The High Cost of Perfection: Medical Student Suicides

Editorial

Debt + Deadlines + Depression: A formula for suicide, during medical school?

When you’re a student, especially a medical student, the need for achievement is high and the sources of stress are many: regular exams, National Boards, mounting debt, the need for perfectionism, the fear of failure, isolation, guilt, fatigue, and uncertainty are just a few.

For one thing medical school encompasses regular, seemingly endless exams. Some exams are computer or paper-based, riddled with multiple choice questions requiring students to choose the single best answer from a sea of possible selections while others are performance-based, requiring students to demonstrate the clinical skills they’ve learned on real, live simulated patients.

And if that’s not enough, the fear that even bigger exams are ahead is instilled during medical school. Early in Year I, students are made acutely aware of that they’ll soon be facing the National Board Exams; and not just one, but three, innocently referred to as steps 1, 2, and 3.

Students are not only under pressure associated with exam-taking, but they must also study for these exams and earn passing scores. These often occur under low fuel, sleep-deprived, and sometimes even panic-stricken conditions. While passing produces relief, nearmisses or failed exams incite their own form of stress.

Uncertainty abounds. This begins in the early weeks of medical school, when transitioning from the competitive arena faced as a premed student to the pass or fail expanse of medical school. Another source of uncertainty is associated with the inexactitudes of medical knowledge a problem magnified if there is any ambiguity in the learning objectives or course content. All of these have offshoots that impact medical school performance, leaving students who are high achievers with the feeling that it’s never enough, a feeling which paves the way for a fear of failure.

High achievers strive for perfection, especially in medical school. Perfectionism has been linked to a fear of failure [1]. When the fear of failure is combined with the need to maintain a strong outward demeanor, ever-increasing debt, the isolation that comes with always having to study and the guilt of spending time away from family and friends, the vulnerability to suicide/suicidal ideation heightens.

Although the exact numbers are not known, it’s estimated that as many as four-hundred US medical students/physicians commit suicide each year [2], a number which has been compared to the loss of an entire medical student class annually. And suicide among medical professionals is not unique to the US it’s a problem of worldwide proportions.

Headlines that read: “Med Student Jumps to Her Death from Dorm Window [3], Medical Student Commits Suicide [4], Medical Student’s Death Ruled a Suicide [5], Medical Intern Dead After Jumping Out of Apartment Window [6],” or “Mt. Sinai Medical Student Dead After Apparent Suicide [7]” are becoming increasingly common.

Not surprisingly, the prevalence of depression among medical students, residents, and physicians has been escalating. A recent meta-analysis of 129,000 medical students evaluated in two-hundred studies from 47 countries found that27% had experienced depression or depressive symptoms during medical school [8]; this number is 2-5 times higher than that of the general population [9].

And it doesn’t end after medical school. Suicide among physicians is estimated to be twice that of other professionals [10]. Moreover, female physicians were found three times as likely to commit suicide as are their male counterparts [11].

One must ask what the prognosis is for the future of our medical schools. Will the changes that are currently taking place will be enough to change the culture of medicine or continue to endanger the well-being of our medical students? Efforts are being made to promote resilience [12]. Most ideas are centered on finding better ways to create a positive, more nurturing learning environment and earlier means of identifying at-risk and/or struggling students [13].

References

1. Rabow MW, Wrubel J, Remen RN. Promise of professionalism: personal mission statements among a national cohort of medical students. Ann Fam Med. 2009; 7: 336-342.
2. Center C, Davia M, Dentre T. Confronting Depression and Suicide in Physicians: A Consensus Statement. JAMA. 2003; 289: 3161-3166.
3. Med student jumps to her death from dorm room window. New York Post. 2016.
4. Medical Student Commits Suicide. Duke Magazine. 2006.
5. Medical student’s death ruled a suicide. The Daily Pennsylvania. 2016.
6. Medical Intern Dead After Jumping Out Of Apartment Window. The Gothamist. 2014.
7. Mount Sinai Medical Student Dead after Apparent Suicide. Harlem Patch. 2016.
8. Rotenstein LS, Ramos MA, Torre M, Sequal JB, Peluso MJ, Guille C, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016; 316: 2214-2236.
9. Oaklander M. 27% of Medical Students are Depressed. Time. 2016.
10. Lindeman S, Laara E, Hakko H, Lonngvist J. A systematic review on gender specific suicide mortality in medical doctors. Br J Psychiatry. 1996; 168: 274- 279.
11. Sinha P. Why Do Doctors Commit Suicide? New York Times, 2014.
12. Prayson RA, Bierer SB, Dannefer EF. Medical student resilience strategies: A content analysis of medical students’ portfolios. Perspect Med Educ. 2016.
13. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences and proposed solutions. Mayo Clin Proc. 2005; 80: 1613- 1622.