A couple of weeks before I started medical school, I admitted to a trusted mentor that I was worried about how my posttraumatic stress disorder would affect my education. He looked me in the eyes and said, “Don’t let anyone find out. That place will eat you alive.”
As it happened, I lost the luxury of privacy my very first semester, when the visceral intimacy of anatomy lab triggered me in front of a large group of classmates and instructors. Remembering my mentor’s advice, I panicked, expecting to be excoriated for my reaction. Since that day, however, the community of students and faculty at my medical school has come together to support me in a way that defies all of the prejudices in our larger society. Nevertheless, I have run into a number of problems related to misplaced good intentions. There are not many of us with visible yet well-managed mental illnesses, and my advocates have had to learn how to offer guidance and flexibility without compromising my autonomy or the high technical standards of my program. Though my experience has been largely positive, that is far from universal. Friends and classmates have experienced discrimination or even been forced to leave their programs. I write anonymously in acknowledgment of that implicit threat but also with the hope that the individual support I have received may become standard throughout the larger medical education system. I strongly believe this will foster a generation of clinicians with rich and varied experiences who can be strong advocates for their coworkers and patients in all states of mental health and illness.
Educators must start by recognizing the high prevalence of mental illness among medical students. A recent global meta-analysis found that more than a quarter of medical students experienced symptoms of depression, with 11.1% reporting suicidal ideation.1 Levels of anxiety and obsessive-compulsive disorder are also high.2,3 However, many professors fail to account for these figures while addressing their classes. One of my preceptors described depression as a contagious illness best diagnosed by its draining effect on the physician. This made one friend feel tremendously guilty, while another felt like her own (compensated) illness was being denied. On two occasions, different lecturers assured my class that no one had failed the final exam who “didn’t have a major mental illness.” The irony is that they were trying to reduce our preexam anxiety, but their words had precisely the opposite effect.
Since mental illnesses have historically been very personal, closeted diagnoses, speaking about mine openly has thrown many professional relationships out of balance. I cannot count the number of times that I have mentioned a medication or a therapy appointment in passing and found myself under evaluation for the classic “SIGECAPS” (sleep, interest, guilt, energy, concentration, appetite, psychomotor, and suicidal ideation) symptoms of depression. Other advisors have repeatedly encouraged me to take a leave of absence. I am extremely fortunate that my illness is episodic and does not impair my judgment, confidence, or ability to advocate for myself. On the one hand, I am grateful for my teachers’ dedication and concern. It is still true that only about 16% of medical students with depressive symptoms ever seek treatment,1 and many of us may benefit from a gentle nudge from a trusted mentor when treatment is needed. On the other hand, for those of us with well-managed symptoms, repeated evaluation fosters imposter syndrome. It should be possible to offer support without compromising a student’s autonomy or privacy. These are rights we routinely respect in our patients but not always in our colleagues.
For students who do need a little extra academic support, I implore medical educators to be open-minded and flexible. For instance, students may periodically miss class to commute to appointments, ask for extensions on assignments, or be prone to panic attacks during exams. Most affected physicians-in-training are dedicated to meeting the technical requirements of medical school but may not know what accommodations are possible or reasonable. Educators should think about the purpose of each requirement and consider how it can be met in different ways. The disability services office can be a great resource for brainstorming solutions. It is also important to keep in mind that advertised campus resources may be only in the developmental stage. Campus therapists are chronically overbooked, wellness events often conflict with mandatory lectures, and designated advisors may be inexperienced. If a student says that a given solution is impractical, he or she should be believed.
Finally, I believe that the single most powerful way in which educators can support students is by leading by example. During my medical school’s orientation week, one of our deans spoke frankly about his own experiences with depression. He was the first person I contacted when I needed advice about managing my own condition as a full-time student, and he has since guided me through a number of critical decisions. With his support, I have felt safe speaking with other faculty mentors and advisors when I needed help or had relevant course feedback. Though he has never pushed me to disclose my diagnosis, his confident vulnerability has inspired me to reach out to other classmates who I know are struggling. In this way, courage and support trickle through a community, far beyond the reach of any one individual.
On one challenging day, my mentor told me that, someday, the scars of my illness would make me a more observant and empathetic physician. His words have given me hope throughout my training, but I did not fully understand their meaning until I started my clinical year. On my last overnight call on my pediatrics clerkship, a teenager was admitted to the toxicology service after attempting suicide. I was assigned to check in on her every few hours. She was fully conscious but with a curiously blank expression that could have been caused by horror, medication, or her underlying depression. Sometime past midnight, I noticed that her eyes seemed glued to my stethoscope. I asked her if she was interested in medicine, and she nodded. In a quiet voice, she confessed that before she became sick, she had wanted to become a doctor. And there, perched on the edge of her bed in the wee hours of the morning, I taught her how to perform a physical exam. I helped her listen to her racing heart and palpate her enlarged liver. Her face shined with the same excitement I had seen on my classmates only a few months before, as we prepared for the wards. I hope I reminded this girl of the dreams that she had held before her illness and perhaps gave her some reason to look forward to the future. Walking home that morning, I could not help but think about my own experiences dealing with mental illness in medical school. A decade ago, I do not think it would have been possible for my patient—or for me—to complete my program. Now, educators are starting to realize the prevalence of mental illness in the medical profession and that students with preexisting diagnoses bring something unique and valuable to the medical community.
The author’s only regret in publishing this Invited Commentary anonymously is that she cannot adequately thank the instructors, mentors, and friends at her medical school who have guided her though this complex academic experience.
1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016;316:2214–2236.
2. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354–373.
3. Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depress Anxiety. 2007;24:103–111.