Reasons why medical students burn out and become depressed

As I finished my 24-hour call recently, I was reminded of a 2009 study revealing a decline in empathy as medical students transition from their mostly-didactic second year to third year, which is essentially an apprenticeship in the hospital with lecture as an afterthought.  I began my third year with what most would argue is the most difficult rotation, surgery, and my experiences over the past 5 weeks have sparked introspection on the things that cause medical students to burn out and wall themselves off during the clinical years.

Numerous factors make the third year of medical school difficult – learning the layout and flow of the hospital, adapting time management skills, the overwhelming volume of knowledge to acquire, and the emotionally-draining experience of moving from 4-5 hours of lecture daily to 14 hours of patient contact in the context of impatient hospital staff are just a few.

However, I noticed that the experiences that are the real body shots to our self esteem can be traced back to our mentors.

Lack of mentor continuity. Being exposed to clinicians at different levels of training and with varied style and substance is paramount to good clinical education.  However, rotating through teams too quickly can leave us feeling lost and disoriented.  Likewise, residents are less inclined to teach when they know they’ll never see us again – they just want to finish the task at hand and steal away for a meal or a nap.

Lack of clinical continuity. It’s hard enough to learn how to manage hospital inpatients, but when doctors start making up their own rules, it gets even harder.  Some surgeons prefer different antibiotics to be given before an operation, and that’s fine, but here is an example of when fussiness becomes detrimental:  my first resident said he never wanted to hear the term “low-grade fever” – the patient was afebrile if their temperature was below 100.4° F.  That same day, our chief resident described a patient as having a low-grade fever.  This week, I presented to my new chief resident a patient who had spiked a 100.9° F several times since his operation and I was told that nothing below 101° F should be reported.  What will it be next time?

Hostile attitudes. To each other, to the team, and to other teams – this is perhaps the most discouraging practice to witness.  Undermining your colleagues is a terrible way to role model, and demeaning your apprentices does not build character, but rather breeds resentment and affects the quality of work your team accomplishes.  The lack of professionalism I’ve witnessed at times was more than just thoughtlessness or off-color humor – it was downright inappropriate.

Lack of feedback. I’m not sure how, but some new doctors who were in our shoes just a year or two ago to forget how lost they felt as third & fourth year medical students.  We often lack direction, and what we need to improve upon is not always clear to us.  Doctors at teaching institutions must be reminded that feedback is the most important responsibility of a mentor, lest the relationship become a one-way street and we regress to the passive nature of the second year.

Lack of forgiveness. Especially true for the technical specialties, like surgery, it’s nearly impossible to get certain things right on your first attempt – I’ve had instruments literally ripped from my hands while trying to suture.  Likewise, I can’t know everything about a concentration a specialist has been practicing for years – I was being pimped on breast surgery during a modified radical mastectomy (the first one I’d seen), and when I got a question wrong my resident would roll her eyes and shake her head in disgust.  Experiences like that don’t really make me excited to come to work the next day.

Avoiding hands-on training. This is a continuation of my earlier point about residents just wanting to finish and move on – it’s difficult to bounce back and forth between doctors who won’t slow down, teach, and let you do and others who expect you to be proficient and are bewildered when you sheepishly admit this is your first time doing something.

Scapegoating. This is the worst – as a third year medical student, you learn early on not to explain yourself when you’re being scalded (it just results in prolonging the agony).  I was recently working the balloon on a Swan-Ganz catheter, an act that requires close cooperation with the person advancing the catheter to avoid damaging vessels.  I faithfully inflated & deflated the balloon as the resident navigated through through the heart and pulmonary arteries – just as the attending walked into the room, the resident realized he was retracting the catheter with the balloon still inflated and told me “Don’t ever inflate the balloon without being told!”  I just stood there & nodded – to correct him in front of the attending physician wouldn’t have been worth it.

I could post one of the numerous papers on depression & burnout in medical school, but instead I’d encourage you to skim this thread on “3rd Year Depression” from a leading internet forum for medical students.  It speaks volumes more than any abstract or numbers I could share with you.

