March 17 is Match Day in the US. At exactly 12:00 pm EST, medical students all over the country, including myself, will be handed an envelope enclosing our fate: the residency program where we matched and will train for the next three to seven years, depending on specialty. For many of us (and our support networks), this is the most momentous day of our lives— a culmination of innumerable sacrifices and hours of studying. But as I look forward to a career in psychiatry, I can’t help but look back at the mountain we traversed and think about how our experiences have shaped our psyches.
Compared to other professions, doctors have some of the highest rates of work dissatisfaction and suicide; around 300 physicians die by suicide each year.1 What I find particularly shocking is that this shift begins in medical school as we become immersed in the intense, often unforgiving culture. Upon entering medical school, studies find that medical students experience lower rates of depression compared with age- and education-matched peers. Yet, during medical school, the prevalence of depression jumps. Almost 30% of students report suffering from depression or depressive symptoms at some time during medical school, and 11% of students contemplate suicide.2 A confluence of factors contributes to these acute changes: the sheer volume of work, lack of sleep, stress from continuous high-stakes examinations, isolation due to academic demands, fears about future capability, feelings of inadequacy, and a non-supportive work environment.3
Emotional and physical crises don’t happen on your timeline.
This past year, I was rotating on internal medicine, providing care for patients with acute hypoxia and congestive heart failure. Meanwhile, on a medicine floor just like mine across the continent, one of my grandmothers died of respiratory failure while the other was hospitalized with a failing heart. Each day, I saw them in the patients I cared for—my grief unexpectedly bubbling up. In medical school, I’ve had three family members pass away and a few health issues, some of these occurring dangerously close to critical exams. The administrators were supportive but could only offer me the option of pushing through or taking the entire year off (one week off meant too many missed requirements).
Medical school has an unceasing deluge of tasks unkind to the unpredictability of life and healing. Through this, I’ve learned the importance of being in conversation with myself to assess (and reassess) my capacity to carry on or my need for time off. I’ve found it similarly essential to communicate with faculty and access support resources to process difficult emotions and prevent compounding them, which can create fertile ground for future burnout.
Emotions and self-worth inevitably become intertwined with our professional roles.
As a third-year student on my surgical rotation, the attending urologist began grilling me on the embryological development of the testes. When I blanked, he would not let up with his questions. He emphatically punctuated the diatribe with, “even a preschooler would have more knowledge than you.” For the rest of the week, my gaze was locked on the floor. I turned inward, questioning my self-worth and whether I deserved to be in medicine.
What that physician said to me was unacceptable: everyone deserves psychological safety in their workplace. When discussing the problematic behavior of senior physicians, one of my classmates said, “shit rolls downhill.” Perhaps, but that does not mean we should have to sit at the bottom and eat it. Improving mental health in medicine requires addressing people who sustain (historically) toxic work environments. In addition to changing this culture, personal reflection can help disentangle our worth from our white coats.
At my core, I know I am a good friend, partner, and person, but these transcendent feelings sometimes become hard to remember. To spend as much time in the hospital/library and sacrifice as much as we do — time, money, relationships, sleep, mental health — means that the line between job and personhood becomes blurred. Cognitive distortions often form and are exacerbated by society convincing us our profession is a “calling.” Given this, it is invaluable to find time for the activities and people that remind us of our identity outside of medicine to re-calibrate our self-worth.
Solidarity can and should take many forms.
“You’re going to meet all your best friends in medical school,” I listened expectantly to my dad (a doctor), as we drove to the airport before year-one orientation. It didn’t take me long to realize that immediate, sorority-like friendship is not everyone’s reality. However, after four years, I can attest that a closeness does develop with classmates. This bond was not immediately obvious to me, and it didn’t come from expertly navigating medical school’s new social norms and high-school-like cliques.
I feel this solidarity as I hurry down the hospital hallways and lock eyes with another fourth-year student. We nod to each other with understanding eyes. This bondedness developed through the unspeakable amount we’ve jointly experienced: from innumerable lectures/exams to difficult rotations where we endured doctors with the emotional intelligence of sea sponges, fluid-filled nights on OB/GYN, or the heat of multi-hour skin grafts on burn victims where they keep the operating room hot. Our closeness is less High School Musical and more Lord of the Flies.
Not everyone’s journey is the same.
Although medical school is notoriously demanding, such demands are shaped by intersectionality and not necessarily borne equally. At my White Coat Ceremony, over a third of students received their white coats from a family member already in medicine– a revolving door of privilege. Medicine has historically been (and remains) a white and high-income space.4,5 Despite more individuals from underrepresented backgrounds entering medical school today, the environments that students arrive to learn in have largely stayed the same. The necessary anti-racist institutional culture, financial resources, mental health support, and representative mentorship that allow students to feel supported are not yet robust.
This cultural disconnect is consequential: one study of medical students found that increased microaggression frequency from colleagues and senior physicians was associated with a positive depression screen in a dose-response relationship.6 The Association of American Medical Colleges (AAMC) is working to increase the number of students underrepresented in medicine. But the goal cannot merely be representation, rather it should be to create a new culture and system where students can thrive. The floor needs to be open for students to describe their experiences while institutions work to address systems that impact their mental health and potential.
It is hard to pause and look back when constantly moving forward.
I remember the shell I became and the neuroticism that set in while studying for the US medical licensing exams (USMLE). For weeks, I sat studying for 15 hours a day, not leaving my apartment, and attempting to sleep while gripped by the stress of my exam score determining my ability to match into the specialty of my choice. After completing our first USMLE (Step 1), my classmates and I were ecstatic, scrambling to organize parties to celebrate before our fast-approaching clinical rotations.
I’ve taken over 400 exams since starting college and, somehow, it hasn’t become less stressful. The stakes have only felt higher as the sunk cost and bearing on my professional future grows. And as the competition for medical school and residency increases, a student must not only have impeccable grades but also be a renaissance person (do ground-breaking research, start a non-profit organization, climb Mount Everest, found a start-up, win a Nobel Prize, etc.); expert extrovert (winning over each resident, doctor, interviewer evaluating us); and world-renowned used car salesman (packaging oneself in countless application essays and interviews). Then, once you finally get into medical school or match into your dream residency or fellowship, they tell you to relax and enjoy it. How is a person whose cortisol and productivity have been running at such a high-octane level supposed to simply chill?
It’s hard to flip the switch into Zen mode– it takes time for our bodies to let go of cumulative stress. Yet, the demands in medicine never stop, and the habits we convince ourselves are temporary often carry over. Unlearning conditioned behaviors is hard, making it vital to learn how to pause (guilt-free) despite the inundation of to-dos early in our careers.
Understanding mental health on an intellectual level is different from questioning its applicability to oneself.
Although physician suicide is the most acute and devastating issue surrounding mental health in medicine, the downstream impacts of medicine’s high stress and isolation are much more expansive. Students around me have struggled with anxiety, eating disorders, exercise addictions, and substance use.
As medical institutions address the external factors contributing to trainees’ mental health challenges, students should also feel empowered and accountable to lend and seek help– dismantling stigma in the process. When we think about physician burnout, we must work upstream and broaden our conceptualization of mental health risk factors and what struggling looks like (a student can still score in the top percentile on exams). We can all play a part in preventing physician burnout by creating a culture of reflexivity, support, and accountability– and joining together to advocate for more robust mental health resources and workplace protections.