Saturday, April 15, 2017

Does Learned Helplessness Explain The Suicidal Thoughts Of Medical Students?

The headlines are everywhere.  Medical students have a significant prevalence of suicidal thoughts and suicides.  The typical explanations are burnout and depression associated with the rigors of medical training.  Considering that medical training has always been rigorous the obvious questions include - is depression and suicidal thinking more prevalent now and if that is true - why?

The research offers little hard data.  There are no consistent longitudinal studies that use the same methodology to look at the issue of suicidal thoughts or suicide attempts in medical students.  The studies are generally cross sectional using diverse methodologies and involving different cultures (1).  The prevalence of suicidal thoughts varied from 11.2 to 14% for a given year.  The prevalence of lifetime suicide attempts ranged from 1.4 to 6.2%.  Some studies have determined suicide rates for male (15.6/100,000) and female medical students (18.9/100,000).  This studied showed no difference between suicide rates in men compared with the general population but higher rates for women.  Most studies do not look at comparison with rates  in the general population.

There is no evidence that I am aware of that medical training has become more rigorous or stressful than it used to be.  In my early training days, I saw residents in particular subjected to training schedules that I am guessing can no longer occur due to limitations on work hours.  Some of the best examples were surgical specialty rotations where second and third year residents hardly ever left the hospital.  Even as an intern in those days it was common to work 24 hours straight and then the next day until 5 PM or (total of 36 hours) every three or four days. Those schedules were exhausting but they were widely accepted until recent changes were made in the allowable hours for trainees.

The volume of material covered in medical school combined with the poorly defined guidelines about what needed to be known to be a proficient physician is not the most efficient approach to study.  Comparing medicine to a rigorous undergraduate course of training illustrates the problem.  If I was taking Physical Chemistry as a chemistry undergraduate, I knew I had to read specifics sections of the text, know the lecture notes, and take the tests on the lecture notes and text.  In medical school, the connections are less clear.  You can read one (or more) texts and know the lecture notes, but the testing was often guess work and typically on a body of knowledge that was more fluid - it might not hold up from year to year.  That level of inefficiency keeps people studying far too long in order to take tests that in the long run mean a lot less.  

The typical way that depression and suicidal behavior in physicians and trainees is studied is to look at the prevalence of depression, suicidal ideation and suicide in these populations.  Those studies generally suggest that suicide as a preventable cause of death is one that physicians as a group are not good at self correcting (2).   The typical comparison is that physicians as a group are better than the public at large when it comes to smoking cessation and reduced risk for cardiovascular and pulmonary disease.  That has led some experts to hypothesize that unlike smoking, getting treatment for depression and suicidal thinking involves many barriers relative to other health care interventions. Physicians may be more concerned about confidentiality, stigma, and the potential impact on career than with standard health measures.  In some cases the issue of reporting and disciplinary action has been mentioned.  Expert opinion generally recommends education about depression and suicidal thinking in physicians and facilitating access to mental health care.  Screening trainees for depression has also been suggested.  Burnout has become a popular theory lately and efforts to put a number on burnout suggest very high rates in most medical specialties.  The relationship of burnout to depression and suicidal thinking is less clear.

As I looked at the problem over time, the most striking factor in medical practice has been the total loss of control by physicians.  Thirty years ago, all of the medical students and residents in training programs were exposed to strenuous training schedules, but they also saw physician models who could provide the latest scientific care and have a direct impact on the patient and the treatment environment in general.  Most medical students start out valuing direct patient contact time.  The ones who don't end up in fields where there is minimal patient contact.  The contrast today is striking.  Today students and residents as exposed to training environments that are under the strict control of business managers.  This management is frequently a direct obstacle to scientifically based care and a frequent obstacle to routine care.  What rational person is going to subject themselves to intensive and stressful training only to see that their professional futures are under the control of people who routinely interfere with care and who can waste physicians time to an incredible degree based on a whim?  To me this seems like a textbook example of the learned helplessness paradigm and observing it.

Learned helplessness is a research paradigm for depression.  In laboratory animals, it is observed when the animal is subjected to an inescapable aversive stimulus.  At some point the animal just stops responding (trying to escape).  That response deficit is associated with biological markers consistent with depression and it can be treated with some of the same pharmacological agents used to treat depression.  Rodent models of learned helplessness are considered screens for molecules that have potential antidepressant effects.  An  interesting variation of this effect is learned helplessness by proxy.  Animal studies show that fear conditioning can be learned by proxy (3,4).  There is a research literature on the intergenerational transmission of anxiety and depression (6).  These studies suggest that the learning effects, especially in environments where there is a significant amount of emotion, can be significant.  Less studied phenomena like identification with mentors are also in effect in these environments.  There are several linear crisis model of suicide that are generally based on a progression of risk factors.  In my experience suicide is a non-linear process that involves subtle changes in the conscious state.  Stressful and emotional environments are more likely to be associated with these altered conscious states.

