Classmate's Suicide

[Jolie South]

Clearly all of these measures are grossly insufficient. 2 suicides in 20 years is far too many.

A 24hr/d buddy system would be preferable. Or mandatory dorm-living, with monitored security cameras in each to ensure that no one tries to hurt themselves.

If there's one thing I've learned, it's that any time someone is part of an organization, however tangentially, that organization is wholly responsible for the welfare of that person. Baylor should be ashamed of their inability to predict suicides and take apporpriate action before the person hurts themselves.

The family should totally sue.

I see what you did there.

I realize that no one's really to blame, but I think more could be done to increase awareness of resources that are out there and that we could all watch out for each other a little more. Obviously, this isn't a problem that only occurs at Baylor. I do think that something needs to be done.

I wasn't seriously proposing mandatory attendance in class. There's no way that would happen. It does help me though to joke around with classmates when I haven't had a good day or am hating some assignment or whatever.

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[Jolie South]

People always want to "do something" when tragedy happens. I understand the sentiment, but at some point you have to accept that sometimes bad things happen and leave it at that. You don't inconvenience an entire class of students to catch the 1 or 2 that will kill themselves every decade. People make choices. It's sad, but it's not the school's problem, and it's really not their classmates' problem.

I get that. However, is this an issue that needs to be addressed in medical education in general? If you look at the study that an above poster mentioned, the incidence of depression and suicidal thoughts is higher amongst medical students than the general population. Is that something that's ok, that we should just say "well, this is a stressful occupation, so it'll happen?"

I'm not sure that I agree with that.

 

[MadameLULU]

This is a serious matter and there is really no need to be sarcastic. Please refrain from such comments. Thank you.

 

[PeepshowJohnny]

Without trying to be glib, I somewhat agree with Tired.

I'm at a school where students have taken their life in the past (i.e. before I was admitted). Although I did not know these students, I have worked with those who did (upperclassmen, residents, etc.) And for both of the cases, not to diminish the tragedy, the consensus I've drawn were these students were not emotionally healthy people.

Be it low self esteem, mood disorder, unreasonable expectations about oneself or from parents, or what have you, but these were not mentally "healthy" people who were driven to commit suicide by being in medical school. Was medical school a factor? I'm certain it was. But would perhaps these same individuals have reacted the same way if they'd gotten a stressful job working in finance and then had their significant other dump them? Who's to say.

This is a long way of saying "There's nothing specifically dangerous about medical school that isn't inherent in any stressful life decision" whether it be pursuing a high powered career or joining the military or moving across the country away from family.

I am all for schools instituting measures, but I wonder if some of this is just doing something to do something. Is any of the things proposed proven to decrease student suicide rate? (I'm actually asking, I'm ignorant about this subject.) I know at my school our "safeguards" are ridicuously easy to bypass. I completely missed my mandatory for each student assesment with our school's counselor because I was playing Playstation and lost track of time. Was I flagged and aggressively followed up as a risk?

Hell no. I was sent a letter in the mail telling me I'd missed my appointment and inviting me to reschedule if I felt the need. What is the sensitivity of catching people at risk with a system like that?

 

[Jolie South]

Without trying to be glib, I somewhat agree with Tired.

I'm at a school where students have taken their life in the past (i.e. before I was admitted). Although I did not know these students, I have worked with those who did (upperclassmen, residents, etc.) And for both of the cases, not to diminish the tragedy, the consensus I've drawn were these students were not emotionally healthy people.

Be it low self esteem, mood disorder, unreasonable expectations about oneself or from parents, or what have you, but these were not mentally "healthy" people who were driven to commit suicide by being in medical school. Was medical school a factor? I'm certain it was. But would perhaps these same individuals have reacted the same way if they'd gotten a stressful job working in finance and then had their significant other dump them? Who's to say.

This is a long way of saying "There's nothing specifically dangerous about medical school that isn't inherent in any stressful life decision" whether it be pursuing a high powered career or joining the military or moving across the country away from family.

I am all for schools instituting measures, but I wonder if some of this is just doing something to do something. Is any of the things proposed proven to decrease student suicide rate? (I'm actually asking, I'm ignorant about this subject.) I know at my school our "safeguards" are ridicuously easy to bypass. I completely missed my mandatory for each student assesment with our school's counselor because I was playing Playstation and lost track of time. Was I flagged and aggressively followed up as a risk?

Hell no. I was sent a letter in the mail telling me I'd missed my appointment and inviting me to reschedule if I felt the need. What is the sensitivity of catching people at risk with a system like that?

Fair enough and that is a good question.

 

[OncoCaP]

Clearly all of these measures are grossly insufficient. 2 suicides in 20 years is far too many.

A 24hr/d buddy system would be preferable. Or mandatory dorm-living, with monitored security cameras in each to ensure that no one tries to hurt themselves.

If there's one thing I've learned, it's that any time someone is part of an organization, however tangentially, that organization is wholly responsible for the welfare of that person. Baylor should be ashamed of their inability to predict suicides and take apporpriate action before the person hurts themselves.

The family should totally sue.

The MS1 deaths that occurred this year were 100% preventable. There is no reason that any medical students sitting in a classroom or in the comfort of their apartments watching videos and taking tests that almost everyone in the class passes (and gets tutored if they don't) or can take over again should have 3 to 5 times the depression and the much higher suicide rate that goes along with it than other college students or other professionals training for high-stress occupations. No reason. If anything, because we (hopefully) understand depression and suicide (at least a little) and we have inspiring faculty, friendly deans, and some of the best psychiatrists and counselors in the country at every turn available to us (even phone numbers and hotlines), we should have a LOWER rate of pain and suffering due to mental health issues in training, not a higher one.

It would be like the most highly sought-after firefighters in training (many of them 2nd or 3rd generation) at the top firefighting schools in the world having a 3-5x higher risk of having their home burn down and dying in a fire in their own home because they were stubbing out their cigarettes into sofa cushions and then tried to extinguish the flames with gasoline soaked blankets and wads of newspapers. Or of police officer cadets having a 3-5x higher risk of being robbed or dying while driving drunk. That would be dumbfounding. MS1's having a higher incidence of depression and taking their own lives is inexcusable; it's not ok. We are supposed to have some foggy clue about how to detect and treat this stuff. These MS1 who died lost their lives for no good reason whatsoever.

The Physician leaders in charge of training in our profession .. the deans and heavyweights who run the medical training business are smart, capable people who could do at least as well as those who train soldiers, stock brokers, air traffic controllers, scientists, firefighters, attorneys, astronauts, pilots, engineers, police officers and pretty much anyone else who has a high stress job. I can't think of any group outside of those involved in actual military combat who have the abysmal mental health stats that medical schools have. Yes, we have great resources and most students do OK. However, as a profession that must train its own we are near the bottom in providing a healthy training environment (at least in terms of mental health). Learning from and implementing changes from the training from essentially any other profession would produce better results. Things are so bad that we have nowhere to go but up if we are willing to try and put forth a competent serious effort. We can and should do better.

We don't need hall monitors, dorms, or cameras. We need to clearly warn incoming students that some (again, by no means all or even most) extremely smart, perfectly healthy incoming medical students who have a lot to offer as physicians and who never have and probably would not otherwise have any non-typical problem with depression or suicide will, starting around the middle of the 1st year, get depressed and, in some cases, actually take their own lives when they would not have done so if they trained to be an investment banker at the best business schools. At least inform the students that this can and does happen from time to time and what to watch for and what to do in that case. Excess depression and suicide has happened before and will happen again because these students are in medical school and pretty much no other reason (and, interestingly, physicians also have an elevated rate of suicide as well).

Astronauts, air traffic controllers, engineers, fighter pilots, elite commandos, etc. etc. all have demanding training programs and they aren't committing suicide at the rate our own are (unless they actually go into combat where they could get blown away at any minute and must kill others or be killed which is far more stressful than any medical environment outside of combat ever should be -- we never need to worry about being blown up by an IED as we turn the corner). I can understand soldiers who are fighting wars or physicians who are in some kind of unusual distaster trauma care having more mental illness than the average professional in a high stress job ... but students sitting in a classroom learning about diarrhea or diabetes having a higher death rate than construction workers dodging massive I-beams, concrete, and bricks 100s of feet in the air having less mortality than students in a classroom? It can never make sense. There simply is no excuse.

