Cathryn J. Lapedis, MD, MPH
Acknowledgment: The author thanks Sarah's family for their generous support in publishing this essay. The name of the student was changed to protect their privacy.
Corresponding Author: Cathryn J. Lapedis, MD, MPH, 2800 Plymouth Road, Building 14 G100-29, Ann Arbor, MI 48109-2800; e-mail, email@example.com.
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Audio. Virginia L. Hood, Annals Associate Editor, reads "Murky Water," by C.J. Lapedis.
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September 28, 2018
A tough profession
A very moving story. United States is famous for its medical training to be the best and unparalelled in the world. Especially the residencies. Probably student training is also more difficult than anywere else. Profession of physician brings similar dangers as army officer or police officer profession. You take stakes and your patient may die or you may die sometimes.This is why it becomes harder and harder for schools to find candidates for students. Suicides among physicians, addictions and alcoholism are all part of the game. US is an exception in one thing : people kill themselves on an impulse because they have gun hanging on a wall.
Titte S. Krishnaswamy, M.D., FACC, FACP
None at present
October 1, 2018
I read the poignant account of the untimely and unnatural death of "Sarah". The author rightly points out that it is the murky water that we should clean up , and that we should not blame the clean fish. The cruel irony is that big institutions, and professors conduct courses to counsel the burned out physicians. Of course these institutions, and the speakers in sojourn perhaps make money.Perhaps some of these professors themselves have abused the students and the trainees. It is like counseling the victims of rape instead of tackling the rapists.I am a meek and humble foreign medical graduate perhaps old enough to be a grandfather or father of the author,and late "Sarah". Hitherto I had thought that only the foreigners and the ethnic, and the racial minorities were being abused. The article by the author is an eye-opener in that regard. Martin Luther King Junior said , " Injustice anywhere will destroy justice everywhere." May the departed soul of "Sarah" rest in peace.
Lawrence K. Loo MD, Daniel I. Kim MD
Loma Linda University School of Medicine, University of California School of Medicine
October 15, 2018
In Lapedis’ poignant description of the suicide of a classmate shortly after receiving her USMLE 1 score, she writes “We know the statistics . . . Rates of burnout, depression, and suicide are significantly higher in medical students, resident and physicians than in an age-matched population.” (1) In a recent Grand Rounds presentation at one of our institutions on burnout, depression and suicide, an anonymous poll found that approximately 70% of the audience, composed of faculty, residents, and medical students, agreed with that statement. In reality, however, the statistics do not completely support that statement. Rates of burnout, depression, and suicidal ideation are reportedly higher in medical students compared to age-matched population. (2) But actual suicides are lower in medical students and residents compared to age-matched peers. (3, 4) Middle-aged physicians (forties and early fifties) have comparable rates to the general population. It is only when physicians entering in their late fifties and beyond, do actual suicide rates exceed the general population. The deleterious effects of prolonged stress and work hours have led to widespread awareness and positive changes in policies regarding the work environment (5). We wonder, however, if the nationwide notoriety and spread of potential misinformation contribute to the enhanced anxiety of young trainees early in their professional education. After our own institutional workshops to heighten awareness of burnout and depression, the authors have heard more than one medical student and resident say, “I didn’t realize I was burned out until I heard this presentation.” Suicide contagion is a term used to describe cluster outbreaks of suicide and is thought to be related to the widespread reporting and sensationalizing or detailed descriptions of the methods of suicide. (5) We propose a similar term “burnout contagion” related not just to the heightened awareness of the topic but in part to the dissemination of misinformation that suicide rates are higher in medical students and residents. The causal relationship between burnout and suicide remain unclear. Our intent is not to minimize the death of any single medical student or resident as acceptable, nor to detract from the movement to increase wellness and resiliency among all physicians. Perhaps, however, we should emphasize that in spite of an increase in reported anxiety and burnout, the fact that actual suicide rates are lower among medicals students and residents may reflect a positive effect of resiliency and supportive environment during their training years. Lawrence K. Loo, MDLoma Linda University School of MedicineLoma Linda, CaliforniaEmail: firstname.lastname@example.orgDaniel I. Kim, MDUniversity of California School of MedicineRiverside, CaliforniaReferences: 1. Lapedis CJ. Murky water. Ann Intern Med. 2018;169:415-416. [PubMed PMID: 30242420] doi:10.7326/M18-1398.2. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, MataDA. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A Systematic Review and Meta-Analysis. JAMA. 2016;316:2214-2236.[PubMed PMID: 27923088] doi:10.1001/jama.2016.17324.3. Petersen MR, Burnett CA. The suicide mortality of working physicians anddentists. Occup Med (Lond). 2008;58:25-9.[PubMed PMID: 17965446]4. Yaghmour NA, Brigham TP, Richter T, Miller RS, Philibert I, Baldwin DC Jr,Nasca TJ. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. Acad Med. 2017;92:976-983. [PubMed PMID: 28514230] doi:10.1097/ACM.0000000000001736.5. Stone DM, Hilland KM, Barthdow B, Crosby AE, Davis S, Wilkins N. 2017. Preventing suicide: a technical package of policies, programs, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Cathryn J Lapedis, MD, MPH, Lisa M Meeks, PhD, MA
University of Michigan, Ann Arbor
November 20, 2018
In Reply to Loo and Kim: We thank the authors for their comments regarding my personal essay recounting the death of a classmate. To more fully address the reader’s comments, I have asked for assistance from my colleague, Dr. Lisa Meeks who has expertise on medical student wellbeing.
We acknowledge that there are significant gaps in the literature regarding medical student suicide rates, risk factors, and mechanisms for intervention.1 Suicide is highly stigmatized, thus lending itself to under reporting. Gleaning accurate suicide data from individual medical schools and even coded death records from residents and physicians is difficult.1-3
Nevertheless, number of deaths by suicide should not be the measure by which we enact change in the medical school and residency environment. There are high rates of burnout, depression, and suicidal ideation among medical students.4,5 Policies, culture, and structure of medical training likely contribute to increased distress, evidenced by higher rates of resident suicide and depressive symptoms in at certain times of academic cycles and levels of training (i.e. intern year of residency).3
We recognize that learners may not be able to identify the cluster of symptoms as burnout without the aid of a label, but do not believe that this makes burnout a contagion. We worry that labeling burnout a contagion risks perpetuating the stigma that leads to silence, further isolation, shame, and a reduction in help seeking behavior. When there are clusters of burnout in trainees, we must make meaningful changes in the organizational culture and structure of the training environment. We must provide resources for coping.
Learning the names for feelings like burnout, depression, and suicidal ideation help us to identify and respond to these conditions. Personal testimony, from those “coming out” as survivors of burnout, depression, and suicidal ideation,6 validates the feelings shared by so many in our community. Not dissimilar to the powerful statements of those in the “me too” movement, stories from those who have experienced burnout, depression, and suicidal ideation reduce the stigma, and alleviate the shame and isolation.
The deeply entrenched pressures and culture of medical training make us intensely vulnerable to burnout and depression. These vulnerabilities can lead to devastating outcomes. We must focus our efforts on making medical school a place that prepares and empowers students to fulfill the societal need of caring for others. Caring for others begins with caring for ourselves and our community.
Note: If you are in crisis, help is available, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741
1.Blacker CJ, Lewis CP, Swintak CC, Bostwick JM, Rackley SJ. Medical Student Suicide Rates: A Systematic Review of the Historical and International Literature. Academic medicine : journal of the Association of American Medical Colleges 2018.
2.Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. General hospital psychiatry 2013;35:45-9.
3.Yaghmour NA, Brigham TP, Richter T, et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Academic medicine : journal of the Association of American Medical Colleges 2017;92:976-83.
4.Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. Jama 2016;316:2214-36.
5.Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Annals of internal medicine 2008;149:334-41.
6.Gupta R. I solemnly share. Jama 2018;319:549-50.
Lapedis CJ. Murky Water. Ann Intern Med. ;169:415–416. doi: 10.7326/M18-1398
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Published: Ann Intern Med. 2018;169(6):415-416.
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