On Wednesday, May 16, we walked onto a stage as students and, after hearing "doctor" before our names, walked off as physicians. One name, however, was not called. Collectively, since receiving our short white coats, we have lost three classmates to suicide, including one valued colleague just weeks before graduation. We were and still are heartbroken, confused, and angry.
Suicide among trainees is a major problem in medical education and certainly not isolated to any single institution. Medical students have of suicidal ideation and suicide is the among medical residents. During our time in medical school, there were seven medical trainee suicides in the New York City area alone.
The medical establishment increasingly recognizes medical trainee suicide as a problem, if not the crisis that it is. However, steps taken thus far by the leadership in our institutions and professional communities are obviously inadequate. To address this issue, we propose a paradigm shift in medical education: mental health care for trainees should be opt-out, not opt-in, and resources should be put in place to help trainees who desire to leave medicine enter alternative careers.
Mental health services for medical trainees should be opt-out, not opt-in
The burden of mental illness, a recognized risk factor for suicide, among medical trainees is large. The prevalence of depression among medical students and residents is estimated to be and , respectively, which is significantly higher than the age-matched general population. In 2014, following the suicides of two New York City area interns (including one of our former classmates), the ACGME introduced new rules requiring round-the-clock access to mental health counseling and urgent care for residents. While widely available, there are significant barriers to accessing these services for medical trainees. One study found that only of medical students meeting criteria for depression were using mental health counseling services. Similarly, another study found that only of medical interns who screened positive for depression were receiving treatment. Among the most frequently cited barriers in the two studies were: lack of time, concerns about confidentiality, and stigma.
We welcome the realization that mental health services should be available to medical students. However, we would argue that these services should be opt-out, not opt-in as they typically are now. Opt-out models are a good public health approach because they result in better compliance. For example, of children receive at least their first dose of the MMR vaccine, which is required for school attendance in . In contrast, only receive their first dose of the HPV vaccine, which is only for school attendance in two states and the District of Columbia. Furthermore, opt-out versus opt-in HIV screening results in of testing. An opt-out approach would also have the added benefit of reducing stigma. If we're all required to see a therapist, this would be considered "normal."
Obvious barriers to implementing opt-out mental health services for medical trainees are cost and lack of resources. However, cognitive behavioral therapy (CBT), an evidence-based approach, can be practiced in a group setting, which may make this idea more financially viable. Furthermore, psychiatry residents receive personal psychotherapy as part of their training (called "supervision"), so there is a precedent and model for providing routine, opt-out psychotherapy for medical trainees. This would not only train medical students and residents in skills to take care of their own mental health in high-stress settings, but like psychiatric residents, it would give them better skills for coping with and treating patients with mental illness. Opt-out CBT from the first week of orientation in medical school would equip our trainees with skills to care not only for themselves but also for their patients.
Medical trainees should be informed regarding alternative career options
Given the narrow traditional pathways in medical training, we propose that the psychological concept "entrapment" plays an additive role in the risk of medical trainee suicide, alongside untreated and undertreated mental illness. Entrapment, defined as "a felt urgency to escape from an unbearable situation from which there is no perceived escape", is a in multiple models of suicide. Within medicine, there are many barriers to transition or respite. In the short term, those residents who need time for their own health are forced to take it at the cost of their peers. In the long term, there is little awareness of other career paths, and there is a significant financial risk for those who do take them.
If barriers to taking a single day off are difficult to scale, barriers to leaving the profession can feel exceedingly high. The decision to enter a career in medicine is typically made in the late teens and early 20s with little to no clinical exposure. In other professions, upon making the realization that one's chosen occupation is not compatible with his or her personality or interests, one can simply enter a different profession. While this is also true, strictly speaking, in medicine, it is not straightforward.
Many career options exist for MDs outside of medicine, such as consulting, medical writing, or hospital administration. These options were discussed not once in medical school. The two-day-long conference, "What Can You Be With A PhD?," put on by the Sackler Institute of Graduate Biomedical Sciences at NYU, educates graduate students about the available to them outside of pursuing a tenure-track academic professorship. This could serve as a model for how medical schools can educate their students about alternate career paths. It could alleviate the sense of stigma, shame, and failure currently associated with leaving medicine.
Conclusions
As physicians, we deal with many unique stresses, from disease and death to byzantine electronic medical records. Burnout, mental illness, and suicide are common but not inevitable reactions to these stresses. Steps can and should be taken to protect medical trainees, including providing opt-out mental health services and increasing awareness of alternative career paths. The lives of our colleagues and the soul of our profession depend upon it.
Julia M. Agee, MD, is a resident physician in the department of medicine at NYU Langone Medical Center in New York City. Her interests include clinical neurology research and writing about ethical and empathic medical care. Jesse Handler, MD, is a resident physician in the department of medicine at Beth Israel Deaconess Medical Center in Boston. His interests include basic science research in molecular oncology and writing about the practice of medicine.