It's time for medical schools and their meta-organizations to start (anonymously) documenting depression and suicide at medical schools and among physicians and develop practical measures to bring our morbidity and mortality in line with other high stress occupations (and if we are so smart, let's even make it lower). Under no circumstances should medical students sitting in a classroom be taking their lives or have an incidence of depression that is 3-5x that of college students or fighter pilots being trained for combat (i.e., before they actually have someone shooting at them). In my mind it is simply a question as to how far are we willing to go, as your piece of satire points out.

We certainly don't need cameras. We don't need 24/7 buddies. We need to warn students coming in of the symptoms of depression and to get treatment. If we were to do a lab that involved handling culture dishes or monkeys infected with live ebola, HIV or whatever, we would want to know of that possibility of catching a nasty bug. Similary, medical students need to be warned and the problem needs to be measured and dealt with to the best of our abilities. Right now the whole thing is rather hush-hush and we have only approximate numbers for what is going on. We do need to have readily available resources for treatment of depression (and we do). We need to get some handle on what is leading to increased depression and really question if it's worth it ... I'm convinced it's not. There are many ways to train physicians and the most lethal way offers no advantages that really matter to the public. There are many improvements that can be made. My goal is not to list them all. If it's a priority, it will get done. We have very capable people around here. We need to document the excess depression and suicide that we are aware of. We need to study ways of preventing excess morbidity and mortality at a regional or national level. If we are so interested in saving lives and reducing suffering, let's show that we actually have skills in that area by demonstrating that we can take care of ourselves and our own physicians in training -- what a concept! The problem even continues on into physician life. That's right Mr or Ms Patient. The person you are turning to for help with your depression and to help counsel your 14 yr old suicidal son is actually more likely to be stressed out, burned out, depressed, and more likely to commit suicide that you are. The irony of it isn't lost on me. It doesn't have to be this way. All it takes is measuring to understand what we are dealing with and systematically solving the problem the way we would for any of our patients.

 

[Tired]

The MS1 deaths that occurred this year were 100% preventable. There is no reason that any medical students sitting in a classroom or in the comfort of their apartments watching videos and taking tests that almost everyone in the class passes (and gets tutored if they don't) or can take over again should have 3 to 5 times the depression and the much higher suicide rate that goes along with it than other college students or other professionals training for high-stress occupations.

Where do you get a higher suicide rate in medical students? A brief perusal of pubmed shows a mix of studies with decidedly mixed conclusions on the true rate (some higher, some lower).

 

[OncoCaP]

Where do you get a higher suicide rate in medical students? A brief perusal of pubmed shows a mix of studies with decidedly mixed conclusions on the true rate (some higher, some lower).

As you know, depression and suicide are not these mysterious things we know nothing about. When it comes to students, 90% of suicides are students who have some kind of depression whether reactive or MDD or whatever. Because it's higher in medical students than in other students we are left to assume that it is "caused" by medical school (by the stress or whatever). Lifetime mortality of someone with ongoing depression (e.g., MDD) is something like 15% according to experts that I have spoken with. Of course, most medical students aren't depressed at all. However, there is still an issue. There is nothing about medical book knowledge that is more depressing than say, studying insurance regulations. It's not like my buddies studying graduate level Electrical Engineering courses are sitting on their tails wondering what to do with their time. They are just as busy as we are, and so it's not just the amount of work. Looking around SDN we find tons of reasons as to why medical students are depressed and many of these reasons are preventable. Other professions are doing it; we aren't dumber or lazier than every other profession. Again, we have people who know how to fix this if it were a priority. Many of these things could be virtually free, but we would need good data to evaluate the effectiveness of various ideas and programs.

Look for suicide stats on medical students and you will find old, stale, or annecdotal poor quality data from the 1980s perhaps or really small studies. If we know the MCAT score of every medical student categorized by every imaginable variable from parent income to race and what undergraduate school they went to ... why don't we even know how many medical students committed suicide last year +/- 10%? Is the fact that more medical students committed suicide than say, law students, somehow not worth figuring out? The best you can do is track depression, so if 3-5x as many medical students are depressed, you have to assume that there are 3-5x as many suicides. That's where we are. It's not good enough, but it's all we have to work with.

There have been some people who have gone out and tried to get actual numbers because all you have is these obituaries and it doesn't say that the person committed suicide. There are a few small studies out there that are very unsatisfying. By contrast I could probably give you the distribution of SAT scores of all medical students in class this term broken down by region, gender, hair color, and beer preference. It's not hard to see where depression and suicide among medical students fits versus preformance of students in reguritating biomedical data as far as the people who train medical students. It's nowhere near as important, but hopefully that will change.

1. Suicide is a feature of the typical incoming MS1 age group/ demographic (18-24yo college students) and we should not be completely surprised if it happens. The issue in my mind is what can we reasonably do to prevent suicides because we value life and good mental health, and is it possible that we have a problem that indicates a unusually stressful or high-risk situation, even among medical schools.
http://www.ct.gov/dmhas/lib/dmhas/prevention/cyspi/aasmediakit.pdf
Even before they show up for their first day of med school, suicide is the #3 cause of death of young adults in the 18-24 age group in the U.S. Based on general population and college student studies ~5-10% or so of incoming MS1's can reasonably be expected have "depression" (one of its various forms I suppose, transient / reactive on up to MDD, etc.)
In 2000, the American College Health Association surveyed 16,000 college students from 28 college campuses.
o 9.5% of students had seriously contemplated suicide. (let's say that's 17 student incoming for a class of 170 medical students)
o 1.5% have made a suicide attempt.
Apparently that's what we start with before they ever show up (I'm open to sources of more reliable better stats).

2. However, in medical school, depression and (we would expect) suicide increases significantly. It's pretty ironic that the people who are supposed to be healers have a greater risk of dying or suffering during their training (or on the job after training for that matter). With respect to students in medical school, there seems to be a consensus that both prevalence of depression and suicide attempts increase dramatically in medical school according to recent articles such as Rosenthal, and Susan Okie (2005) and others. Roughly around the middle of the 1st year, there is a detectable increase in "depression." Laurie Raymond, a psychiatrist and the director of the Office of Advising Resources at Harvard Medical School, "believes that students' coping strategies and personal health deteriorate as they progress through medical school. Students "see themselves going into a very narrow tunnel," she said. "A lot of the depression we see halfway through the [first] year — it's a reaction to having constricted themselves down to studying these subjects in a very intense way. It's pretty unidimensional."

3. For medical students overall, 15% - 25% are "depressed" (see sources below). Compare that with 5-7% in the general student population at any one time and you get 3-5x. So we go from maybe about 17 depressed students coming in with a largish incoming MS1 med school class to maybe 34 by around 3rd year. Most students (~60-75%) never seek treatment mostly because they are too busy with their training (Coverdale and Roberts, 2007). I would like real numbers if schools ever decide this is serious enough to get some hard data on.

***

Here are some snippets of articles. You can't tell me that it surprises you that medical students are more depressed than students studying to become stock brokers or fighter pilots in training. You also know that a certain fraction of people who are depressed will commit suicide.

Snippets of articles I found …


NEJM
Volume 353:1085-1088
September 15, 2005

Number 11


White Coat, Mood Indigo — Depression in Medical School
Julie M. Rosenthal, and Susan Okie, M.D.
Audio of interview with authors
http://content.nejm.org/cgi/content/full/353/11/1085/DC1