With physicians at all levels of training there are several factors that make it very difficult to escape a real or imagined failure in pursuing a career in medicine.  The debt factor is significant (7). One of the ongoing justifications of physician salaries in the US is the high cost of medical training.  Walking away from that is an anxiety producing scenario and yet one study showed that 40-46% of medical students considered that due to excessive workload and exam stress (1).  The expectations of mentors, friends, and family is a variable consideration that can increase the thoughts of failure for men and women at this life stage.  Most physicians in training have some idea of what real medical practice will be like when they are finally ready to make that transition.  There used to be clear models in the form of the attending physicians encountered on rotations.  My recollection of these attendings were that they appeared to have normal and full lives, especially in the time they were not active in clinical rotations.

Today medical students and residents don't see practicing physicians with normal lives.  They don't see physicians coming in for one or two month rotations.  Now they see practicing physicians who rotate one week on and one week off all year long for the rest of their lives.  They see primary care fragmented between clinic staff and hospitalists.  In the case of psychiatric rotations, they generally see people hospitalized in settings where nobody wants to stay, nobody really gets much better, and readmission rates are very high.  Ruling all of this are case managers with no medical training - telling the attending physicians what to do.  That has got to be a shock that puts many medical students off of the idea of a career in medicine even before they get started.  It gives them the message that they did not really need to go to medical school when their decision making is dictated by business managers.  It also gives them the message that they are a cog in business-of-medicine machine and cannot expect much personal contact with patients or medical treatment based on that relationship.  Finally - they notice the science of medicine that they were immersed in has suddenly become relative to the next great idea of the head administrator.  Whatever that business idea is - suddenly all of the physicians in the organization are doing it whether it is scientific or relevant.

Concerns about suicide prevention are always a legitimate endeavor, irrespective of the quality of the epidemiological evidence.  As physicians we have an obligation to recognize when our colleagues are in crisis and try to help them.  There do appear to be significant barriers to medical trainees and physicians getting help and that should be widely recognized.  I fear that the deteriorated practice environment is not being given sufficient weight as an etiological factor.  What sense does it make to go through what is widely acknowledged as very stressful training, when in the end physicians are no longer allowed to practice as professionals?  What impact occurs when trainees observe that many physicians are  currently practicing like they did when they were residents - with no end in sight?  Learned helplessness has always been there - but now instead of  being limited to training it is a permanent dimension of medical practice.    

That sounds like a recipe for desperation to me.   It is time for the profession to acknowledge that professional control of the practice environment is necessary not only for the good of our patients but for our own well being as well.

And there is nothing wrong with that.

George Dawson, MD, DFAPA


1: Rau T, Plener P, Kliemann A, Fegert JM, Allroggen M. Suicidality among medical students - a practical guide for staff members in medical schools. GMS Z Med Ausbild. 2013 Nov 15;30(4):Doc48. eCollection 2013. Review. PubMed PMID:24282451, (figures cited above are from numerous references in this paper).

2: Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF 3rd, Silverman MM. Confronting depression and suicide in physicians: a consensus Statement. JAMA. 2003 Jun 18; 289 (23): 3161-6. Review. PubMed PMID: 12813122.

3: Ramaker MJ, Dulawa SC. Identifying fast-onset antidepressants using rodent models. Mol Psychiatry. 2017 Mar 21. doi: 10.1038/mp.2017.36. [Epub ahead of print] PubMed PMID: 28322276.

4: Bruchey AK, Jones CE, Monfils MH. Fear conditioning by-proxy: social transmission of fear during memory retrieval. Behav Brain Res. 2010 Dec 6;214(1):80-4. doi: 10.1016/j.bbr.2010.04.047. Epub 2010 May 2. PubMed PMID: 20441779.

5: Jones CE, Riha PD, Gore AC, Monfils MH. Social transmission of Pavlovian fear: fear-conditioning by-proxy in related female rats. Anim Cogn. 2014 May;17(3):827-34. doi: 10.1007/s10071-013-0711-2. Epub 2013 Dec 6. PubMed PMID: 24310150; PubMed Central PMCID: PMC3984423.

6: Nauta MH, Festen H, Reichart CG, Nolen WA, Stant AD, Bockting CL, van der Wee NJ, Beekman A, Doreleijers TA, Hartman CA, de Jong PJ, de Vries SO. Preventing mood and anxiety disorders in youth: a multi-centre RCT in the high risk offspring of depressed and anxious patients. BMC Psychiatry. 2012 Apr 17;12:31. doi: 10.1186/1471-244X-12-31. PubMed PMID: 22510426.

7: Priceonomics.  Which Graduate Degree Gets You Out of Debt the Fastest?  April 13, 2017.


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  1. I agree. As a current trainee the hours I work are less than previous residents but the quality is different. They were on call taking care of patients. I'm on call doing checklists, forms, admin work, social work with no end in sight. I don't see how wellness or resilience workshops would help

    1. Thanks for that input. Treating physician burnout like it is an inherent weakness in physicians (wellness, resilience, yoga, etc) is more administrative rhetoric. Physician burnout is bad management and bad management is all that we have these days:

      Physician of all ages need to unite and take the profession (and its management) back.

      Very happy to hear from current trainees and what that experience is like.