Medical student stress and burnout leave some with thoughts of suicide

Two years have passed since Heather Finlay-Morreale and her University of Cincinnati College of Medicine peers studied carbon monoxide poisoning. She recalls the lessons that taught them how the gas creeps into the blood and slowly suffocates the body's organs, binding to red blood cells much faster than oxygen.

But mostly she remembers the day of their biochemistry exam -- when they were told one of Finlay-Morreale's small-study-group members took his own life with the toxic gas they had researched.

"One by one, as we left the exam, we found out," said Finlay-Morreale, now a third-year student. "I asked, 'Who? Can you repeat the name?' I wanted a clear explanation."

That same year, Duke University School of Medicine lost a second-year student to an apparent suicide. A few years earlier, a first-year student at Harvard Medical School shot herself in the school library bathroom.

Once inside the pressure cooker of academic demands, some medical students find it difficult to endure the crucible of training.

A study in the Sept. 2 Annals of Internal Medicine found that 50% of approximately 2,200 medical students surveyed at seven medical schools reported burnout, while 11% said they considered suicide in the past year.

"There is extensive literature demonstrating medical students begin medical school with mental health profiles similar to their non-medical peers," said study co-author Tait D. Shanafelt, MD, director of the Mayo Clinic Dept. of Medicine Program on Physician Well-Being in Rochester, Minn. "But through the course of medical school they experience substantial deterioration in their mental quality of life."

While previous research tied such behaviors and ideations to depression, these findings directly link medical student burnout -- depersonalization, emotional exhaustion and low personal accomplishment -- to thoughts of suicide.

"The link was strong and independent of symptoms of depression," Dr. Shanafelt said.

An estimated 400 physicians commit suicide each year.

"It has been known for some time that suicide rates among doctors are higher than the general population. The gap in suicide rates evidently begins as early as medical school," said Eva Schernhammer, MD, DrPH, assistant professor of medicine at Harvard Medical School in Boston. She was motivated to study physicians and suicide after four doctors committed suicide during her year as an oncology fellow in Vienna, Austria.

Many medical students find themselves, perhaps for the first time, in the bottom of their class. "This is intensely stressful. A good number will get a 'C' or fail, and maybe this is their first failure," said Finlay-Morreale.

Getting students to help students

Deepa Sannidhi, a second-year medical student at New Jersey Medical School in Newark, struggled her first year. "I came to medical school because of a love of learning, and I felt like I wasn't learning. It was so hard to keep up with the curriculum."

Her own uncomfortable feelings and the suffering of a friend spurred her to action. With the American Medical Student Assn., she developed an Internet-based grassroots endeavor -- the AMSA Mastermind Project -- designed to help medical students help each other. The program will begin in a few months.

"My idea is to bring together peer support groups online and over the phone so we can push each other forward," she said.

All accredited medical schools are required to provide personal counseling, according to guidelines by the Liaison Committee on Medical Education. But the University of Cincinnati's comprehensive counseling program could not reach Finlay-Morreale's classmate.

"He refused treatment that may have saved his life," she said. "I struggle to comprehend his final act."

Refusing such help is not unusual.

"Medical students have typically been extremely successful throughout their prior academic and professional experiences, and it can be difficult for them to ask for help when they struggle," Dr. Shanafelt said. "They may be reluctant to access these [counseling services] because of confidentiality concerns."

The University of Pittsburgh School of Medicine offers students free counseling. And the school recently piloted a Web-based depression and stress screen.

"When [students] fill it out, I get an e-mail alert," said Lee Wolfson, a psychologist with the school's counseling program. "I send feedback to the student and can have an Internet dialogue."

Liselotte N. Dyrbye, MD, lead author of the Annals study and assistant professor of internal medicine at the Mayo Clinic, said the study "suggests that burnout is reversible. We need to look at those who do recover and what makes recovery possible."