Medical students are more prone to depression than their nonmedical peers. Researchers recently surveyed first- and second-year medical students at the University of California, San Francisco (UCSF), and found that about one fourth were depressed.1 Others have suggested that although the rate of depression among students entering medical school is similar to that among other people of similar ages, the prevalence increases disproportionately over the course of medical school.2 Laurie Raymond, a psychiatrist and the director of the Office of Advising Resources at Harvard Medical School in Boston, said that she met individually with 208 medical students — about one quarter of the student body — between July 2003 and July 2005. Thirty-one students (15 percent) presented with self-described depression — 20 of them with transient, "reactive" depressed mood that improved with supportive counseling or therapy and 11 who had a history of major depression. The majority (130 students) consulted Raymond because of concern about academic performance, but major depression was diagnosed in 25 of them. A fourth-year medical student at Harvard estimated that three quarters of her close friends in medical school have taken psychiatric medications at some point during the four years.
Depression not only affects students' lives but may also have repercussions for patient care in the long run. Jennifer Tjia, an instructor in internal medicine at the University of Pennsylvania School of Medicine in Philadelphia, believes that many practicing physicians are afraid of being treated for depression and thereby revealing that they have the condition. But "if people don't know how to treat their own depression, it has a negative impact on how they treat patients," Tjia said.
Why does being a medical student increase the risk of depression? Raymond believes that students' coping strategies and personal health deteriorate as they progress through medical school. Students "see themselves going into a very narrow tunnel," she said. "A lot of the depression we see halfway through the [first] year — it's a reaction to having constricted themselves down to studying these subjects in a very intense way. It's pretty unidimensional."
Symptoms of depression in medical students can be difficult to distinguish from the effects of the stress inherent in student life. Students often dismiss their feelings of despondency as a normal emotional response to medical school, where they live from test to test and don't take time for themselves.
"It's hard to ask about depression in medical students, because you ask about sleep, and all medical students aren't sleeping," explained Angela Nuzzarello, a psychiatrist and dean of students at Northwestern University's Feinberg School of Medicine in Chicago. "They are overwhelmed, they are working hard, and they aren't having fun socially. . . . Of course they are fatigued."
The emotional and academic challenges involved in becoming a physician wear on students. Their initial encounters with illness and death may unmask psychological vulnerabilities. Such encounters often resonate with unresolved episodes of loss or trauma in the student's past or come as a shock to those who have had little experience with death. The treatment of death as a part of the daily routine may appear cold and calculating to students, who may fear becoming emotionally detached. Some become overwhelmed by the emotional toll of caring for others.
For students who have been lifelong achievers, getting a mediocre grade on an exam often is shocking. As a fourth-year student at Vanderbilt University School of Medicine in Nashville put it, "The transition from college to medical school [is] definitely an eye-opener . . . especially if your academic performance isn't up to par. If you get C's on your first set of tests, I can see that it would be easy to get depressed." At the end of his second year, this student lost 15 or 20 pounds. "Retrospectively, I can say I was clinically depressed," he said, "but at the time it was just one of those rough things." He never sought treatment, he added, because "as a medical student, you are supposed to just deal with it."
References
1. Sharfstein SS, Sharfstein MS: The two-physician family: a balancing
act of work and love. Acad Psychiatry 2007; 31:133–
134
2. Riba MB, Riba A, Riba E: Life as a balance beam: practical
ideas for balancing work and home. Acad Psychiatry 2007;
31:135–137


http://content.nejm.org/cgi/content/full/353/11/1085


Alan Louie, John Coverdale, and Laura Weiss Roberts
Balancing the Personal and the Professional: Should and Can We Teach This?

Academic Psychiatry, 31:2, March-April 2007, p129
"…Data regarding the physical and mental health of medical
students suggest that it is not too early to begin focusing
on self-care practices and personal well-being in medical
school (15). In a study of 1,027 medical student-participants
performed by one of us with others (16), 90% of students
expressed a need for health care during medical school, but
48% reported difficulty obtaining health care, including
37% who said they were "too busy to take time off," 28%
who were "worried about cost," and 15% who were "worried
about confidentiality." In this study, 57% of students
who needed care did not seek care, mostly due to time
constraints associated with training. Interestingly, in this
study, 63% of students endorsed seeking some sort of
"curbside consultation" or informal care, primarily related
to convenience, time and financial limitations, and confidentiality concerns. In a longitudinal subsample of 94
medical student-participants (at one school) in this study,
it was found that the need for care, difficulties in seeking
care, avoidance of necessary care, and informal consultation
practices all increased significantly by the time students
were in their clinical years of training (17). Other
studies have indicated that 20% to 25% of medical students
have been depressed during medical school (18).


Journal of American College Health
Issue: Volume 53, Number 5 / March-April 2005
Pages: 219 - 224
URL: Linking Options

DOI: 10.3200/JACH.53.5.219-224
Factors Associated With Undertreatment of Medical Student Depression
Jennifer Tjia A1, Jane L Givens A1, Judy A Shea A1
A1 University of Pennsylvania Philadelphia
Abstract:
The authors measured factors associated with undertreatment of medical students' depression. They administered a cross-sectional Beck Depression Inventory and sociodemographic questionnaire to students at 1 medical school, defining their outcome measure as the use of counseling services or antidepressant medication. Of an estimated 450 available student participants in the study, 322 (71.6%) completed the questionnaire. Forty-nine students (15.2%) were classified as depressed and 10 (20.4%) reported experiencing suicidal ideation during medical school, but only 13 (26.5%) of the depressed students reported treatment. The researchers observed no difference in treatment by year in school, completion of psychiatric requirement, race, or depression severity. Treatment for depression was significantly associated with older age and personal and family histories of depression. Despite the availability of effective medications and confidential mental health services, medical students with depression are undertreated. The authors' findings support the need for targeted messages to help medical students recognize their depression and refer themselves for appropriate treatment.

There is more data I could pull if you need it. Again, a big issue is just collecting good data in the first place to know what we are up against.

 

[sirus_virus]

I am surprised no one has suggested reducing the actual stress of medical education. Is there anyone in their right senses who believes most of the junk they make medical students memorize is really a good way to train doctors? If so, then tell me why practicing physicians are proud to remind you about how they have forgotten 90% of that information, and geuss what, they are doing okay. Medical training is the most inefficient, money grubbing, hazing exercise I have ever heard of, and there is no better evidence that this is true than the fact that PAs and NPs are getting less 'training' yet functioning in a comparable capacity and even better in some instances than physicians. Now you have people depressed or even taking their lives because they fell into the circle of doom. Not blaming the whole suicide thing on medschools, but when you combine huge debt with ambitious students running through senseless hoops, hopelessness/helplessness will creep in, and next comes depression and suicide. So instead of expanding their counseling services, medical trainers might just need to look at the very bone of contention here which is the damn training.

 

[OncoCaP]

...
My main issues with your arguement though, are that:

(1) There is a difference between true depression and adjustment disorder, which is noticably ignored when this topic is discussed. Assuming the situation is the primary cause of the depressive symptoms, the "light at the end of the tunnel" is probably reducing the overall number of suicides.

I was surprised by the lack of care with the "depression" terminology as well. Until we get better data we are going to need to assume that it doesn't matter if it's adjustment disorder or MDD; the medical student in both cases is very unhappy ... sometimes unhappy enough to hurt themselves.

(2) If we increase identification of those with depressive symptoms, it might be used to screen out students from the profession. All mental illness, including adjustment disorder/depression is reportable to medical boards. Many (including myself) don't think individuals with such disorders belong in the profession period. Are you really prepared to stigmatize sad med students for the rest of their careers?

That's quite a leap there, Tired. I assume you know this well-known story:

http://agonist.org/story/2004/12/28/45854/619 .

Despite his problems and ultimate tragic death, this physician did a lot of good for many patients. Highly respected guy. If you want to keep people like this out of the profession, you've got a lot of explaining to do.

(3) What makes you think an "educational" approach to suicide prevention even works? We already teach depression and suicide awareness in medical school as part of the curriculum, yet the rates of depression (and maybe suicide) remain elevated. What difference does it make to add yet another session? Looking at the link above, the evidence-based programs (and seriously some of that "evidence" is pretty sketchy) used sustained, multi-pronged approach involving education, mentoring, and monitoring. Do we really have time for that? Or the resources?

I'm all for doing what works. We can't do random psychological testing on medical students without their permission. We can't look over their medical records as part of the admission process. We can't very well watch them on cameras to see if a person looks more "sad" than usual and bring them in for counseling if they show up with a frown. Only preventative and student-initiated approaches are legal.

I'm very confident that the brilliant hard-working physicians who run medical school training can make it happen if they are given the mandate to measure and reduce/eliminate excess depression and suicide among medical students relative to their non-medical peers (students in other graduate level training programs). It would probably involve some kind of multi-school study to figure out what is causing the depression and increased suicide and trying various reasonable approaches. The extra sessions are fairly easy to do but they might not work at all (in which case we shouldn't do that). Let's just say other professions are able to do this and so can we. There is no reason why we can't fix the problem. Here is a recent Annals of Internal Medicine Article you may want to look at:

http://www.annals.org/cgi/content/abstract/149/5/334
ACADEMIA AND CLINIC
Burnout and Suicidal Ideation among U.S. Medical Students
Liselotte N. Dyrbye, MD; Matthew R. Thomas, MD; F. Stanford Massie, MD; David V Power, MD; Anne Eacker, MD; William Harper, MD; Steven Durning, MD; Christine Moutier, MD; Daniel W. Szydlo, BA; Paul J. Novotny, MS; Jeff A. Sloan, PhD; and Tait D. Shanafelt, MD

..
Objective: To assess the frequency of suicidal ideation among medical students and explore its relationship with burnout.

