According
to a new meta-analysis spanning four decades of research, 28 percent of medical
students are depressed and 5.8 percent have considered suicide. Researchers
from Singapore analyzed 77 studies, examining nearly 63,000 medical students
across the globe. Distress in medical students is not just a first world
problem. The percentage of students with depression or depressive symptoms
ranged from 20 percent in Europe to 31.8 percent in the Middle East. Medical
students in North America had the second highest prevalence at 30.3 percent.
Still, there were no statistically significant differences in depression by
region, sex, or even between medical students and non-medical students.
As one of
the authors of a study included in the meta-analysis, it is clear to me that
the numbers do not capture the stress students face. During medical school, I
traveled to Mainland China to conduct a study on depression and suicidal
thoughts in medical students. I was shocked while speaking with Chinese medical
school students who were dealing with stressors we rarely encounter in the
United States. One student said that medicine was not his first career choice,
but his university entrance exam score was not high enough to place into
computer science. Also, students feared for their safety because of increasing
patient violence towards health care professionals.
External
stressors alone may not be the culprit. Physicians are more likely to be
obsessive and perfectionists, which may make them more emotionally reactive to
failure. In addition, adolescence and early adulthood are the peak years of
depression in the general population. Add the stresses of medical school to
this vulnerable period of life, and the prevalence of depression is not
surprising.
Depression
is chronic and recurrent. It is associated with burnout and substance abuse.
Indeed, a recent meta-analysis of 54 studies found 28.8 percent of resident
physicians—doctors who recently graduated medical school—are depressed. Given
the findings from medical students, it is likely that the residency experience
is not the beginning of depression and suicidal thoughts, but a continuation
from medical school.
A Safety Concern
Although
a few studies found levels of depression between medical students and
non-medical students to be similar, there is one big difference. After
graduation, former medical students become primary caretakers for others, while
most non-medical students do not. Depressed doctors may put patients at risk.
To put this in perspective, imagine being an airplane passenger. You are
preparing for takeoff, and the safety announcement comes on saying the
following:
There is
a nearly one in three chance that your airplane pilot is depressed. Also,
around 6 percent of pilots think about ending their lives, and we do not have
good documentation of those who commit suicide. Only about 13 percent of pilots
seek formal mental health services. But rest assured the Airline recently
started a yoga program for pilots.
Passengers
would call these safety measures absurd and may not even take the flight. The
Federal Aviation Administration would likely open an investigation.
Unfortunately,
this analogy reflects the current state of medical education. Despite personal
distress resulting from depression and having the responsibility of patients’
lives in their hands, few medical students and residents receive the help they
need. Sadly, we lose 400 doctors—the equivalent of number of seats in a jumbo
jet—to suicide every year. We can no longer ignore the mental distress of
medical students.
How To Reduce Medical Student Stress
There are
immediate steps medical school leadership and accreditation bodies can take to
improve the mental health of medical students. First, school administrators can
improve the learning environment by making grading pass-fail. Pass-fail
curriculum during preclinical years is the trend in the United States, but not
overseas.
A
pass-fail system adds two key benefits. First it makes students less
competitive and more collaborative. Competition and the social isolation that
comes with it breeds stress. A review found that pass-fail grading decreased
stress without a significant compromise in academic performance. Second, it
helps foster a better work-life balance. Students have more flexibility to
determine how and when they want to study and attend to their personal needs.
Second,
mental health services need to be more prominent. Stress reduction programs are
effective for medical students. Mental health screening should be the default
at the beginning of medical school. Students would have to opt-out. While some
may perceive this approach as intrusive, medical students get similarly tested
for tuberculosis and Hepatitis B as a patient safety measure. Depression is
also a safety issue for patients and is a lot more prevalent than tuberculosis
and Hepatitis B in United States medical students. In addition, default
screening ideally would normalize the experience and demystify mental health
care and thereby circumvent the common barriers to care including stigma,
embarrassment, and fear of lack of confidentiality.
If mental
health treatment is needed, care should be easily accessible to accommodate the
hectic schedule of medical students. An open-door policy where students can
drop in as needed would be best. The cost of mental health services should be
free of charge. To provide this service to students, schools can hire a mental
health provider part-time or per-diem, or contract with providers in the
community. Medical schools that are part of universities often have counseling
services available to students. Alternatively, there are free internet-based
programs such as MoodGYM that are widely available and can be used in private
settings. MoodGYM was effective in preventing suicide ideation in medical
internship, arguably the most stressful year of medical training.
Medical
school is supposed to be a time of personal and professional development. We
have enough data to show that depression is rampant in medical students. Now we
need to take the steps to foster well-being. We owe it to our colleagues and
our patients.
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