What's Up, Doc?

Burnout U

Depression and suicidal thoughts in medical students.

Are medical students more prone to depression?

Problem: Over the years, many medical students have talked to me about their stress. But so have undergraduate students, interns, residents, fellows, and practicing physicians—leading me to wonder if medical students’ stress was actually extraordinary. I remember my medical school days as moderately stressful, but, as my wife points out, I was somewhat insulated during medical school because I already had a family, had left behind another career, and was older. Her perspective is wise, as I have learned from a recent paper in the Annals of Internal Medicine that looked at stress and its consequences in U.S. medical students.

Findings: The main findings are worrisome, indeed. The study included more than 2,000 students at seven medical schools and looked for evidence of burnout and suicidal thinking. About half the medical students reported the feelings that define burnout (emotional exhaustion, a feeling of a loss of personal identity, a sense of poor personal accomplishment). Many showed signs of depression and a decreased mental quality of life compared with peers not in medical school. The most disturbing finding was that each year about 10 percent of the observed students had active suicidal thoughts—a symptom we know carries a substantial risk for a future suicide attempt. Even more—about one student out of four—had thoughts about suicide sometime during medical school. The good news is that sometimes things do get better: Checking in a year later, the researchers found that about one-quarter of the students who experienced earlier burnout had recovered and showed a decrease in suicidal thoughts.

Explanation: Why should medical students be so stressed that fully half feel burned out and so many have contemplated suicide? Sometimes it is the result of the process of medical education itself. Medical students are expected to master an enormous volume of knowledge—more than can possibly be achieved. Students experience great anxiety in anticipating the moment when they just can’t recall something of enormous importance and, as a result, commit some awful error, potentially harming a patient. Faculty and the residents who do a substantial amount of clinical teaching press students hard, leaving them with feelings of incompetence and uselessness. When students move from the classroom to clinical rotations, they shift through different medical specialties. Just when they have a sense of having acquired a basic knowledge base of pediatrics or psychiatry or orthopedics, they’re transferred to a new rotation, again starting at ground zero. As this is happening, opportunities for recreational breaks are limited while long hours can lead to a crushing fatigue.

There are other problems, too. Medical students are frequently exposed to human suffering and death—experiences most have never encountered before. They can feel abused, taken advantage of by institutions or superiors by overwork or inappropriate assignments (“run down to the cafeteria and pick up our lunch”). Most are experiencing the stresses of dating (and, sadly, no—real life isn’t like the medical TV shows), and many are wondering if medicine was the right choice after all. There’s one more source of anxiety and depression: Almost no one leaves medical school without accumulating a huge debt—now $140,000 on average—which has to be repaid somehow.

Possible solutions: As is usually the case, it is easier to identify and define a problem than to come up with a fix. We need to be alert to the signs of burnout, depression, and suicidal thinking in medical students and to make available the mental-health services needed to help with these problems. Unfortunately, medical students with clinical depression are no better (indeed, perhaps worse) than the general population in seeking mental-health services. Medical schools need to create an atmosphere in which it is understood that there is no shame in seeking help. We need to change faculty teaching styles toward the positive and supportive. And senior physicians need to teach by example how to confront issues of life and death—and what to do and say when, really, there is nothing to do and say.