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    Healing the very youngest healers

    Almost 30% of medical students and residents suffer from depression and 10% report having suicidal thoughts. Now, a growing number of medical schools and teaching hospitals are developing programs to identify and help at-risk trainees.

    doctor on gurney

    Rahael Gupta was leaving the library one night in 2015 when she stepped into a dark, poorly lit street hoping to collide with an oncoming bus. The second-year medical student at the University of Michigan Medical School envisioned her head hitting the asphalt, her brain banging around inside her skull, and the driver leaping out of his vehicle in horror to locate her body.

    Gupta had never been diagnosed or treated for depression prior to medical school. But like many medical students, she was overwhelmed. She had moved from Oregon to Michigan — hundreds of miles from close friends and family. She was suffering from chronic stress, anxiety, and exhaustion. And then she failed a neuroscience sequence. "I just wanted to end it all," she says.

    Unfortunately, Gupta's experience is not uncommon. In a recent study, 9.4% of fourth-year medical students and residents reported having suicidal thoughts in the previous two weeks. According to the American Medical Student Association, medical students are three times more likely to die by suicide as their same-age peers. And while it’s unclear how many physician trainees die by suicide each year, suicide is the leading cause of death among male residents and the second leading cause of death among female residents.

    These figures first came to light several years ago. In response, a growing number of leaders in academic medicine have been launching initiatives aimed at helping students and residents navigate the difficult training years. Some schools have instituted small learning communities and developed resilience curricula. Others have implemented interactive online screening protocols and launched extensive support services. Still others are shifting to two-tier, pass/fail grading systems. For residents, national medical organizations are calling for creating more positive work environments and reducing sources of physician burnout, particularly those that do not contribute to patient care. Many of these recommendations are outlined in a 2019 report released by the National Academy of Medicine (NAM): "Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being."

    "Students will see people suffer and die with illness. They will see families struggle with the loss or impairment of their loved ones and they will confront the issue of patients who can’t afford care. All of those things create enormous stress for people who are in training."

     — David Muller, MD, Icahn School of Medicine at Mount Sinai

    "Academic health centers have been real leaders in terms of trying to put programs in place to help counter burnout, depression, suicide, and related problems," says Darrell G. Kirch, MD, co-chair of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience and president emeritus of the AAMC.

    The goal? To ensure young physicians-to-be can access the support they need to feel safe, be healthy, and derive purpose from their work.

    A Population at Risk

    Medical training is intense. Medical students and physician trainees study and work long hours, often in stressful environments where they must confront death on a regular basis. According to NAM, overwhelming job demands and insufficient resources can lead to burnout — a workplace syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment from work.

    Burnout can have far-reaching implications. It can impact job performance, increase turnover, and lead to medical errors and clinician suffering. "Students will see people suffer and die with illness. They will see families struggle with the loss or impairment of their loved ones and they will confront the issue of patients who can’t afford care. All of those things create enormous stress for people who are in training," says David Muller, MD, dean for medical education at Icahn School of Medicine at Mount Sinai in New York. "We're so focused on taking care of patients and providing quality care that absent from our education is how we take care of ourselves."

    Excessive stress can create a short path to developing a mental disorder, depression, and suicidal ideas and behavior."

     — Darrell G. Kirch, MD, co-chair of the NAM Action Collaborative on Clinician Well-Being and Resilience and president emeritus, AAMC

    Studies show that students arrive at medical school with the same or better mental health as their peers. But after two years, they tend to suffer significant burnout, stress, and anxiety.  As they continue to progress in their training, they are at significant risk for depression. In a 2014 Academic Medicine study of medical residents, 60% met the criteria for burnout, more than half screened positive for depression, and roughly 8% experienced suicidal ideation.

    "Excessive stress can create a short path to developing a mental disorder, depression and suicidal ideas and behavior," Kirch says.

    Many of these trainees know they're in crisis. But only one-third of medical students experiencing burnout or depression seek help — mainly because they're afraid of what it might do to their careers.

    Destigmatizing Mental Illness

    Confronted with the startling statistics around burnout and depression, academic medical centers across the country are increasingly making physician well-being a top priority — not only for faculty but also for students and residents. The first step for many of these institutions is hiring a "chief wellness officer."

    "That job description creates a whole kind of ethos the institution is concerned about wellness," says Michael F. Myers, MD, professor of clinical psychiatry at State University of New York (SUNY) Downstate Medical Center and author of Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared. Those officers are then charged with developing programs, policies, and procedures that support physicians’ mental health and well-being.

    Several medical schools, including Johns Hopkins University School of Medicine, Saint Louis University School of Medicine, and Weill Cornell Medicine, are folding resilience training into students' coursework. In 2016, on the heels of a fourth-year medical student's death by suicide, Mount Sinai developed a four-year wellness curriculum co-created by senior students and residents in psychiatry. The PEERS (Practice Enhancement, Engagement, Resilience, and Support) program at Mount Sinai enables students to meet in small groups with a faculty facilitator twice a year to tackle stressors specific to each stage of training. Its goal is to provide learners with tangible skills to help manage personal and academic challenges and thrive. Other institutions are hosting town hall-like forums where discussions about the "second victim phenomenon," stress, and burnout take center stage.

