On August 17, 2016, a medical student at Mount Sinai School of Medicine died by suicide when she jumped from her dorm room while her roommates slept. Approximately 400 physicians are lost to suicide each year in the United States.

I could have been one of them.  

Most of the articles on this blog address study tactics, scheduling, high yield topics on the USMLE, or other academic aspects of the medical education we all go through. Today, I wanted to address another side that has been tragically overlooked: the all too common despair, depression, and suicide that exists at all levels of medicine from medical students to interns and residents all the way to seasoned attending physicians.

Depression and Medicine: A High Risk Profession

The very real link between the medical profession and depression is one that’s only recently being brought to light.  Some members of the medical community  like Pamela Wible, M.D.  have made it their mission to raise awareness about this issue and influence change in our current system to prevent this epidemic from continuing. Others are petitioning the AAMC and ACGME to start keeping track of physician suicides so that prevention strategies can be implemented. Others are writing about their personal experiences when colleagues or friends have committed suicide.   

When we consider the context, this trend is not surprising. We know that one of the greatest risks for suicide is depression, and that the field of medicine has many features that place physicians and trainees at an increased risk for it. Some of these have to do with the nature of the work itself, like seeing so much death and despair amongst those we are tasked to care for. Some other factors have to do with the way our training programs are set up, which we’ve been told there’s no way around (including things like sleep deprivation due to long work hours and study time, the burden of student debt, and regulatory burdens placed on trainees and attending physicians alike). Whether or not the current system is truly the only one possible is a discussion for a different post.

Unfortunately, there is also the time-honored tradition of humiliating, dehumanizing and hazing medical trainees through various means. I believe this must change, not only for the good of people practicing medicine, but for the good of our patients as well.

However, today I am not going to speak about any of these things at length. Today, I would like to take the time to add another voice to the conversation, and to let you know that if you are suffering from depression, you are not alone.

My Own Story

Many people enter medicine as perfectly happy, well-adjusted people and get depressed when the stresses of the field overwhelm them. My story is somewhat different.

I come from a family of people who suffer from depression. As a teenager, I lost four close family members to various illnesses, which seemed to seal my fate as a depressed individual. Though I always did well academically, I struggled with depression throughout high school and college in the aftermath of these tragic losses. I was still struggling when I entered medical school.

People often ask me if the deaths in family led me to decide to become a doctor. The truth is, I really don’t know. I always knew that I wanted to be in the helping professions, and I was a good student with an interest in how the body worked as well as how it could be modified. I graduated summa cum laude from college and did pretty well on the MCAT  before I knew it, I was in my first year of medical school.

The pressures were high and I was already trying to cope with my mood at the time, but while my classmates were sleep deprived due to staying up late and studying, I was sleep deprived due to the demons in my head. Still, I managed to finish my first year of medical school ranked third in my class in a fairly large school. By all measures, I should have been thrilled, but instead I shrugged it off. “Who cares?” I thought. “My academic abilities are natural and nothing to be proud of anyway.”

My second year was much of the same. The USMLE came and went, and predictably, I did quite well on that too. Things didn’t begin to go downhill career-wise until my third year. Word on the street was that it was imperative to figure out what you wanted to specialize in so you could set up the “right” rotations for fourth year and position yourself to get into the best residency possible in your chosen field. As I continued to battle severe depression, it seemed impossible to get particularly excited about any specific field. In the end, I set up fairly random electives, just to fill the time, hoping I’d run straight into the right field and just “know.”

It was during my third year rotations that I began experiencing the verbal abuse and ridicule that so many of us endure in our medical training. I can remember a specific instance where my attending was yelling about something that I assumed was my fault, although I didn’t quite understand how. When I apologized, he started yelling more, “What the hell are you apologizing about? It’s not your fault! Stop apologizing!” Suffice it to say, I felt like I couldn’t do anything right.

Until that time, I had been a star student wherever I went. Suddenly, I knew nothing and felt completely inadequate. “How am I ever going to care for patients independently?” I thought to myself but was too afraid to say aloud. Don’t get me wrong, I think a good dose of humility and skepticism about how much you know is healthy for trainees and seasoned doctors alike. However, thinking that you’re an idiot and completely inadequate is not a healthy way to look at yourself.

Looking back on those days, I realize that I wasted a lot of energy focusing on all of my perceived weaknesses instead of just using my energy to become more knowledgeable.

As time went on and I felt worse and worse about myself, I continued to avoid thinking about what type of medicine I actually wanted to practice. My fourth year rolled around, and I actually set up electives in three or four different fields. When it came time to apply for residency, I applied to three different fields because I still had no idea what I wanted to do. I got a bunch of interviews, all of which I went into with absolute dread  something that probably showed through to my interviewers. I knew things were not going well and became convinced that I would not match anywhere, that my career would be over before it began. I was also, of course, concerned about the nearly $200,000 of debt I’d accrued to pay for medical school. At the last moment before the match closed I put a prelim medicine year at the bottom of my list, even though I had a bad feeling about the program. When the results were finally published, I found out that I had matched to my last choice with no match for my subsequent years. I was devastated.

