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.
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.
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.