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A medical student’s struggle with suicidal ideation during the COVID-19 Pandemic

Updated: May 16

Wellness and the pitfalls with resiliency training: A medical student’s struggle with suicidal ideation during the COVID-19 Pandemic


Thomas Agostini

Fellow, Medical University of South Carolina, 2022


Wellness and resiliency have received recent attention in higher education as way to improve and maintain mental health in students [1,2]. Although these topics certainly have a place in the conversation, from my perspective, the way that we talk about resiliency in medical education is disheartening. Our current “resiliency training” starts and stops at the mention of the word; little action is taken to teach medical students how to actually be resilient. My worry is that institutions are approaching the issue with a narrow perspective, fulfilling yet another required task by incorporating the terms wellness and resiliency but not putting in the work to back the talk up with meaningful action. While it is no substitute for systemic change, it may be the only tool to help future physician advocates from burning out. Students hear that we must “keep fighting” when some of us fight every single day to stay well, to achieve resiliency, and in some cases, to stay alive. As someone who struggles with suicidal ideation, the use of this language without further action is not enough. It fails to acknowledge the emotional effort that students are already putting in to keep going in these challenging times.


Anxiety, depression, and stress levels are prevalent in medical trainees due to the adversity brought on by the pandemic, with increases in burnout and cynicism pre- and post-COVID-19 [4,5]. 45 to 60% of medical students and trainees reported burnout symptoms prior to the COVID-19 pandemic [7]. Perceived median emotional exhaustion and burnout and medical students jumped from a median = 2 (IQR 2,4) self-reported score to a median = 4 (IQR 2,5) since the pandemic started [8]. Resilience is even found to be lower in pre-professional students experiencing COVID-19 related stressors compared to their peers [3]. This focus on resiliency, however, entirely ignores the culpability of training programs to make necessary changes to protect and support students.


I’ve struggled with suicidal ideation for the past three years, but it became much worse throughout the pandemic. Each day feels like an active fight to stay alive, constantly listing the people in my life that make life worth living to stop myself from dying by suicide. During the pandemic, I found myself more alone than ever. Cut off from family, friends, and my support networks like our school counseling, I struggled to maintain my health. The everlasting uncertainty added to my existing feelings of hopelessness, making it harder and harder to keep up with my academics. While I understand that there was a certain level of competency students had to maintain while in lockdown, I found the lack of apparent flexibility in standards to be isolating. Instead of meeting students where they were, we were expected to meet the same benchmarks with fewer resources and interactions with our instructors. It seemed as if no one acknowledged the fact that we were completing the majority of our medical education virtually. The same level of mastery was expected on our exams, and there was a two-month period where administrators refused to move our exams virtually, even though other medical schools made the change swiftly. We ended up having two large exams, exams that comprise of 5-6 weeks of material, within 10 days of each other.


My grades gradually fell, throwing me further into a place of unworthiness. Contributing to my own internal struggles, my class size dropped from roughly 180 students to about 140. Losing close to 20% of my class left me with mixed emotions. I was grateful for the health of myself and family but mostly heartbroken to lose so many friends in my cohort.


In addition to the academic stress, there was additional pressure to perform as advocates for change during COVID-19. I found myself, along with other dedicated students and faculty, worn down trying to provide more resources and support for my community, to no avail. The feeling of helplessness drove me further into despair with very little standing support. Many students tried to mobilize and keep student-run free clinics operational, but AAMC (Association of American Medical Colleges) guidelines originally restricted clinical participation for non-clinical students. For the first two weeks of the pandemic, we were initially restricted from providing the same care to uninsured patients. Most of our administrative duties were shifted to residents and attendings, already burdened with the unrelenting clinical overload with their primary patients. Fortunately, we were able to resume our roles due to persistent advocacy from dedicated clinicians, but I couldn’t help but feel like a bother to first-responders already going through such a traumatic experience.


I am grateful to be here today to share my experience, knowing that I am fortunate to have found a way to keep going, but I worry, unless our system changes, that other students won’t be so fortunate. I certainly do not blame my school, nor do I think what I experienced is any different than the national standard for medical student wellness; I’m arguing for systemic change that alters the way in which medical education handles the mental health of all trainees. Too often it feels like we are being subjected to a high level of scrutiny and stress, not because it will help us become better physicians, but rather our predecessors had to do it so we should as well. Instead of changing medical education as emerging evidence suggests some of our current practices may be harmful, too often suggestions for change are met with skepticism and dismissal [6].


