Medicine’s Ugly Secret: The Epidemic of Physician and Medical Student Suicide

In the past decade, numerous studies have shown that physicians and medical students have higher rates of suicide than the general population.^1,2 The American Foundation for Suicide Prevention reports that over 400 physicians and medical students commit suicide each year in US.³ The medical profession consistently ranks at or near the top of occupations with the highest suicide risk.

• The suicide rate in male physicians is 1.4 times higher times the general population¹
• The suicide rate in female physicians is 2.3 times higher times the general population¹
• 27% of medical students have depression or depressive symptoms and 11% have suicidal ideation²
• 6% of US surgeons reported suicidal ideation in the past year and a majority fail to seek help due to concern it could affect their medical licensure⁴

Matriculating medical students do not have a higher prevalence of depression compared to their age-matched college graduate peers.² The rise in the prevalence of depression during medical school is likely multifactorial and includes the intense workload, lack of autonomy, work-life imbalance, high stakes board exams, and large debt burden. These stressors can lead to “burnout”, characterized by emotional exhaustion, depersonalization, and a sense of decreased personal accomplishment.⁴ Further, medical school (and residency) training continues to foster an environment that can be perceived as bullying, with hierarchical pimping and public humiliation considered to be a requisite part of the training paradigm. These stressors come at a time when many students have moved to new cities to pursue their training and lack a support system, while concurrently facing chronic sleep deprivation and high-intensity situations involving critically ill or dying patients for the first time.

Unfortunately, only 16% of medical students with depression will seek help.² For high-achievers, seeking help is seen as a sign of weakness and failure. The stigma over seeking help for mental health problems for medical students (and physicians) is very real, as concern for future licensure/credentialing, academic standing, and job security are pervasive. On a medical student website blog, one student shared how he sought help after his M3 year after recognizing depression and active suicidal ideation. He wanted to write about his experience overcoming depression and how it shaped him as a physician in his personal statement for residency applications. His advisers universally recommended that he “leave all mental health issues out” and to “just do not bring it up at all” during the residency application process. This practice of non-disclosure of mental health treatment by physicians is perpetuated through residency, fellowship and in practice, and maintains the stigma associated with seeking mental health treatment.

While medical schools have become more adept at identifying and helping students with mental illness, they are not doing a good job to address the systematic problems in the training process that contribute to mental illness.

Potential Interventions⁵:

1. Change to pass-fail grading first 2 years and some institutions no longer have limits on the number of high marks that can be awarded during clinical rotations.
2. Yearly mental health check-ups to foster the mindset that mental health care should be as routine as any other type of medical care.
3. Wellness programs that emphasize sleep hygiene, nutrition, and exercise.
4. Foster a non-judgmental environment so students feel comfortable asking for help.
5. Zero tolerance for work place abuse and mistreatment of trainees.

We should all strive to help usher in a new era of medical culture that promotes sustainable medical careers. In addition to monitoring our trainees (and colleagues) for signs of depression or burnout⁶, we need to set an example for them. This includes living a balanced lifestyle, utilizing appropriate teaching methods, and making our personal health a priority.

Signs of Depression/Burnout:

1. Increased irritability.
2. Verbally abusive to staff and/or patients.
3. Change in sleep habits.
4. Showing up late/missing routine commitments.
5. Increased drinking and other reckless behaviors.
6. Isolating themselves from friends and/or activities.

¹ Schernhammer E.S., Colditz G.A. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004; 161: 2295-302.

² Rotenstein B.A., Ramos M.A., Torre M. Segal B., Peluso M.J., Guille C., Sen S., Mata D.A. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA 2016; 316: 2214-36.

³ Physician and Medical Student Depression and Suicide Prevention.  https://afsp.org/our-work/education/physician-medical-student-depression-suicide-prevention/

⁴ Shanafelt T.D., Balch C.M., Dyrbye L., Bechamps G., Russell T., Satele D., Rummans T., Swartz K., Novotny P.J., Sloan J., Oreskovich M.R. Suicidal ideation among American surgeons. Arch Surg 2011; 146: 54-62.

⁵ Goldman M.L., Shah R.N., Bernstein C.A.  Depression and Suicide Among Physician Trainees: Recommendations for a National Response. JAMA Psychiatry 2015; 72: 411-12.

⁶ Make the Difference: Preventing Medical Trainee Suicide. https://www.youtube.com/watch?v=I9GRxF9qEBA