The alarming situation of medical student mental health.

Numerous studies documented in several recent reviews attest to the poor mental health of medical students over several decades[1]-[3] and the marginal and limited efficacy of most interventions.[4],[5] This is not a crisis but rather, in the language of public health, a disease condition that is endemic to medical schools. Through this commentary we hope to make a convincing argument for greater resolve in addressing medical student mental health, enough to generate effective action.

Several studies have also reported that medical students have mental health scores below those of age matched peers or the general public[2],[3],[6]-[8],[9]-[12] who are themselves experiencing poor mental health.[13]-[16] That medical students score lower than those who are already low highlights the alarmingly poor status of their mental health. Studies at one Canadian medical school show high levels of stress over almost 10 years.[11],[17],[18] Furthermore, it appears that medical schools negatively affect the health of our students.[9],[19] If we can do something about this, are we not morally accountable to do so? And should not this responsibility extend beyond initiating and maintaining programs and policies to actual outcomes such as lowering the general level of distress and demonstrably improving medical student mental health?

Given the high and persistent rates of mental health concerns among medical students, and the so far limited effectiveness of measures implemented to address these concerns, we believe the response of medical schools and the medical education community has been inadequate and needs to improve. This statement does not lay blame with any group or set of individuals within medical schools or the medical education establishment generally. What we mean to state is the logical conclusion that there has been little or no improvement over many years despite well-intentioned interventions and expressions of genuine concern.

Wellness programs and access to tertiary care services have not only had limited effect but they may have distracted us from addressing the root causes of this distress and burnout. To illustrate this point, we include here the articulate but distraught voice of a family member who observed the deterioration of a resident’s mental health and well-being. While the condition of being a resident is different in many respects from that of a medical student, the point made in this blog is applicable:

“Practices like mindfulness and gratitude and other forms of yuppie “self-care” are generally benign unless and until they obscure the material causes of people’s suffering. No amount of meditation will compensate for not having nutritious food to eat, time to sleep or emotional bandwidth to spend on one’s loved ones.”[20]

Let us amplify what she has just told us: We need to fix the problems not the people. More resilience training and wellness programs are unlikely to make a difference.[22] We believe we need a comprehensive approach that also addresses the systems and structures in which the medical students live and learn.[22]-[24]

Leaders in medical schools have a responsibility to address conditions within their control that contribute to this unacceptable endemic disease state among medical students. Health services and programs to enhance medical student wellness have not been successful in the past.[4] It is unlikely that well-crafted accreditation standards or medical school plans that mandate these standards, without recommended outcomes and vigilant monitoring, will be effective in the future.

We therefore appeal to medical education leaders in medical schools to act on this persistent and pernicious situation. We need leaders to step up and make the kinds of substantive changes in systems and cultures that will create measurable improvements in medical student mental health. An actionable item under the control of medical schools would be reducing the unreasonable amount of content in the overcrowded medical school curriculum that both contributes considerably to the excessive and chronic stress medical students experience[25]-[31] and functionally prohibits students from engaging in necessary self-care.[7] Managing the excessive demands of the curriculum would be a good place to start.

If we were seeing a spike in cases, we might be justified in calling this alarming situation a crisis. Perhaps we have become inured over the last several decades to the poor mental health that is endemic among medical students. If labeling it a crisis will mobilize us to engage in timely, resolute, and effective action, then a crisis we should call it.