This piece is part of in-Training Mental Health Week.
Editor’s note: Lindsey McDaniel and Angelica D’Aiello write this editorial on behalf of the in-Training Editorial Board.
On March 4, 2015, JAMA Psychiatry published an article entitled “Depression and Suicide Among Physician Trainees: Recommendations for a National Response” calling for “[a] national commitment to support residents and fellows throughout the challenges of medical training.” However, we believe that the term “physician trainees” should also be inclusive of medical students. While this article has certainly raised awareness about an important issue among residents, it failed to address the mental health of students during medical school — an often stressful period that necessitates the development of coping skills that will prove essential for mental well-being in later stages of training.
The medical community has known for decades that there are increased suicide rates among physicians in the United States; the aforementioned piece cited an earlier article published 12 years ago that emphasized this very point and called for action. However, nothing much has changed in the past decade; high rates of depression and suicidal ideation are still present throughout the medical community, including in residents and medical students. Thus, we draw attention to the idea that the goal of medical education should not be restricted to the production of competent doctors. Rather, medical education should aim to form physicians who are able to manage the inevitable stressors that pervade medical training and practice. The first step in doing so is vocal acknowledgement from the medical community that mental health promotion for medical students is a vital goal.
A study by Goebert published in Academic Medicine in 2009 concluded that depression of all levels of severity increases throughout the first two years of medical school and remains high in the third year, before decreasing significantly in the fourth year. Additionally, this study found that “rates of suicidal ideation among medical students were much higher than for residents,” which was not at all shocking to the authors, nor do we find this surprising given the numerous stressors faced by medical students today. The study went on to cite “a greater number of hurdles such as board exams, applications to residency, and the match process” as high stress events experienced by medical students. Students generally have more supervision and a lighter patient load than do residents, reducing individual responsibility for the lives of patients, but for the medical student level in the training process, we have strenuous demands on our time, skill and intellect. Goebert stated that “medical students often lack a sense of control over these and other events, which may be a factor in the increasing depression and suicidal ideation.” We agree with this assessment that one commonality to many of the stressors in medical education is the real or perceived lack of control that medical students have over these events, and that the lack of control over our own lives and schedules can be incredibly distressing at times.
The culture of medicine and the education process itself can be a persistent obstacle to the amelioration of the mental illness epidemic among physicians and trainees. A 2014 study in the journal Academic Medicine found that medical students start school with comparable mental health to non-medical student age-matched peers, but that they go on to develop depression at higher rates. They conclude that this is due to something within the training process that causes a deterioration in mental health and, consequently, that the learning environment needs to be changed.
Additionally, we find that there continues to be a culture in medicine of poor self-care, despite the oath we will take to care for others. This is likely rooted in a long-standing stigma toward the admission of weakness or vulnerability — many physician trainees, who are under frequent evaluation, carry a deeply ingrained fear of not being good enough or not living up to expectations, and do not want to be seen as weak or less capable due to a mental health problem.
This is not a simple problem; nor is there a simple solution, but is critical that the medical community addresses it nonetheless. So what can we do about this issue in medicine today?
As medical students, we certainly do not have all of the answers; we do not have the time or knowledge to change things alone, but that doesn’t mean we shouldn’t try or shouldn’t get the process started now. One of the most important, immediate changes that we as medical students can make is to start the process of destigmatizing mental health in medicine. Opening up and talking about mental health issues, including our own struggles, will help our fellow classmates feel safe and comfortable enough to seek help when they are in need and can go a long way towards changing the culture of medicine and medical education. This won’t change the world of medicine overnight, but we can take a big step in that direction.
If we start advocating for mental health and encouraging safe dialogue about this issue early in our medical education, perhaps we can cause real change for generations of doctors to come. We can call for mental health services for medical students and other health care workers and actively resist the stigma associated with seeking those services. We can push for coping skills education, for supportive communities and mentors that encourage us to open up about our struggles, and create a safe space for talking about mental health. We can recognize that learning how to take good care of patients also means learning how to take good care of ourselves and our mental health — these are not mutually exclusive concepts and one doesn’t have to come at the expense of the other. Addressing mental health issues among ourselves will not only make us happier, healthier medical students in the short-term. Early attention to mental health and wellness, and to the development of coping skills, can help to ease our transitions into residency and physicianhood. Doing so is an essential, though commonly overlooked component of overall well-being, and one that will make us better physicians in the long-term.
In order to maintain our quality as physicians when dealing with mental illnesses of our own, we need to be taught how to better perceive and address our own emotional and self-care needs, rid ourselves of the negative societal associations with mental illness, and to not only feel safe reaching out for help, but also have the resources in place to do so. The onus lies on all members of the medical community — current physicians, medical educators, and us as physicians-in-training — to make such changes happen. The conversations have begun this week with the pieces published during in-Training‘s Mental Health Week. Let’s keep going.