    "There's a lot of suffering among medical students, residents, and physicians. As leadership, we can act to decrease their suffering. We can be a voice for cultivating compassion," says Sunny Smith, MD, clinical professor in the department of family medicine and public health at the University of California San Diego (UCSD) School of Medicine.

    The increasing push toward small learning communities, as opposed to massive lecture halls, also allows faculty to more easily recognize when a student is struggling. "With learning communities, faculty members know when students don't show up or when they show up with tears in their eyes — and they can connect them with the available resources," Smith says. The smaller, more intimate learning approach also encourages peer support.

    Some institutions have even made peer support part of their mental health assistance protocol. At Johns Hopkins, Harvard Medical School, and Temple University School of Medicine, peer support programs are available to students, practicing physicians, and faculty. "When a crisis hits, we want the person sitting next to our resident, regardless of profession, to know how to get someone help and resources," says Jessica Kovach, MD, vice chair of clinical psychiatry and behavioral science and associate professor and director of the psychiatry residency program at Temple University School of Medicine.

    A national focus

    Additionally, several national medical training organizations, including the AAMC, the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine, are actively promoting physician wellness and burnout prevention. In 2017, the ACGME revised Section VI of its Common Program Requirements for residency and fellowship training programs to include an enhanced section on well-being. The revisions require programs to provide support to individual residents — including 24/7 access to urgent and emergency care, confidential mental health assessment, counseling, and treatment — and include standards for creating a culture of well-being within residency programs.

    In December 2019, the ACGME launched the AWARE suite of resources, including on-demand tools such as a well-being skill development video workshop, an AWARE app, and AWARE podcasts to promote well-being, mitigate the effects of stress, and prevent burnout among physician trainees and faculty members.

    The National Academy of Medicine is also calling on institutions to develop initiatives that promote professional well-being and improve the work environment. Each of these organizations is urging leaders in medicine to make assistance programs, peer support, and mental health providers readily available to physicians and trainees.

    "It's in the benefit of individuals and society to help human beings who are uniquely qualified to comfort and cure stay in medicine," Smith says. That's where UCSD's Healer Education Assessment and Referral Program (HEAR program) comes in. HEAR is a two-pronged approach to educate and identify colleagues at risk for burnout, depression, and suicide through an online, anonymous interactive screening program, or ISP, created by the American Foundation for Suicide Prevention (AFSP).

    "The ISP is highly effective at helping people who are not engaged in support and treatment but who are the most at risk and the most reticent to get help," says Christine Moutier, MD, chief medical officer of AFSP. Since its inception in May 2009 among UCSD health science staff and trainees, more than 400 individuals have accepted a referral for treatment. The ISP is now being utilized by 33 hospitals and medical schools, where it connects at-risk physicians, trainees, and students with a counselor either in person, by phone, or electronically.

    While it would be difficult to attribute improvements to any one program – UCSD introduced several changes simultaneously – the rate of suicide at UCSD has dropped dramatically. "There were 13 suicides over the 15-year period that preceded the launch of the UCSD HEAR Program and in the decade since its launch, there has been one," says Moutier.

    "We recognized early on that our students suffered from information overload, excessive class time, and unreasonable academic demands, so we reduced that load and the pressure on our students. In backing off, academic outcomes did not suffer, as might be expected, but rather they improved as did the mental health of our students."

     — Stuart Slavin, MD, former curriculum dean, Saint Louis University School of Medicine

    At Saint Louis, former curriculum dean Stuart Slavin, MD, was determined to assess students' well-being in comparison to national averages. "Our students' mental health was very good at orientation but deteriorated across their four years of medical school," Slavin says. "The only plausible conclusion: We were harming our students."

    Slavin embarked on an ambitious effort to:

    • Reduce unnecessary stressors and enhance the learning environment.
    • Teach students skills to better manage their stress and encourage help-seeking.
    • Create more opportunities for students to find meaning in their work.

    Changes included switching to a pass/fail grading system, cutting curriculum hours, instituting learning communities, and assessing mental health with an optional confidential assessment for depression and anxiety at four points during the pre-clerkship years.

    The results were striking: The percentage of the Class of 2018 that reported moderate-to-severe symptoms of depression was 4% at the end of their first year and 6% at the end of their second year. In comparison, the percentage of the classes of 2012 and 2013 (which preceded the initiative) that reported these symptoms was 27% at the end of their first year and 31% at the end of their second year.

    "We recognized early on that our students suffered from information overload, excessive class time, and unreasonable academic demands, so we reduced that load and the pressure on our students," says Slavin. "In backing off, academic outcomes did not suffer, as might be expected, but rather they improved as did the mental health of our students."

    Now an advocate for suicide prevention, Gupta champions changes like these — efforts that focus on lightening the hefty load on physician trainees rather than providing them with more tools in the form of meditation, massage, and yoga classes.

    For Gupta, taking time away from the intensity of training was lifesaving. After nearly colliding with a bus, Gupta went to her school counselor for help and began therapy within weeks. She started medication and took almost a year off schooling. Now a resident psychiatrist at UCLA, Gupta is newly engaged and thriving.

    "About a month after I started treatment, I remember walking on that same street where I had those suicidal thoughts," Gupta says. "It was snowy and icy. The sky was gray. The same scene that had looked so formidable and disgusting to me just a month before looked almost beautiful. That's when I knew I was getting better."