Depression is a serious challenge confronting medical students. There are many contributing causes, from the strenuous work hours to the difficulty of seeing patients suffer and sometimes die. Another cause that has yet to gain traction in the public sphere, but with which medical students and medical school administrators are all too familiar, is the immense difficulty of holding supervising doctors accountable for bad behavior in the hospital.
The numbers on depression are astounding. According to the latest estimate, published earlier this month in the Journal of the American Medical Association’s medical education theme issue, 27 percent of medical students worldwide reported depression or major depressive symptoms, while 11 percent reported having suicidal thoughts.
As a recent medical school graduate, I’ve seen many of my colleagues struggle with depression. It’s often compounded by anxiety, stress, and self-doubt in an already competitive and stressful environment. From numerous conversations with classmates, as well as through my own experiences, I believe that a significant contributor to medical student depression is how difficult it is to report authority figures when they act in an abusive, humiliating, or condescending way to students, staff or patients in the hospital.
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That is the grist for many discussions that administrators, deans, and mentors never hear about. These are the small, quiet conversations that happen between students in the cafeteria over a meal, during late night phone calls after long days on the wards, or when out for some fun on a weekend evening.
At the root of the issue is a culture of hierarchy that protects itself from change by the very nature of how it is organized. Those implicated in inappropriate behavior are often high enough in the hierarchy, with regard to their academic standing and influence, that removing them or enacting any punitive measures would likely come with the threat of professional repercussions, particularly to the student who made the complaint.
Take, for instance, the quintessential example of the established but abusive attending physician (these are the senior physicians on a medical team) outlined in a case study presented in the same issue of JAMA. In this case, the attending aggressively quizzed a student on a difficult medical question and then proceeded to make condescending jokes about the student’s inability to answer correctly. This is by no means an uncommon occurrence, and may be a reflection of the culture from which many of today’s senior physicians were trained. A classmate, for example, told me that an attending surgeon made disparaging comments about her inadequacy in suturing at the end of an operation — the first time she ever did this procedure on her surgery rotation.
Medical students, medical residents, and staff physicians will inevitably bear the brunt of an unhappy (and probably depressed) attending at some point in their medical careers. But there is usually a large deterrent for medical students to report or challenge abuse by one of them: Medical students potentially have a lot to lose given the power dynamic between them and attending physicians.
Students worry that accusing an attending of verbal, emotional, or physical abuse could lead to negative evaluations from him or her on their clinical rotations. If the attending was excluded from evaluating the student, he or she could still talk down the student to colleagues.
One would hope that attending physicians would be willing to accept negative feedback and consider being more conscious of their behavior without seeking retribution. But that doesn’t always happen in the real world. A valid concern for a medical student is this: Could reporting an abusive attending affect his or her chances of matching into a medical residency, particularly at the student’s home institution?
In a medical community that is small, especially in specialized fields, making enemies isn’t smart. So most medical students internalize negative feelings and march onward without addressing the emotional burden of abuse and the impunity of abusers that may be contributing to depression.
Some medical schools aim to maintain the anonymity of complaints, but this offers its own set of challenges. Most people, especially established authority figures such as attending physicians, will want to know the details when told they have transgressed and need to change a behavior. If the physician is given the specifics of the report, he or she can often figure out which student filed it. If the physician isn’t given specifics, it becomes difficult to point out what he or she actually did wrong.
Consistent with the situation at many top medical schools, mistreatment of medical students was a significant issue at the David Geffen School of Medicine at UCLA, where I went to medical school. Its failed efforts to eradicate abuse were highlighted in a seminal paper published in the journal Academic Medicine in 2012. As president of the student council, I was responsible for sharing the views of my classmates regarding their well-being with deans and faculty. Despite the development of an online system of anonymous reporting of mistreatment in clinical rotations, few medical students submitted abuse reports, which we knew was not representative of reality. I had personally heard of numerous incidents in which hurtful comments were made regarding a student’s gender, sexuality, race, or intelligence. These were sometimes passed off by attending physicians as “jokes.”
Hearing how my classmates and friends felt when they could talk safely made it clear to me that these situations were far from joking matters. Yet there was a pervasive fear that even if a student made an anonymous report, there would be no way to ensure that the physician in question would be unable to figure out who had submitted the report. For a student, having to encounter the physician in question in the hospital, the halls of the medical school, or on the local campus could be difficult if the physician discovered which student had reported him or her.
Medical education creates undue anxiety, stress, and depression among students. But more than a low test score or a less-than-perfect evaluation, true pain is inflicted when those we trust to teach and guide us demean, ridicule or dismiss us. The medical community must find better ways to hold authority figures accountable for their words and actions. Until we do this, I don’t expect that we will see a major improvement in depression among medical students.
Abraar Karan, MD, is a master of public health candidate at the Harvard T.H. Chan School of Public Health.