Often it takes a tragedy for a discussion to open up about medical student and resident suicide. People will wonder why a bright young student or physician decided to end his or her life, but it rarely translates into positive changes within the training environment.
However, changes are in the works. The Accreditation Council for Graduate Medical Education, the governing body for 9,600 residency programs is developing a national program designed to curb the epidemic of physician distress. In addition, some pioneering medical schools have implemented changes in the learning environment to improve this situation.
Rather than elaborate on the problem that has been thoroughly presented elsewhere, this article intends to show how a select group of medical schools have approached the problem with programs that are having a significant impact.
According to Dr. Srijan Sen, a psychiatrist from the University of Michigan who directs an on-going research project on clinical depression of more than 10,000 interns at 55 institutions, “only 22% of interns who are depressed get any help.” 1
Prior to their internship, about 4% of doctors have clinical depression, which is comparable to the general population. However, as interns, the frequency rises to as much as 25%. Programs detailed below have attempted to impact these numbers.
The first is the Healer Education Assessment and Referral (HEAR) program at the University of California, San Diego (UCSD). We first reported on this program in our March 2012 issue of The Physician Lifeline, the Missouri Physicians Health Program e-newsletter. HEAR is designed to identify and assist students, residents, fellows, and faculty members who are depressed and may be at risk for suicide. Their process begins with an invitation to participate in a web-based, brief, anonymous survey. Each respondent is then grouped according to his or her responses in 3 tiers based on risk level with Tier 1 as the highest risk category. A counselor reviews all questionnaire responses and responds with a personalized reply based on their individualized assessment. The counselor invites each respondent to communicate online if desired via an anonymous website dialogue page. All Tier 1 and 2 students are urged to contact the counselor to schedule an in-person evaluation. The counselor then evaluates the participant more fully, discusses treatment options, and makes referrals as appropriate. This program has achieved a high percentage of those categorized as either high or moderate risk accepting referral. As reported previously, participants who were surveyed indicated that they would not have made an appointment to see a mental health professional without the online screening program. 2
Second, is a pilot program at Stanford University to improve work-life balance for emergency medicine doctors that includes providing meals, house cleaning, and babysitting in exchange for long hours.
Stanford also put together a program to “promote psychological well-being, physical health and mentoring. Every week one of the six groups of surgery residents has a mandatory psychotherapy session with a psychologist. Each senior resident mentors a junior resident and residents are given time for team bonding”. 3 Additionally, they are given information on recommended professionals for medical and dental care, as many residents don’t have a personal physician or take the time to visit one, plus a refrigerator in the surgery residents’ lounge stocked with healthy foods. The Balance in Life program has to constantly battle for operating funds, but they justify it by reminding other faculty that it was a response to a recent physician suicide at their institution.
The State University of New York Downstate Medical Center has provided free counseling for medical students and physicians for 20 years. Their program incorporates peer support, which has helped alleviate the stigma involved with asking for help. The service is provided confidentially and does not become part of the student’s record.
Closer to home, St. Louis University (SLU) has implemented a significant curriculum revision to address issues of stress, depression and anxiety and to impact the occurrence of medical student suicide. Dr. Stuart Slavin, MD, MEd, began by surveying the medical students at SLU to develop an accurate picture of the problem. “In their first year, 57% expressed moderate to high symptoms of anxiety; 27% reported moderate to severe symptoms of depression.” 4 Students cited the demands of the curriculum and competition for grades as their primary stressors.
With the support of SLU leadership, Dr. Slavin initiated curricular changes starting with the class of 2013. A pass/fail grading system for preclinical courses was implemented; contact hours were reduced by 10% the first two years to give students more time to “participate in new learning communities and longitudinal electives. This change allowed students more freedom to explore their interests, to create mentorship relationships with faculty and School of Medicine alumni and to engage in service and/or research with more continuity. The learning communities were given the task of designing and implementing new electives, developing a lunch lecture series, identifying faculty mentors, and expanding service and research opportunities.” 5
Later, additional changes were implemented including a required resilience and mindfulness program. The third set of changes involved the demanding Anatomy course, which was a major source of reported stress. Further, students were given more time to choose a specialty.
