While I was in medical school, near the end of second year, I was burnt out. We were all preparing for USMLE Step 1 and final exams for Pathology, Pharmacology, etc. at the same time. I had the distinct feeling that if the school had for some reason added two more courses to our workload it would have been unnoticeable. I was already fully overwhelmed, stressed, and worn out. Having more work to do might have lowered my test scores, but it couldn’t feel any worse. I was discussing this with an attending physician with whom I had a friendly relationship, and he said: “Look, medical school sucks. Second year really sucks. Third year sucks in a different way. Fourth year is fantastic, and that’s good, because the year after that, internship, sucks more than anything that came before.” I didn’t find this discouraging, but oddly reassuring. Not only did I know that I wasn’t alone, but I knew that I was right on schedule, and that things were tough because they had to be, not because I was wildly off track or over my head.
The current issue of JAMA is devoted to medical education, with a few articles about the mental health and attitudes of medical students. In the past, medical students have been popular research subjects, and all manner of experimental procedures and treatments were done on them. There’s not a good history of this research (hello, Lawrence K. Altman, maybe this is your next book?), and it’s now fairly rare as IRBs are very protective of students as a “disempowered” population. But medical students continue to fascinate doctors, and a fair amount of research has been done into the mental states of medical students.
The results are fairly consistent, and not very surprising to anyone who has been or known a medical student or resident. Medical students are more prone to depression, anxiety, suicidality, and more likely to die by suicide than others of the same age. The study in JAMA notes that depressed medical students are more likely than their non-depressed classmates to think that seeking treatment would be more stigmatizing or more likely to damage their academic reputation. This is most likely a combination of the facts that depressed people have a more negative outlook than the nondepressed but also a more realistic one. One reassuring finding in the depression study was that the depressed students reported that they were less professional and made more errors than their peers, but there was no evidence that they actually did so.
Mostly, these findings demonstrate that medical students, and therefore doctors (even your doctor) are human beings. Residents who felt that self-sacrifice was no excuse to accept inappropriate gifts were more likely to state they would accept gifts from drug companies after they were asked to reflect on the sacrifices they have made for their job. Another article discusses pervasive “presenteeism” among residents, coming to work despite illness, that is likely part of that perceived hardship.
There’s no doubt that medical trainees face difficult situations, extreme stresses, and significant barriers to mental health treatment. There seems to be a persistent interest by medical educators to address these issues, and as the system becomes more humanized (continuing adjustment of work hours rules, etc.) they may actually make some progress. There continues to be a perception, however, among medical students and residents, that they should work as many hours as possible, consistently do excellent work, never complain (except to each other), and never get ill. And the inability to be superhuman, or the desire not to attempt it, can lead to guilt, depression, and resentment. This is a complex problem, and with the social and economic status of doctors remaining in flux, it does not appear it will become simpler any time soon.