the protected walls of the hospital, they would need treatment for PTSD," said Hernandez.
She came to her job after a career as an intensive care unit nurse. In that work, she saw first-hand as overwhelmed residents struggled to deal with the pressures of caring for patients.
"Some of these residents were inconsolable. I would see them and they would pull me into an empty room and just sob," she said.
Hernandez’ job is to make sure physicians, especially new ones, are developing health habits to deal with that stress.
Of course, these issues aren’t new to medicine. She said the profession has a tradition of a certain mindset of infallibility and self-sacrifice.
"Physicians have no needs, should not talk about emotions, should never complain ... When we have people to subscribe to that, it’s a quick recipe for burnout," said Hernandez.
Burnout is more than fatigue. It can be dangerous. One study reported in 2015 in JAMA Psychiatry found that 23 percent of first-year residents had suicidal thoughts. They can have high rates of other depressive symptoms, too.
Guidelines from the Accreditation Council aim to address this by making sure physicians have flexibility in their busy schedules. They’re encouraged not to work when they’re overly fatigued and to take time during the day to handle their own medical appointments. If they work on charts at home, they’re instructed to count those hours toward their maximum 80-hour work week.
"It’s a recognition that physicians are human beings, and that we get tired, we get sad, we have problems in our social lives, just the way anyone else does," said Dr. Daniel Giang, Loma Linda’s head of graduate education.
This year, first-year residents will be allowed to work 24-hour shifts. That’s an increase from the 16-hours they’ve been limited to since 2011. The longer shift puts their hours on par with older residents. The decision was based on research.
"A 16-hour limitation did not make it any safer for patients that we could determine," Giang said.
Giang said residents didn’t report more satisfaction with the shorter shifts either.
For D’Artagnan DeBow, a fifth-year surgical resident, long shifts are part of the on-the-job training for new doctors, some of whom haven’t had a job before.
"Now they’re working 80 hours and working a 24-[hour] shift on a Friday night with a busy trauma service, and going to the operating room and taking care of sick patients on the floor. You have to be able to triage your time appropriately," said DeBow.
As an administrator, Giang sees the change in hours as a way to keep teams with different levels of experience together. He wants residents to find a work-life balance with the help of attending physicians.
Dr. Cynthia Tinsley’s dual role comes into play here. She makes sure the residents she supervises understand the medicine they practice, but she also serves as someone they can seek out when they need help.
Tinsley includes wellness in her curriculum, teaching the residents coping strategies for stress and the warning signs to watch for when it's time to seek help.
"One of the common things is when you have anger management issues, when you’re finding that you’re seeking alcohol — 'I need a drink.' If you’re not sleeping well, if you’re not eating well. You’re finding that you’re losing interest in life and you’re going through things in a mechanical way," she said.
Over her career, Tinsely has seen doctors develop these weak coping behaviors. That’s why some of them have poor bedside manner. She’s training physicians to be alert to those risks.
Having Tinsely and others to talk to has made a big difference for Dr. Silva. He said he’s living a healthier lifestyle this year than he did in his first year of residency and his program has been a big support in this.
"If you came in with no anxiety, no depression and you’re leaving with depression and anxiety that’s not going to do anyone any good, whether it be the physician or the patients that they take care of," said Silva.
Loma Linda administrators say that’s the point.
"It is certainly very important to medical educators at all levels trying to decide, how can we help residents and medical students and junior physicians and even senior physicians take care of their health better, realize that’s part of their professional responsibility, to present themselves ready to give their best in caring for their patients," said administrator Giang.
He wants to make sure residents are doing their best for the patients they are treating both now and 15 years in the future.