I’m not trying to shift the blame for anyone’s poor performance, but I know I’m a hard worker with the best intentions and I shouldn’t be made to feel lousy so often.  My colleagues and I shouldn’t have to shoulder these concerns during this especially demanding period of our education – many of us have already begun to dread our future residencies and entered a kind of “survival mode,” but it doesn’t have to be this way.  When we work with thoughtful, professional and understanding physicians, all of these worries dissipate, we perform exponentially better, and with the compassion we swore to display when we first donned our white coats.

James Haddad is a medical student who blogs at Abnormal Facies.

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  • Jeannette

    I have always wondered why they must make it so hard on med students. I mean, I get it, it is a tough job and they must be put through the paces. It is very much a survival of the fittest type environment.

    I was just finishing my last year of pre-med and was on my way to med school the following year having already been accepted. I don’t mind telling you that it scared me to death. I was very fearful of burning out because I was well aware of how med students are put through the ringers. I ended up not going to med school because my husband passed away and I simply had too many responsibilities to continue on. I made that decision in part because I knew what kind of pressure I would be under at med school along with suddenly becoming a single mother.

    I have however been a nurse for 21 years. The College of Nurses promotes a wonderful nurse-mentor program that makes all the difference in the world. Now granted, we are talking about nursing and not medicine but this type of program would translate well to medicine. Having a nurse with many years experience being strategically placed to mentor a new nurse makes for a much better outcome. It must be someone that wants to teach and is willing to put in the time required to pass on their many years accrued knowledge.

    If an individual wants to become a doctor, great! We need more doctors, but I don’t believe that anyone benefits by putting so much pressure on a med-student. Why on earth would we want our doctors burned out and depressed? Offer them the support they require to develop into exceptional physicians. Now that makes more sense to me! No?

    • Jim

      Jeannette, I think that’s a great idea, but tough to institute. I believe one can’t be assigned a mentor, but rather has to find him or her independently. This can take years, but is worth it. I have been part of a forced mentorship, and it doesn’t really work.

      Thanks for being a Nurse.

      • Jeannette

        Oh dear, that is really too bad that it would not work for medicine. It was very kind of you to thank me for being a nurse. I don’t recall the last time anyone said that to me, if ever. Thank you to you as well!

        P.S. Really enjoying your blog, it is very well done.

    • ravindra

      In India, the relationship that medical students have with their mentors is generally much more relaxed while nurse educators are much more hard.

      • Jim

        I’ve seen nurse educators at my institution drop the hammer, and it doesn’t look like it’s any more enjoyable than being a med student in the same situation.

        I do agree that, in general, they seem to be a bit more forgiving.

  • ninguem

    My training days, I started taking surveys of faculty.

    Given a certain described scenario, what would you do?

    Would you do “A” or “B”?

    I was upfront about it, as what was happening was I’d do “A” when faculty on duty would do “B”. Blasted at with moral outrage for being stupid enough to do “A”. So I’d check around with faculty I respected, to figure out if “A” versus “B” was a judgement call, in which cast I’d let it roll off, or if I was really wrong to do “A” instead of “B”.

    Most of the time, vast majority of the time, it was a judgement call. Of course, occasionally I really was wrong and deserved the chewing out. Fairly rare.

    Now a “grown-up”, I see that same attitude persist, unfortunately, in peer review and courtrooms. They can’t tell the difference between a judgement call and standard of care.

    A corollary of that judgement call thing. The moral outrage for missing a certain test. So I learned to order everything. Trainees never got chewed out for ordering too much.

    • Jim

      Thankfully, there are some at my institution who ask “will the results of that test change your treatment plan?” – it’s encouraging to see, but you’re right: far too often, we just order up a storm and move on to the next patient.

      • ninguem

        It wasn’t at my training place. It became far easier to just order everything in sight, for everything.

        Actually, bullying far worse than described, but probably not appropriate for a forum like this.

        Just internship. I got out for residency, I was disgusted.

        Years later, they wanted me back, as faculty, in the worst way. It was an embarrassing phone call, actually. It was from one of the very, very few faculty I respected there.

        Told the guy I would not set foot in the place……ever. Ten years later, and I remembered details, names.

        “Wait, let me tell you about salary, benefits and all that, you’ll get fast-tracked to promotion……etc”

        I didn’t care, I would not consider the place, no matter what pay they offered, I didn’t even want to hear it.

        I couldn’t believe how I was talking. And the phone call came to me on the ward, in earshot of staff, who could figure out the conversation easy enough.