My wife and I began our arrangements for the move and I became increasingly more and more depressed and desperate. I felt like I didn’t want to live, but I didn’t feel like I could tell anyone. So I moved and I even went to residency orientation. By the time the second day of orientation rolled around, I was aware that I was a danger to myself and the very sick patients that I was supposed to take care of in less than a week’s time. I was thinking more about my own death than I was about my future.

I went to the residency administration and told them how I was feeling, and they informed me that they were required to report me to the NRMP. I sought out help from a psychiatrist for evaluation and treatment of my depression. The NRMP then told me there would be a match violation assessed against me that would prevent any program from accepting me for one year.

The hospital pressured me to accept the violation because the case was still hanging — they had to wait until it was closed in order to fill my spot. I knew that this would make it difficult for me to get into residency after I recovered, so I appealed the process for a couple of months. The NRMP, I reasoned, would take a diagnosis of depression seriously enough to let me out of the contract so I could get the treatment I so desperately needed.

I was wrong. Depression was not considered a serious enough illness to matter to the NRMP. Did I have a life threatening illness, like cancer? They wanted to know. I had no money to pay an attorney and the NRMP would not budge, so eventually I accepted the match violation so the hospital could get another intern and be less short staffed.

By then it was already November, and the NRMP informed me that due to the appeal process the one-year ban would begin from the time of the final decision. This meant it would be impossible to re-enroll in the match for another two years. I knew this could potentially prevent me from ever reentering the profession. I continued treatment throughout the year while finding work with MST to help my wife pay the bills. I found a loophole and a residency program that would take me for the following year. It was far from the choice I would have made if the circumstances had been different.

When I applied for my training license for residency, one of the questions was about mental health diagnoses in the past five years. I decided to tell the truth. Because of it, I ended up being called before the state board, where they asked me dozens of questions about what happened. I found myself at a hearing with physicians who were being questioned about illicit sexual relationships with patients, getting violent in the workplace, prescribing narcotics inappropriately and showing up to work while under the influence of drugs and alcohol. I assumed they’d let me off the hook. Instead, I was told I would need an “independent” psychiatric evaluation and was given a short list of board-approved psychiatrists. The one-hour evaluation cost $600, while the report the psychiatrist filled out on my behalf cost another $600. Needless to say, I wasn’t exactly rolling in money at this point.

I continued to get treatment and finally began my residency. Fast forward several years: I’m now a Board Certified Physician and my depression is under control. I sometimes wonder what life would be like as an academic rheumatologist or endocrinologist. I always loved physiology and teaching, and I believe that had I not had the difficulties I had along the way, I would have taken one of those paths. However, getting help when I needed to — even if it meant my career took a detour — is the only thing that kept me from being one of the 400 physician suicides that year.

This is Not About Me — It’s About You

I am not writing this post primarily to tell my story. I am writing it because many of you have stories of your own. In my case, my struggles with depression began long before I ever decided to become a physician. For some of you that may be the case, while for others, your struggles may have begun during your training.

There is much that needs to change in the culture of medicine, but today I am writing this for you now. If you are feeling depressed, or even if you’re not sure if you are depressed, please get help sooner rather than later. In medical training, we are taught to treat things like cancer, diabetes, coronary artery disease, and rheumatoid arthritis. We know that it is important to treat most of these diseases early to minimize the morbidity and mortality that they can cause. I’m here to tell you that depression is no different. It is a disease that can cause suffering, death and disability just like any other. If, like most medical trainees, you are between the ages of 25 and 40, it’s actually more likely to harm you or end your life than any of these other diseases.

There are many resources that can help you:

• Medical schools and residencies generally offer help in the form of counseling centers, support hotlines, and the like. These resources are strictly confidential.
• If you don’t want to go that route, most towns and cities have centers where they offer low cost mental health in the forms of counseling and psychiatric services by way of grants and/or student training centers.
• If you are feeling depressed or hopeless, please reach out to your friends and family. I guarantee you someone else is feeling like you do, or did at one point in time.
• You can also call Lifeline to talk to a trained counselor: 1-800-273-8255.

Most importantly, don’t feel ashamed and don’t delay. It is not worth your life. You cannot care for others if you are aren’t well yourself. Know that recovery is possible, although it is a process. In most cases, this will not require stopping your medical education like it did in my case. In severe cases it may, but I’m here to tell you it’s worth it if that is necessary.

Lastly, if you are not depressed, please do not think that you are immune. Spend at least some time and effort on self-care. That can mean different things to different people  anything from meditation, spinning, lifting weights, reading books or watching stupid movies. I don’t care who you are. You’re not Superman or Wonder Woman, nor should you think you need to be.