Understanding depression and distress among medical students.

MEDICAL SCHOOLS ARE ENTRUSTED WITH TRANSforming bright and humanistic students into capable, compassionate physicians who will dedicate their lives to serving others. How best to fulfill this responsibility has emerged as a central concern of the medical profession. Research and self-honest observation over decades have revealed that many of the experiences of medical school may overwhelm and exhaust rather than inspire and instruct students. Indeed, contrary to the intent of medical educators, the experiences of medical training may damage the well-being and diminish the professionalism of many early-career colleagues. Two valuable and innovative research reports in this issue of JAMA explore how the prevalent phenomena of depression and distress may relate to serious issues in medical training ranging from medical student suicide to professional misconduct. In a cross-sectional study with 505 medical student participants at the University of Michigan, Schwenk and colleagues found that 14% endorsed symptoms consistent with moderate to severe depression, a result that fits with previous work revealing that up to one-third of medical students acknowledge significant depression. Symptoms of anxiety disorders, including acute and posttraumatic stress symptoms associated with clinical training activities, may in fact be more common than mood disorders among medical students. As in other self-report surveys and interviews (but not all), women students in the Michigan survey were more likely to acknowledge mood symptoms. Depressed students were more likely to seriously consider suicide, think about dropping out of school, and express greater sensitivity to the stigma associated with being recognized as depressed by peers, teachers, and clinical caregivers. These results are consistent with the findings of other investigators who, for example, have identified links between suicidality and the decision to leave medical school before graduation. The report by Schwenk et al is also consistent with the extant literature on the personal health concerns of medical students, their perceptions of academic vulnerability, and barriers to appropriate care. In their multi-institutional survey study involving 2682 medical students, Dyrbye and colleagues found that 53% of respondents met criteria for professional burnout, a composite measure of emotional exhaustion, depersonalization, and a low sense of personal accomplishment. Beyond this important result, in an innovative approach the investigators sought to separate this notion of burnout (“professional distress”) from depressive symptoms or low mental quality of life (indicators of “personal distress”) to test the hypothesis that professional distress would have a greater negative effect than personal distress on medical student professionalism. The authors predicted that professional distress would be more strongly associated with self-reported cheating behaviors, inability to recognize unethical practices in interactions with industry, and less altruistic attitudes related to the care of vulnerable and underserved patients. Dyrbye et al found that “burned out” students did in fact more commonly acknowledge unprofessional behaviors, and, as hypothesized, the investigators did not find as strong an association of personal distress with a lack of professionalism. Because “stress” is commonly asserted as a principal cause of unprofessional behavior and yet is intuitively associated with depression and mental illness more broadly, the absence of a strong link between personal distress and unprofessionalism represents a valuable preliminary finding. However, the interplay among trainingrelated stresses, personal illness experiences, and professionalism warrants further study. Early narratives and empirical work involving physicians in training and physicians suggest that the personal experience of becoming ill may be underrecognized for its salutary formative effects in fostering empathy for patients and giving rise to an enduring commitment to professionalism in clinical work. Future work may clarify the positive and negative factors that influence professionalism. Such findings would suggest targets for curricular innovation that strengthen students’ professionalism. This effort may also reduce inaccuracies, prejudicial attitudes, and stigma that surround the personal health experiences of trainees.