Design: Cross-sectional 2007 and longitudinal 2006 to 2007 cohort study.

Setting: 7 medical schools in the United States.

Participants: 4287 medical students at 7 medical schools, with students at 5 institutions studied longitudinally.

Measurements: Prevalence of suicidal ideation in the past year and its relationship to burnout, demographic characteristics, and quality of life.

Results: Burnout was reported by 49.6% (95% CI, 47.5% to 51.8%) of students, and 11.2% (CI, 9.9% to 12.6%) reported suicidal ideation within the past year. In a sensitivity analysis that assumed all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 5.8%. In the longitudinal cohort, burnout (P < 0.001 for all domains), quality of life (P < 0.002 for each domain), and depressive symptoms (P < 0.001) at baseline predicted suicidal ideation over the following year. In multivariable analysis, burnout and low mental quality of life at baseline were independent predictors of suicidal ideation over the following year. Of the 370 students who met criteria for burnout in 2006, 99 (26.8%) recovered. Recovery from burnout was associated with markedly less suicidal ideation, which suggests that recovery from burnout decreased suicide risk.

Conclusion: Approximately 50% of students experience burnout and 10% experience suicidal ideation during medical school. Burnout seems to be associated with increased likelihood of subsequent suicidal ideation, whereas recovery from burnout is associated with less suicidal ideation.

*** So according to this study, we need to reduce burnout, and we could try some reasonable methods to accomplish that and see if we get better results. There are many ways we could go about this. Again, other professions have done this and so can we.

(4) Is this an appropriate function of a medical school anyway? We're not talking about children, these are college-educated adults. Some people get depressed, some people commit suicide. It's sad. But to me, that doesn't give educational institutions the justification to push themselves into the lives and heads of their students. Adults have the right to be left the hell alone with their problems, and schools need to focus on education, not fixing personal problems.

You have a point. The medical school is there to train people, not deal with their personal problems. After all, why should it be the school's problem if a few medical students are taking their lives as long as the school graduates some of the best trained physicians in world? A few die because they are "weak" and couldn't cut it. We don't want to soften the program and wind up with less skilled physicians who are less able to deal with stress. It's survival of the fittest; it happens with sea turtle babies making a run across the beach and medical students vying for a plastics residency. It keeps the species competitive. Not everyone is going to make it. So sad too bad. Life sucks sometimes; let's keep going.

The counterargument is that physicians are here to improve health and save lives of the public of which they are a part. Physicians serve no other higher value in society. There is nothing else that physicians do that is more relevant to the public in terms of priority. It is job #1. If medical students were dying because they were pushing young children out of the way of oncoming cars speeding down the road, they would call them heroes and bury the dead in an elaborate ceremony. No one would question heroic self-sacrificial deaths like this except maybe people considering the medical profession.

On the other hand, if physicians-in-training (and for that matter, physicians) are dying at 3-5x the rate of non-medical peers because of stress-induced depression and burnout leading to suicide with no measurable benefit and no attempt to measure the problem (compared to say, MCAT or STEP 1 scores), then that's a different story. I'm not even talking about doing better than the 'background' rate of depression and suicide that we find in the population (which is already too high). What have here is worse. It really puts a big question mark on physicians' ability to improve health and save lives -- job #1. Do you think I'm going to have you repair my car if you car breaks down more than mine? If your kids are dying from preventable illnesses, you think I'm going to want you as my physician? No, because your failure to take care of your own to even an average level would raise immediate questions about your ability to accomplish your mission. Similarly, if medical students and physicians are 'sicker' than average, it raises all kinds of questions about the ability of the medical profession to accomplish its primary mission. I'm convinced we can do better as long as we prioritize it. Accomplishment in medicine should not come at an unreasonable (3-5x) increase in the morbidity and mortality of medical students.

Will anything really happen to improve this situation? I know there are capable physicians and deans are sincerely working very hard on this problem. There is hope that things will get better but certainly no guarantee that there is an easy fix here that doesn't involve a tradeoff. It may take some time to figure out what actually is effective here without messing up the things that medical education does very well. Again, other professions have done it, we can also.

 

[riverie]

Oncocap, great work on the data-pulling. I agree with pretty much everything you've said. And sirus-virus, I also thought, when I heard about the second suicide in less than a year, that maybe something needs to be done about the stress of med school itself, instead of trying to put band-aids on the situation alone. What's also concerning is that they both happened with first years, so maybe the transition to med school needs to be made smoother somehow. Maybe it's the perfectionism inherent in most med students that rears its ugly head when suddenly you aren't the top student anymore. Maybe it's the voluminous amount of seemingly redundant information inherent in the basic science curriculum. All these possible reasons have been mentioned in many of the articles quoted above by Oncocap and elsewhere. But who's to know what was going through these people's minds exactly that caused them to take the most extreme way out? Were these people so-called more susceptible to depression and the stress of med school simply brought out suicidal tendencies that were already present? That said, it is difficult to deny that if med students and physicians have a higher rate of depression and suicide than the general population, then something about medical training and practice must lead to more extenuating emotional circumstances that increases our risk of psychological disturbances. If instituting mentoring programs and awareness campaigns, and stressing counseling availability (all band-aids which have been implemented at Baylor since the first suicide) have not prevented another one, maybe it's time to address the presumeable cause of that increased risk - the stress.

 

[DoctorDreamer]

I don't know if this has anything to do with anything; however, a few months ago, I was playing around on the residency forum, and I noticed a thread discussing how baylor has one of the most "malignant" residency programs in the country. I am sure that residency programs are completely separated from the medical school, but I just thought it was an interesting coincidence. Been trying to find that thread, but I can't. Also, I may be wrong, and I could be thinking of another school in TX, but I'm pretty sure it was baylor.

I don't know what you mean by "malignant."

However, BCM has amazing residency programs in most areas, and especially the peds and med/peds residents I have spoken with are some of the happiest people on earth.

Regardless, the medical school and the residency programs are separate.

Here's the thing, if you are obsessed with honors or high passing everything, med school will be stressful for you wherever you go. If, however, you enjoy it for what it is, pass when all you can do is pass with the time you want to put into it, and stop freaking out, it's just not that bad.

I'm saying this as a medical student who has been through crap and back this semester. When I cared abut rank, I was miserable. Now that I've resigned myself to just learning what I can and having fun in my free time (which I actually have since I don't study around the clock), I'm much happier, and med school isn't stressing me out.

I understand that every med student is different and handles things differently, and depending on the residency you are trying to get you may need to honors everything. But I am saying that BCM in particular is not some uber-stressful, depressive environment.

They made depression and stress, and the help you could get for them, very openly discussed from the beginning. The mentorship and support is abundant and helpful. The faculty and administration are caring and concerned.

You can't blame this on a school.

90% of people who commit suicide have some sort of mental illness. Med school attracts OCD, Type A, obsessive people who aren't used to failing and not being perfect. As a result, you have a higher incidence of some of these tragic things.

Don't blame the school, the classmates, or even medical school in general. Blame the mental illness that claimed a life. Almost all diseases have mortality rates, and mental illness is no exception.

That's my $0.02. You don't have to agree, but people searching for some explanation and placing the blame where it doesn't belong are hurting people and schools, and those kind of rumors and negativity only perpetuate these cycles we want to stop.

 

[anoncurious]

I don't know if this has anything to do with anything; however, a few months ago, I was playing around on the residency forum, and I noticed a thread discussing how baylor has one of the most "malignant" residency programs in the country. I am sure that residency programs are completely separated from the medical school, but I just thought it was an interesting coincidence. Been trying to find that thread, but I can't. Also, I may be wrong, and I could be thinking of another school in TX, but I'm pretty sure it was baylor.

I agree with what others said in response to this, but also - the school that you are thinking of is UT Southwestern, not BCM.

 

[phospho]

I agree with what others said in response to this, but also - the school that you are thinking of is UT Southwestern, not BCM.

