After working so hard and achieving success, why are so many medical students depressed?

The first time David thought about becoming a doctor, he was 13 years old, in the eighth grade. He recalls that everyone thought it was a great idea. As a bright, naturally curious and diligent student with an outgoing personality, it seemed to his parents, teachers and friends a natural and entirely appropriate decision. All were supportive. In fact, they were enthusiastic. What loomed ahead, all came to realize, was the task negotiating the highly competitive medical school application process. For the next several years, this became a major focus of attention for David, his parents and teachers. The process was researched in some detail. Most decisions, from what courses to take, what recreational and volunteer activities to pursue, even vacation destinations, became framed, or at least influenced, by how it would impact David’s medical school aspirations. David committed himself to his goal. Adept in sciences and an avid learner, he achieved remarkable academic success through high school and his undergraduate degree program, all while accumulating an impressive portfolio of volunteer and other experiences designed to reflect his interest and commitment to public service and medicine in particular. He engaged the application process with vigour and strong support (including financial) from his parents. He was successful, getting accepted to medical school. He, his parents, his friends, were jubilant, and shared in his success. All, it seemed, was good and proper. All was as it should be.

 

David continued his academic success in his first year where the curriculum is largely about knowledge acquisition, a process with which he had become very comfortable. But the clinical aspects of medicine were troubling to him. He found that engaging patients and their illness distinctly uncomfortable, causing him to be nervous and anxious before, during and after each encounter. He found it difficult to deal with emotionally charged issues and, accustomed to engaging problems one at a time at his own pace, he found dealing with multiple simultaneous and urgent problems very difficult and stressful. This caused him to feel guilty and somewhat ashamed. As an aspiring doctor, shouldn’t all this come naturally to him? For the first time ever, he began to question his career choice. He greatly feared disappointing his parents and those who’ve supported him. To his peers, seemingly enjoying their medical school experience, questioning the benefit of being a medical student was incomprehensible. Not sure where to turn, he came to a faculty member to seek help.

 

What happened here, or perhaps more appropriately, what didn’t happen? Did David make a bad decision? Is he ill suited for a career in medicine, or simply adjusting to practical realities and challenges that are new to him?

 

In considering David’s dilemma, it’s helpful to consider the process that leads young people to make informed and, hopefully, durable career commitments. Fortunately, there’s an extensive and very interesting literature on this subject and considerable active investigation. Unfortunately, it’s largely in the realm of developmental psychology, an area in which most physicians are far from expert. “Career Theorists” abound, with various approaches and perspectives on the subject. I provide a list of representative articles below for those interested. There’s certainly much for us to learn that will help guide and support medical students struggling with career choice.

 

Career decision, it seems, is a developmental milestone that can only be achieved after an individual acquires and reconciles two key components; 1) knowledge of self, and, 2) knowledge of the world around them.

 

The first component, development of self-awareness, promotes independent thought and self-confidence. With those attributes comes the ability to make good decisions. Put another way, one can only make good decisions if they’re based on a full and honest understanding of one’s own attributes, interests and motivations. The term that’s been used for this process of personal development is “Individuation”, and has been attributed to the esteemed psychologist Carl Gustav Jung who describes it as follows:

 

“In general, it is the process by which individual beings are formed and differentiated (from other human beings); in particular, it is the development of the psychological individual as being distinct from the general, collective psychology”.

 

It is a progressive personal process that has no fixed schedule. It requires engagement of increasingly independent roles and challenges. It can be thought of as beginning the first time a child steps alone into a school bus for their first day of school and progresses through increasingly complex and increasingly independent life challenges. The challenge for parents, who must progressively relinquish control and security, is to allow these events to occur naturally, continuing to balance their desire to influence and guide while not inhibiting needed growth experiences.

 

Contemporary developmental theorists, notably David Kegan and Marcia Baxter Magolda, provide what might be considered a pragmatic perspective. They describe “Self-Authorship” as the ability to take charge of one’s own decisions, shifting from a developmental stage where we uncritically accept external authority to one where we consider information from multiple sources but ultimately make our own decision, achieving that they term “internal authority”. They argue (I think convincingly) that this is essential not only to personal well being, but to effective and responsible citizenship.

