As a pathology resident, much of my time is spent looking down a microscope, searching for clues that will guide a final diagnosis. Some diseases, however, cannot be seen at 100x magnification. Mental illness is one such disease. Its impact is profound, yet it often remains invisible to the naked eye. In fact, the National Alliance on Mental Illness estimates that one in five adults in the U.S. lives with a mental illness, and the prevalence of depression among resident physicians is even higher than the public. This represents not just a challenge to the individual facing the disease but is currently considered a public health emergency. Addressing the mental health stigma in medicine begins with recognizing mental illness as a legitimate disease and treating those with compassion who are living with something we may not see or understand.
When I was a first-year medical student, I was struck by severe depression that ultimately led me to take medical leave. My depression was multifactorial, brought on by sleep deprivation, anxiety, impostor syndrome, stress from a recent surgery, social isolation, and academic failure. During my time off, I received treatment and discovered I had underlying conditions such as obstructive sleep apnea and thyroid issues, both of which likely contributed to my mental health struggles. Over time, I began to understand that my depression was not a personal weakness but a recognized medical condition. I often sensed my own colleagues did not believe I could handle the rigors of medical training. My adversity did not feel validated as an illness but often felt judged as a dramatic reaction to life’s disappointments. Nonetheless, I returned to school with a renewed sense of purpose, pursuing a Master of Public Health during my year off and regaining my confidence in my dedication to medicine. I feared my leave of absence would be interpreted as a red flag for certain specialties. I simply did not care what anyone thought of me. I knew what I experienced was a disease.
Unfortunately, there is still a pervasive and damaging belief in the medical profession that struggling with mental illness reflects weakness, fragility, or an inability to handle the rigors of training. This stigma often prevents physicians-in-training from seeking the help they need for fear of being deemed unfit to practice or less capable. Additionally, state medical licensing boards often inquire about a history of mental health treatment, further discouraging openness about personal struggles.
The realities of residency training exacerbate these issues. Long hours, overnight shifts, and high levels of stress are endemic in residency. Residents are often required to work 80- to 100-hour weeks and endure 24-hour call shifts. A study published in the Journal of the American Medical Association (JAMA) found that the risk of depression rises by 59 percent with each additional hour of lost sleep, even before beginning training. Sleep is not just important for emotional regulation; it is critical for brain function. Inadequate sleep has been linked to a range of serious health problems, including an increased risk of Alzheimer’s disease due to impaired beta-amyloid clearance from the brain. It also increases the risk of heart disease, hypertension, and seizures. One study found that individuals who sleep five hours or less per night are twice as likely to develop prediabetes as those who get a full seven hours.
Sleep deprivation is also a key contributor to burnout, a serious condition that affects up to 75 percent of medical residents, particularly those in surgical fields. Burnout does not just harm the physician—it harms patients as well. It is associated with increased rates of medical error, the third leading cause of death in the U.S. Medical errors cost the U.S. health care system roughly $20 billion annually.
Given the aging U.S. population, the increasing prevalence of chronic diseases, and the looming physician shortage, it is critical that we address mental health stigma and advocate for residency reform. How can we ensure a strong future physician workforce if we refuse to acknowledge these problems exist in the first place?
To ensure a strong and sustainable physician workforce, we should aim to reform outmoded aspects of residency training. This includes reducing work hours where possible, restructuring 24-hour shifts, and providing residents adequate time for rest and a semblance of work-life balance. Institutions must also foster a culture where seeking help for mental health is not looked down upon but encouraged. Finally, we must address the systemic causes of burnout, including excessive workloads and lack of resident support, to create a more humane experience.
If we are to live by the oath “First, do no harm,” we must promote a culture of acceptance and encourage help-seeking for those struggling with something we may not see or comprehend. The current residency training system requires significant changes to improve the well-being of trainees. In its current form, it is harming both our colleagues and patients.
This essay is cited in the KevinMD record on residency.
Claire Bise is a pathology resident.
