October 2, 2014

By Dr. Ann Loewen

Picture a bright young woman or man pursuing their medical training at a well-respected university. Perhaps they are there on a scholarship; without doubt they have received many expressions of congratulations on achieving entrance into this program. Their peers come from a variety of backgrounds and have many interests. At the end of their degree is the promise of secure employment with good pay and a high degree of autonomy. This young person is likely living his or her dream. And yet he or she may be simultaneously struggling with depression, anxiety, or both.

Dr. Jack Perlov, a child and adolescent psychiatrist and Associate Professor at the University of Manitoba’s Faculty of Medicine, observes that “Medical students are typically individuals who are determined, goal-oriented, perfectionist and overcompensating. They are therefore vulnerable to feeling disappointed when they cannot achieve their goals, fail, or are the target of criticism. This leads to feelings of anxiety and depression. However, clinical depressive disorders may be difficult to differentiate from these stress-induced, situational depressions. Given the chronic stress of medical school and then residency, students assume they are reacting to the various stressors, and do not recognize that their coping skills are limited because of a depressive disorder, resulting in delay of diagnosis and treatment.”

The paradox of attaining high levels of achievement while experiencing deep unhappiness is not often discussed in the pressured environment of medical school and residency. And yet the occurrence of mood disorders among our learners is distressingly high.

“Studies indicate that up to 30% of students develop depressive disorders during training,” says Dr. Perlov, who is also with Faculty Counselling Services and MD Care. “Many do not have family doctors, nor do they seek help, so it is not uncommon for them to call in distress after failing a rotation or exam and requiring urgent crisis interventions. This will include a rapid assessment, supportive psychotherapy, family therapy, and pharmacotherapy. Many have suicidal thoughts and some have already formulated a plan. The staff at Faculty Counselling Services takes these concerns seriously, although with rapid intense therapy, few require hospitalization.”

Several factors are entrenched in the selection and training of physicians, and predispose to the high rate of mood disorders. Among them are:

Perfectionism – The late Dr. Lee Lipsenthal, cardiologist and physician health champion, sought to understand why otherwise healthy doctors he saw as a consultant were having myocardial infarctions. He found a significant correlation between the physicians’ cardiac outcomes and their tendency towards perfectionism – as opposed to the healthier goal of excellence. Perfectionists are the kind of people who are selected for, and who manage to get through, medical training. But over-achievers experience great degrees of stress in an imperfect world, and are often unable to experience in-the-moment happiness because their focus is on the world’s deficiencies rather that its delights.

Delayed Gratification and Impulse Control – Impulse control is widely cited as a predictor of present and future success. Getting into medical school and through medical training requires the postponement of many activities that would otherwise be pleasurable. By definition, then, medical trainees have good impulse control. But the delay in gratification is so long that the accumulated unmet needs, including such basics as socializing, sleep and just plain old fun – do not favour a happy life, however much one might otherwise love learning.

Competitiveness and the Culture of Bravado – Staying up late studying, remaining on the ward beyond quitting time in clinical rotations, having the latest research trial results at the tip of one’s tongue are ways of achieving academic goals and the reward of praise from one’s superiors. But the dehumanizing and stress-inducing cost of these behaviours detracts from the pleasure of learning.

Bullying – A BMJ study of 2000 medical students (class of 2003) from 16 U.S. medical schools reported that 27% of students reported being harassed by house staff, 21% by faculty, and 25% by students. Even more frequently, 71% reported having been belittled by house staff, 63% by faculty members and 43% by patients. Mistreated students were more likely to be stressed, to be depressed or suicidal, and to drink alcohol (although, as a Journal Watch editor points out, “it is unclear whether harassment provokes depression and alcohol use, or whether depressed or alcohol-using students have a lowered threshold for perceiving certain behaviours as harassment”). Frank et al BMJ 2006 Sept 30 and Wood, DF BMJ 2006 Sept 30.

Medical students and residents experiencing depressed and anxious mood need understanding and action from their support network, but even more so from the medical community itself. “Most lay people cannot totally appreciate the demands and stress these students are under,” Dr. Perlov relates. “In fact the students do not totally comprehend how unnatural these chronic stressors are. There is a movement in medicine recently to help physicians and students find balance in their lives, and develop a “wellness” preventative program which would include exercise, meditation, developing peer relationships, hobbies, volunteering and importantly address toxic workplace environments. Mentoring and learning to reduce stoicism by having support groups or a counsellor is important as well.”