Kaitlyn Elkins was a medical student at the Wake Forest School of Medicine in North Carolina and a member of the Class of 2015. She excelled academically, named the valedictorian of her high school class and graduating summa cum laude from Campbell University. She wrote poetry in her free time. She had a cat, lovingly named Gatito. On April 11, 2013, just weeks before beginning her clinical rotations, Kaitlyn Elkins took her own life. She left behind a note revealing her battle with depression, a struggle that was hidden from her family for years.
A few months ago, in separate incidents, two medical school graduates in the early weeks of internship jumped to their deaths. An estimated 300 to 400 physicians die annually from suicide, and as many as 21.2% of medical students suffer from depression.
At first glance, the genesis of this problem seems obvious: stress. Beginning with the application process and increasing with cutthroat tests and hours of toiling away in the wards, medical school can be a crucible of intensity. Students are under more pressure than ever to achieve, particularly because residencies haven’t kept pace with growing medical schools. Things don’t look too stable on the other side of graduation either: tectonic shifts in insurance markets, new payment and delivery systems, reductions in reimbursement, student loan debt, and tens of millions of patients added to already bursting patient panels. This is an intimidating list of challenges, and it is telling that an article labeling ours as “the most miserable profession” went viral in medical circles. A kind of malaise has settled over the field.
The “stress” argument is convenient. It’s logical and neat, and its conclusion is fairly obvious — namely, that we need to reduce medical student and physician stress. Who wouldn’t get behind that?
Convenient though it may be, a review of the literature and a little soul-searching reveal this argument to be incomplete at best. Plenty of occupations are stressful, and while we all experience stress, most students are not depressed and will not commit suicide. Personal distress (i.e. depression) has been shown to be distinct from burnout in medical students. One article also found that depressed medical students are more likely to have had a pre-medical school episode of depression than non-depressed students and that medicine seemed to “unwitting[ly] select…predisposed students.”
Depression among medical professionals is perhaps more deeply rooted than we’d care to admit. A landmark study of physician attributes uncovered a whole range of psychological vulnerabilities: self-criticism, a refusal to seek help, pessimism, passivity, self-doubt, and feelings of inferiority, among others. The authors suggested that these intrinsic characteristics were more predictive of personal and psychological dysfunction later in life. Stressors, personal or professional, may only be triggers that expose deeper wounds.
Wounded healers. It’s a concept from Jungian psychology thought to be inspired by the story of Chiron, a centaur in Greek mythology who was renowned for his skills as a healer. Chiron was wounded by a poisoned arrow but his immortal status sustained him despite the incurable wound. He was thus condemned to spend eternity roaming the earth in agonizing pain, healing everybody but himself. Jung applied the concept mostly to psychoanalysts, but the phenomena of depression and suicide among medical students and doctors suggest that we too fit into this archetype.
These wounds present a double-edged sword. On one hand, they can be powerful motivators. Johnson suggested that some physicians pursue their craft in response to negative childhood experiences, whether from illness, trauma or neglect. Vulnerability may also allow for more empathetic and meaningful patient interactions. Dr. Alice Flaherty, author of “The Midnight Disease,” has repeatedly stated that her experiences with bipolar disorder have made her a better caregiver. It has also been demonstrated that physicians with a history of depression are significantly more likely to investigate suicidal ideation in depressed patients than physicians without a history of depression. Healers are better equipped to care for the sick if they have experienced sickness firsthand.
But the same qualities that lead to success in medicine can have tragic consequences, as evidenced by the alarming statistics on depression and suicide in the profession. This leads to a complicated question: what can we do about it? Few medical students with depression actually seek out treatment; when asked for reasons, they cite lack of time (48 percent), lack of confidentiality (37 percent), stigma (30 percent), cost (28 percent) and fear of documentation on their academic records (24 percent).
Fortunately, medical schools nationwide have been making efforts to address this crisis. Academically, the shift to now ubiquitous pass/fail grading systems was partially motivated by a desire to reduce levels of student stress, anxiety and depression. Other resources at the student level like mindfulness training, peer mentoring, service opportunities and student wellness groups are all welcome developments. Further, the LCME now mandates the provision of counseling services delivered by professionals who are kept separate from students’ academic experience. Some schools go a step further and provide financial assistance if and when mental health care is indicated. Though counseling services are guaranteed, the jury is still out on their efficacy, underscoring the need for research in this area. And, given the aforementioned self-identified barriers to treatment, medical students would benefit from greater assurance that the use of mental health services is confidential and completely separate from academic records.
But the most meaningful change is not institutional. It’s cultural. Even in medical circles, depression remains poorly understood and stigma is rampant. 56 percent of depressed students suspect they would lose the respect of their colleagues if their depression became public; 83 percent of depressed students suspect that faculty would view them as unfit for their responsibilities. One student confided to me that he had stopped attending a depression support group because it was held in a building on campus, and that he didn’t want to risk being recognized by any students or faculty. Changing the culture of medicine to be more supportive and accepting is a slow process, but it is also the part that we can most directly influence. It’s also necessary — how can we hope to care for patients if we don’t take care of our own?
Kaitlyn Elkins’ mother, Rhonda, was devastated by the loss of her daughter. She wrote a book, “My Bright Shining Star,” and started a blog. The website is a chronicle of her grief, expressing emotions that range from shock and anger to misty-eyed remembrance. Reading it is a gut-wrenching experience. Rhonda also became a tireless advocate for mental health awareness, bravely sharing her experiences with others. She even posted on the forums at StudentDoctor.net, offering support to medical students. She touched the lives of countless people, many of whom she would never even meet.
On August 29, 2014, Rhonda Elkins took her own life. She was 54 years old.
- My thanks to the Elkins family for sharing Kaitlyn and Rhonda with us and for allowing me to tell some of their stories here.
- If you are experiencing an emotional crisis, are thinking about suicide, or are concerned about a friend, call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). You are never alone.
Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.