 

How does this happen? In simple terms (that even a non-psychologist would understand), self-authorship develops by engaging the world. This brings us to the second key component required for effective career decision making – learning. Baxter Magnola and others remind us that not all worldly experiences provide valuable learning experiences that will promote effective personal development. She describes three key foundations of effective learning. Cognitive maturity involves intellectual rigour, judgment and problem solving ability (what the medical world might term critical thinking). Integrated Identity refers to understanding of one’s own history, autonomy, connections and “place in the world”. Finally, the Interpersonal component involves the development of mature relationships, respect for self and others, expressed through effective collaboration. The point is made that the latter can only be achieved by engaging diversity during the critical developmental years.

 

These three foundations are essential to the development of independent and effective decision making. They also provide a very effective blueprint for the design of effective educational systems. From kindergarten to university, our teaching and learning should promote cognitive maturity, individual autonomy and engagement of mature, diverse and collaborative relationships with peers and the broader world.

 

The case of David (fictitious name) is provided because it is representative of many students caught up in the modern world of pragmatic, goal-oriented and often competitive career engagement, and raises a number of rather unsettling questions:

 

  • Does the process that students must undertake to achieve success delay or inhibit the growth experiences necessary to achieve individual maturation?
  • By vigorously supporting a child’s early ambitions, are parents and others inhibiting that child’s development and self-realization?
  • Are our educational systems moving in the wrong direction, catering to targeted career development and placement rather than the development of personal attributes necessary to life success and effective citizenship?

 

In short, we must recognize that all these factors may result in students who come to full self-realization late in the game, after they’ve already engaged careers in which they (and those close to them) have invested considerable energy and resources. Change, or adaptation to new challenges, becomes very difficult, and they may feel trapped. But the failure to fully consider their true interests or the struggle to sublimate their interests in favour of what they feel is expected of them may have disastrous long-term consequences, and may, at least in part, underlie the recently publicized concerns regarding the physical and psychological health of medical students.

 

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As medical educators and mentors of these vulnerable young people, at various and individual points along their developmental journey, it’s critical that we’re fully aware of their environment, pressures and needs. These considerations should both inform our admission processes and provide perspective to those counseling troubled students.

Admission processes should seek to identify students who’ve achieved the developmental characteristics that allow for a fully informed career decision.

When students like David struggle, we should suspect that their personal circumstances or the process they’ve undertaken to get accepted may have prevented them from achieving some critical developmental milestones. Identifying that deficiency, helping them complete their development, and exploring what aspects of medical practice might best suit their true strengths may well be the keys to both their success as a physician and personal wellness.

 

David is modeled on a former student. To allay your fears, he’s doing fine, now content and making effective contributions in a medical specialty where acute patient contact is minimal. That resolution only came about after a considerable period of reflection and engagement of very uncomfortable issues in his life.

 

As Dr. Rotenstein’s study points out, there are other Davids out there who need and deserve our understanding and support.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

Baxter Magolda MB. Evolution of a Constructivist Conceptualization of Epistemological Reflection. Educational Psychologist 2004; 39: 31

Baxter Magolda MB. Three Elements of Self-Authorship. J of College Student Development 2008; 49: 269.

Earl JK, Bright JEH. Undergraduate Level, Age, Volume and Patternof Work as Predictors of Career Decision Status. Aust Journal of Psychology 2003; 55: 83.

Hodge DC, Baxter Magolda MB, Haynes CA. Engaged Learning: Enabling Self-Authorship and Effective Practice. Liberal Education 2009; 95(4).

Kegan R. In over our heads: the mental demands of modern life. Harvard University Press. Cambridge MA. 1994.

Super DE, Developmental Concept. https://www.careers.govt.nz/assets/pages/docs/career-theory-model-super.pdf

 

Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.

9 Responses to After working so hard and achieving success, why are so many medical students depressed?

  1. Dr. S,

    Thanks for an interesting and new perspective on this hot topic.

    I was particularly interested in the term “self-authorship”.

    You wrote: “They describe “Self-Authorship” as the ability to take charge of one’s own decisions, shifting from a developmental stage where we uncritically accept external authority to one where we consider information from multiple sources but ultimately make our own decision, achieving that they term “internal authority”. They argue (I think convincingly) that this is essential not only to personal well being, but to effective and responsible citizenship.”

    It is not a term that I have heard before but it is a term that I like a lot. Considering self-authorship on the path to medical school is important as you point out. Some may walk the the doors from a path entirely self-authored while others entering medical school may be living, in part, someone else’s narrative.

