A meta-analysis was published in JAMA December 2016 characterized the prevalence of depression and suicidal ideation in medical students (Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation amoung Medical Students). The results, maybe not unsurprisingly, found depression or depressive symptoms in slightly over 1 in 4 medical students (27.2%). Suicidal ideation was also not uncommon, at about 1 in 10 medical students (11.1%). This is higher than the general population. Of those with positive depression screens, only 15.7% sought treatment.
As this meta-analysis supports, medical students are certainly at high risk for depression. This is something I’ve long suspected, though the numbers are pretty alarming. The next logical question is, why? What is it about either medical training or the students themselves that the tendency towards depression becomes more common? Here are a few of my personal thoughts…
You take students who have always been in the top 10%, and statistically make half of them below average.
It’s hard to get into medical school, really hard. It’s the students who have a rare combination of excellent academics with well rounded backgrounds and personalities. Many of us have few personal failures we can list by the time we get into medical school. We were the top of the class in high school and among the top in college. Then in medical school, that pool of students who were always in the top 10%, suddenly find themselves on a new bell curve – one that statistically is going to make half of them constantly feel below average. This new reality is hard to deal with for many and represents an almost existential crisis.
Personally, I had never seen what a “B” looked like before medical school and then suddenly found myself struggling just to pass in a system of high pass/honors. I found I couldn’t out study many of the extremely bright people in the class. No matter how hard I worked, for the first time in my life the results were disappointing. Even when I got to the point I didn’t have to worry about just passing, the prospect of high pass or then even honors kept me unsatisfied. That takes a toll on your psyche, living for literally years being disappointed even with success. I try to remind so many on #LifeofaMedstudent, that by being a medical student you are already great, you are already successful – because there are many ways medical school takes that feeling away.
The bottom line is it IS a competition, one of which the stakes are life defining.
We heard over and over in medical school that collaboration was key. That
what was good for the class, was good for the individual. We weren’t competing against each other, but to succeed as a class. While this sounds good, I think most medical stude
nts see right through it. Bad scores and you might not get into the specialty you want, might not get into the residency you want, might not become the doctor you dreamed of. Each exam becomes high stakes and with it a daunting level of stress. Failure on a test becomes not just a setback or hurdle in one subject, but potentially a setback on your entire future. You can’t just settle in, because there is always someone else working for the same goals you are – possibly at your expense.
Yes many of us would study together, and yes several of my life-long best friends were in my medical school class. But I knew the statistics on USMLE scores. I knew what scores were needed for what residencies. I knew programs only took a certain number of spots. I knew that if I received that spot, someone else wouldn’t, and vise-versa. I knew a less desired program or specialty was something that could literally have a life long affect. The competition is real and hovers over every class, rotation, and exam throughout medical school. The outcomes can be life changing.
Medical school is a lot like continuing the hardest part of college, while all your college friends are starting real life and careers.
Medical school is in most ways much more similar to college than a career. You don’t really have a job and most your money comes from student loans. You spend a lot of your time in class or studying. Except because of the much greater study load, you tend to have very limited time for all the fun things you did between classes in college. Instead of football games on Saturday, there’s 12 hour study marathons in the library. Then thanks to the prolific spread of social media, you get to watch all your best friends of your age group go off and start their lives. They get real jobs and can afford things a college or medical student shouldn’t. They settle down and start raising families. And there you are, grinding away day after day learning all about the Kreb’s cycle, Charcot’s triad, or the treatment algorithms of asthmatics. As you go through the years of medical school, many have a lost identify. You don’t really consider yourself a student, but you don’t feel like a doctor either.
I underestimated this effect when I was accepted into medical school and choose to stay in the same location as my undergraduate college. Many of my closest friends at the time were “super-seniors” for an extra semester. I could tell they often didn’t really understand how the guy with a 4.0 through college who rarely missed a tailgate, Saturday night at the Fraternity house, or social event – suddenly always “had” to study. And when I tried to do-it-all like I always had managed before, I failed – very nearly literally, in anatomy that first semester. As they drifted off after finishing college and started settling down near and far, so did our friendships. This can lead to a feeling of isolation during the hardest academic years of your life.
After the brutal basic science years, you take a bunch of OCD, Type A personalities – and let a computer algorithm decide their future.
There couldn’t be a post on medical student depression without mention of The Match. The Match is the process by which residency spots are paired with prospective students is based on a frequently poorly understood algorithm. The National Residency Matching Program (NRMP) advertise the match as “100% objective, 100% accurate, and 100% committed to a fair and transparent process.” While certainly fair, the process is anything but relaxing. The students rank their list of desired programs, the programs rank their applicants, and on a single day during forth year – the algorithm spits out a “match” effectively deciding a students future. That future, of which students feel they have little control over, is more than just academic. The location of their match often has long lasting implications for families, relationships, and future practice opportunities.
As a dedicated planner and someone who often feels they can make the best of any known situation – the lack of control and certainty during my experience with the match was nearly paralyzing. I would have felt so much better simply knowing I had matched with a lesser desired program and been able to plan following that outcome, than the many months of having no idea where I’d be the next 4 years. To complicate matters, I started dating my now wife just a few months before interview season – a relationship I was serious about but knew my future location would have a significant impact on it’s success. In many ways, this was the most emotionally stressful time of medical school for me.
Medical school is simply damn hard, and rightful so. The pressure because of that can be overwhelming.
Medical school is hard, ok? It just is. And I even think it should be! Medicine isn’t for everyone, and it takes a combination of strong intellect as well as certain personality skills to make it through. The fact is, patients will depend on you with their lives and you should be put through vigorous study and training. Even the best of the best feel that constant pressure to be great, if not just for themselves, for each patient they will take care of. Anything less than great is felt not just as a disappointment, but as a failure to patients.
My own thoughts on the issues are intertwined above because these are real issues I faced through medical school. These aren’t just words on an article or numbers in a study, the feelings of depression happen to medical students, many of which are friends and some of us personally. I don’t know if I would have tested “positive” for depression as the study stipulates, but it wouldn’t surprise me if I would have. I know medical school was hard. I know I had struggles and dark days through it. Personally, the hardest parts of medical school were the 1st semester and the couple of months before the match. I struggled with the work load adjustment and the feeling of isolation early on. I struggled with the unknown about my future towards the end.
What can be done about medical school to improve the mental health of medical students? That is a whole other topic for a different day. The short answer is probably not much, though I’ve long been an advocate of pass/fail only grading curriculums in medical school. It simply lessens that constant feeling of disappointment that even when passing, one isn’t achieving the next higher level of grading scale. If you make it to medical school and can pass the courses, that should be it. Let the USMLE and shelf exams sort out competitiveness for residencies.
Otherwise, short of changing the culture of medical school the only advice I can give is to seek help if you need it. Sadly, only about 15% of those screening positive for depressive symptoms sought help in the above study and because of this we lose a few medical students each year to depression and suicide. By discussing the numbers above, we can as a group see how common this is. Considering the statistics on my own medical school class of the 300+ students, 75 would have had depressive symptoms and a shockingly 30 may have had suicidal thoughts. If it isn’t you, these are many of your peers! Hopefully, by identifying the reasons depression is so prevalent through these years, we can slowly make changes to reduce those numbers and simultaneously reduce the stigma of those effected. In the meantime, all those reading in medical school know that it does get better and you do belong! Keep positive when you can through the struggles and when needed don’t be afraid to seek help – many, many of us have been there, too.
What do you think? Are there other reasons medical students have high levels of depression and depressive symptoms? What else can be done?
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