The article1 by Sen et al in this issue is rich with implications. Most obviously and disturbingly, this study makes a major contribution to a modest literature—well reviewed by Tyssen and Vaglum2—demonstrating that medical internship is associated with a substantial increase in depressive symptoms. Most of the risk factors they identified for increasing depressive symptoms (eg, neuroticism, history of depression, difficult early environment) have been frequently seen in other samples,3,4 suggesting that the mechanisms through which internship increases depressive symptoms are probably shared with other environmental adversities. Of greater interest, because of the implications for prevention, are the internship-specific risk factors. Here the list is smaller, only increased work hours and perceived medical errors. Unfortunately, the results of this investigation are inconsistent with 4 prior studies that have not found a relationship between long hours and emotional disturbances in physicians in training.2 In a recent review of longitudinal studies of work stress and depression, Bonde5 noted that perceived working conditions, especially lack of control and high demand, rather than objective measures such as work hours, best predicted depression. Medical educators have to take these results seriously and ask what can be done to reduce the depressogenic features of our medical training system.
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