This piece is part of in-Training Mental Health Week.
It has been a little over two years since Kaitlyn Elkins, a second-year medical student at Wake Forest, took her own life. Her death stunned friends and family, who had been largely unaware of her protracted struggle with depression that was ultimately revealed in her suicide note. Kaitlyn’s mother, Rhonda Elkins, dedicated herself relentlessly to advocating for mental health awareness before succumbing to her own grief, committing suicide one year later.
The tragedy that the Elkins family has endured and the suicides of up to 400 physicians annually has lent renewed urgency to the discussion of mental health among medical providers, particularly since depression can be managed and suicide can be prevented. Making changes in medical education may help get a handle on this problem. Much of the discussion has centered on issues like stress and burnout, and medical culture and stigma. A few months ago, I lent my own take — that there is something inherent to the healer personality that predisposes some to depression.
In the days after that article was published, medical students began reaching out to me with their own experiences with depression. I realized that just as patient narratives are so often neglected in medicine, so too were those of students. Most literature on medical student depression focuses on metrics that are objective and quantifiable, like stress levels and symptom severity. Useful though these methods often are, they do not give voice to struggling students — a voice that may very well have some intrinsic therapeutic value.
To create a forum for these students, in-Training managing editor Nina Nguyen and I created an informal survey that was distributed through email and social media. We asked questions like “What don’t people understand about mental health in medical school?” and “What are the challenges that have made managing your mental health difficult?” among others. Our survey was not scientific, and it was likely biased in favor of institutions represented by in-Training staff and MS1s and MS2s who conceivably have more free time than MS3s; however, our goals had never been scientific in nature — they were narrative. What follows are the stories of just under 50 medical students from across the country and their experiences with mental illness.
When asked about particular challenges presented by medical school, academic pressure and stress were frequently identified as triggers. One anonymous MS2 said:
“There was one point I was so upset at the fact that I worked so hard for shitty grades, I just felt apathetic about my life. Like, why am I torturing myself in vain? There was one point where I cried myself ‘empty’ and then I tried cutting myself because I felt like I deserved the pain for being such a failure. That was then when I looked up the mental health services at school. I scared myself.”
Another MS2 from the University of South Florida stated:
“I was really pushing myself because I hadn’t done well on the previous exam…I have never been good at displaying a lot of emotion, and certainly not in front of people, so I remember coming home, turning on the shower, sitting down, and crying.”
Medical school has often been compared to a “pressure cooker” in its intensity, and medical students often feel they are held to high expectations by attending physicians, residents, peers and even themselves. The daily grind, combined with the sense of disillusionment that most students likely feel at some point, creates a perfect storm for depression and burnout.
Other respondents shared stories of seeking counseling, and though most found it useful, concerns about confidentiality and side effects associated with antidepressants were prevalent. A physician allegedly told one MS3, also at USF: “You are clinically depressed, but I won’t put that in your chart so you can be protected and so no one will find out.” It should be noted that the LCME currently mandates that medical schools provide counseling services with providers without a direct academic role, but students continued to express concern that they might encounter their therapist while on rotations.
But the common thread was a critique of the culture of medicine and the stigma of mental illness, as exemplified by these responses to our survey:
“There is an expectation that medical students are ‘above’ mental health issues. And [that] if medical students have mental health issues in medical school, they won’t make good doctors and they aren’t cut out for medical school.” –MS3, University of South Florida
“I think medicine has built a culture, a sort of idea that this is a tough field and you will have to deal with tough stuff so you need to control your emotions, get over yourself, and toughen up. Kind of like the idea, ‘Well, it’s tough being a doctor, so either deal with it or leave, no one is going to help you because you have to be able to deal with it.’” –MS2
“Sometimes it’s the feeling that no one at the school actually cares if I succeed or fail that bothers me the most.” –MS3, SUNY Downstate College of Medicine
“When we learn about mental health the class may have a title like ‘coping with the clinics’ that seems aimed towards helping its students with their mental health, when in reality it is about how not to have our mental health affect our jobs…I would appreciate some support within the curriculum that gives me reason to believe that I am not alone and that it is not shameful to be struggling.” – MS2
It is ironic that a field that ostensibly should be more enlightened vis-à-vis mental health remains caged by such antiquated thinking. Clearly, medical culture needs to change, but effecting that change is something of an ambiguous exercise. To some extent, lasting change will be driven by the summation of individual attitudinal changes. But there are efforts that our institutions can, and should, undertake to accelerate that progress.
First and foremost, medical schools need to do more to guarantee the confidentiality and integrity of counseling services. The incidents mentioned above are likely not isolated, and students need to feel confident that seeking out mental health care will have no bearing on their academic lives.
Other innovations may also prove useful. Mindfulness training, for instance, focuses on developing emotional self-awareness, based on the premise that self-awareness fosters self-management. It is a growing trend at medical schools but is still largely confined to the elective space. Integrating it into the core curriculum would both address mental health needs and promote the development of self-management skills. Medical school is, after all, professional school, not graduate school.
At the University of South Florida, students in the SELECT program participate in “peer coaching,” longitudinal one-on-one relationships. Though expressly designed and used for professional development purposes, the intimacy that this mentoring fosters inevitably provides a safe space to address personal issues. One student in the program thought that all medical students could benefit: “I think a lot of people might find it more comfortable to be able to go to a friend first vs. outside help.” Full disclosure: I am also in this program, and I strongly agree with the student’s comments. The peer coaching relationship seems to provide permission to discuss topics that I might otherwise be reluctant to share.
Curricular changes at St. Louis University School of Medicine, such as switching to pass/fail systems, use of problem-based learning, and flipped classroom learning have also been associated with lower depressive symptoms, though this data is still fairly limited. Elsewhere, Vanderbilt Medical School has a robust focus on mental health through a student wellness council, advising and mentoring resources, and an emphasis on personal development.
Many of these reforms are young and tentative, but they show promise and are sorely needed — particularly as our health system grows to depend even more on the availability of healthy physicians who are satisfied with their careers. Our field, and more importantly, our patients, can’t afford to lose 400 physicians a year to suicide. As one MS2 poignantly said:
“While some students may not have reached a level of major concern, we shouldn’t have to wait until they commit suicide to realize we should have done something.”
I couldn’t agree more.
Columnist and in-Training Staff Member
Morsani College of Medicine at the University of South Florida
Ajay is a pediatric resident and a Class of 2017 graduate of the SELECT MD program at the University of South Florida. He is passionate about delivering primary care to underserved populations—specifically, low-income and homeless patients in urban centers. Ajay will be specializing in pediatrics, with a particular interest in child maltreatment.
M.D. or Bust
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.
