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Students’ time in medical school should help them grow and become insightful, caring doctors. Instead, medical education is somehow turning smart, gifted, enthusiastic applicants into exhausted and unhappy students who become interns, residents, and physicians at increased risk of depression and burnout.

I’m no stranger to the demands of medical school. My father and father-in-law were both doctors. I’m a pulmonologist, my wife is a nephrologist, and we have a son who is an internist and another who is in medical school. These issues are personal to me. As the dean of a medical school, they also focus my efforts to modify the learning environment to keep pace with new generations of students.

As difficult as it is to quantify, my sense is that medical education seems vastly more rigorous and traumatic for students today than it was for me, and possibly for the generations before me.

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In a 2014 study from the Mayo Clinic and Stanford University, more than half of all U.S. medical students had symptoms of depression, and 56% reported themselves to be burned out. The same study found that medical students were two to five times more likely to have clinically significant depression than similarly aged college graduates pursuing other careers. Indeed, a 2016 meta-analysis showed that the rate of depression in medical students in 47 countries was 27%, far higher than rates in the general population.

This raises concerns about how effectively medical students with psychological distress will take care of future patients. It also invites the question of how medical education contributes to this disturbing trend.

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For many generations of students, medical school has traditionally promoted a culture of self-sacrifice over self-care. Pressure to perform academically is relentless. Reaching the point of being able to practice medicine is the overriding focal point, even in the face of frustration and fatigue over long hours studying a tremendous volume of complex information, learning to treat patients, and tackling other unfamiliar challenges.

Compounding the problem, students entering medical school have long been accustomed to being the best academically, but soon discover they’re surrounded by others who are equal, or even better, academically. Though successful, many get overwhelmed — an experience that law students, biomedical graduate students, and other professional students also relate to.

Students can easily lose track of why they wanted to become doctors in the first place. They may see any admission of vulnerability or exhaustion as signs of inadequacy compared to their peers. And those who get depressed or anxious often feel ashamed, doubt their own abilities, and tend to keep it to themselves instead of seeking professional help.

The good news is that some medical schools and professional societies are taking steps to improve well-being and resilience among students. They’re taking closer looks at whether current learning environments are a major contributor to the problem. Educators are paying particular attention to common stressors in medical education, including the curricula, the role of standardized testing and competition among peers, and the transition to residency, to assess if academia is keeping pace with the ways newer generations learn or function. The common goal is to more fully recognize and understand issues such as burnout and adapt the system to better support students, residents, and physicians alike.

Take the mental health care program at the University of Pittsburgh School of Medicine, a progressive approach described last year in the New England Journal of Medicine. About 1 in every 6 students there receive mental health care services. Students need this kind of outlet, in which they can feel comfortable opening up, seeking support, and breaking through the silence that accompanies stigma.

At Weill Cornell Medicine, where I work, the number of medical students reaching out for appointments with psychiatrists has increased by about 60% in the past four years. And we have expanded our free counseling and mental health services to match this rising need.

My conversations with deans and administrators at other medical schools informally confirm this promising trend in medical education. In addition to more medical students getting the treatment they need for emotional difficulties, including medication or talk therapy, more are coming to better understand the humbling experience of being a patient and increase their capacity for empathy.

Next month, as a modest next step, Weill Cornell will host the first National Conference on Medical Student Mental Health and Well-Being, in partnership with the Association of American Medical Colleges, the Associated Medical Schools of New York, and the American Foundation for Suicide Prevention. Medical school administrators and faculty members, mental health professionals, students, and others will convene to identify innovative approaches to resilience training and mental health treatment that can be implemented at medical schools around the country.

But we need to do much more to reform the medical education system. The central challenge is to help students develop resilience.

First, schools should integrate comprehensive wellness and mental health support into the learning environment. One strategy Weill Cornell Medicine plans to implement is to assign all medical students to advisory groups that include physician wellness mentors. These coaches can act as role models for coping with adversity and stress during the training period and beyond.

Second, medical schools should commit to documenting and reporting anonymized data about psychological distress among medical students. This will help further destigmatize it, allow us to better understand its causes and extent, and develop new solutions.

Third, medical schools should evaluate shifting to a pass-fail grading system. A major source of stress for medical students is academic. The competitive pressure to achieve top grades and honors runs directly counter to establishing healthy relationships among peers. Many institutions are already moving toward a pass/fail approach during all four years of medical school, according to the Association of American Medical Colleges.

Fourth, researchers should conduct studies to pinpoint the causes of mental health issues among medical students — and, equally valuable, trace any links, internal and external, between stressed-out students and burned-out physicians. Teasing out cause and effect could enable institutions to better promote clinician resilience.

Despite these challenges, I’m optimistic. Medicine remains one of the most respected professions and continues to attract talented, idealistic students eager to make a difference. The millennials now enrolled in medical school are generally more willing than prior generations to admit to facing stress and seek help, and are more likely to see burnout as systemic rather than fault themselves for an inability to cope.

It’s past time for adding the dimension of self-care to formal and informal medical education curricula. Only if medical students learn to take care of themselves will they ever truly excel at caring for others.

