Burnout among medical students isn’t just an individual problem; it’s systemic. It’s important for organizations to put policies in place that support students—even those who don’t proactively seek help.
John P. Fogarty, MD, dean of the Florida State University (FSU) College of Medicine, shared the outpouring of grief following a medical student’s suicide and outlines the FSU Wellness Committee's efforts to create a culture that promotes wellness for students. Dr. Fogarty, a family physician and graduate of the U.S. Military Academy at West Point, spent the first 20 years of his career as an Army family physician and academic leader, rising to the rank of colonel.
This article is drawn from an episode of the “AMA Moving Medicine” podcast, which was the third of a three-part series on physician well-being and taken from a talk originally presented at the 2018 AMA Interim Meeting. Below is a lightly edited transcript of that presentation.
A crisis in medicine
I was just at the AAMC [Association of American Medical Colleges] meeting this past week and Darrel Kirch, the president and CEO of the AAMC, was giving his final address. He actually talked about one of the crises in medicine, and that is burnout, depression and suicide among physicians at all levels—from student, to resident, to attending.
He called it a crisis in medicine, and we really have to expose it. We have to get it out there. What I find interesting is that we've heard from Dr. Tutty that the AMA is looking at this. The AAMC is looking at this. The ACGME [Accreditation Council for Graduate Medical Education] is looking at this. The National Academy of Medicine has now formed a collaborative to basically look at this on a real basis.
You've heard, 20 years ago, the report on To Err is Human. We're all expecting a report from the National Academy on “to care is human.” Again, looking at the same factors associated with ... patient safety and errors. That is, no longer looking at somebody to blame, but looking at the processes that lead to these problems within that. I think you can say the same thing about burnout, depression and suicide among physicians. It's not an individual problem as much as a systemic problem. Those are the things we need to look at.
The medical school that I've been at for the last 10 years—we're not immune to these issues. And I'll tell you a story about what's happened at our medical school and how that's impacted us going forward thinking that it couldn't happen to us, when in fact it did.
Reviewing the problem, that's easy. Some of this has already been covered a little bit. We'll talk about the epidemiology again. Reinforcement is a good thing in medicine. You hear it enough times, it actually sticks. Some of that what's happened at the Florida State University College of Medicine and then some of the approaches that we've taken since that time. Here are the facts. You've seen most of these.
Dr. Tutty and Dr. Buckley both talked about the high risk of depression, burnout and poor work-life balance. All ages, stages—challenges are not unique. Nurses and other health care professionals also have significant issues around this.
When altruism fades
What I find interesting is that most medical students report to medical school with high quality-of-life scales, lower depression symptoms, those type of things. I remember the altruistic medical student that I was in the first three months.
I was living in a dorm at the time. For some reason, there was a fourth-year medical student that was also living in our quad. That probably said something about that student, but that's another story. I remember there were three or four of us that were sitting around the table. We were all excited. We were learning anatomy. We were learning whatever we were learning that particular semester.
This fourth-year medical student comes dragging in in his white coat that was dirty, and he was disheveled and it looked like he hadn't shaved for a while. He goes into his room, and he slams the door. Five minutes later he comes out and says, "Yeah, well, you're idealistic now, but don't worry. You'll change." And slams the door again.
We're like, "What the heck was that?" This is medical school. Pattern reverses early in medical school. Poor well-being can persist and the national burnout rates you've already seen about.
What are the stressors for medical students? Well, getting into medical school. The imposter syndrome. The feeling of: “My God, the admissions committee must have made a mistake. What am I doing here?”
No longer top dog
I mean, it's all about for the first time in your life you're not in the top 10% of your class. You might actually be in the bottom half of your class. Can you imagine that? Keeping up, test anxiety, having the right stuff, do I belong here, stigma and reluctance to ask for help. We'll talk about a little bit of that and some of the things that we've tried to do around that.
How do you meet the expectations of your friends, your peers? You'll always compare yourself to somebody that's smarter than you are. You know, you'll always feel a little bit less capable than they are. Obviously, step one in all the conversations that we're having around [United States Medical Licensing Examination] Step 1 anxiety, my second-year students are beginning to disappear from view anymore. They're going underground, they're doing whatever they're doing, they're focusing on UWorld rather than coming to lectures. That's what happens.
Then, what does that lead to? The Match, and here we go again. I've got to prove myself. I've got to do it. I've got to prove to somebody out there that they really want me.
It's a very difficult issue. What does it look like? This has been described in all the literature. Emotional exhaustion, detachment, low personal achievement, depersonalization. I'm finding it very interesting that one of the things that's really driving the health care system to begin to look at this, I mean, this has been published by the AMA 20 years ago in terms of the issues around physician burnout.
Now, the industry is realizing that physicians that are not happy—that are burned out—they actually produce less, they make more errors, their satisfaction scores, patient reviews and all that type of thing. It's like, “Whoa, hey, we've got to score high on our scores. Maybe we ought to actually do something about it.”
If that's what leads to the difference, I'm happy to see that.
