The World Health Organization declared COVID-19 a pandemic on March 11, 2020, just 4 months before the start of a new residency cycle. Referred to as “COVID interns,” PGY-1 residents transitioning out of medical school in 2020 faced an unprecedented challenge of doctoring within a confused and ill-prepared health care system, while senior residents scrambled to adjust to their rapidly changing training programs. Each subsequent week brought more sobering news of increasing hospitalizations, intensive care unit admissions, and deaths; hospitals across the country resorted to the redeployment of residents across all specialties to buffer the growing need within their internal medicine and critical care units.1 And while the news and social media blurred into a collage of ventilator shortages, politicization of science, and “#healthcareheroes,” one study showed53.7% of medical interns (N=108) were struggling with mild to extremely severe depression, while 63.9% reported mild to severe anxiety.2
Many shortcomings of our health care system—ill preparedness, racial disparity, health illiteracy—were highlighted during the COVID-19 pandemic, and providers’ mental health was no exception.3 Classic psychosocial risk factors, such as high demands, lack of control, lack of institutional support, and absence of reward defined the workplace, leading Theorell4 to call it “a randomized trial for maximal worsening of the work environment.” Stress and burnout during residency are not novel concepts. A 2002 survey including 415 medical residency programs with a response from more than 4000 residents found depressive symptoms in 35% of respondents, paired with feelings of increased cynicism and decreased humanism despite major curricular reforms and duty hour limitations.5 Unfortunately, the statistics in the coming years hardly budged and, in the wake of the pandemic, culminated to more than 50% to 76% of physicians worldwide reporting burnout in 2020.6-8
As a COVID intern at Brigham and Women’s Hospital (Boston, Massachusetts), I also experienced the demanding workload and witnessed the struggle of my colleagues firsthand. Brigham and Women’s Hospital, similar to many of its peer institutions, implemented frequent mental health check-ins within its curriculum. Known as the Intern Humanistic Curriculum, these check-ins essentially were an echo chamber to unload the psychological burdens of our workdays, and we eagerly shared what made us angry, sad, hopeful, and hopeless. During one such session, I learned about moral injury, a term originating in the military defined as the psychological stress resulting from actions—or the lack of actions—that violates one’s moral or ethical code.9 With the onslaught of patient deaths for which most of us felt unprepared, we had all endured varying degrees of moral injury. Greenberg et al9 described 2 potential outcomes after moral injury: (1) the development of mental health disorders such as depression and posttraumatic stress disorder, or (2) posttraumatic growth, which is the bolstering of psychological resilience. Notably, the outcome is based on the way someone is supported before, during, and after the challenging incident.9
With the aim of psychological growth and developing resilience, residents should prioritize mental health throughout their training. To this end, several resources are readily available, many of which I actively use or frequently revisit, which are reviewed here.
Mindfulness Meditation App
Calm (https://www.calm.com/) is one of several popular mobile applications (apps) that delivers mindfulness mediation—the practice of attending to experiences, thoughts, and emotions without bias or judgment. With more than 100 million downloads, Calm includes meditation tutorials, breathing exercises, nature scenes and sounds, and audio programs taught by mindfulness experts for $69.99 a year or $14.99 a month. Systemic reviews have demonstrated reduced sleep disturbance, decreased ruminative thoughts and emotional reactivity, and increased awareness and acceptance in those practicing mindfulness meditation. Calm users have reported these benefits, with many able to forego the time- and cost-intensive cognitive behavioral therapy that requires highly trained therapists.10-12
Exercise to Relieve Stress
Both aerobic and anaerobic exercises are antidepressive and anxiolytic and also lower one’s overall sensitivity to stress. Whether it is governed by neurotransmitters such as the activation of the opioid systems or the release of endogenous endorphins or time spent focusing on a different task at hand, the benefits of exercise against mental stressors have been extensively studied and established.13 Consider obtaining a new gym membership at the start of residency or joining an intramural team. Both have the added benefit of expanding your social circle.
Socialize With Others
Social isolation and perceived loneliness are key stressors linked to neuroendocrine disturbances that underlie depression, anxiety, and even schizophrenia.14,15 Throughout residency there will be several social events and opportunities to gather with colleagues—inside or outside of the work environment—and residents should attend as time allows. Even virtual social interactions were found to reduce stress and help in the treatment of social anxiety disorder.14