Interesting, thanks for correcting me. I better delete my post then.

 

[OncoCaP]

I don't know if this has anything to do with anything; however, a few months ago, I was playing around on the residency forum, and I noticed a thread discussing how baylor has one of the most "malignant" residency programs in the country. I am sure that residency programs are completely separated from the medical school, but I just thought it was an interesting coincidence. Been trying to find that thread, but I can't. Also, I may be wrong, and I could be thinking of another school in TX, but I'm pretty sure it was baylor.

I'm not sure I believe what you read there. I can assure you that BCM's medical school experience is demanding but very good and can easily be enjoyed. If there is a problem ... it is that's you are going to have some amazing classmates; if you think you'll come in here and rank #1,5, or even #10 on exams because you were always #1 or very near the top at whatever you did and your identity is tied up with this superiority to those around you, you may have a very very rude awakening. They teach us a lot here and give us a lot of freedom and help. You can have a lot of fun here unless you simply decide that your life will revolve around studying all the time; there are students who do this ... I discourage that and think it's essential to have balance in life, even if it's tilted toward schoolwork. Students really help each other out a lot and no matter what you are interested in, you can find someone here to hang out with. My take is that exceptional students can actually be more vulnerable because they have never had to deal with busting their tail just to get average or even below average grades or just to pass. Being in the bottom 50% of your BCM doesn't change the fact that you'll learn a lot and be very well prepared for residency. I would trust every classmate here with my life or my child's life. There is no one here who is incompetent.

 

[PeepshowJohnny]

While I suspect the med student suicide rate is higher than the national populations, I don't think we can make a one to one correlation between depression and death as Tired pointed out.

That said, I see a disturbing trend in this thread toward putting the root cause on medical education as a whole for this. Someone earlier in this thread suggested it may have something to do with the way first years curriculum is taught with "useless" information. While I'll never argue that medical school curriculum can't be improved, I think we're missing the mark by blaming it on the curriculum.

In my opinion, it'd be better to look at not the system but the culture we med students bring up. Medical schools put a premium on recruiting the most idealistic "save the world" type people they can now. These are the type of people who are going to be most susceptible to an insult to the ego when they discover medicine isn't what they thought was. I have personally seen this first hand. While some idealists retain it throughout, I've seen others get hit hard when they find the world can be a dark cruel depressing unfair place.

Add to that, we take the best and brightest students and put them into competition with one another. While some of this competition is "real" (Hey, derm and plastics are hella competitive), a lot of it is imagined up by competitive premeds. Do you see how often we tell people on this forum it doesn't matter that they got a low average grade on anatomy and they want to be a surgeon? Yet year after year med students, previously top of the class, get dropped to the middle percentiles or lower and take as the end of the world.

Then we get into the "I'm going into medicine for the wrong reasons" crowd which is such a huge problem I don't even want to go into it here, but similarly they tend to get crushed when they experience the realities of med school.

So, absolutely we can change medical education to accomdate these people, but it's just going to push the burden even more into residency. Do we get rid of grades, decrease hours, keep patients away from the druggies, drunks, and sociopaths of our society, as well as when bad things happen to good people? Sure, we can do that. But it's just going to make that adjustment to residency and a life of practice of medicine that much harder. How do you think a student is going to react when he finds out *Gasp* not only did he not match into what he wanted, but he's going to have to double his work hours, double his studying, and see medicine's ugly side for the first time.

This is not saying medical school's can't change, but I don't think we should throw our efforts at making the curriculum and structure safer. Absolutely we need screening and detection increased, but as I alluded to before, I don't know if these things work and just implementing a lot of programs makes you feel better (and legally safer) but if they're as easy to bypass and avoid as mine were and not implemented properly, what's the point?

 

[phospho]

I agree with what others said in response to this, but also - the school that you are thinking of is UT Southwestern, not BCM.

Actually, it did turn out to be baylor. A few threads I found.

http://forums.studentdoctor.net/showthread.php?t=256596&highlight=baylor

http://forums.studentdoctor.net/showthread.php?t=181105&highlight=baylor+malignant

http://forums.studentdoctor.net/showthread.php?t=506840&highlight=baylor+malignant

http://forums.studentdoctor.net/showthread.php?t=359544&highlight=baylor+malignant

But like I said, this probably has little to nothing to do with the medical school - Just mentioning it because I just thought it was an interesting coincidence.

 

[MadameLULU]

Actually, it did turn out to be baylor. A few threads I found.

http://forums.studentdoctor.net/showthread.php?t=256596&highlight=baylor

http://forums.studentdoctor.net/showthread.php?t=181105&highlight=baylor+malignant

http://forums.studentdoctor.net/showthread.php?t=506840&highlight=baylor+malignant

http://forums.studentdoctor.net/showthread.php?t=359544&highlight=baylor+malignant

But like I said, this probably has little to nothing to do with the medical school - Just mentioning it because I just thought it was an interesting coincidence.

Most of the threads you reference are all speculation.

 

[phospho]

Most of the threads you reference are all speculation.

I completely agree with you. But speculation doesn't come from nowhere. It must have started somewhere. Either way, this is irrelevent to the topic of this thread.

I mentioned those threads because in a way i'm sort of wondering if it's possible that the entire school/hospital as a whole might be expecting so much of the students/interns/residents, i.e. I think it speaks, even if a little, about baylor's culture.

 

[MadameLULU]

I completely agree with you. But speculation doesn't come from nowhere. It must have started somewhere. Either way, this is irrelevent to the topic of this thread.

I mentioned those threads because in a way i'm sort of wondering if it's possible that the entire school/hospital as a whole might be expecting so much of the students/interns/residents, i.e. I think it speaks, even if a little, about baylor's culture.

As a person familiar with the Baylor culture, I am going to disagree with your assessment. The culture of the departments and residency programs are separate and are not the issue here. The medical school is far from "hard core" as you are impling. Again, perhaps this conversation would be more fruitful if everyone would refrain from speculation, inappropriate sarcasm, and discuss the issue at hand. Thanks.

 

[OncoCaP]

"Diagreeing with the mod will result in a ban. Thank you for your participation in SDN."

Well, look at it this way. If concern for your fellow man or woman taking his/her own life from stress doesn't move you, you could take it to a practical level and realize that depression and suicide actually interfere with teaching of medical students. It's distracting and you get less smarter doctors. I could go to even more callous reasons we should be preventing suicide for our own personal benefit....

Taking it one step further, right now we have something like 400 U.S. physicians commiting suicide every year. That's about two medical school classes killing themselves every year. If we could nip this in the bud in medical school by promoting healthier stress coping and eliminating unnecessary & unproductive stresses, we would have less of a physician shortage and be better able to fulfill our public mission.

http://www.ama-assn.org/amednews/2008/10/20/prsb1020.htm
PROFESSIONAL ISSUES
Medical student stress and burnout leave some with thoughts of suicide
Medical schools offer counseling to help students who may be at risk, but some refuse such assistance.
By Kathleen Phalen Tomaselli, AMNews correspondent. Oct. 20, 2008.
"An estimated 400 physicians commit suicide each year.

"It has been known for some time that suicide rates among doctors are higher than the general population. The gap in suicide rates evidently begins as early as medical school," said Eva Schernhammer, MD, DrPH, assistant professor of medicine at Harvard Medical School in Boston. She was motivated to study physicians and suicide after four doctors committed suicide during her year as an oncology fellow in Vienna, Austria.

Many medical students find themselves, perhaps for the first time, in the bottom of their class. "This is intensely stressful. A good number will get a 'C' or fail, and maybe this is their first failure," said Finlay-Morreale.

...

"Medical students have typically been extremely successful throughout their prior academic and professional experiences, and it can be difficult for them to ask for help when they struggle," Dr. Shanafelt said. "They may be reluctant to access these [counseling services] because of confidentiality concerns."

The University of Pittsburgh School of Medicine offers students free counseling. And the school recently piloted a Web-based depression and stress screen.

"When [students] fill it out, I get an e-mail alert," said Lee Wolfson, a psychologist with the school's counseling program. "I send feedback to the student and can have an Internet dialogue."

Liselotte N. Dyrbye, MD, lead author of the Annals study and assistant professor of internal medicine at the Mayo Clinic, said the study "suggests that burnout is reversible. We need to look at those who do recover and what makes recovery possible."