        Amazed me, too, how much that had hurt, a decade later.

        • pj

          Boy do I sypmathize w/Ninguem and the author.

          Ning- you gotta admit, that was too cool that they begged you to return.

          Jim, you sound wise beyond your years.

  • Kristin

    The attitude that I’ve seen expressed in blogs and forums seems to be very reminiscent of hazing strategies: it’s going to be a hard world out there, they’d better learn to deal with it now, it was good enough for us, if they really want to be doctors they’ll take whatever anyone dishes out… It’s the same argument, in many respects, for not making residency less of a pill to swallow. (By instituting work hour restrictions, programs for better communication between team members, clarifying the roles of medical student team members vs resident team members, allowing residents collective bargaining power–the list goes on.)

    I’m encouraged by the apparent divide of opinion. It’s far from a unitary opinion; many people in the younger generation have been brought up since birth with concepts like work-life balance and hostile work environment. We’re post-Boomer, post-Vietnam, post-HIV, post-Patriot Act, and we want more of an explanation than “Because it worked for us” or “Because that’s the way it is.” We grew up watching unnecessary suffering brought about by terrible bureaucratic decisions and status-quo maintenance, and we want something more for the future.

    I don’t think it means that this generation is any less invested in medicine. I think it means that we’re invested in becoming the kind of doctors we’d like to see. The constellation of psychological morbidity that goes with excessive and prolonged exposure to stress isn’t pretty, it’s directly biologically traceable, and yet the medical establishment is in denial about the effects this has on patient care. Particularly in light of the other things that doctors with currently established practices are complaining about (decreasing autonomy, decreasing duration of patient visits), it doesn’t seem unreasonable to suggest that the process of becoming a doctor be less needlessly painful.

    Unless they want to create another generation of doctors who burn out. If you want doctors with depression, anxiety, poor memory, insomnia, anhedonia, decreased personal skills, and increased risk of diabetes, infection, and cancer, go right ahead. The HPA axis is just a biological fact, after all. We probably didn’t need those hippocampal cells anyway.

    • Jim

      “I don’t think it means that this generation is any less invested in medicine. I think it means that we’re invested in becoming the kind of doctors we’d like to see.”

      Very well-put, and a great analysis.

    • pj

      Thanks Kristin- wish more folks would wake up and see things as clearly as you.

  • Mark

    Nothing you described sounds that bad or different from the minor bullshit you have to put up with in any job. I think you are being too sensitive.

    • Jim

      Mark, I see where you’re coming from. Some of my close family has had to put up with verbal/emotional abuse on the job – I’m aware of the horror stories out there. I’ve also had first-hand experience while working my way through college, and officer training with the Navy had it’s share of verbal abuse, too.

      But I’m not complaining about any of those things – in my opinion, this is different. If I had my pick, I’d select a doctor who was trained with compassion and understanding, not shame and guilt.

      Keep in mind that this is not a job, but a learning experience (that medical students pay big bucks to subject themselves to); the residents are the ones with the jobs – jobs we will one day soon have to perform.

      • ninguem

        Plenty of similarities. Difference is, society expects doctors to be ethical with patients……and with each other.

        The safeguards that may exist in other workplaces, did not exist in medicine. That’s changing.

        Society sort of figured we were philosopher-kings of our domain. It was more like Plato’s Stepchildren in the original Star Trek.

        I was the midget.

  • endo doc

    Although difficult at times,I feel the medical students should feel free to inform the program director/chief resident or assigned mentors if they are in a situation which is detrimental not only to their learning but well being as well.
    Residents and mentors often forget the students are not there as their work extensions ,they are there to learn.
    Teaching in their assigned role should be their number one priority.

    • Jim

      I agree with you – and our clerkship director did encourage us to come to him with any and all issues we had. I just believe you have to pick your battles, and didn’t feel most of these instances even warranted reporting.

      “Residents and mentors often forget the students are not there as their work extensions ,they are there to learn.” – I couldn’t have said it better myself.

    • The Scrivener

      Endo Doc,

      Yes, the medical students *should* be able to go to an authority figure or mentor to discuss these problems. A really good mentor will either help you figure out a way around the problem, or take your side should the issue go further.