Hit like a ton of bricks
Well, this is what happened to us. In February 2017, one of our students that normally was very prompt at coming to the clinical learning center was not there. We were a little worried about him. Finally called some people, finally had to break down the door of his apartment. He had taken his own life. A complete surprise to us. Something that never would have been expected. You know, the school went through the usual grief, as you can imagine.
Everybody was kind of like, “I don't understand. He just renewed his lease for another three months before he went off to the regional campuses in June. He had an appointment with the psychologist the next day. What was going on with him? What could he have been thinking?”
As far as we know he didn't leave a suicide note other than on the white board in his apartment that just simply said, "I'm sorry."
You know, he didn't seem to have a plan B. His dream was always, you know, he had been an EMT. He had been an emergency medicine technician. He'd done a number of different things. He actually worked on a suicide-crisis hotline in the past. All of these things, all of his peers and classmates and we had an incredible memorial service for him. His parents came. They seemed to be more concerned about his classmates. "Are you guys doing OK?" It was one of these amazing experiences. We launched balloons in the courtyard afterwards in his memory.
Went to his church that weekend where again his churchmates—it was a young church—his churchmates were all talking about he was the one that was always checking in with you. He was always the one that was concerned about you. Apparently, he couldn't do that for himself, and so obviously, it hit us like a ton of bricks. We just couldn't believe that this had happened to us. I'd always bragged about how we have happy medical students. We have a happy medical school.
Addressing the culture problem
What did we do? We had very public grieving. Memorial services at Florida State and his church. We acknowledged the problem. We have to look at this. We really have to dig deep inside of ourselves to find out what's going on. We put together a wellness committee of faculty, staff and students.
This is not just a student problem. This is a culture problem. Darryl Kirsch, again, last Sunday, basically said culture eats strategy for lunch every single time. You really got to look at your culture. You've got to find out what's going on.
Holding wellness events. We frequently tease about—I don't know what you guys did for the eclipse a couple of years ago, but we had a big party for the eclipse. Everybody came out of the building. We saw students, staff, graduate students, medical students, you know, undergraduate students all that were in the courtyard sharing glasses looking up at the sky, looking down at the sun as it came through the leaves to see the little eclipse on the ground.
It was like, “I didn't know we had this many people in the College of Medicine. Can we schedule an eclipse every six months or so?”
It was amazing watching the interactions, and so we've tried to get people out of their offices, and out of their classrooms, and out of their programs in order to do that on a regular basis with wellness events. Whether it be ice cream socials or yoga in the atrium or whatever it might be. ...
Expanding our mental health resources. We thought we had what we needed and then we really had to bring it out in the open. I've done a couple of grand rounds now really talking about this issue, much deeper dive into the epidemiology and statistics and all about burnout and the things that go on.
So this is our wellness committee created their own little logo for that. Really creating that culture, assessing the students, improving the knowledge of the science, identify efforts to reduce stress, develop wellness programs and work to build that culture—that's so critical.
We've got a wellness website on our webpage, has resources on the campus, resources around the state, free tools, community programs and a lot of things on our medical library webpage for these types of things too.
We've had learning communities that students will participate in that I consider it their homeroom—someplace where they can go and each of the learning communities has a kitchen and has four small group rooms where they can do individual study. They can get together, they can do the type of things we're trying to build the community that we want.
This year, or the last two years actually, instead of just having our counseling staff for people that might need to go see them, we actually mandated that every student in the first year in the orientation week has to spend 15 minutes with our mental health counselors, just to get to know them. Just to say: This is who we are. This is what we do. This is why we're here.
The most gratifying thing for me as dean was, when I was talking to one of our counselors, she said to me, “I've had at least 10 referrals in the last month from people who said their classmates said they should come.”
And so again, it's one of these things where you're building the culture of people expecting that this is normal. “Hey, Joe, it looks like you're not doing really well today. What's going on?”
Strengthen the social networks and the time for personal renewal. This is what we're up against folks: the British Medical Journal [now called The BMJ] recently ran a piece about how doctors have a responsibility to be at their best. Hippocrates and purity and holiness. I will guard my life and my art—that is, sacrifice yourself at the altar of medicine. You know, do everything that you can do, leave yourself behind, leave your personal [life] behind.
And that does—obviously, it doesn't work.
I think resilience and looking for joy, it's a great conversation to talk about. It’s the ability to bounce back. So what do you do when you fall down. Do you get back up? What do you do with that? How do you adapt in the face of stress or disruptive change?
Stress... is anything that causes you to need to react. It's distress. That is stress, that's overwhelming to you, that causes you to break down. As you heard from my bio, I was in the military for a whole lot of years. We talked about stress fractures and stress issues and how do they happen? We'll it's from overloading a bone that's not ready to be overloaded. If you work on your training program, you do it in small intervals, you gradually build up to it, you actually build stronger bones as opposed to those bones breaking down. So internal attributes, external, and then the skills model are things that are really critical for you.
How do you build it? Well, we want to educate the students and residents about what this is all about. I think, you know, finding joy is a perfectly apt metaphor for that. Countering the stress of medical school by taking care of yourself, developing programs, and working with teams, after-action reviews and coaching.