Augustine M. K. Choi, M.D., is the dean of Weill Cornell Medicine and provost for medical affairs at Cornell University.

  • Another major factor is that students come to medical school to care for patients. They soon get inundated and intoxicated by biomedical science, losing sight of the reasons that they wanted to be doctors- to care for, to connect with, to share in the humanity of patients and their families. More of that connection with real patients early and in a sustained way might be a buffer against burnout. Let’s study that!

  • “…scientific medicine in America…is today sadly deficient in cultural and philosophic background. …The imposition of rigid standards by accrediting groups has made the medical curriculum a monstrosity, leaving medical students little time to stop, read, work or think.”
    – Abraham Flexner, 1925 (15 years after publication of the Flexner Report)

  • Medical education is broken from admissions through curriculum and evaluation. Surrogate markers of MCAT and sGPA select for non-resilient and emotionless students, rather than compassionate physicians. The academic ivory tower persists in teaching, or rather, hazing students in irrelevant minutia, while residency programs put 90% of selection criteria on culturally-biased, standardized exams. To add insult to injury, the minutia is taught poorly and not relevant to either board exams or medical practice. This seems to be an American issue and could be addressed by the more realistic and practical medical education models in Europe and other parts of the world (6 years post high school, easier admission, emphasis on primary care and service). Unfortunately, I don’t see the educational-medical-industrial complex (looking at you, Cornell), changing anytime soon.

  • ‪ “First do no harm.” (Hippocrates). Medical schools need to change toxic culture by a culture of well-being and appreciation of human factors in medical practice.‬

  • The crap one goes through in Med school is easier as compared to residency. Which is possibly not as bad as being an attending. I’d say it’s just a primer of the miserable existence that they’re going to endure. About 1 in 100 doctors I know would actually recommend becoming a doctor.

  • This article said nothing about the all too common abuse medical students endure from attending physicians and educators.

  • Dr Choi, I completely agree with you and appreciate your article especially coming from a Dean of a medical school. The system promotes this dysfunction by using USMLE scores to ‘weed’ applications for residency etc.

  • Many students are opting out of formal medicine due to cost and stress. Instead of joining AMA they are developing medical DNA analytics and machine learning. Many of my cohorts at the US Human Genome Project saw medicine as a lucrative dead end. With doctors studying yesterdays news and selling it to unsuspecting patients. Oncotype DX and Mammaprint revolutionized breast cancer diagnosis and treatment. It was developed by biologists and computer scientists. Oncology will be forever changed by DNA analytics. CRISPR will forever change many other medical professions. The single biggest medical problem is not doctors but technical staff that can learn and utilize this new tech. Jupyter notebooks and scikit-learn may be an example. High school students are now learning this a NM Supercomputer Challenge.
    https://www.anaconda.com/distribution/
    https://www.nmtechworks.com/supercomputing-challenge.html

  • Dr Choi, I respectfully dissent. My clearly alluding to your family intergenerational ties to the medical field a big red flag popped up. Having a physician parent or relative ( usually in the parlance of the 12 step program sense of the concept of the family hero) can be an issue in and of itself.
    Second you also really showed the incestous nature of the entire medical field by cultural, ethnicity, and socioeconomic class.
    Thirdly, by using psychiatry which I am guessing is not the type practiced by Rachel Naomi Rumen MD who specifically worked with medical students, and mentioning medication use um maybe in and of itself you are playing to the hands of Big Pharma- a pill for every medical student!
    Fourthly, Trauma ir secondary or tertiary forms are excluded- why?
    The classic first trauma medical school tale is of the dissection lab and really how many first year year medical students have either run out or vomited during work with the dead corpse? The first death, as Dylan Thomas wrote-“ after the first death there is no other”- and the first error, the first night on call- one medical resident had his wife come in and sleep with him- the first too much to drink glass or the first close call I will take just two extra. And the kisses in the stairwell not seen because intentionally not looked for. Trauma or as some say human life abounds.
    I would strongly recommend two courses of first action. Do a thorough research and bibliography on trauma say with Dr. Gabe Mate and others, possibly dip into the writings of former docs or docs that wrote while working such as Walker Percy MD, William Carlos Williams MD and Dr Paul Farmer MD to name a male few.
    Then ah Maria Montessori MD. Her work and her thoughts on education and learning might be invaluable.
    Fifthly, look into your own culture and family and know the why if your choice to enter the medical field. For my father, it was seeing his oldest brother being taken to the hospital called the pest house and never seeing him again alive. There are always seed and root stories.And lastly, read T. S. Eliot’s “The Four Quartets” his thoughts might help clarify things for you.

    • I took pre-med but opted out of the idea of going to medical school, because of the lack of nutritional and herbal education, which in my view should be the main load of the course, specially when you consider that people today are moving away from drugs as therapy. I would certainly become depressed and frustrated in that scenario. Yet nobody dares to talk about this issue. Although drugs can save lives, is a failure when it comes to chronic deseases. So each should hold the correct measure of importance in the curriculum. This generation is aware of this problem but the veto on talking about still goes on. No wonder they have been driven to insanity.

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