By PAULINE W. CHEN, M.D.
Several years ago, I learned that a physician in a town not too far from where I was practicing had committed suicide. Neither I nor my hospital colleagues knew him, but according to the story we heard, he was the father of young children, was respected by doctors and patients alike and had struggled privately with mental illness since medical school.
But it was not the details of his life that haunted us; it was the details of his death. He had locked himself in a room in the hospital, placed a large needle in his vein and injected himself with a drug that so effectively paralyzed his muscles he was unable to breathe.
Or call for help.
For days afterward, the doctor’s death came up repeatedly in conversations. We talked about the grief his family must have been experiencing and speculated on the extent of depression and self-loathing he must have experienced, but we dared not speak of, let alone imagine, the agony of his final moments.
Always, we ended up asking one another the same question: How could a doctor — who most likely knew about what he was suffering from and about the treatments available — never seek help?
For several decades now, studies have consistently shown that physicians have higher rates of suicide than the general population — 40 percent higher for male doctors and a staggering 130 percent higher for female doctors. While research has traced the beginning of this tragic difference to the years spent in medical school, the contributing factors remain murky. Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout and other mental illnesses at higher rates. Despite better access to health care, they are more likely to cope by resorting to dysfunctional behaviors like excessive drinking and are less likely to receive the right care or even recognize that they need some kind of intervention.
Researchers have offered several theories to explain these seemingly paradoxical findings. Some have faulted the increasing social isolation of medical education, training and practice. Others have pointed to the tendency for doctors to be highly critical of themselves and to blame themselves for their own illnesses. Still others, in light of the particularly high rates of suicide among female doctors, have suggested that workplace harassment may have a role.
Despite the many studies, theories and, more recently, student wellness programs and confidential mental health services offered by more and more medical schools, the grim statistics for medical students have hardly budged over the last generation. Up to a quarter of young doctors-to-be suffer from depression, more than half may be experiencing burnout, and a just more than 10 percent may be harboring thoughts of suicide.
These sobering numbers have remained unchanged in large part because our understanding of this issue has been hampered by inadequate research methodologies and insufficient financial support. We haven’t had the sophisticated tools needed to analyze the causes or appropriate interventions; and even if we did, we haven’t had the money to do anything with them.
Now two groups of researchers, using innovative methods and financed by medical school programs and departments with a keen interest in physician well-being, have published separate studies in The Journal of the American Medical Association that go beyond incidence statistics and theoretical considerations. Each study offers new findings about medical student distress and how the learning environment both fosters and exacerbates it. Read together, they offer disquieting views of the world in which tomorrow’s doctors are formed.
“There’s no arguing anymore over whether there’s a high prevalence of distress,” said Dr. Liselotte N. Dyrbye, lead author of one of the studies and an associate professor of medicine at the Mayo Clinic in Rochester, Minn. “What’s important now is that we hold a mirror up to ourselves and ask why this is happening, because it is clearly not what we medical educators have intended.”
Previous studies have linked medical student distress to unprofessional behavior. But, as Dr. Dyrbye and her colleagues show in their research, different types of distress — professional versus personal — can have very different effects on a young doctor’s sense of what is right and wrong.
Surveying more than 2,500 medical students across the country, the researchers found that students who suffered from professional distress, more commonly referred to as burnout, a constellation of emotional exhaustion, detachment and a low sense of accomplishment, were more likely to admit to cheating on tests, lying about the status of a patient’s laboratory tests or physical exam and espousing less altruistic views regarding their role as physicians. Conversely, students who suffered from personal distress, defined as poor mental or physical quality of life or depression, were not more susceptible to these unprofessional behaviors and self-centered beliefs.
“There certainly is some overlap,” Dr. Dyrbye said. “But depression and burnout are two separate entities.”
One result of erroneously conflating the two types of distress is stigmatization of mental illness. According to the second study, conducted by researchers from the University of Michigan in Ann Arbor, medical students who are depressed or prone to depression often believe they are viewed as inadequate and incompetent by those around them.
“They feel this from every direction — from other medical students, faculty members, counselors, and even in their applications for residency training,” said the study’s lead author, Dr. Thomas L. Schwenk, a professor of family medicine at the University of Michigan. While depression can cause individuals to have negative and distorted views of their surroundings, “the culture of medical school makes these students also feel like they can’t be vulnerable or less than perfect.”
Given that students must compete with one another throughout medical school for postgraduate training positions, many have a difficult time admitting to any perceived weakness. For those who do and want help, there are more obstacles: with the sense that peers, faculty members and others are likely to judge distressed students as less competent, it is nearly impossible to find somewhere truly safe to turn.
But this “survival of the fittest” mentality can affect all medical students, not just those who are depressed or burned out. And it can affect patients by wearing away at a young doctor’s sense of empathy.
“If this is the way that students view each other,” Dr. Schwenk said, “how do they view their patients who are depressed or struggling with mental illness?”
More long-term studies are needed to test interventions and analyze the factors contributing to student distress. “We have to assume that starting in medical school, there’s a pipeline of experiences that leads to an increased risk of suicide,” Dr. Schwenk said. But without more evidence-based interventions, even the best intentions of medical educators will continue to do little to stem the tide of medical student distress and physician suicides.
That failure has already and will continue to come at a tremendous cost to doctors and patients. “I still believe that the people who are the most vulnerable are often the most empathic,” Dr. Dyrbye said. “They are the ones who get most attached and put the needs of the patient first.”
Dr. Dyrbye continued, “Until we know what really helps them and what works best, our learning environment will continue to eat away at our students’ empathy and altruism.”