All these changes have had a very significant reduction in the frequency of depression and anxiety. Among first year students, moderate to severe depression has been reduced to 8% down from the starting figure of 27%, and moderate to severe symptoms of anxiety were reduced to 23% down from 57%.
Critical to the success of any of these programs is confidentiality. Students are afflicted with paranoia and mistrust that utilizing services that are available from their respective schools may jeopardize their future careers. Thus, many students suffer in silence and don’t reach out for help.
Medical schools could benefit from utilizing an independent third party, such as the Missouri Physicians Health Program (MPHP), which is not part of the administration of the university. Students would not need to fear exposure by conferring with a MPHP representative.
As an example, recently a third year resident in Missouri hadn’t told anyone of his heroin addiction until he heard a talk given by Robert Bondurant, RN, LCSW, Executive Director of the MPHP. After hearing his presentation, the student felt safe enough to contact us. The MPHP then advocated on his behalf to secure the help he needed to get clean and into recovery. If he hadn’t heard this presentation, his story may have turned into a tragedy.
It is also vital that the training facility feel that the MPHP is credible and a safe place with which to entrust their students. Another student with addiction issues, an eating disorder, and family issues was recently referred to us by her school. The MPHP isn’t a monolithic approach. We deal with a broad range of issues, not just addiction, that have the potential of leading to suicidal thoughts and behaviors.
People often ask how many suicides we have aborted. We have only physically intervened in two instances where we literally stopped someone from killing themselves. However, the real question is how many suicides have been prevented by resolving other issues, any one of which could have led to a suicide. It is impossible to say, but, by our involvement, we changed the dynamics involved which otherwise may have led to a death by suicide.
One reason we seek to speak annually to incoming medical students, as well as residents and faculty at every training facility in the state is to inform every listener that there is a confidential and safe source of help available to them. Virtually every time we speak, a referral results because the individual feels a sense of safety and comfort in doing so. Typically, it is a situation where the individual has not disclosed his or her problem to anyone before. They often didn’t know that the MPHP was designed to help physicians in training, and senior physicians as well, with a breadth of issues, such as mental health, including burnout, addiction, behavioral issues such as “disruptive behavior”, licensure issues, boundary violations, and even physical illness that may be affecting their performance.
Just recently another presentation to residents resulted in a phone call. This resident, after hearing Mr. Bondurant speak, felt safe in contacting us. This time, the problem was with his spouse. She had had a medical problem and was prescribed opiates, which quickly turned into an addiction to narcotics. Her desire for more drugs led her to procure additional scripts through on-line sources. Eventually, she tearfully went to her husband and informed him of her addiction. Her husband felt safe in calling Mr. Bondurant after hearing his presentation, who assisted him in determining the best source of detox and treatment, which was covered by their insurance. We often receive calls such as this. We do not only help physicians, but physicians’ family members as well.
Another advantage that we bring to the table is that we have many years of experience in handling these issues. We are familiar with their challenges, and know the best resources for professional assistance. In the case of addiction, where the individual has accepted referral to a treatment facility, we provide long term monitoring of their recovery to ensure their success, which separates us from other programs that don’t offer rigorous monitoring and follow-up.
Yes, the data on physician suicide and depression is of deep concern. This article has detailed some of the innovative approaches that we have encountered across the country. We are hopeful that more training facilities will strive to better inform their students and residents that there is hope and help available.
References 1. Mandy Oaklander, “Life Support: Inside the movement to save the mental health of America’s Doctors,” Time, Sept 7-14, p. 46. 2. Nancy Morton, “Identifying Suicide Risk,”,The Physician Lifeline, March 2012, p.1. 3. Mandy Oaklander, “Life Support: Inside the movement to save the mental health of America’s Doctors,” Time, Sept. 7-14, p. 46. 4. Julie Parker, “Medical School Answers: The Saint Louis University Experiment,” St. Louis Medical News, Aug. 2015. 5. Ibid.