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Medical student depression: what to do about it

This week I posted links to two interesting pieces about medical school:

1. Medical students tired, underworked? (a NYT article about sleep deprivation among medical students)

2. Medical students: tired, bored, and depressed? (a New England Journal piece about the high rate of depression among medical students)

Let's take the depression piece first. There have been some good comments on physicians' blogs about the reasons why medical students get depressed. Sydney at Medpundit acknowledges that medical school is a "completely transformative process" and a time of profound change, and then she blasts the brutality of the clinical teaching:

The third year of medical school, when students enter the hospitals and see patients, also marks the moment that their teaching is handed over entirely to practicing physicians - and they are brutal. The brightest and best students are treated as know-nothing scum and burdens to be born by the rest of the medical team. There is never, never, any praise - only denigration. At least, that's the way I remember it, with few exceptions.

I don't know how many years it's been since Sydney graduated from medical school, but her venom here reminds me of several conversations I had with alumni of my medical school. They were still viscerally angry at the way they were treated as medical students, even though they'd graduated ten years earlier.

This anger certainly isn't universal. Several commenters on Dr. Kevin Pho's blog seem to have had a much more pleasant experience:

Med school was the best four years of my life. The comraderie was great. I became more efficient and it seemed easier (perhaps because it was always interesting) than actually getting into medical school. I also met my wife, ran a marathon, and had a lot of good times while going 120K in the hole.

My own experience in medical school was a little bit of both. I ran three marathons, but my times got worse with each race. (I attribute that to the chronic sleep deprivation of med school...) Medical school was a happy time because I was learning so much and doing so many interesting things. You can't help but be thrilled when you've learned enough to take a thorough and efficient history from a patient in the ED, or when you can start to decipher an EKG, or (even better) when you've learned to juggle both tasks in a busy ED at three in the morning (my attraction to emergency medicine may be obvious here). On the other hand, I can remember being treated like a "know-nothing scum" on some of my rotations. That's not fun. I remember feeling isolated because I almost never got to rotate through a service with my friends, and just when I felt I was starting to get to know people on one rotation, it was time to move to a different one, sometimes at a different hospital, and once again I wouldn't know anyone at all. I hated the feeling that I was constantly being evaluated, and not just on my patient care and my knowledge, but on my "enthusiasm." Sometimes it all felt like I was never allowed to just be myself.

I don't know if any of these anecdotes are helpful for identifying systemic reforms. Much of how you experience medical school depends on your individual situation. If you're lucky enough to meet some good mentors, or an inspirational former cardiologist from El Salvador, or your future spouse, then you'll like it a lot more. Perhaps any systemic reforms ought to be aimed at ensuring that these things happen more often.

Here's some off-the-cuff suggestions:

  1. Give medical students more control over their schedules. There's plenty of studies out there showing that hopelessness is correlated with feeling unable to control what happens to you. Medical school curricula that don't allow any electives until the fourth year, rotations that give students no control over their call schedules, and attendings that don't give students any responsibility for deciding when to go home each day all contribute to the sense that you're not driving your own bus. Also, if you have more control over your schedule, the chances that you'll rotate with your friends will increase, so your sense of isolation will decrease. It's probably much more effective to give students more control than it is to limit their work hours or give them more time off.

  2. Adopt a zero-tolerance policy for unprofessional behavior by attendings and residents. It's unprofessional to belittle a medical student (or anyone else) at any time, but especially in front of the patient or the medical team. Attendings who routinely do this often claim that they're just providing constructive criticism, but it's funny how their constructive criticism of people with authority over them is never the same as their criticism of underlings. These attendings know what's right, but they just choose not to do what's right. Everyone's going to be grumpy or angry from time to time, but there are professional and unprofessional ways of expressing anger. Apologies are always free. If medical school deans and department chairs are proactive and lead by example, the instances of unprofessional conduct towards underlings will decrease dramatically. It's got to start from the top.

  3. Each service should explicitly define the role of the medical student as much as possible. Many of the problems described in the NYT article above come from not being clear about what the medical student's role is. Vague slogans like "the medical student's role is to learn as much as possible and to assist the team" aren't inaccurate; they're just insufficient. Is the student's primary job to learn as much as possible? Then he or she shouldn't be expected to get burritos for the team at 11 pm. Let them do it if they want, or if it's fair, but don't forget to ask why they aren't reading about the patient they just admitted instead. Or maybe the student's role is to assist the team -- like it often is on a busy ob/gyn service. Be explicit about that. "Hey, we're so busy that the best way to teach you and still care for our patients is to designate you as the all-around gofer. Expect it, keep your antennae out, and you'll learn a lot." Maybe the only role for the student is to observe, like perhaps on a third-year neurosurgery rotation. In that case, explicitly allow the student to go home when there aren't any more cases scheduled.

Medicine can be an infinitely rewarding profession. The intrinsic desirability of the career shouldn't be an excuse for medical schools to get lazy and to neglect the basic principles of effective education. Medical school deans ought to worry when they see such high rates of medical student depression, and they ought to think seriously whether there's anything they can do about it. Even if most depression turns out to be caused by the student's first exposure to sickness and death, for example, the medical schools could ameliorate this problem by admitting more students with clinical backgrounds like EMTs and nurses who've seen sick patients before.

Ultimately, we owe it to our patients to make sure that we're the best physicians we can be. Depressed physicians can't function as well over the long term as non-depressed physicians. If the medical schools did their part, and if the medical students did theirs (by taking care of themselves and seeking help when they need it), our patients would reap the benefits.

EDIT: You can read more anecdotes at over my med body.


wish my dean would read this :P though it's nice to know that others share my plight

Exactly what I'm going through, right now!!!!!!

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