Physicians are trained to be guardians of health. Throughout our medical training we learn the ins and outs of the human body and what we can do to preserve health and wellbeing. However, that training is becoming ever more hypocritical. We are taught that sitting for long periods of time is unhealthy, yet we are expected to sit through hours of lecture and study;, we are taught that chronic stress can have serious implications for overall health, yet we are subjected to workloads that induce stress day after day. Beginning from the first day in medical school, to the last day of practice, a medical career requires students/physicians to sacrifice their own health for the sake of their patients. According to US News, a career in medicine is considered the most stressful career in the United States1. With that stress comes a series of mental and physiological conditions that many physicians struggle with daily, beginning as early as day 1 of medical school.
Why does this hypocritical paradox exist? Well, at the medical school level it begins with institutions attempting to produce competent, well-rounded physicians when entering residency. This places a heavy burden on students to ensure they are adequately keeping up with the material and performing on exams. A recent meta-analysis of 195 articles illustrated an overall prevalence of 11.1% for suicidal ideation in medical students, 44.6% scoring high on the burnout index, 28.0% reported an intermediate burnout level, 58.2% screened positive for depression, and of those positive screenings, only 15.7% sought treatment2,3. These numbers are jarring to see as it indicates that more than half of every medical school class suffers from depression and so few receive treatment. There are multiple proposed reasons why indicators of poor mental health are more prevalent amongst the general medical student population. The rigor of current medical education, curricular format, the belief that students must be ‘strong’ enough to handle stress to succeed, and the lack of attention given to mental health in comparison to physical health problems are all contributing factors2. However, the effect of each individual component is still unknown. Despite this, proactively attempting to ameliorate stress by helping students manage rigor, changes to curriculum such as pass/fail grading, support for struggling students, and promotion of student wellbeing may serve to decrease these numbers4.
Once graduating medical school, students leave behind the stressors of their medical school days and enter the world as physicians with a whole new set of stressors that negatively impact health. Residency and fellowship have long been thought to be exceptionally stressful times in a physician’s career. During training, long work hours and financial hardship are coupled with complicated and often emotionally difficult situations with patients as well as colleagues5 6. These new stressors all working in tandem have significant implications on physical and mental health. Recent studies on residents have shown similar numbers to what has already been seen in medical school. In one study, 158 residents completed a screening where 43% screened positive for moderate to severe depression, 11% screened positive for hazardous alcohol consumption, and 15% endorsed thoughts of death or suicide7. Furthermore, out of 181 resident physicians at McGaw Medical Center of Northwestern University, 61% felt they would have benefited from psychiatric services. Only 24% of those who felt they needed care sought treatment. The most reported barriers to seeking care were lack of time (77%), concerns about confidentiality (67%), concerns about what others would think (58%), cost (56%), and concern for effect on one’s ability to obtain licensure (50%)5. Again, the data reflect morbid results about the quality-of-life individuals who pursue a medical career are expected to have. The concern has sparked many not only to continue research in this field but also make systemic changes to the system to address these issues.
One such change came when the American Association of Medical Colleges (AAMC) announced that the United States Medical Licensing Exam (USMLE) step 1 was changing from traditional numerical scoring to a pass/fail score8. The hopes of this change are to improve student wellbeing and remove the emphasis surrounding the 3-digit score. However, since it is a new change, many researchers are patiently waiting to assess how it will affect students and residency programs alike. Some medical institutions are also doing their part to change their curriculums, providing resources, and supporting their students to address the concerns surrounding student health and wellbeing. Another change sweeping the United States is removal of the requirement to disclose psychiatric history for licensure9. Although the change is still heterogenous, many states have adopted this policy in line with the Americans with Disabilities Act9. The change is intended to encourage physicians to seek mental health care without the fear of losing or not obtaining licensure. As stated previously, half of the residents were discouraged form seeking proper care because of concerns regarding licensure. Students, physicians, and institutions alike should all advocate for more changes to improve the quality of life for those striving to become doctors. Physician health is equally as important as the patients they treat because if we do not take care of our physicians, there will be none left to care for patients.
References
1. Williams G. The 25 Most Stressful Jobs. February 1, 2022, 2022. https://money.usnews.com/careers/company-culture/slideshows/the-most-stressful-jobs
2. Jordan RK, Shah SS, Desai H, Tripi J, Mitchell A, Worth RG. Variation of stress levels, burnout, and resilience throughout the academic year in first-year medical students. PLoS One. 2020;15(10):e0240667. doi:10.1371/journal.pone.0240667
3. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. Dec 6 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324
4. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. Mar 2014;89(3):443-51. doi:10.1097/ACM.0000000000000134
5. Aaronson AL, Backes K, Agarwal G, Goldstein JL, Anzia J. Mental Health During Residency Training: Assessing the Barriers to Seeking Care. Acad Psychiatry. Aug 2018;42(4):469-472. doi:10.1007/s40596-017-0881-3
6. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. Sep 7 2011;306(9):952-60. doi:10.1001/jama.2011.1247
7. Nobleza D, Hagenbaugh J, Blue S, Skahan S, Diemer G. Resident Mental Health Care: a Timely and Necessary Resource. Acad Psychiatry. Jun 2021;45(3):366-370. doi:10.1007/s40596-021-01422-1
8. Katsufrakis PJ, Chaudhry HJ. Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs. Acad Med. Mar 2019;94(3):305-308. doi:10.1097/ACM.0000000000002559
9. Jones JTR, North CS, Vogel-Scibilia S, Myers MF, Owen RR. Medical Licensure Questions About Mental Illness and Compliance with the Americans With Disabilities Act. J Am Acad Psychiatry Law. Dec 2018;46(4):458-471. doi:10.29158/JAAPL.003789-18
