Work-related posttraumatic stress disorder (PTSD) is three times higher in interns than the general population, new research shows.
Investigators assessed PTSD in more than 1100 physicians at the end of their internship year and found that a little over half reported work-related trauma exposure, and of these, 20% screened positive for PTSD.
Overall, 10% of participants screened positive for PTSD by the end of the internship year, compared to a 12-month PTSD prevalence of 3.6% in the general population.
"Work-related trauma exposure and PTSD are common and under-discussed phenomena among intern physicians," lead author Mary Vance, MD, assistant professor of psychiatry, Uniformed Services University, Bethesda, Maryland, told Medscape Medical News.
"I urge medical educators and policymakers to include this topic in their discussions about physician wellbeing and to implement effective interventions to mitigate the impact of work-related trauma and PTSD among physician trainees," she said.
The study was published online June 8 in JAMA Network Open.
Burnout, Depression, Suicide
"Burnout, depression, and suicide are increasingly recognized as occupational mental health hazards among healthcare professionals, including physicians," Vance said.
"However, in my professional experience as a physician and educator, I have not come across many discussions about work-related trauma exposure and its psychological consequences among physicians, despite observing anecdotal evidence among my peers and trainees that this is also an issue," she added.
This gap prompted her "to investigate rates of work-related trauma exposure and PTSD among physicians."
The researchers sent emails to 4350 individuals during academic year 2018-2019, 2 months prior to starting internships. Of these, 2129 agreed to participate and 1134 (58.6% female, 61.6% non-Hispanic White, mean [SD] age 27.52 ([2.50]) completed the study.
Prior to beginning internship, participants completed a baseline survey that assessed demographic characteristics as well as medical education and psychological and psychosocial factors.
Participants completed follow-up surveys sent by email at 3, 6, 9, and 12 months of the internship year. The surveys assessed stressful life events, concern over perceived medical errors in the past 3 months, and number of hours worked over the past week.
At month 12, current PTSD and symptoms of depression and anxiety were also assessed using the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5), the 9-item Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder 7-item scale (GAD-7), respectively.
Participants were asked to self-report whether they ever had an episode of depression and to complete the Risky Families Questionnaire (RFQ) to assess if they had experienced childhood abuse, neglect, and family conflict. Additionally, they completed an 11-item scale developed specifically for the study regarding recent stressful events.
"Crucible" Year
A total of 56.4% of respondents reported work-related trauma exposure, and among these, 19.0% screened positive for PTSD. One tenth (10.8%) of the entire sample screened positive for PTSD by the end of internship year, which is three times higher than the 12-month prevalence of PTSD in the general population (3.6%), the authors note.
Trauma exposure differed by specialty, ranging from 43.1% in anesthesiology to 72.4% in emergency medicine. Of the respondents in internal medicine, surgery, and medicine/pediatrics, 56.6%, 63.3%, and 71%, respectively, reported work-related trauma exposure.
Risk factors associated with trauma exposure (after adjustment for demographic characteristics) are listed in Table 1.
Table 1. Risk Factors Associated With Trauma Exposure
| Risk factor | Odds ratio (95% CI) | P value |
|---|---|---|
| Non-Hispanic White race/ethnicity | 1.51 (1.14 - 2.01) | .004 |
| More hours worked | 1.01 (1.00 - 1.03) | .03 |
| Early family environment | 1.03 (1.01 - 1.05) | < .001 |
| Stressful life experiences at baseline | 1.46 (1.06 - 2.01) | .02 |
Work-related PTSD also differed by specialty, ranging from 7.5% in Ob/Gyn to 30.0% in pediatrics. Of respondents in internal medicine and family practice, 23.9% and 25.9%, respectively, reported work-related PTSD.
Table 2 lists the risk factors associated with PTSD, after adjusting for demographic characteristics.
Table 2. Risk Factors Associated With PTSD
| Risk factor | Odds ratio (95% CI) | P value |
|---|---|---|
| Being unmarried | 2.00 (1.07 - 3.73) | .03 |
| Non-Hispanic White race/ethnicity | 1.77 (1.01 - 3.11) | .05 |
| Stressful life experiences during internship | 1.43 (1.14 - 1.81) | .002 |
| Depression at month 12 of internship | 2.52 (1.36 - 4.65) | .003 |
| Anxiety at month 12 of internship | 2.14 (1.13 - 4.04) | .02 |
Vance called the intern year "a crucible, during which newly minted doctors receive intensive on-the-job training at the frontlines of patient care [and] work long hours in rapidly shifting environments, often caring for critically ill patients."
Work-related trauma exposure "is more likely to occur during this high-stress internship year than during the same year in the general population," she said.
She noted that the "issue of workplace trauma and PTSD among healthcare workers became even more salient during the height of COVID," adding that she expects it "to remain a pressure issue for healthcare workers in the post-COVID era."
Call to Action
Commenting on the study for Medscape Medical News, David A. Marcus, MD, chair, GME Physician Well Being Committee, Northwell Health, New Hyde Park, New York, noted the study's "relatively low response rate" is a "significant limitation" of the study.
An additional limitation is the lack of a baseline PTSD assessment, said Marcus, an assistant professor at Donald and Barbara Zucker School of Medicine, Hofstra/Northwell Health, Hempstead, New York, who was not involved in the research.
Nevertheless, the "overall prevalence [of work-related PTSD] should serve as a call to action for physician leaders and for leaders in academic medicine," he said.
Additionally, the study "reminds us that trauma-informed care should be an essential part of mental health support services provided to trainees and to physicians in general," Marcus stated.
Also commenting on the study for Medscape Medical News, Lotte N. Dyrbye, MD, professor of medicine and medical education, Mayo Clinic, Rochester, Minnesota, agreed.
"Organizational strategies should include system-level interventions to reduce the risk of frightening, horrible, or traumatic events from occurring in the workplace in the first place, as well as faculty development efforts to upskill teaching faculty in their ability to support trainees when such events do occur," she said.
These approaches "should coincide with organizational efforts to support individual trainees by providing adequate time off after traumatic events, ensuring trainees can access affordable mental healthcare, and reducing other barriers to appropriate help-seeking, such as stigma, and efforts to build a culture of wellbeing," suggested Dyrbye, who is codirector of the Mayo Clinic Program on Physician Wellbeing and was not involved in the study.
The study was supported by grants from the Blue Cross Blue Shield Foundation of Michigan and National Institutes of Health. Vance and coauthors, Marcus, and Dyrbye have reported no relevant financial relationships.
JAMA Netw Open. Published online June 8, 2021. Full text
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