"Factoids on "Contemplating suicide"
More than 2,200 medical students from seven medical schools participated in a study on whether they had suicidal thoughts.

"Ever considered suicide 25.1% Yes, 74.9% No
Ever made suicide attempt 1.9% Yes, 98.1% No
Considered suicide in the last year 11.2% Yes, 88.8% No

"Source: "Burnout and Suicidal Ideation among U.S. Medical Students," abstract, Sept. 2, Annals of Internal Medicine (www.annals.org/cgi/content/abstract/149/5/334 ).

**** What do these stats mean? If we extrapolate the survey results from the study above to all medical students and schools, then 1.9% of the ~70,000 medical students currently enrolled in U.S. medical schools ever made a suicide attempt. It isn't clear if all those attempts happened while enrolled in medical school. Let's assume that 50% of those suicide attempts occurred in medical school sometime during a 4 year program. If we distribute these over the 125 medical schools then we get 70000 med students x 1.9% ever attempted suicide x 50% attempted while in med school (assumption) / 125 schools / 4 years = ~1.3 suicide attempts occur at every medical school per year on average. Of course, not all would be lethal or evenly distributed by school. Moscicki (2001) determined that there are between 8 and 25 attempted suicides for every suicide death. Medical students might be more likely to be lethal due to their understanding of the human body (let's say 8:1). That brings us to 1.3 / 8 attempts = 0.166 lethal suicides per school per year or about one lethal suicide per medical school every six years on average. That's roughly in line with numbers like one suicide every 10 years at a medical school that I have heard quoted before. Totalling that across all 125 medical schools, we would expect 21 medical students to commit suicide every year for ~170 suicide attempts per year. These are rough estimates and I hope we will get accurate, downward trending data someday soon.

**** I do find these stats unacceptably high with respect to suicide risk. We need to do something about it. If that's considered paternalistic (or maternalistic as the case may be), I'm fine with that. I would rather have some extra pater/maternalism than having my collegues taking their own lives for no justifyable reason.

This has been happening across the country for many years. Here is another article about a first year student who took her life midway through the first year. I don't know how many 1st year students need to take their life about mid-way through medical school before wake up to this issue and correct it.

http://www.thecrimson.com/article.aspx?ref=102610

Tired, with respect to your offhand comment in a previous message ... if you think about suicide just about about every day and you think there is nothing wrong with that, it doesn't mean anything to you, and is not worth doing anything about, I'm sure you'll find yourself in a minority on that opinion, particularly if you discussed this with physicians who are an experts in this area. I would suggest that you do talk to a counselor at your school about that. Of course you might be reluctant to do so because if you were found to be depressed, then by your own value system you might not be cut out for medicine. This is wrong thinking. Depression is often treated very successfully. Even depressed people who do not take their own lives often don't live up to their full potential if they don't get treatment. You may be holding yourself back by not getting help. Getting help could very well save your life someday. It might help you save the life of someone you do care about. Just because someone has depression doesn't mean that they cannot be an excellent physician; nothing could be further from the truth. Take care.

 

[sirus_virus]

Taking it one step further, right now we have something like 400 U.S. physicians commiting suicide every year. That's about two medical school classes killing themselves every year. If we could nip this in the bud in medical school by promoting healthier stress coping and eliminating unnecessary & unproductive stresses, we would have less of a physician shortage and be better able to fulfill our public mission.

But this will involve eliminating the bulk of medical school and residency. Most of medical training is unproductive and borderline ridiculous.

 

[dnagyrase]

Again, perhaps this conversation would be more fruitful if everyone would refrain from speculation, inappropriate sarcasm, and discuss the issue at hand. Thanks.

To follow up on this: I really don't think it is productive to bring the perceived reputations of specific medical institutions into this discussion. If there is some specific tangible thing about the school's medical education program, that might be up for discussion.

Some might have a tendency to think that the name of the medical school has a huge defining mark on the personality type of the people who attend that school. I think that is so much garbage. I attend a school that has a reputation in Texas as being "hypercompetitive" and a "gunner" school. But every class here and at every medical school is made up of so many different types of people and not stereotypes. Even within a school, the personality mold of one class can be different from the other classes (even though the school hadn't changed any of its admissions preferences). As MS1s, we are all going through so many of the same issues. Lets just focus on the dynamics of those issues.

To the people at Baylor who are reading this: I know many people at UTSW took pause at hearing the news as we have many friends who attend BCM. Our hearts, thoughts, and prayers are with the BCM community.

 

[phospho]

As a person familiar with the Baylor culture, I am going to disagree with your assessment. The culture of the departments and residency programs are separate and are not the issue here. The medical school is far from "hard core" as you are impling. Again, perhaps this conversation would be more fruitful if everyone would refrain from speculation, inappropriate sarcasm, and discuss the issue at hand. Thanks.

To follow up on this: I really don't think it is productive to bring the perceived reputations of specific medical institutions into this discussion. If there is some specific tangible thing about the school's medical education program, that might be up for discussion.

Some might have a tendency to think that the name of the medical school has a huge defining mark on the personality type of the people who attend that school. I think that is so much garbage.

Please don't get me wrong. I am in no way trying to belittle anyone's reputation. However, we are talking about two suicides in 20 years. How do we know if this is too much or too little? If you can give me the name of another allopathic school in the U.S. who has had more suicides in the last two decades, then I will be quiet. There is something inherently wrong with your system.

P.S. my heart goes out to everyone involved.

 

[Orthodoc40]

I completely agree with you. I'm still shocked that there have been two medical student suicides in two different schools recently (Baylor and KU), and there is absolutely no media coverage at all.

you would think that for the sake of public awareness, someone would at least "consider" mentioning those few med students who killed themselves.

I asked about that this summer when someone at our school was found dead one morning only 6 weeks after beginning classes. To be clear, the cause of death was never revealed to us.

Aside from respecting family wishes, schools give the least amount of information to students (and anyone else) as possible because they know there is often an occurrence of 'copy cat' suicides. The intention is to protect others who might be encouraged to go ahead with it themselves. Suicide among med students, residents, physicians is actually not that rare. Which school it happens at this year or next year isn't really relevant.

They almost will always set up extra support for classmates.

 

[anoncurious]

Please don't get me wrong. I am in no way trying to belittle anyone's reputation. However, we are talking about two suicides in 20 years. How do we know if this is too much or too little? If you can give me the name of another allopathic school in the U.S. who has had more suicides in the last two decades, then I will be quiet. There is something inherently wrong with your system.

P.S. my heart goes out to everyone involved.

Harvard had a medical student commit suicide in 2000. Another student commited suicide at the medical school in 2007 (in fact, it was exactly one year ago from tomorrow). This information is simply what I found through google. This is also the first school that I googled; I'm sure there are many more (including the school that you would be lucky enough to attend). Note that none of the suicides at BCM were found through google..just how many more unpublicized suicides are present at other schools we will never know.

Now please stand by your claim and stop illogically bashing other schools.

 

[Jolie South]

Please don't get me wrong. I am in no way trying to belittle anyone's reputation. However, we are talking about two suicides in 20 years. How do we know if this is too much or too little? If you can give me the name of another allopathic school in the U.S. who has had more suicides in the last two decades, then I will be quiet. There is something inherently wrong with your system.

P.S. my heart goes out to everyone involved.

Frankly, I'm a little offended by your need to lay a certain reputation on my school, especially as a pre-med.

I guess I'm a little sensitive regarding this situation, but if anyone had told me this would happen before it did, I would absolutely have dismissed it. Seriously, my class doesn't have a "gunner" feel to it and the faculty was super supportive even before the suicide. I don't feel like there was anything inherently horrible about the environment that encouraged this.

You're looking to see something that isn't there. Sure, there are a good number of people that are stressed out by med school, but there are also a good number of us that are happy to be here. I actually like going to school and am generally happy with what I'm doing. That's not to say that there aren't moments when I'm annoyed with something or wish I had more free time to spend with my husband. That's the nature of the beast, regardless of the school you attend.

 

[OncoCaP]

Frankly, I'm a little offended by your need to lay a certain reputation on my school, especially as a pre-med.

I guess I'm a little sensitive regarding this situation, but if anyone had told me this would happen before it did, I would absolutely have dismissed it. Seriously, my class doesn't have a "gunner" feel to it and the faculty was super supportive even before the suicide. I don't feel like there was anything inherently horrible about the environment that encouraged this.

