Suicides among Medical Students: A Rising Concern

The trend of increasing incidents of suicides in general and among medical students in particular is a very disturbing trend, which we are witnessing currently and needs immediate attention. Medical students are placed in a special situation where they have to deal with lot of pressures simultaneously, like academic pressure, financial pressures (funding their education), long working hours without breaks, exposure to human suffering, and the false belief that they will be taken less seriously if they seek help. The present editorial would like to throw light on factors which are contributing to suicides among medical students, looking at the systemic lacunae which are perpetuating this crisis and give some actionable strategies which will go a long way in reducing the suicides among medical students.

THE MAGNITUDE OF THE PROBLEM

Suicide is a leading cause of death among youth globally and medical students in particular. A systemic review showed that the prevalence of suicidal ideation among the medical students is from 7.4% to 24.2%, greater than the general population. ¹ Coming to India, a 2021 study finds that 3.9% of medical students had attempted suicide with occurrence of suicidal ideation among 15.7% of students. These statistics shows us the seriousness of the problem and the need to take concrete and urgent steps to reduce the number of suicides among medical students by targeted interventions within medical education system. ²

Medical students have to cope with academic pressures. In academics if they do not perform well, they equate it with their self-worth. The curriculum in medical education is one among the toughest in the world; they have to face competitive exams while shouldering clinical responsibilities. This mixture sometimes creates chronic stress. A study done in US revealed that 27% of medical students showed symptoms of depression; only 15% went for psychiatric help due to stigma and the fear of repercussions with the faculty and peers in their profession. ³ The pressures and the goal of perfectionism in medicine increase the feeling of inadequacy, pushing some students towards taking extreme steps.

UNIQUE STRESSORS SPECIFIC TO MEDICAL STUDENTS

Many factors contribute to the increased incidence of suicides among medical students. The workload which is demanding on medical students leaves very little time for self-care or any social support from family or friends. Some students stay in hostels that lead to a sense of isolation. Sometimes the duties stretch for 36 hours and they have to work 80-hour work weeks, which leaves them burned out having not enough for sleep. Burn out among medical students was found to be as high as 44.2% in a meta-analysis done in 2020; this correlates strongly with suicidal ideation. ⁴

Medical students frequently encounter deaths and witness human suffering, which can drain them emotionally and lead to moral injuries. Witnessing patient’s death and without any adequate psychological support can drastically effect resilience among student community. A qualitative study done in Australia highlighted how the medical students felt when they were not ready to handle the emotional toll of patient’s death, leading to feelings of helplessness and loneliness. ⁵

To seek help for mental health problems carries with it a huge stigma not only in the general population but also among medical profession. Students do not feel confident to share their mental health problems for fear this may stand between them and their academic career, later in their medical registrations also. In a survey done in the United Kingdom in 2019 found that 80% of medical students with mental health problems did not seek professional help due to concerns about confidentiality and its impact on their career. ⁶ This ostrich attitude regarding seeking help for mental health problems leads to more problems with increased untreated mental illness.

SYSTEMIC LACUNAE AND INSTITUTIONAL RESPONSIBILITY

A significant role in exacerbating mental health issues is played by the medical education system itself. Old teaching methods of public shaming to make students learn can backfire and intimidate students and their self-confidence. A medical education study done in 2018 noted that such approaches contribute to a toxic learning environment, leading to anxiety and self-doubt among students. ⁷

A general lack of structured mental health support system in many medical colleges compounds the problem. Some medical colleges offer counseling services but to access them becomes difficult due to academic schedules, clinical rotations etc. In some medical colleges, particularly low- and middle-income countries, where trained manpower and mental health resources are scarce may not have access to any professional support. In India, a 2023 study found that only 23 % of medical colleges had functional mental health program for students. ⁸

Competition among medical students also pitches one student against another, leading to isolation rather than collaboration. The pressure of performing well in entrance examinations and with failure in them being perceived as catastrophic intensifies the stress among students manifold. These are some of the systemic issues or lacunae which highlight the need for reforms systemically to prioritize the student’s well-being.

Steps to be taken:

The issue of suicides among medical students is multifaceted involving individuals, institutions and policy makers. Given below are the strategies to mitigate this crisis that is evidence based.

1. Discussion about mental health issues should be included in the curriculum. Destigmatizing mental health by normalizing discussions about stress and vulnerability must be done by the medical colleges. The faculty can lead from the front by discussing their own issues while going through the medical education system. There should be a peer support program that will work. Examples, programs implemented in Stanford University. This will go a long way to reduce isolation and encourage students to seek help. ⁹

2. Mental Health services should be made accessible

Medical colleges should provide confidential, accessible counseling services that are tailor made to medical students and fitting with their schedules. Counseling online, tele-mental health options can be used in areas in which resources are less. In a 2021 randomized trial demonstrated that online cognitive behavior therapy significantly reduced suicidal ideation among medical students. ¹⁰

3. Curriculum reforms

By reducing excessive workload and incorporating wellness training can decrease stress. Some medical colleges have adopted pass/fail grading systems during preclinical years, that a 2019 study found to decrease anxiety without compromising academic performance. ¹¹ Teaching resilience and coping skills early in the curriculum can equip students to handle emotional challenges.

4. Training of the faculty

Faculty must be trained to recognize signs of distress and avoid harmful teaching practices. Medical colleges should implement policies to address bullying and harassment, ensuring a safe learning environment. In 2020, an initiative in Canada trained faculty to identify- at risk students, resulting in a 30% increase in early interventions. ¹²

5. Policy level interventions

Government and medical councils should revise license policies to protect students to seek mental health care. In the US, some states have removed questions about mental health history from licensing applications, reducing barriers to treatment. ¹³ Increase in funding for mental health program in medical colleges must be prioritized.

6. Role of Students and Peers

Medical students themselves can play a pivotal role in fostering a supportive community. Initiatives, such as mental health awareness campaigns and support groups, can create save spaces for sharing experiences, by the students and their peers, social media platforms properly used can increase these efforts by disseminating resources and challenging stigma.

CONCLUSION

The rising rate of suicides among medical students is a clarion call for change. By addressing the unique stressors of medical education, dismantling systemic barriers, and fostering a culture of empathy, we can protect the mental health of future doctors. Policy makers, medical colleges and faculty must act swiftly to implement evidenced based interventions, ensuring that students are supported not only as professionals but as human beings. The cost of inaction is too great- measured not in statistics, but in lives lost.