Understanding Depression and Distress Among Medical Students

Medical schools are entrusted with transforming bright and humanistic students into capable, compassionate physicians who will dedicate their lives to serving others. How best to fulfill this responsibility has emerged as a central concern of the medical profession. Research and self-honest observation over decades have revealed that many of the experiences of medical school may overwhelm and exhaust rather than inspire and instruct students. Indeed, contrary to the intent of medical educators, the experiences of medical training may damage the well-being and diminish the professionalism of many early-career colleagues.

Two valuable and innovative research reports in this issue of JAMA explore how the prevalent phenomena of depression and distress may relate to serious issues in medical training ranging from medical student suicide to professional misconduct. In a cross-sectional study with 505 medical student participants at the University of Michigan, Schwenk and colleagues¹ found that 14% endorsed symptoms consistent with moderate to severe depression, a result that fits with previous work revealing that up to one-third of medical students acknowledge significant depression.^{2 - 4} Symptoms of anxiety disorders, including acute and posttraumatic stress symptoms associated with clinical training activities, may in fact be more common than mood disorders among medical students.^{3 ,5 - 6} As in other self-report surveys and interviews^{3 ,7} (but not all² ), women students in the Michigan survey¹ were more likely to acknowledge mood symptoms. Depressed students were more likely to seriously consider suicide, think about dropping out of school, and express greater sensitivity to the stigma associated with being recognized as depressed by peers, teachers, and clinical caregivers. These results are consistent with the findings of other investigators who, for example, have identified links between suicidality and the decision to leave medical school before graduation.^{2 ,8 - 9} The report by Schwenk et al¹ is also consistent with the extant literature on the personal health concerns of medical students, their perceptions of academic vulnerability, and barriers to appropriate care.^{3 ,10 - 11}

In their multi-institutional survey study involving 2682 medical students, Dyrbye and colleagues¹² found that 53% of respondents met criteria for professional burnout, a composite measure of emotional exhaustion, depersonalization, and a low sense of personal accomplishment. Beyond this important result, in an innovative approach the investigators sought to separate this notion of burnout (“professional distress”) from depressive symptoms or low mental quality of life (indicators of “personal distress”) to test the hypothesis that professional distress would have a greater negative effect than personal distress on medical student professionalism. The authors predicted that professional distress would be more strongly associated with self-reported cheating behaviors, inability to recognize unethical practices in interactions with industry, and less altruistic attitudes related to the care of vulnerable and underserved patients.

Dyrbye et al¹² found that “burned out” students did in fact more commonly acknowledge unprofessional behaviors, and, as hypothesized, the investigators did not find as strong an association of personal distress with a lack of professionalism. Because “stress” is commonly asserted as a principal cause of unprofessional behavior and yet is intuitively associated with depression and mental illness more broadly, the absence of a strong link between personal distress and unprofessionalism represents a valuable preliminary finding. However, the interplay among training-related stresses, personal illness experiences, and professionalism warrants further study. Early narratives and empirical work involving physicians in training and physicians suggest that the personal experience of becoming ill may be underrecognized for its salutary formative effects in fostering empathy for patients and giving rise to an enduring commitment to professionalism in clinical work.^{13 - 14} Future work may clarify the positive and negative factors that influence professionalism. Such findings would suggest targets for curricular innovation that strengthen students' professionalism. This effort may also reduce inaccuracies, prejudicial attitudes, and stigma that surround the personal health experiences of trainees.