Suicidality is complex and there is not a one-size-fits-all solution to help every person dealing with it. In my experience, many of the wellness initiatives fall short and fail to address what truly causes medical students distress. For instance, my school had a wellness challenge that was quantified by the number of steps we walked. Ironically, I won our wellness challenge while actively having suicidal thoughts. This highlights how approaches to promoting mental health in medical education are often insufficient. These wellness initiatives are not unique to medical education, but they should be examined critically when used as the sole action to collectively support and improve mental health in medical education. Certain steps like making Step 1 pass/fail are being taken to help with burnout and mental wellness, but that is merely the beginning of the change that needs to occur to protect students and allow them to learn in a supportive environment.


Some may wonder if a student experiencing thoughts of suicidal ideation should be actively involved in medical education. Would it have been more appropriate for me to take a leave of absence? This was my initial thought as well, until I was presented with my options: I could either withdraw for a year and lose my health insurance, loan money for rent, and access to free psychiatric care, or I could re-enroll in a “catch-up” curriculum that would allow me to keep these benefits but would require me to repeat parts of the curriculum that caused me enormous distress, while continuously reporting to faculty members. Given these options, I felt like I had to stay enrolled to avoid the two situations that might make my suicidal ideation worse. It seemed I had no choice but to persevere and pray that things would get better.


Students struggling with mental health should have more flexibility in the options that are presented to them. Alternative schedules for clinical years, modifications for USMLE (United States Medical Licensing Examination) Step Exams scheduling, and other accommodations offered at school are rarely advertised to dissuade students from seeking out alternative options. After I had already decided to remain enrolled, I later heard of other accommodations offered to my classmates that were never made available to me. Transparency around these options may encourage students to be more vulnerable and disclose when they are struggling. This open line of communication may allow for trainees to feel like they’re not alone, rather than keep options hidden.


Over the past few months, I’ve contemplated diluting this piece to make it more palatable. The fear of retaliation and backlisting from residency programs has made me hesitant to share my experience, but I firmly believe that change is necessary to protect medical trainees. I am writing to prompt an open, transparent discussion around suicide specifically, and mental health broadly, that is more pre-emptive and less reactive. By making my story public, I pray that this positively contributes to the conversation around mental health and wellness in medical education. I am thankful for the support that I have received from our school’s counseling center, a small group of administrators in our Dean’s office, and the wonderful faculty members who supported me through my preclinical career and created safe spaces for me to confide with them. I do not have all the answers but I do hope my story will create a call to action to our leaders to make evidence-based decisions about changes in medical education for the survival of our peers and the field itself.




References

1. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 2008 Jan-Feb;32(1):44-53. doi: 10.1176/appi.ap.32.1.44. PMID: 18270280.

2. Low R, King S, Foster-Boucher C. Learning to Bounce Back: A Scoping Review About Resiliency Education. J Nurs Educ. 2019 Jun 1;58(6):321-329. doi: 10.3928/01484834-20190521-02. PMID: 31157900.

3. Smith CA. Covid-19: healthcare students face unique mental health challenges. BMJ. 2020 Jun 29;369:m2491. doi: 10.1136/bmj.m2491. PMID: 32601100.

4. Shailaja B, Singh H, Chaudhury S, Thyloth M. COVID-19 pandemic and its aftermath: Knowledge, attitude, behavior, and mental health-care needs of medical undergraduates. Ind Psychiatry J. 2020 Jan-Jun;29(1):51-60. doi: 10.4103/ipj.ipj_117_20. Epub 2020 Nov 7. PMID: 33776276; PMCID: PMC7989454.

5. Zis P, Artemiadis A, Bargiotas P, Nteveros A, Hadjigeorgiou GM. Medical Studies during the COVID-19 Pandemic: The Impact of Digital Learning on Medical Students' Burnout and Mental Health. Int J Environ Res Public Health. 2021 Jan 5;18(1):349. doi: 10.3390/ijerph18010349. PMID: 33466459; PMCID: PMC7796433.

6. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016 Dec 6;316(21):2214-2236. doi: 10.1001/jama.2016.17324. PMID: 27923088; PMCID: PMC5613659.

7. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington (DC): National Academies Press (US); 2019 Oct 23. PMID: 31940160.

8. Harries AJ, Lee C, Jones L, et al. Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study. BMC Med Educ. 2021;21(1):14. Published 2021 Jan 6.

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