      The problem is that, at least at my school, students do not trust the faculty or administration enough. These people determine our grades, which are subjective enough without worrying over being labeled a “trouble-maker” or not dedicated enough to patient care. And unfortunately, teaching is not anywhere near #1 for most faculty at my research-oriented institution. While there have been some superb preceptors, attendings, and residents, the majority make it clear that they are only doing this to maintain their academic affiliation.

      These issues aren’t unique to medical education. Perhaps the profession should look at how other groups protect their most junior members.

  • John, MSIV

    I burned out sometime in 2nd year. They give you just enough clinical exposure up to that point to make you realize all the great things about medicine aren’t so great….and all the bad things are worse. This fact is seared onto the soul during 3rd year- literally the worst year of my life. An entire year of standing around all day doing absolutely NOTHING while waiting to finally be told “go home.” Or, on the one rotation where you do get to do things, constantly doing them wrong. I have often questioned why I went to all this trouble, and still can’t quite answer that.

    Your post has a lot of points that are unique to surgery and OB/GYN- at least in my training, but I think it’s more the type of people in those fields than anything else. Hostility, aggressive pimping, never being able to do ANYTHING perfectly, always feeling like a failure. Surgery was the only time I’ve ever cried in the hospital (thankfully I barely made to the bathroom in time so I didn’t get caught)…

    However, I see this as my fault. Surgeons are surgeons and that will never change; being on surgery as a medical student means doing your best and ignoring all criticism. I’m not saying ignore how an attending wants you to present, but ignore the fact that you got it “wrong” the first time. Because something is always going to be wrong; there’s nothing you can do perfectly in surgery, ever. You can either ignore it, or else let it get you depressed, miserable, and wishing, as you write your personal statement in 4th year, that the events in your life had never brought you to medicine in the first place. Like me.

    • Jim

      I feel it’s better to view the criticism as tough love – ignoring it is too hard. I think most of the residents I work with have good intentions, but are stressed and don’t know how to effectively communicate with students yet.

      Being a doctor is all about being a teacher, in my opinion, but that’s not necessarily in the job description, and is certainly not selected for in med school.

      There’s a hint of truth in your last paragraph – I just got back from a case in which I was told my bites were too big while suturing; the resident proceeded to take identical bites at the same incision site. End result? It looks cosmetically great, don’t see what the stress was all about. C’est la vie!

      • Allen

        “Being a doctor is all about being a teacher, in my opinion, but that’s not necessarily in the job description, and is certainly not selected for in med school.”

        Right on! The very word “doctor” is, in fact, derived from the Latin “docere”–to teach! It’s a profound shame that so many in training leadership positions don’t know this or don’t take it to heart.

        It follows, too, that “doctor” is not synonymous with “physician.” Instead, a doctor in the truest meaning of the title is someone with a doctoral degree who is devoted above all else to teaching, irrespective of field or discipline. In healthcare, teaching patients how to optimize self-care (in the proverbial seven minute appointment) is a true reflection of one’s calling as a doctor, in addition to teaching junior clinicians and investigators. Best to all of you who embrace teaching as the core of being a doctor.

  • solo fp

    Third year true experiences that encourage burnout:
    1)My surgery mentor was an orthopedic 1st year attending who would fall asleep at his desk while I was presenting my patients
    2)One of the OB attendings would watch Gilligan’s Island during 6 pm checkout rounds when res/students would present. No call rooms for the OB rotation, as you were expected to no sleep on call. Expected to work from 4:30 AM on one day and go home at 6:30 PM the next day and start again at 4:30 AM 6 days a week.
    3)Only 4 days off a month, including weekends. Long hours away from family/friends with no income for years.
    4)An IM attending and rotation mentor who I knew seemed odd/crazy. He looked strung out. Three years later he was disciplined by the state for overprescribe narcotics to patients and prescribing oxycontin to himself
    5)A pediatric surgeon who had a god complex on rounds. He made most of us feel stupid. A few years later he was disciplined for prescribing adult strength bowel preps to pediatric patients with a resulting infant death.
    It is easier to look back on rotations as a private attending and realize that much of the rounding and OCD attendings could not function in the private practice world of medicine. Much of medicine, as long as it meets the standard of care, is based on experience and judgment calls.