    Regardless of what self-writing skills students have when entering medical school, I am certain that medical training needs to do a better job of supporting the development of continued self-authorship once they have entered the doors. In many respects it does quite the opposite. Often, we again learn to uncritically accept external authority. If you came in an author of your narrative, that may not be how you leave. I can think of nothing more dangerous than taking away William Shakespeare’s pen. I am sure he would end up depressed too. I think we need to look reflexively at whether medical school actually takes people further ahead in development towards internal authority and self-authorship or reverts their progress. I worry that we would find overwhelming evidence for the latter.

    Eve

    • Thanks Eve, for those insightful comments. Completely agree that medical school, and all educational programs, develop environments where students can not simply gather information, but grow as individuals. I was intrigued to learn that development of the “interpersonal” aspects of maturation require encounters with diversity, supporting our ongoing efforts to develop diverse educational environments.

  2. Adrian Baranchuk says:

    Another great piece from Dr Sanfilippo. Thanks for shedding some light in this concerning topic.

  3. Dr. Stephen Bagg says:

    Thank you for this excellent blog, Tony. As I read the material, I can think of countless students who I have encountered over my past 28 years as at Queen’s who, although not depressed, are clearly struggling with clinical encounters, even with simulated patients with close observation and mentoring. It seems to me that you hit the nail on the head by pointing out that “Admission processes should seek to identify students who’ve achieved the developmental characteristics that allow for a fully informed career decision”.

    Unfortunately, Queen’s, like most Medical schools, use grades as the “first filter” when dealing with a large volume of applications for admission in Med School. I believe that this process needs to be completely revised. Specifically, it is my view that all applications should be fully reviewed in an attempt to evaluate an individuals cognitive maturity, “integrated identity” and interpersonal development before eliminating a large number of applicants simply based on marks. Of course this would require an increase in the time and manpower required to review the applications. However, I suspect that this practice would have a positive impact on the prevalence of depression in medical school.

    • Excellent points Steve. I would add that the review of applications (or interviews) will only be effective if focused on those three key elements you list,through appropriate orientation of reviewers and development of robust assessment methods.

    • bhatiameghan says:

      Hi Dr. Bagg,

      Thanks for the wonderful comment, and Dr. S for the thought provoking blog post. I’m pondering why grades as a “first filter” is suggested for change. It seems to me from numerous blogs that there is an abundance of “marks” qualified medical students applying to medical school. I wonder if within the pool of the cutoff marks, there could be an increased focus on the elements of “self authorship”. Im curious to know in more detail what your take of marks as a filter was?

      The application after the cutoff is where I previously believed the difference should be, and perhaps even brought it into my file review process myself. The value we give to their application seems based in foundations of medicine which do not directly coincide with self- authorship. For example, I wonder if the value we give to paid work experience and varying jobs was the same as a research paper, or clinical encounters.

      -Meghan, Meds ’18

  4. Jonathan Krett says:

    Thanks for another great blog Dr. Sanfilippo.

    I would suggest that in the process of self-authorship and individuation we are constantly writing and re-writing our narrative. The serendipitous aspects that led to us picking one fork in the road over another are viewed through the lens of hindsight. Just as we come to judge the consequences of our decision, new decisions and more life experiences come to the top of the pile. As we live out the aftermath, events of the past form a new meaning. What we write next is also subject to the fallibility of memory, molded not only by outcomes, but by our feelings and thoughts at the time when we decide to put ‘pen to paper’. As we reconsolidate that record through memory, we may well add and subtract details that don’t fit with the way things ultimately went. It’s much easier to go back and read a linear narrative, than one that reflects the randomness and irrationality of how one often decides in the moment.

    I wonder how David will remember his time in medical school many, many years down the road. Will he see it as a time that was truly formative not only for his career but for his character? Did he achieve something medical students should have figured out when they decide to pursue this vocation?

    Although it would be convenient for many of us to believe we had our internal authority sorted before admission to medical school, a decent number of us probably didn’t (or still don’t). As you mentioned, it will be key to help students navigate discovering who they are as people while they discover who they are as professionals at the same time. I’m not sure if this process is ever complete. In the end, I think it’s often a path worth taking, even for those who end up in a vastly different place than they expected at the outset.

    -Jon, Meds’18

    • Well said Jon! Seems to me that the vast majority of students, like yourself, have these issues well underway at the outset and continue to develop thier identity and “internal authority” during their medical school experience, and beyond. Fellow students can have a big role in facilitating that process. Thanks for your contribution(s).

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