Normalizing the Pursuit of Mental Health in Medical School

With the recent deaths of fashion designer Kate Spade and celebrity chef Anthony Bourdain, suicide prevention has become part of a growing national dialogue on mental health. It has challenged some of our preconceived notions about who might be at risk for suicidal ideation and how we can address it.

Across the country, medical students are being trained to screen for signs of depression in their patients. What some may not realize, however, is that the mental health and well-being of these future healers is of equal importance.

As the Vice Dean for Medical Education at the Keck School of Medicine of USC, my charge is to support medical students on their four-year journey and promote their wellness. In practice, we are witness to both joy and pain.

Tragedy touched our program a few years ago with the suicide of a medical student, adding urgency to a conversation about emotional well-being we had initiated some years earlier.

Truth be told, it’s challenging to gauge the exact prevalence of suicide among medical students. There is no national repository of information on the country’s 80,000 medical students and until very recently, research was scarcely more than anecdotal. In a 2016 Washington Post article, Dr. Nathaniel Morris wrote that “few studies have addressed the issue, with varying results. But suicide is a major issue for medical schools. In surveys, roughly 10 percent of medical students have reported having thoughts of killing themselves within the past year.”

Thankfully, the research drought may be ending. A study published in the December 2016 issue of The Journal of the American Medical Association — an edition devoted to medical education — found a high rate of depression and suicidal ideation among medical students. A review and analysis of nearly 200 studies involving 129,000 medical students in 47 countries found that the prevalence of depression or depressive symptoms was 27 percent, that 11 percent reported suicidal ideation during medical school and only about 16 percent of students who screened positive for depression reportedly sought treatment.

We have long known that stress rides along on this four-year journey, too often silently and in the shadows. Indeed, stress kicks in well before medical school begins; the typical medical school accepted just 7 percent of applicants in 2017–2018, according to U.S. News and World Report — and for many, stress doesn’t abate for years.

Read one way, medical school is a basket of stressors. Consider: curriculum (the so-called “curricular culture of perfection;” the feeling of constantly being evaluated and compared to others; the uncertainty of the third and fourth years); career and residency (the pressure of choosing a specialty and the truncated time in which to do so); financial (the high tuition and high debt that adds to stress); and the experience itself (the pain of watching children suffer; making mistakes and feeling powerless; feelings of distress about the time devoted to medicine; the ambivalence that comes from questioning whether medicine is, in fact, the right livelihood). And so on.

Bound up with all that is a culture that, perhaps understandably, simply isn’t receptive to admissions of failure or weakness. Medical students are by definition high achievers — highly motivated, outstanding in the classroom, with years of stellar grades and of making their parents proud. They’re perfectionists. Each brings to medical school a personal tradition that, after 20+ years, is difficult to contravene.

Within the crucible of medical school, the culture is sadly one of entirely too much isolation — a lack of awareness of how universal these stresses are, of how withdrawn so many students have become, of how elusive personal and professional balance really is. Families aren’t the first place they seek help if they seek help at all.

A culture can’t be “fixed” by fiat, but it is possible — and essential — to begin a dialogue about how hard these issues are. Regardless of how “smart” everyone is, defenses aren’t cognitive so much as emotional. For medical students, acknowledging vulnerability can be a shock to the system. Students may be advised to develop coping mechanisms or a support network to get through — but these do not develop in a vacuum. It takes a community.

Wellness is clearly on our agenda and is central to the medical school experience at USC. We have implemented programs that, collectively, we hope will serve as a framework for other institutions. We have incorporated wellness into our curriculum and hired two additional psychologists who serve our medical students exclusively to provide programming and counseling services. As educators and clinical professionals, we fervently believe that an ongoing, national conversation on wellness — and its inverse — is long overdue.

It’s time for us to heal each other.

Donna Elliott, MD, EdD, is Vice Dean for Medical Education, Chair of the Department of Medical Education and professor of Clinical Pediatrics and Medical Education (educational scholar) at the Keck School of Medicine of USC.