Game day and mental health

March 17 is Match Day in the US. At exactly 12:00 PM EST, medical students across the country, including myself, will be handed an envelope containing our destiny: the residency program where we matched and will train for the next three to seven years, depending on the specialty. For many of us (and our support networks) this is the most momentous day of our lives – a culmination of countless sacrifices and hours of study. But as I look forward to a career in psychiatry, I can’t help but look back at the mountain we’ve crossed and reflect on how our experiences have shaped our psyches.

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 shift begins in medical school as we become immersed in the intense, often unforgiving culture. Upon entering medical school, research shows that medical students experience fewer depressions compared to their peers and schoolmates. But during medical school, the prevalence of depression jumps. Nearly 30% of students report suffering from depression or depressive symptoms at some point during medical school, and 11% of students consider suicide.2 A confluence of factors contribute to these acute changes: the sheer workload, lack of sleep, stress from constant high-stakes exams, isolation due to academic demands, fear of future abilities, feelings of inadequacy, and an unsupportive working environment .3

Emotional and physical crises don’t happen on your timeline.

For the past year I rotated to internal medicine, providing care to 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 a failing heart. Every day I saw them in the patients I cared for – my grief bubbled up unexpectedly. In medical school, three family members have died and I’ve had a few health problems, some dangerously close to critical exams. The administrators supported me, but could only offer me the option to persevere or take the whole year off (one week off meant too many missed requirements).

Medical school has an incessant deluge of tasks that are unfriendly to the unpredictability of life and healing. Because of this, I learned the importance of having a conversation with myself in order to assess (and reassess) my ability to continue or my need for time off. I’ve also found it essential to communicate with educators and access support resources to work through difficult emotions and prevent them from getting worse, which can provide fertile ground for future burnout.

Emotions and self-esteem inevitably become intertwined with our professional roles.

As a third-year student on my surgical rotation, the attending urologist began grilling me about the embryological development of the testes. When I stopped doing it, he wouldn’t give up his questions. He pointedly underlined the diatribe with, “even a preschooler would be more knowledgeable than you.” For the rest of the week my gaze was on the floor. I turned inward, questioning my self-worth and whether I deserved to be in medicine.

What that doctor said to me was unacceptable: everyone deserves psychological safety in their workplace. When one of my classmates discussed senior doctors’ problematic behavior, he said, “shit rolls downhill.” Maybe, but that doesn’t mean we have to sit at the bottom and eat it. Improving mental health in medicine requires addressing people who live in (historically) toxic work environments. In addition to changing this culture, personal reflection can help decouple our value from our white coats.

Essentially, I know I am a good friend, partner, and person, but these transcendent feelings sometimes become hard to remember. To spend as much time in the hospital/library and sacrifice as much as we do – time, money, relationships, sleep, sanity – means the line between work and personality becomes blurred. Cognitive distortions often form and are exacerbated by society convincing us that our profession is a “vocation”. That’s why it’s invaluable to find time for the activities and people who remind us of our identity outside of medicine to recalibrate our self-esteem.

Solidarity can and should take many forms.

“You’re going to meet all your best friends at medical school,” I listened expectantly to my dad (a doctor), as we drove to the airport for freshman year orientation. It didn’t take me long to realize that instant, sorority-like friendship isn’t the reality for everyone. After four years, however, I can confirm that a close bond is formed with classmates. This connection wasn’t immediately apparent to me, and it didn’t come from skillfully navigating the new high school social norms and cliques.

I feel this connection as I run through the corridors of the hospital and make eye contact with another fourth-year student. We nod to each other with understanding eyes. This closeness has come from the unspeakable amount we’ve been through together: from countless lectures/exams to tough rotations where we’ve endured doctors with the emotional intelligence of sea sponges, fluid-filled nights on OB/GYN, or the heat of hours of skin grafts on 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 equally behaving. During my White Coat Ceremony, more than a third of the students received their white coats from a relative who is already studying medicine – a privileged revolving door. Medicine has traditionally been (and still is) a high-income white space.4.5 Despite more people from underrepresented backgrounds entering medical school today, the environments students come to learn have largely remained the same. The necessary anti-racist institutional culture, financial resources, mental health support, and representative mentorship through which students feel supported are not yet robust.

This cultural disconnect is consistent: A study of medical students found that an increased frequency of microaggression from colleagues and senior physicians was associated with a positive depression screening in a dose-response relationship.6 The Association of American Medical Colleges (AAMC) is working to increase the number of underrepresented medical students. But the goal can’t just be representation, rather it should be to create a new culture and system for students to thrive in. The floor should be open for students to describe their experiences as institutions work on systems that impact their mental health and potential.

It’s hard to pause and look back when you’re constantly moving forward.

I remember the shell I became and the neuroticism that came up while studying for the US Medical Licensing Exams (USMLE). For weeks I spent 15 hours a day studying, not leaving my apartment and trying to sleep while gripped by the stress of my exam score that determined my ability to match with the specialty of my choice. After completing our first USMLE (Step 1), my classmates and I were ecstatic, rushing to throw parties to celebrate before our fast-approaching clinical rotations.

I’ve taken over 400 exams since starting college and somehow it hasn’t gotten any less stressful. The stakes have only grown as the sunk costs and impact on my professional future grow. And as the competition for medical education and residency increases, a student must not only have impeccable grades, but also be a renaissance person (do pioneering research, start a non-profit organization, climb Mount Everest, found a start-up, win a Nobel Prize , etc.); expert extrovert (winning every resident, doctor, interviewer who evaluates us); and world famous used car salesman (wrapping himself in countless job application essays and interviews). Then when you finally get to medical school or match with your dream residency or fellowship, they tell you to relax and enjoy it. How must a person whose cortisol and productivity have run at such high octane, simply hang out?

It’s hard to flip the switch into Zen mode – it takes our bodies time to let go of the cumulative stress. Yet the demands in medicine never cease, and the habits we convince ourselves are temporary are often transferred. Unlearning conditioned behaviors is difficult, making it vital to learn how to pause (without guilt) despite the plethora of tasks at the beginning of our careers.

Understanding mental health on an intellectual level is different from questioning its applicability to yourself.

While physician suicide is the most acute and devastating mental health problem in medicine, the downstream effects of medicine’s high stress and isolation are far greater. Students around me have struggled with anxiety, eating disorders, exercise addictions, and substance use.

As medical institutions address the outside factors that contribute to interns’ mental health issues, students must also feel empowered and responsible to borrow and seek help — dismantling stigma in the process. When we think about physician burnout, we need to work upstream and broaden our conceptualization of mental health risk factors and what struggling looks like (a student can still score in the top percentile on exams). We can all play a role in preventing physician burnout by creating a culture of reflexivity, support and accountability – and by advocating together for more robust resources for mental health care and protection in the workplace.

Game day and mental health

Leave a Reply

Your email address will not be published. Required fields are marked *

Scroll to top