Drs. James Griffith and Lynne Gaby wrote a thoughtful paper entitled “Brief Psychotherapy at the Bedside: Countering Demoralization from Medical Illness“. I obtained a copy of this paper from a more senior resident during one of my months on the consult service and reviewed it earlier this evening. The phrase “the patient is likely demoralized” thereafter appeared frequently in my notes in consultation requests for assessments of depression.

A definition of demoralization included in the paper states that it refers to the

“various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive. Demoralization occurs so commonly that it can be regarded as universal human experience.

As such, the dimensions of demoralization described in the paper are applicable not only to patients dealing with medical conditions, but also to physicians in training. I have wondered if the studies on clinical depression in interns and residents actually reflects the demoralization that most, if not all, of us have experienced.

This paper argues that there are two distinguishing features between demoralization and major depression:

• In demoralization, “responsivity of mood is usually preserved, in that cessation of adversity rapidly restores a capacity to feel enjoyment and to hope.”
• Demoralization features “subjective incompetence due to uncertainty over what course of action to take” while in depression, “apathy predominates even when a needed action is clear”.

Thus, demoralization and depression reside on the same spectrum and may overlap in some respects, but they are not identical.

The axes of “existential postures of vulnerability and resilience to illness” as applied to medical training is as follows:

Confusion versus coherence. Residents—particularly interns—may feel confused about their roles in providing care to patients—what are the limits of their responsibilities? what are their appropriate roles? Getting bogged down in details may result in pursuit of goals that patients (and/or attendings) do not endorse. Navigating an unfamiliar medical system (where are the charts? what information does the attending want? where are the bathrooms?) may make doing the actual work frustrating and fragmented.

Communion versus isolation. Residents may not have many opportunities to commiserate with other trainees about their experiences. We all know of people, either in medical school or residency, who retreated to the bathroom or stairwell to cry due to the perception that no one else (1) understood or (2) cared about uncomfortable or unfortunate events that involved patients, other trainees, or other staff. Fears of “being too sensitive” and “not fit for medicine” often surface, along with the beliefs that no one else shares these exact same thoughts.

Hope versus despair. Physically, intellectually, and emotionally taxing experiences in the hospital can result in residents wondering if they are (1) smart enough, (2) skilled enough, (3) tough enough, and/or (4) resilient enough to complete training and become a “real doctor”. Few people are fully prepared to witness codes, deliver bad news, and humbly handle mistakes of varying degrees that can adversely affect patient outcomes. If one does not have hope in oneself and one’s resilience, one does not have the motivation to learn more about the craft and associated skills. Unfortunately, sometimes the hospital, with all of its barely restrained chaos, does not offer as many positively reinforcing experiences for residents, further facilitating feelings of despair.

Purpose versus meaninglessness. The practice of medicine may deviate significantly from what traineess believe it to be. People entering primary care may envision personal delivery of “holistic care” and opportunities to get to know the patient as a person, not merely as a set of diagnoses, only to learn that health care economics essentially prohibits these possibilities. Surgeons may desire opportunities to perform both life-saving and life-improving procedures under well-rested and clear-minded states, only to realize that the most intense and critical procedures may occur when they are significantly sleep and energy deprived. Psychiatrists may dream about mastering different types of psychotherapies to help optimize the lives of patients, only to learn that they are pigeon-holed into prescribing pills. This disappointment may lead residents to question their roles as doctors and in the health care system.

Agency versus helplessness. Hospital and clinics can be ravenous machines that consume and assimilate residents. The system (whether that be the actual organizational system or the hierarchy of physicians) may prohibit the resident from pursuing ideal therapies and interventions; the personal preferences of senior staff may also override what autonomous decisions the residents would have otherwise pursued. There is also the frequent fear of patient death; fully accepting that 100% of people will die, often in spite of what we do, is difficult. We would all like to control all variables, but those are not the rules of the game.

Courage versus cowardice. As with all other things in life, there are risks in the various aspects of practicing medicine. Residents learn where their boundaries are with patients, superiors, colleagues, and the system. Some residents will always kowtow to their superiors; others will find the courage within themselves to assert themselves against what may be unreasonable forces. Learning to defend one’s position, often as an advocate for the patient, can cause apprehension, as can efforts to avoid collusion in ethically murky situations (e.g. interactions with pharmaceutical companies).

Gratitude versus resentment. Trainees commonly grow weary of their duties: patients surreptitiously transform into “hits” or lose their identities completely (”the nurses are calling about the HIV liver guy again”). The lack of sleep makes people irritable and the thought of interviewing the (annoying and whining) patient for more information induces groaning and eye-rolling. The perception that people are taking the interns for granted only incites ire in those first-year residents who literally make things happen on the front lines. It is difficult to remember to be grateful for these opportunities to affect positive changes in the lives of people; the focus is instead on the barely tolerable, cumulative stressors contained within the health care system.

As with patients, residents benefit from opportunities to reflect upon their resilience and chances to demonstrate to themselves that they are not incompetent, but are undergoing the rigors of training and are experiencing natural reactions to these events. Insight does not necessarily result in behavior change, though it can certainly facilitate it. It is difficult to counter demoralization alone, however, and though most residents can commiserate with other members of their cohort and receive support from friends both inside and outside of medicine, we are not all so lucky.