  • John Q

    I think academic medicine is pathetic. For the most part, I would bet most physicians in academic medicine would fail miserably in private practice or any setting where charisma, kindness and genuine interest in people is required. That is why so many medical students become bitter and vindictive when they enter residency.

    • Jim

      “That is why so many medical students become bitter and vindictive when they enter residency.”

      I think this is the point I was trying to convey – it’s really interesting considering the recent Harvard med symposium on training physicians to be resilient, making comparisons to Navy SEAL training.

      If you ask me, this is one of those situations where you really do catch more flies with honey..

  • Penny

    Gads I would hate to become a doctor. I don’t think I could “tolerate” the type of abuse I’ve read about so many times.
    It sounds so much worse than anywhere else. You would think that their teachers, as doctors, would understand more than anyone else that such abuse often just makes those working under them twice as anxious, depressed, and likely to make mistakes. Seriously, I think that doctors who treat new doctors that way should be evaluated for temperament, and if their nerves are that bad, maybe they shouldn’t be teaching.

  • Pol

    You are also forgetting the LOANS. They can be trapped in a scenario they do not like, feeling like there is no alternative or way to escape. This quadruples the fear of failure, and can often lead to pure misery for the medical student, drowning in loans.To quote Yoda, “Fear leads to Anger. Anger leads to Hate. Hate leads to suffering.”

    • Jim

      Can’t argue with a Yoda quote.

  • Molly Ciliberti, RN

    Why do physicians and nurses eat our young? It is so self defeating ultimately. I love your blog and all of your points are excellent.

    • Jim

      Thank you for the kind words Molly.

  • Med School Odyssey

    The fundamental problem is that, in virtually every other field on earth, respect, authority, and responsibility are largely earned. In medicine, they are simply granted once a person has been able to endure all the scut and crap. The end result is a field of individuals that have the maturity of a 13-year old, but infinite power and authority over the lives of patients and anyone else lower on the food chain than they are.

    The medical profession is the most selfish, self-centered, and arrogant field I can imagine. There are days I wonder why the hell I have any interest in medicine at all.

    • Molly Ciliberti, RN

      I don’t know “Med School Odyssey, I think lumping an entire profession into such a horrible description isn’t quite right. My husband is an ED doc and I have met so many physicians both working as a critical care nurse and through my husband and they are not all horrible people. Most of them are good, honest, caring people trying to do a very difficult job where their decisions can result in a person’s death and under less than ideal conditions where people expect you to pull miracles out of your a$$. I would use your description for Wall Street folks, bankers (from big banks) and CEO’s of large corporations. Loved the blog.

    • Jim

      I have to agree with Molly – that’s a gross exaggeration. There is arrogance in medicine, but it’s not pervasive.

      I conducted interviews for applicants to my medical school over this past year, and I’ll tell you I favored candidates with prior job experience – the humbler, the better.

      Personally, I think communication skills are a bigger issue than character flaws.

  • Lost Third Year

    I just started third year this week, and was incredibly elated to see this piece posted. I was feeling lost, confused, doubting my career choice, and wondering how on earth the system even functions to produce the hundreds of thousands of doctors that it has.
    There are very few “teachers” in teaching hospitals. It is the consensus among my other student colleagues and I, that things would flow much better if we were just not there. Half the time, we are not even acknowledged or asked questions, or given pearls of wisdom.
    The greatest shock to me? How depressing the wards are at a teaching hospital. General internal medicine seems like a glorified game to see how fast a team can “turf” a patient, so as to not ruin the attending’s “length of stay” record. All the idealism that they build in us over the first two years on the “right” way to treat a patient, and how to deal with socioeconomic issues is useless. I start shutting down when we’re forced to discharge a patient because he/she is indigent, and keeping them a few extra days is too costly. It’s hard to go to the hospital every morning when all you are reminded of is how the practice of medicine which I’ve dedicated most of my conscious idolizing and priding myself on, is now what tears down my psyche on a daily basis.

    There are few third years that express their feelings, or feel that its okay to admit that they feel like crap at the end of the day. Because we’re not supposed to feel that way, we have to push through and get through it. Some can’t. Some are just too scared to admit that weakness, and see no way out. 4 days into 3rd year, a classmate killed himself.

