It’s the hard knock life for us

You know what’s really stressful, and not so very good for the mental health?

Medical school.  From the Times:

It’s been clear for several years now that while aspiring doctors may start medical school as happy and as healthy as their non-doctoring peers, four years later they aren’t.

More than 20 percent end up with depression, more than half suffer from burnout, and in any given year, as many as 11 percent contemplate suicide. All of these statistics, of course, bode poorly for patients. Doctors who are burned out are more likely to make errors and to lose sight of the altruism that led them to go into medicine in the first place.

Fortunately, the subtext of this growing body of data — that there is something toxic about the medical education process — has not been lost on the educators who run this country’s medical schools. Some have hired mental health experts for their institutions, created counseling centers and set up confidential Web sites and hot lines; others have developed elective courses in meditation and mindfulness, switched from letter grades to pass-fail systems and revamped class schedules to foster better work-life balance.

Despite the good intentions, their efforts continue to be stymied by one thing: Students aren’t participating. As one educator recently told me, “I keep seeing the same 10 students at all these events, and I’m not even sure they’re the ones we need to be reaching.”

My reaction to these strategies is probably the same as how most conservatives react to various social programs.  A problem presents itself, and well-intentioned people engineer a solution that doesn’t work in real life.  (I’m not necessarily endorsing this criticism.)

There are lots of reasons I can think of for why these attempts to help struggling medical students fall flat.  As indicated in that last quote, the students who avail themselves of what’s provided are probably the ones who don’t need it.  Furthermore, medical school is incredibly demanding of one’s time and energy, and I suspect that most medical students are loath to sit through some elective on mindfulness when there’s something better they could be doing. 

The article goes on to describe an interesting, “Hogwarts-esque” approach that Vanderbilt has taken.  I think it’s commendable that it and other medical schools are taking the issue seriously, and I don’t want to seem unduly cynical about their efforts.  However, the article also concludes on an equivocal note:

While no one yet knows the long-term effect of Vanderbilt’s innovations – or, for that matter, of any programs designed to promote “wellness” — Dr. Rodgers and his colleagues and students at Vanderbilt remain committed to their initiatives. For them, the implications of medical student depression and burnout are simply too important to ignore.

I wish them well.  But nothing in this article says what seems obvious to me — medical school involves unique challenges and stressors, which are likely to take a toll on the mental health of students.  Nothing that any medical school can do can obviate the fundamentally stressful nature of the profession, and of the training program that grants entry into it.

Medical schools are, first of all, highly competitive to enter.  This already selects for a highly competitive student body.  I think it’s great to have a pass-fail grading system (my school did, with an “honors” evaluation for superlative performance), but that’s not going to change the underlying reality that medical students are still going to be competing with their peers (in their school and around the country) for choice residency spots afterward.

It’s not merely the competitiveness that makes medical school unique, however.  There are lots of academically challenging and competitive career paths out there.  There’s also the reality that medical students are confronted (probably for the first time in most cases) with trying to make people better, and failing.  They start with that much-vaunted idealism and altruism, and have yet to be confronted full-force with some hard truths.  Patients sicken and die, sometimes right in front of you.  Sometimes this happens because they ignored your advice, sometimes it happens despite rigid compliance with your best-laid plans, and sometimes things go wrong and your plans make things worse.  All of these things happen eventually to just about every doctor, and it’s a bitter pill to swallow.  Add in a lot of the tedium and drudgery that comes with practicing medicine in our United States, and of course students will get stressed and bitter and some will burn out.

Maybe it’s my dark, tar heart talking, but better they learn these things in medical school than later.  Better the ones who burn out do so in medical school than when they’re writing the orders.  While I think residencies are unduly harsh and still make residents work harder and longer than is good either for them or their patients, it’s best that medical students be prepared for the experience.  I am entirely sincere when I commend the efforts of Vanderbilt to make things are good for their students as they can, and I hope they are successful in helping the ones who need it.  But medical school is hard because medicine is hard, and it probably always will be.