Compared to other professions, physicians have some of the highest rates of job dissatisfaction and suicide; about 300 doctors die by suicide each year.1 What I find particularly shocking is that this change starts in medical school, when we become immersed in the intense and often relentless culture. Upon entering medical school, studies find that medical students have lower rates of depression compared to peers of the same age and education. However, during medical school, the prevalence of depression increases. Nearly 30% of students report experiencing depression or depressive symptoms at some point during medical school, and 11% of students contemplate suicide.two A confluence of factors contributes to these acute changes: high workload, lack of sleep, stress from high-risk continuous exams, isolation due to academic demands, fears about future ability, feelings of inadequacy and an unfavorable work environment .3
Emotional and physical crises don’t happen on your timeline.
Last year I rotated through internal medicine, caring for patients with acute hypoxia and congestive heart failure. Meanwhile, on a medicine floor like mine across the continent, one of my grandmothers died of respiratory failure while the other was hospitalized with heart failure. Every day I saw them in the patients I cared for – my pain would bubble up unexpectedly. In medical school, I had three family members who passed away and a few health issues, some of them occurring dangerously close to critical exams. The admins were supportive but could only offer me the option to continue or take the whole year off (a week off meant a lot of missed requirements).
Medical school has a relentless deluge of assignments unbecoming to the unpredictability of life and healing. Through this, I learned the importance of talking to myself to assess (and reassess) my ability to keep going or my need for time off. I found it equally essential to communicate with faculty and access support resources to process difficult emotions and prevent them from escalating, which can create fertile ground for future burnout.
Emotions and self-worth inevitably intertwine with our professional roles.
As a third-year student in my surgical rotation, the attending urologist began quizzing me about the embryological development of the testes. When I went blank, he wouldn’t stop with his questions. He emphatically punctuated the diatribe with “even a preschooler would be more knowledgeable than you”. For the rest of the week, my gaze was fixed on the floor. I turned inward, questioning my self-worth and whether I deserved to be in medicine.
What that doctor told me is unacceptable: everyone deserves psychological safety in their work environment. In discussing the problematic behavior of senior physicians, one of my colleagues said, “Shit goes downhill.” Maybe, but that doesn’t mean we should sit in the back and eat it. Improving mental health in medicine requires addressing people who sustain (historically) toxic work environments. In addition to changing that culture, personal reflection can help separate our worth from our lab coats.
Deep down, I know I’m a good friend, partner, and person, but those transcendent feelings sometimes become hard to remember. Spending so much time in the hospital/library and sacrificing as much as we do – time, money, relationships, sleep, mental health – means that the line between work and personality becomes blurred. Cognitive distortions often form and are exacerbated by society convincing us that our profession is a “calling”. Given this, finding time for the activities and people that remind us of our identity outside of medicine is invaluable to recalibrate our self-worth.
Solidarity can and must take many forms.
“You’re going to meet all your best friends in med school,” I listened expectantly to my father (a doctor) as we drove to the airport before freshman orientation. It didn’t take me long to realize that immediate, brotherhood-like friendship isn’t everyone’s reality. However, after four years, I can attest that a closeness develops with classmates. That bond wasn’t immediately obvious to me, and it didn’t come from deftly navigating the new societal norms of medical school and high school cliques.
I feel that solidarity as I run through the hospital corridors and look into the eyes of another fourth grader. We nodded at each other with understanding eyes. This union has developed through the indescribable amount we have experienced together: from countless lectures/exams to difficult rotations where we support doctors with the emotional intelligence of sea sponges, fluid-filled nights in obstetrics/gynecology or the heat of the skin for several hours grafts in burn victims, where they keep the operating room warm. Our proximity is less High School Musical and more lord of the flies.
Not everyone’s journey is the same.
While medical school is notoriously demanding, such demands are shaped by intersectionality and not necessarily supported equally. At my White Coat Ceremony, more than a third of the students received their white coats from a family member who was already a doctor – a revolving door of privilege. Medicine has historically been (and remains) a white, high-income space.4.5 Despite more individuals from underrepresented backgrounds entering medical school today, the environments in which students come to learn have remained largely the same. The necessary anti-racist institutional culture, financial resources, mental health support, and representative guidance that allow students to feel supported are not yet robust.
This cultural disconnect has consequences: A study of medical students found that increased frequency of microaggressions from peers and senior physicians was associated with a positive depression screening on a dose-response relationship.6 The Association of American Medical Colleges (AAMC) is working to increase the number of underrepresented students in medicine. But the goal cannot be just representation, but rather create a new culture and system where students can thrive. The floor needs to be open for students to describe their experiences as institutions work to address systems that affect their mental health and potential.
It’s hard to pause and look back when we’re constantly moving forward.
I remember the shell I became and the neuroticism that set in while studying for the US Medical Licensing Exams (USMLE). For weeks I sat studying 15 hours a day, not leaving my apartment and trying to sleep while overcome with the stress of my exam score, determining my ability to match the major of my choice. After completing our first USMLE (Step 1), my colleagues and I were ecstatic, scrambling to organize parties to celebrate before our clinical rotations quickly approached.
I’ve taken over 400 tests since I started college, and somehow it hasn’t gotten any less stressful. The stakes have only increased as the sunk cost and impact on my professional future has increased. And as competition for medical school and residency increases, a student must not only have impeccable grades, but also be a renaissance person (do groundbreaking research, start a nonprofit, climb Mount Everest, found a start-up). up, winning a Nobel Prize, etc.); extroverted expert (winning every resident, doctor, interviewer sizing us up); and world-renowned used car salesman (packing himself into countless essays and interviews). So once you finally get into medical school or match your dream residency or fellowship, they tell you to relax and have fun. How can a person whose cortisol and productivity are functioning at such a high octane level simply cold?
It’s hard to switch to Zen mode – it takes time for our bodies to release cumulative stress. However, the demands of medicine never stop, and habits we’ve convinced ourselves are temporary often stick around. Unlearning conditioned behaviors is difficult, making learning to take a (guilt-free) break despite the flood of tasks early in our careers vital.
Understanding mental health on an intellectual level is different from questioning its applicability to oneself.
While medical suicide is the most acute and devastating issue surrounding mental health in medicine, the downstream impacts of high stress and isolation in medicine are far more expansive. Students around me struggle with anxiety, eating disorders, exercise addictions, and substance use.
As medical institutions address the external factors that contribute to interns’ mental health challenges, students must also feel empowered and responsible to borrow and seek help — dismantling stigma in the process. When we think about medical burnout, we must work upstream and broaden our conceptualization of risk factors for mental health and what the struggle is like (a student can still score in the top percentile on exams). We can all play a role in preventing medical burnout, creating a culture of reflexivity, support and accountability – and coming together to advocate for stronger mental health resources and workplace protections.