You're looking to see something that isn't there. Sure, there are a good number of people that are stressed out by med school, but there are also a good number of us that are happy to be here. I actually like going to school and am generally happy with what I'm doing. That's not to say that there aren't moments when I'm annoyed with something or wish I had more free time to spend with my husband. That's the nature of the beast, regardless of the school you attend.

I can see why a pre-med would be nervous about this kind of thing. The key point that every pre-med should realize is that medical school will most likely challenge every student, no matter how smart they are. Unfortunately, exceptional students often do not get help when they need it, and, even more unfortunately, sometimes the medical culture seems to suggest that suffering is just part of life and the student should just deal with it. It almost seems to get worse the better the student is. If every medical student got help when they felt depressed or totally stressed out and was honest and open with their counselor, we would see the suicide numbers drop dramatically. The trouble is, of course, that exceptional students may never have had to do that before and it can be almost impossible to swallow the pride and say that they have an issue they can't figure out. It's important to get help when you feel inadequate, feel like a failure, or can't figure how to go on. It could happen and when it does, it usually turns out that things are nowhere near as bad as they seem. Like essentially every medical school, BCM has excellent counselors and faculty who are available to help, but they can't do that if a student refuses to tell anyone that they need help. The student has to take that first step. Those who do take those steps get help and those who don't suffer alone, sometimes tragically so.

I estimate that we have 20 suicides per year among medical students across the U.S. (see calculations above). Needless to say, we hear nothing about all but a few of those. When we do hear of suicides we should not assume that this is an extremely rare situation. It's not. It happens far to often, not just in medical schools but also elsewhere. People who commit suicide almost never want to die. They are often extremely distressed and don't see a way out without hurting their pride, feeling embarrassed or being forced to confront something they don't want to deal with. So instead, they hurt the people who love them most. It's not a solution at all. It just transfers the pain to the people who care the most about them. Again, there is absolutely no reason to suffer or hurt oneself in medical school. There are lots of people there to help but they can't do that if they student pretends that everything is just perfect.

 

[OncoCaP]

Assuming those numbers are actually high.

And anecdotally, they don't really seem to be.

Will post a longer reply tomorrow, but it just seems like you're manufacturing a problem where there isn't one.

When was the last suicide at your medical school?

 

[Docere]

I didn't know this person very well though we did know each other since we went to the same high school. Heard about it the day it happened. I wish his family and his friends the best.

And thank you for all the insightful articles everyone has linked/posted.

 

[Orthodoc40]

The key point that every pre-med should realize is that medical school will most likely challenge every student, no matter how smart they are. Unfortunately, exceptional students often do not get help when they need it, and, even more unfortunately, sometimes the medical culture seems to suggest that suffering is just part of life and the student should just deal with it. If every medical student got help when they felt depressed or totally stressed out and was honest and open with their counselor, we would see the suicide numbers drop dramatically. The trouble is, of course, that exceptional students may never have had to do that before and it can be almost impossible to swallow the pride and say that they have an issue they can't figure out.

^A huge key to your good points.

To add something into the mix here, most medical students are also in the age range where (if it is going to happen) they will have their first psychotic break. People see the need and supply the treatment needed.

Depression with suicidal ideation is something that we all can't pick out of a crowd of 300 classmates. Know what it looks like - especially know what it sounds like - and know your best resources.

 

[Jolie South]

I can see why a pre-med would be nervous about this kind of thing. The key point that every pre-med should realize is that medical school will most likely challenge every student, no matter how smart they are. Unfortunately, exceptional students often do not get help when they need it, and, even more unfortunately, sometimes the medical culture seems to suggest that suffering is just part of life and the student should just deal with it. It almost seems to get worse the better the student is. If every medical student got help when they felt depressed or totally stressed out and was honest and open with their counselor, we would see the suicide numbers drop dramatically. The trouble is, of course, that exceptional students may never have had to do that before and it can be almost impossible to swallow the pride and say that they have an issue they can't figure out. It's important to get help when you feel inadequate, feel like a failure, or can't figure how to go on. It could happen and when it does, it usually turns out that things are nowhere near as bad as they seem. Like essentially every medical school, BCM has excellent counselors and faculty who are available to help, but they can't do that if a student refuses to tell anyone that they need help. The student has to take that first step. Those who do take those steps get help and those who don't suffer alone, sometimes tragically so.

I estimate that we have 20 suicides per year among medical students across the U.S. (see calculations above). Needless to say, we hear nothing about all but a few of those. When we do hear of suicides we should not assume that this is an extremely rare situation. It's not. It happens far to often, not just in medical schools but also elsewhere. People who commit suicide almost never want to die. They are often extremely distressed and don't see a way out without hurting their pride, feeling embarrassed or being forced to confront something they don't want to deal with. So instead, they hurt the people who love them most. It's not a solution at all. It just transfers the pain to the people who care the most about them. Again, there is absolutely no reason to suffer or hurt oneself in medical school. There are lots of people there to help but they can't do that if they student pretends that everything is just perfect.

I agree. The point I was trying to make, albeit ineloquently, is that this could have happened at any school. There was nothing particularly malignant about the environment. I obviously don't know all the reasons behind why this person did what they did, but there were resources and he didn't reach out for them.

It's really hard to understand what med school will be like until you are there. Going in you'd probably never believe that you could be at the bottom of the class. However, with the amount of material and the manner with which it's introduced and tested, this is a possibility. Figuring out how to study isn't as intuitive for some as it is for others.

I can understand how someone would be distressed by hearing about this from the outside. I apologize for overdramatizing things in my previous post.

 

[DoctorDreamer]

I agree. The point I was trying to make, albeit ineloquently, is that this could have happened at any school. There was nothing particularly malignant about the environment. I obviously don't know all the reasons behind why this person did what they did, but there were resources and he didn't reach out for them.

It's really hard to understand what med school will be like until you are there. Going in you'd probably never believe that you could be at the bottom of the class. However, with the amount of material and the manner with which it's introduced and tested, this is a possibility. Figuring out how to study isn't as intuitive for some as it is for others.

I can understand how someone would be distressed by hearing about this from the outside. I apologize for overdramatizing things in my previous post.

Jolie, you know I agree with you. But, on a very important note, what on earth are you doing up at 4-something in the morning?

 

[midn]

I agree with what others said in response to this, but also - the school that you are thinking of is UT Southwestern, not BCM.

Come now, let's not spread rumors.

 

[mercaptovizadeh]

The curriculum needs to be changed not because of suicide but because it is inefficient. Any rigorous curriculum will be stressful but when it is inefficient and ineffectual and downright absurd, that only exacerbates the stress.

I have no evidence to back this up, but I firmly believe that there are two major reasons that make medicine different from other professions and that lead to the elevated suicide rates:

1.) Insane indebtedness making it extremely difficult for a student that has completed one year, much less two or three, to simply quit when they figure out this is not the profession for them. Law has a pretty high degree of indebtedness and probably not quite the suicide rate, so that cannot explain it all. I would wager that the suicide rate of people who have financial relief, such as those on scholarship, MD/PhD, etc. is probably lower.

2.) The "medicine as a calling" or a "meaning of life" phenomenon. Few electrical engineers or businesspeople feel that their jobs are a calling. Medicine has an almost religious aura of "saving people." When these delusions (which I endorsed at one time) are shattered by the drudgery and the reality of endless study, inefficient practices, noncompliant patients, abusive teachers, spiteful peers, etc. it can be hard to accept all the pain for little reward. It would be much healthier if students approached medicine as "just another profession," rather than a calling *before* they start the program.

 

[Jolie South]

Jolie, you know I agree with you. But, on a very important note, what on earth are you doing up at 4-something in the morning?

Don't you know that block exams are in two weeks?!!

J/K I really have no idea. I just woke up and couldn't go back to sleep. *shrug*

 

[OncoCaP]

The curriculum needs to be changed not because of suicide but because it is inefficient. Any rigorous curriculum will be stressful but when it is inefficient and ineffectual and downright absurd, that only exacerbates the stress.

I have no evidence to back this up, but I firmly believe that there are two major reasons that make medicine different from other professions and that lead to the elevated suicide rates:

1.) Insane indebtedness making it extremely difficult for a student that has completed one year, much less two or three, to simply quit when they figure out this is not the profession for them. Law has a pretty high degree of indebtedness and probably not quite the suicide rate, so that cannot explain it all. I would wager that the suicide rate of people who have financial relief, such as those on scholarship, MD/PhD, etc. is probably lower.

