With a few days of 5th year left, I can’t help but sit wide-eyed when retrospecting on how the big dragon of 2017 blew its fiery breath all over my development as a fledgling student Doctor. Fiery it was, and I often compare it to an unnecessary veld fire ignited by a glass beer bottle tossed out by an intoxicated passer-by, and landing in the unforgiving eye of the merciless sun. Thankfully the past 2.5 weeks have been spent in Family Medicine – a rotation which has both rejuvenated me and illustrated by contrast just how intense the past few rotations have been; a welcoming fireman in the foresty blaze that was 2nd Semester.
It makes it incredibly easy to believe that the global prevalence of depression among medical students specifically is as high as 28% [according to a meta-analysis of 77 cross-sectional studies conducted on 62 728 medical students and 1845 non-medical students*]. In South Africa, the stats are much the same with a study published in the SAMJ, conducted on 874 medical students from Tuks, UCT and UFS, revealing that there is a 3 times higher risk of suicidal ideation and attempt among medical students compared to the general age-appropriate South African population, and that 15.8% of said students use mood-enhancing medication [antidepressants], 37.5% reported that “life is not worth living”, 55% reported being so dissatisfied with their career-choice that they have considered changing degrees, and 35% reported that their career choice was ‘incorrect and uninformed’.** These tendencies are far from what should be considered as ‘normal student life’.
Medical students are often intense, perfectionist and competitive by nature, which has manifested in the grossest way since starting SIC, thus it’s plausible that this above-mentioned anxiety and depression is self-propelled – a rogue fuel plane leaking gasoline over the inferno veld below. I believe, however, that this is only an exacerbating factor in a deeply-flawed system, and has much less to do with the student than it has to do with said system.
Medical school is often likened to a ‘pressure-cooker’ – serving a large dish of depression with juicy sides of anxiety and self-doubt – and 3 definite reasons contribute towards this unfortunate buffet of misery:
- The stigma of mental illness:
Mental health is given a low priority even by those professionals who are supposed to understand mental illness the best. Getting time off for a broken arm would be far easier than if it was because you felt crippled by anxiety, melancholy and burn-out. In this system – and it has much to do with the culture of medicine too – disclosing mental struggles of any form and severity would be labelled as one not being ‘capable enough’ of dealing with ‘everyday, ordinary stresses’. Only, in medical school, these stresses are often everything BUT ‘ordinary’.
- The medical school culture:
This is a cut-throat environment, and the apathy by senior Doctors towards your progress can become stifling. Stupidly enough, once you become a medical student the world starts viewing you as some type of infallible humanoid cockroach; never failing or falling ill, and certainly never succumbing to the poison that is the med school environment at times. In this culture, one would be blamed and shamed should one need mental reprieve from time to time, and one is told that: “You knowingly chose a tough degree, thus you must learn how to suck it up and deal with your emotions, or else leave if you don’t feel you are capable emotionally.” Intraining.org summed it up beautifully by saying: “It is ironic that a field that ostensibly should be more enlightened vis-à-vis mental health remains caged by such antiquated thinking…”.***
- Medical school as an inherently-depressing environment:
Throughout the 6 year medical degree, the following risk-factors for depression and anxiety (and other mental illnesses) are strongly prevalent:
- Chronic sleep deprivation (due to clinical and academic duties)
- Constant exposure to illness, death and dying
- Long clinical hours in a high-intensity environment
- Possible relocation in internship, with subsequent loss of major support systems
- Constant role transitions, especially when one enters the final clinical years
- Less room for anti-depressive strategies such as proper eating, exercise and enough time spent with friends/family and relaxing
- Chronic stress in the form of a high-intensity environment characterised by a rigorous daily grind (often with menial tasks and lectures that are way beyond the level of a med student) and a high potential for burnout as one is constantly forced to make sacrifices in many other important areas just to keep abreast of the strenuous medical schedule
- Constant exposure to hostility in the form of haughty consultants, competitive peers and the constant quest to validate one’s abilities against the unforgiving back-drop of each clinical rotation
- Substance abuse – which is what many students unknowingly rely upon to ease the primordial discomfort of an emerging depression/anxiety
These factors alone pose a great risk of developing mental illness to some extent, and against the back-drop of major illness and experiencing some or other major life event – all of which are highly likely within the 6 long years that one is a medical student (marriage, moving, death of a loved one etc.) – this creates for a storm waiting to happen.
The implications are far and great. What was once hopeful drive and passion is replaced by a cynical detachment and burnout, and what was once a dream job becomes that which robs us of our dreams and happiness before even becoming a Doctor. This sounds harsh, but what is harsher is students having their burn-out and unhappiness underplayed and ignored to the point of it becoming a debilitating, chronic problem.
Most universities offer ‘support systems’, however according to the above-mentioned study published in the SAMJ only 45.6% of medical students were aware of these structures, and of those only 28.3% could actually name the structure. The HPCSA’s National Strategy on Impairment Providers states that: “Training institutions should become concerned about student needs in relation to workload, relaxation, social adaptation, personal and financial matters as well as provide adequate counselling.”** This will avoid ‘impairment’ in undergrad medical students, and includes effects caused by mental conditions. If this is the aim, then clearly not enough is being done to reach these ideals. The provision of counselling services is the extent of intervention by most tertiary institutions, and most students find it inaccessible anyway.
The following measures are practical and effective ways to go about reducing the stress associated with medical school, and in turn in reducing the prevalence of mental illness and the exacerbation of pre-morbid mental states – most notable depression and anxiety:
- Reduce/focus the volume of work to study (as proposed by AMSA). Some of what we learn is not applicable to our level – as generalist trainees and not specialist trainees. Mark some work as ‘self-read for non-test purposes’, and test us on what truly counts so that we can learn the pertinent stuff well (quality over quantity!).
- Allow students to take ‘mental health days’, if necessary, and the option to do lectures correspondence (as proposed by yours truly – through personal tried and tested (and self-veto-ed 😉 experience). I still think that by allowing myself to do this over the years – with or without the permission of those in charge – is the reason I’m still in med school today. Mental health matters!
- Facilitate mentor/one-on-one peer counselling services/relations for the duration of the degree (as proposed by the University of South Florida). We all know that the most comforting words are: “I haven’t started studying either!” ;).
- Facilitate and encourage time for extracurricular activities (as proposed by the Vanderbild University’s Medical School). Make the period of 2pm – 4pm non-academic zones in which students are encouraged to exercise/read/blog, and in which academic duties/tests/class are banned. Or put a 2pm cap on clinical duties; we are constantly told that we are not the workforce, and having a full-length work day paired with the volume we have to study thereafter at home is just silly.
- Encourage help-seeking at guidance centers/ ‘support services’ (as proposed by Harvard University’s Medical School).
These solutions ease the flaws of the system by allowing students more time to pursue that ever-evasive ‘balanced lifestyle’ which we preach to our own patients on a daily basis, because waking up feeling depressed should never be normalised, and feeling like a normal student from time-to-time will make us all far less depressed.
“You don’t want to lose your humanity by becoming a doctor.” – Dr Scott Rodgers, Dean Associate of Student Affairs at Vanderbilt School of Medicine
[Take THAT, Vancouver! 😉 ]