Since doctors are financially well off and are generally held in high esteem by the public, I suspect that most people are surprised when they learn that the rate of suicide among practicing physicians is higher than that for the general population. Indeed, I think most would be inclined to think that doctors would be less likely than others to take their own lives. Since the incidence of depression—the medical condition that predisposes to suicide—is no higher for physicians than for the general population, there must be other reasons that contribute to why doctors commit suicide. Although the reasons are presently not known, the American Foundation for Suicide Prevention has embarked on a project to find them.1
Given the higher suicide rate among practicing physicians, members of the medical education community should be aware of what is known about depression and suicide among tomorrow's physicians: medical students and residents. I suspect that many do not realize that the incidence of depression is much higher for medical students than for members of other groups similar in age and educational background. Nor are they likely to know that most medical students who are depressed do not seek mental health care. One reason for this may be that students worry that seeking care might hurt their standing in medical school and, therefore, jeopardize their career goals.2 Since suicide is the second leading cause of death among medical students, it is incumbent on medical educators and those holding leadership positions in academic medicine to be attentive to the mental health needs of their students as well as their residents. The authors of several Articles and Research Reports appearing in this month's journal provide information relevant to this issue.
To begin, Nuzzarello and her colleagues have made an important contribution by documenting some of the factors that may influence whether students will seek treatment for depression and other mental health problems. One of their findings is that students tend to underestimate their risk for depression. Another finding is that students’ lack of personal experience with mentally ill persons—including mentally ill patients who could be seen during clinical education—may contribute to their decision not to seek care for themselves. Since students are not inclined to seek care on their own, deans and faculty members must be proactive in identifying and counseling students whose behaviors suggest that they may have mental health problems. And if they hope students will seek the care they need, they must emphasize that doing so will not stigmatize them or hurt their academic standing. It is essential that student affairs deans and others develop programs that students will perceive as “safe harbors” to use if they feel they need mental health services.
Pitt et al. confirm the value of this approach, though their article focuses on the needs of residents, not students. These authors provide a nice review of pertinent literature and then describe a special program—the House Officer Mental Health Program—developed at the University of Michigan to meet their residents’ mental health care needs. Although the number of residents availing themselves of this service during the period analyzed is impressive, the authors point out a continued concern for those who need the service but do not use it.
In his article, Mareiniss argues that aspects of the educational process itself can contribute significantly to the mental health problems experienced by residents. Citing the nature of the work environment, he identifies long duty hours and financial burden as two key factors contributing to undue stress among residents. He goes on to suggest that these factors can foster behaviors that run counter to the tenets of medical professionalism and that may influence the quality of care physicians provide to their patients. If he is correct—and there are good reasons for believing he is—then institutions that sponsor residency programs must be more attentive to the environmental forces that may adversely affect residents during their training.
Two other reports appearing this month suggest how this might be done. Levy et al. describe the experience with a residents’ mentoring program established in the Department of Medicine at Brigham and Women's/Faulkner Hospital in Boston. The program was developed to provide one means of support for residents experiencing the increasingly stressful environment of major teaching hospitals. By encouraging mentoring relationships, the department hopes residents will seek their mentors’ guidance and help in dealing with personal and professional issues affecting their overall sense of well-being and/or their careers. And finally, Heard and her colleagues describe an institutional system for monitoring residency programs that will ensure the quality of the educational experiences provided, and help protect residents from the kinds of work-related excesses that can contribute to stress and other mental health problems.
So what should we make of all of this? I believe the message is clear. Medical educators and those holding leadership positions in academic medicine must acknowledge that the traditional design and conduct of medical education programs may well contribute to some of the mental health problems experienced by medical students and residents—problems that may lead to more serious mental health problems later in physicians’ lives. They also should acknowledge that these same factors may contribute to the development of professional behaviors that will adversely affect the way students and residents interact with future patients. Given this, they must be diligent in addressing the factors that may foster students’ and residents’ mental health problems, and establish programs to provide special help if such problems occur. There is, after all, a lot at stake—the well-being of physicians, and the quality of care they provide to their patients.
Michael E. Whitcomb, MD
1. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians. A consensus statement. JAMA. 2003;289:3161–66.
2. Givens JL, Tjia J. Depressed medical students’ use of mental health services and barriers to use. Acad Med. 2002;77:918–21.