2.) The "medicine as a calling" or a "meaning of life" phenomenon. Few electrical engineers or businesspeople feel that their jobs are a calling. Medicine has an almost religious aura of "saving people." When these delusions (which I endorsed at one time) are shattered by the drudgery and the reality of endless study, inefficient practices, noncompliant patients, abusive teachers, spiteful peers, etc. it can be hard to accept all the pain for little reward. It would be much healthier if students approached medicine as "just another profession," rather than a calling *before* they start the program.

You raise some interesting questions that merit further study. Although I don't have any of the data you want, I do wonder whether it is really necessary to take such a "low" view of medicine. I realize lots of people hate medical training, and I'm fine with that. Most people hate their job but like the money so it's worth it to them. It's not necessary to love what you do. What puzzles me is why one would continue the relationship ... like staying married to an abusive spouse unless there really is not better alternative (life has a certain level of boredom and stress). Maybe find something somewhat lower paying but much more enjoyable. Live a little simpler.

With respect to debt, do you actually know anyone who decided to ditch medicine and lived a life of misery due to the debt? The people I'm aware of that ditched medicine after 2nd year, etc., either are doing fine or made many times what they would have made as a physician and had no difficulty paying back their loans (I don't know if they paid the loans back, just that some are very rich and doing something they really love). I haven't heard of a single person who left medicine and felt crushed by the debt. I realize it's no fun to pay off a huge debt on a small income, but to live a life of misery sounds even worse. Lots of people have bad credit; it's not a showstopper. Sometimes when you're in a hole it's better to stop digging. I realize that probably no med student would feel comfortable walking off the well-marked path (we are all well trained, mostly), but perhaps if some people would start to do it, it might reduce the misery.

With respect to the "...delusions (which I endorsed at one time) are shattered by the drudgery and the reality of endless study, inefficient practices, noncompliant patients, abusive teachers, spiteful peers, etc. it can be hard to accept all the pain for little reward," again, I would ask the question ... why not just walk away? There is no reason to stay doing something you hate. Just walk out the door and don't come back. Find something you love and do that. Even after you graduate, just because you have an MD doesn't mean you must practice as a physician or even do a residency. Other career options such as becoming an attorney, working for pharma, teaching school, running for public office, or working for a medical software companies are out there. With a law degree you could spend your life suing the physicians who are ruining the medical care system by providing incompetent care, abusing students, and inflict tremendous pain on the carcinomas of health care that might even improve the situation (just make sure you defend the good physicians ). Again, many of these other options don't pay well, but if you are selling your soul to make a wad of cash, you should not expect 100% happy times on the job. Many high-paying jobs have a stressful downside; the least we can do is to find something where there is at least some compatibility (preferably a lot).

If you do have a very strong motivation for doing something (a "calling" or a dream), it seems like it could help you push through those dark times, especially if you make sure you build a network of people who care about you and vice versa.

 

[OncoCaP]

I am not aware of there ever having been one. I'm sure there has at some point, but I never heard any stories about it, and there were none while I was there (or since, as far as I know).

How about we look at this from a numbers standpoint.

There were almost 17,000 students graduated from med school last year, so we can estimate about 68,000 students total in the U.S. at any given time in the 155 accredited MD and DO schools.

The baseline suicide population in the U.S. is 18.5 per 100,000 per year. So we would expect, at baseline, about 13 suicides every year in the med student population, or approximately 1 every 10 or so years at any given school.

Baylor has had 2 in 20 years, which is right in line with the expected rate.

So my question remains, if the suicide rate among medical students is right in line with the general population, do we still need all these programs?

That's good that your school hasn't had any in recent memory.

A 13 suicide per year "baseline" based on incoming students sounds about right (although, as you know I don't like it). However, I suspect medical schools are closer to 21 suicides per year nationally as I explain above. Until someone gets permission, authority and funding to measure this accurately for the purpose of developing or recommending effective suicide prevention among medical students or another worthy goal, it will be difficult to know whether we have more suicide than comparable college classes (non-medical programs) or not.

One suicide about every ten years or so (comparable to other schools?) is how it was at BCM until this year. Supposedly before this year, the last suicide at BCM was about 10 years ago (~1998?). At BCM we had a suicide in January 2008 and another this month, November 2008, both were MS1's about midway through their MS1 year (two consecutive classes). That's roughly 3 suicides in 10 or 11 years with the last two in just one year (the current one, 2008). It's the two in one year that are the shocker ... well beyond anything anyone here at BCM or anywhere else is even remotely comfortable with.

There will be changes to address this and I'm confident in the ability of the administration. Some sensible improvements are already planned and more are being worked out from countless ideas that have been contributed. The administration here is very good and considers all the factors and various student concerns when they make their plans. (They recently worked around the situation with Hurricane Ike in a very efficient & humane way). They are very capable. When the suicide in Jan 2008 occurred at BCM, there was no obvious reason to believe that we were seeing anything beyond the unfortunate suicide every 10 years that apparently all schools have, more or less (cold as that may sound and I'm certainly not even remotely "satisfied" with one suicide every 10 years but apparently is not so easy to do better than that). When we had the second one this year in 2008, it was a shock which I have heard will lead to very carefully developed changes that several world experts in this field of psychiatry dealing with physicians and medical student issues are currently working on. The difficulty is ... what exactly should the changes be and will they really work? Well meaning efforts don't necessarily produce results, especially when you are dealing with fighting an adverse outcome that is rare at any one school. If we have no more suicides for a while, it doesn't necessarily mean we made the "best" or most necessary improvements ... if we have another suicide (heaven forbid), it doesn't mean that BCM hasn't taken the best most amazing steps. Also, there is there anything we can learn here so that other schools don't need to go through this awful experience? Will the steps BCM takes, no matter how well thought-out and well-intentioned really prevent all suicides if, for example, suicide is going up among college students overall? We could have more suicides if the mental health of incoming MS1's nationally is worse even with the best prevention programs.

Many of the stresses (grade distributions and such) have been proven to drive people to do their best ... to study hard so they get those great board scores and learn their stuff and get into the top residencies. It's not trivial to know how to motivate students to learn a mountain of material and perform very well compared to other schools nationally on a consistent level. The rumor I heard (and I really hate to repeat rumors, but even if this turns out not to be true it sort of makes sense), at BCM they tried a true pass/fail program a while back and board scores went down from what I heard ... not enough stress to study as hard, I guess. They went back to the Honors/high pass/pass/marginal pass/fail scale (several years ago from what I understand) because they were able to show that students performed better on national boards. This is a rumor and I could be getting this wrong. However, if this rumor is true (and I'm not saying it is), spreading out the grades somewhat was a compromise because the pass/fail hurdle is still humane, but to make consistent honors is a demanding task. BCM is by no means unique in spreading out the grades and they don't require that there be a certain number of honors (limited) like some schools do.

From what I have read, suicide rates on college campuses are going up, and so the situation BCM is faced with could simply be due to suicide increasing for all 18-24 yr olds and BCM just having the bad luck of having two very rare events happen back to back (if you flip a coin 10 times and it always winds up heads, is it just a rare event or is the coin "rigged"? Occam's razor doesn't always work and sometimes patients have both ticks and fleas (there could be multiple issues; various possibilities must be considered). No one is waiting around treating these deaths as random. That's why I think we need good measurements because even saving a few lives of students is worth a significant effort.

In any case, I hope we can figure out how to motivate students to do their best and get students who are distressed the help that they need and compete to their full potential as well. I have a great deal of confidence in our administration. They are very capable and very committed to the well-being of the students. That's what has made BCM a fun place for most (probably the overwhelming majority) of us. This situation with the suicides is an issue all medical schools face to some extent and BCM has reached a point were it will take intelligent steps toward significant improvements in medical student mental health and suicide prevention (and services were already excellent and certainly on par with other medical schools). I can't think of anything that inherently more stressful at BCM than other schools and many many things that make BCM seem less stressful. I just wish there was better data out there on the national extent of the problem and what is working well and what isn't. It seems very difficult to know how well a suicide prevention program is working because some talented students will commit suicide no matter what you do (some geniuses are very troubled souls). It's not until you look at a large population that you have any hope of drawing any scientific conclusions about whether the steps you are taking at a school level are making any difference.