    The upper-levels in academia need to acknowledge that the practice of medicine right now is changing, mainly due to insurances and a large indigent population. This DOES affect how we practice medicine, and this is the main stress that leads to burnout. Doctors have to keep corporations and businesses running. It’s not a pure practice of medicine.

    Maybe this will change. And I’ll keep pushing through to see if it does. I’m still young and idealistic, and maybe these 2 years will jade me. Only time will tell.

  • solo fp

    Med school is more of a rite of passage. My best teachers and most compassionate/caring teachers were the volunteer community docs on the rotations. Many of the academics spent time doing research and dreaded seeing patients without residents present 2-4 days a month, which equates to less than 1/2 day of direct patient care a week. Many of the academics took thousands in grants from the drug companies for drug research. The academic docs had a high turnover, with many of them going from university to univeristy every 2-3 years.

    I work 60+ hour week. I have a panel of quality, mostly insured patients who appreciate my care and who I look forward to seeing daily. Most academics stay bitter, as they could not function in a private practice setting.
    Often it is the student or resident doing the notes and the majority of the workup on a patient, with the academic doc simply coming by and writing a 1-2 sentence agree with above statement. Med students and residents are greatly under appreciated.

    • Jordan Milenkovski

      Absolutely true! I remember in my third year the first important manual thing we learned when in surgery was how to tie a knot (the Vienna type), and guess who taught us? Of course the surgery resident. And after all I barely remember the things we have learnt from our professors, if there are any at all!!. :D

      Yes I’ve heard about 45-55 hrs. but 60+ hrs it’s definitely insane.

  • MD

    Part of the reason for the poor environment medical students have to endure is because of the pressures facing residents and attendings. Everyone is under pressure to achieve perfect outcomes and not to make mistakes. This is not possible of course but the expectations of our modern medical system and legal system. On top of this, the government keeps cutting reimbursements, imposing more regulations but the work hours and demands keep increasing. I think this general environment in medicine is what leads to a poor learning environment for medical students. Do not think it is a any better in any other fields however. Be happy that you will have a job upon graduation.

  • Bill

    Having been involved in the medical profession for over 50 years, I will bet that many of those people who are being so hard on the medical students had a difficult time in med school. I have heard some physicians say, “They didn’t make it easy for me, and I am not going to make it easy on you”. This is unfortunate and does not promote the proper environment for training students who are stressed to the limit before the hazing by REAL MD’s.

    • Molly Ciliberti, RN

      Bill, you are correct and to me it makes no sense. Why wouldn’t you be more understanding and more helpful if you had gone through this rediculous rite of passage previously. When i have mentored others, I have always tried to help them with the cruelties that come from other not so understanding people in their profession. Being put through hell doesn’t make you a better physician and it can even harden your heart. Some how the patient seems to be the biggest looser in all of this.

    • Penny

      What a terrible attitude. Reminds me of the father who says, “I was beaten as a child so I’m going to beat my son too”, the last way I would expect most doctors to think.
      Sounds like those types are insecure and fearful that some of the younger ones may take their place.

      • Molly Ciliberti, RN

        Penny, as the child of an abusive mother, I totally agree with you. Although the Conventional Wisdom says that abused children grow up to be abusive adults, my experiences tell me that is a lie to justify abuse. I would never harm anyone because I know how it feels. Therefore the old “well that’s how it was when I was in medical school or residency” just doesn’t cut it.

  • buzzkillersmith

    No doubt about it, the third year of med school is exceedingly nasty. My advice: Keep your head down and get through it. Your life will get better. BTW James, have you considered the effects that airing this dirty laundry might have on your career? Just sayin’.

    • Jim

      This article isn’t about airing dirty laundry or how bad our lives are – it’s about issues that impede learning in the clinical setting. These are pervasive issues I’ve witnessed since before I even entered medical school, and are not directed at any institution or team of clinicians.

      My overall experience has been great and I love what I’m doing. These are simply examples of moments where we could be doing better by our trainees.

      Unfortunately, as I pointed out, these moments do add up for some of us. I don’t like what I see happening to some of my colleagues.

      I worry about what will happen if we continue to tell each successive class of young doctors to “just keep their heads down.” I don’t think that’s the answer to helping disheartened medical students find their lost empathy.

  • MedicalStudentSyndrome

    I have seen first hand some students get burned out. You really need a devotion to the job in order to succeed in medical school.

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