These 2 articles^{1 ,12} serve as reminders of how difficult it is to be a medical student. The initial encounters with severe illness and the extremes of life are poignant and profoundly affecting. Confronting the limits of modern medicine and learning to help patients bear illness, pain, and distress are hard experiences too, particularly when the demands placed on the student's intellect, physical and mental health, and personal relationships are so great. From the perspective of professionalism, students are continually challenged in their efforts to remain open hearted and generously motivated in dealings with others and to become increasingly reflective and nonformulaic in their responses to complex ethical issues. These challenges become even more difficult when the training environment is riddled with examples of unprofessional behavior.^{15 - 16}

The 2 reports, taken together, reveal encouraging findings about the formative experiences of medical school. The majority of medical students in the study by Dyrbye et al, whether in their first or last year of school, expressed altruistic attitudes regarding the care of disadvantaged patients and by their fourth year, students more clearly recognized ethical practices in interacting with industry. In the study by Schwenk et al, third- and fourth-year students expressed less stigmatized views of depression in peers. For example, advanced medical students in this study were less likely to see an ill student as potentially dangerous to patients and as depressed by choice. These data suggest that the iterative experiences of medical training may inspire more accurate and empathic understanding of the illness experience, whether in a patient or a colleague.

The potential value of tailored interventions that are attuned to students' needs, professional development, and learning settings is reaffirmed by the findings of these studies. The report by Schwenk et al issues a clear invitation to intervene with depressed and at-risk students, particularly during the transition between the second and third years of medical school when suicidal thoughts and the wish to leave medical training may be greatest.^{2 ,7} These data raise the issue of whether students develop symptoms in relation to the general milestones of medical education, such as when taking national board examinations or transitioning onto the wards, or if students' symptoms arise in the context of specific curricular or institutional cultures, as suggested by some early work on medical student physical and mental health needs. Whether the stigma perceived by depressed medical students is a sign of illness (ie, a negative cognitive distortion), as the authors suggest as a possibility, or an accurate “read” of the culture of medicine, it is important to deconstruct stigmatized attitudes toward mental illness. Such efforts will be seen as superficial unless secure, affordable, and confidential pathways to mental health care, preferably outside of their usual training settings, are created for physicians in training across all levels.^{2 - 3 ,17} Moreover, efforts to reduce professional distress experienced by students hold promise because they may greatly enhance the milieu for learning and indirectly provide sustenance to the professional attitudes and behaviors of medical students.

Survey studies involving medical student participants pose many challenges, and this is especially true when assessing sensitive topics like depression, distress, stigma, and professionalism. From the perspective of methodology, for instance, the survey studies reported by Schwenk et al¹ and Dyrbye et al¹² have the same problems as other social scientific work, such as concerns related to study site selection and cross-sectional approaches, social desirability and reporting biases, and the real meaning of certain statistical analyses. Although tools to assess mood disorders are well established, measures related to stigma and evaluating professional attitudes and behaviors or behavioral intention are underdeveloped. For instance, despite some very elegant conceptual work on professionalism,^{18 - 19} there is little consensus among bioethics and medical professionalism scholars regarding the foundation of commitments and practices that constitute physician professionalism.²⁰ Moreover, little is known about whether attitudes expressed correlate well with future ethical practices of physicians. Fortunately, there are data suggesting that physicians in training and physicians with excellent self-care tend to provide clinical care in a manner that similarly emphasizes preventive health.²¹ These results suggest that efforts to help medical students—a worthy endeavor—will have an amplified effect by benefiting their future patients as well.

With respect to human research issues, the federal regulations guiding ethically sound research may be interpreted variably, and medical students who volunteer to participate in research may not have adequate human subjects protections.²² The need for appropriate safeguards is great when students are asked to disclose intimate information and when academic faculty may undertake overlapping roles in students' lives as teacher-investigator or teacher-, academic dean−, or clerkship director−investigator. From a financial point of view, few funds are dedicated to research on medical education, making it difficult to perform rigorous and sufficiently broad-based work to develop meaningful findings in this area. Despite these obstacles, it is critically important that further research be conducted to explore the experiences, perspectives, and well-being of early-career physicians. Indeed, the future of medicine rests on the shoulders of today's medical students, and the care with which medical school administrators and faculty attend to their learning and well-being may bring good to them as well as to the patients of tomorrow.