by Eric J. Keller, Northwestern University SOM Class of 2017

Medical education is a daunting road requiring dedication and endurance. Unfortunately, this challenging journey has a dark side which demands continued discussion and intervention. The prevalence of burnout, depression, and suicidal ideation among US medical students and residents are estimated to be 49.6%, 21.2%, and 11.2%, respectively (1,2). When compared to the prevalence of depression and suicide ideation among all US adults (9.1% and 3.7%, respectively) it is clear that physicians-in-training need to tend to their mental wellbeing (3,4).

Authors have discussed both superficial and deeper sources of poor mental health during medical education. Some point to lack of sleep, financial debt, large workload, high competition, and lack of sexual activity (5). Others suggest deeper sources such as a common physician psychology and medical culture (6,7). For example, medical students tend to be perfectionistic and detail-oriented with high expectations of themselves. Although these qualities can help one gain admission to medical school, they can also exacerbate poor mental health.

Efforts aimed at helping students with poor mental health are important resources, but an ounce of prevention is often worth a pound of cure. I’m not a psychiatrist, but I have struggled with my mental wellbeing as a medical student and spoken with other students about their struggles. Below are some tools that seem to work.

Regular physical activity and good sleep habits can help boost one’s mood and mental functioning. Although traditional aerobic exercises and weight lifting are great options, they are not exclusive. If you don’t like running, don’t run. Try dancing, yoga, cycling, or anything else you enjoy that gets you up and moving. It’s also important to get an adequate amount of sleep at a regular time each night. Many authorities recommend 7-9 hours of sleep per night. Of course many students may be reluctant to give up their precious time. I can definitely empathize with that concern, but I see these habits as investments. I know the extra hours I’ve spent running or sleeping a little longer have paid off in terms of productivity and performance.

Another useful tool is having an interest outside of medical school and incorporating it into your regular routine. Perhaps it’s training for a marathon or taking a sketch book to an art museum for a few hours each Saturday. I’m continually amazed by the diverse interests of my classmates, but we can lose sight of these important opportunities to escape the stress of a demanding curriculum. Taking time to regularly get away from it all is a worthwhile investment to consider.

A healthy mental attitude can also have significant impact. The pressure cooker of medical education can make small setbacks seem catastrophic. One question I often ask myself is “What will it matter in 10 years?” Will I remember how I did on that exam? Will I remember what that attending thought of me? Perhaps, but it is unlikely to matter much to me. Additionally, it is helpful to avoid the “what ifs.” Ambitious students seem particularly skilled at putting pressure on themselves. One way we do this is by asking ourselves a series of “what ifs.” What if I don’t get that research position? What if I can’t get into the residency I want? These are not unfounded concerns, but fixating on those questions can add a lot of stress. A final helpful approach is stopping to remember what is under your control. Often we spend a lot of time trying to be something, emulate someone, or focusing on our faults. There’s not anything inherently wrong with these thoughts as long as they are balanced with an appreciation of one’s strengths and an understanding that the only person you have to be is you.

There may also be value in viewing medicine as a calling rather than a career choice alone. Often articles discussing rising levels of physician dissatisfaction blame differences in professional expectations (8-11). For example, a physician may enter medicine with plans of spending most of his or her time treating patients only to find him or herself consumed by administrative paperwork and rushing clinical encounters in response to diminished reimbursements. Medicine may instead be viewed as a call to humble service to the health of one’s community. This does not eliminate professional frustrations, but it can add meaning and direction to the personal sacrifices demanded of physicians.

Beyond these personal tools, sharing your inner experiences with your classmates can be cathartic and supportive. At one level, socializing with other students who share similar insecurities and demands can help defuse some of our stress. At a deeper level, self-reflection and discussion can help us better understand our motivations while gaining useful perspectives. It can be tempting to approach mental wellness like principle-based ethics and look for “skills and concrete rules,” but mental wellness seems more like a personal journey with unique challenges and solutions. As we progress on that journey, exploring our perspectives and those of our colleagues can help confirm our path or offer direction when something blocks the path we’re taking. Perhaps Carl Rogers said it best: “The more I open myself to the realities in me and in the other person, the less do I find myself wishing to rush in to “fix things.”

Although prevention has much to offer, it will not always be successful. Many medical schools offer free mental health services to students, which can be immensely helpful. Often students fear breaches of confidentiality and stigma, but these services are often cognizant of these concerns and willing to ensure one’s confidentiality. If you are suffering in silence, I’d encourage you to reach out for help. It might be one of the hardest things you do, but I guarantee you’re worth it.

The mental health of medical students is a major issue facing medical education. Everyone’s journey is different with unique challenges, demanding unique solutions. Hopefully some of the tools suggested above may help support your mental wellbeing on your journey to become a physician.

References:

  1. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008; 149:334–341.
  2. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med 2009; 84:236–241.
  3. Centers for Disease Control and Prevention (CDC). Current depression among adults—United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep 2010; 59:1229–1235.
  4. Crosby AE, Han B, Ortega LAG, Parks SE, Gfroerer J, Centers for Disease Control and Prevention (CDC). Suicidal thoughts and behaviors among adults aged ≥18 years–United States, 2008-2009. MMWR Surveill Summ 2011; 60:1–22.
  5. Myers MF. The Support and Welfare of the Student. In: Gask L, Coskun, Bulent, Baron, David, ed. Teaching Psychiatry: Putting Theory into Practice. Chichester, UK: John Wiley & Sons Ltd; 2011.
  6. Keller EJ. Philosophy in medical education: a means of protecting mental health. Acad Psychiatry 2014; 38:409–413.
  7. Myers MF, Gabbard, Glen O. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. Washington, DC: American Psychiatric Publishing, Inc.; 2008.
  8. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289:3161–3166.
  9. Holsinger JW, Beaton B. Physician professionalism for a new century. Clin Anat 2006; 19:473–479.
  10. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res 2009; 9:166.
  11. Pathman DE, Konrad TR, Williams ES, et al. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract 2002; 51:593.