If you read The Right Stuff from 40 years ago, they talked about the Navy fighter pilots or the Navy test pilots, they'd fly out every day. Occasionally one of their colleagues would auger in—and that's how they would describe it. They would be a smoking hole in the ground. They would go to their funeral, they would go out the next day and they'd fly again. They never really talked about it ’cause obviously Joe or Sam, or now it would be Sally, didn't have the right stuff—but we have the right stuff. It's not going to happen to us.
I think that's been the emphasis on medicine for all these years in terms of just saying, well, if you're a failure, it’s just because you don't have the right stuff as opposed to taking care of yourself.
The ACGME, the LCME [Liaison Committee on Medical Education] are both looking at these issues, as I mentioned. And, again, the licensure board. We’ve got to figure out the right questions to ask. ...
What contributes to resilience? Basically, what your mother said: taking care of yourself, exercise, sleep, nutrition, mental exercise, humor, taking away time from work, having passion, having purpose, optimism. Are you a half full, half empty person? Having people smile at you, as suggested, is really a good thing. Face your fear, understand what it is. What is your faith life? Where's your moral compass? What do you do? Where were you heading in life? And the social supports more than anything else.
This is something I just want to spend just a little time with because we hear this all the time. What's wrong with the work-life balance? ... The problem with this is that if all you're doing all the time is waiting for the life side of this balance, I think you're really missing something, when you think about the work that you're doing as a physician should be one of the most gratifying things you could possibly do.
It shouldn't be work as bad, life as good.
I was called up short about 20 years into my career when my wife said to me, “So, Jay, when is it going to get better?”
And I was kind of like, “You mean it's not yet? I thought it was great.”
So, maybe not for her, but we are professionals. ... The question is how to find joy in whatever we do, and I think that's important. It's not just a matter of—later, later, later—delayed gratification. Let's figure out how to do that now. And that's really what we've worked on.
So, where are you on this scale? Withdrawn or present? Are you present to your patients? Are you withdrawn for your patients? Are you defeated? Are you bouncing back? Are you going through the motions or actually fully engaged in what you're doing all day long? Brittle and rigid or bending, but not breaking? Cynical and hopeless or have a positive attitude? Hypercritical or have a light touch? Willing to listen before you reflect back on them? Feeling ineffective or becoming stronger?
I mean, I admit there were times in my residency, there are times as an attending when you said, “Have I done anything for anybody today?”
Saying your thankfuls
You hope you find that as you're going along. Treading water versus moving forward. I think one of the things that I found, even in our wellness committee, is that we have “thankfuls” before we start the committee meetings to say, “OK, what are you thankful for today? Tell me something positive that happened to you.”
When I go visit my grandsons in North Carolina, part of their prayer before they go to bed is that we go around the room and do the thankfuls. So Pop-Pop and Mom-Mom have to do their thankfuls along with Ethan and Jacob and their parents, and how do we do that? How do we reflect on that day?
Let's talk about the good things that happened today as opposed to focusing on the negative. Fearing change, welcoming change, kind of the idea of the Darwinism issue is we have to learn to change. We have to learn to adapt.
Look out for each other
This is the message you were trying to take to our medical students all the time and to our staff and our faculty too is: be a friend, work with others, avoid isolation. I will tell the students that, as dean, I'm pretty removed from some of the students, although I like to get to know them. I make learning community rounds. I was just at one of my regional campuses last night, checking in on the medical students there and thanking the faculty that participate in our program at Daytona Beach, but I can't be the one to diagnose stress, burnout, depression and all in the medical students.
They really have to take care of each other. They have to be friends to each other. They have to know. They have to look. Pay attention, looking for the signs. See something, say something—that applies to so many things in our life today, and unfortunately.
We'll have the tragedies that we have, but I think it also plays a huge role in terms of our ability to have the students kind of diagnose each other.
“Hey, Joe, if you're having a problem, maybe you need to go see Carol or Cheryl. Then you need to go see these folks. Maybe you need to have a conversation. If you're not having any problems, great, but let's let a professional figure out that for you.”
So are they cynical? Are they exhausted? Have they lost their joy, lost their sense of humor. Is there a feeling of worthlessness, lack of value, etc.?
We do have an FSU student-resilience project at the undergraduate level, as the same problems happen at undergraduate institutions also. At FSU, the College of Social Work has put this together to really have some modules that people could take, even coming in as freshman college students. Again, that whole issue of the imposter syndrome: How am I going to do here? It's a new environment, it's all new. It's all new, just to have some tools that people can learn from.
A shoutout to the AMA in terms of the STEPS Forward™ program and things to prevent burnout. I think we've already covered some of those, but wellness is a quality indicator. Start a wellness committee, annual wellness surveys. You really got to know how your folks are doing, and what they're doing.
Meeting regularly, the leadership issues that we've already heard about. What are we doing to intervene? Repeating the survey, plan, do, check, act, same, same, same. You hear that again. Identify your problems, making intervention, recheck and see how it's doing.
Somebody has to do something. It's just incredibly pathetic. It has to be us. We need to take responsibility for this and go from there. Thank you very much.
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