Refer to: Kitchen LW: Suicide among medical students (From a Medical Student). West J Med 129:441-442, Nov 1978
From a Medical Student
Suicide Among Medical Students LYNN W. KITCHEN, MD, Stamford, Connecticut FOLLOWING THE SUICIDE of a student at my medical school, a committee was created to "look into the psychiatric care of medical students." Along with my fellow classmates, I received a letter from the committee chairman: would I be willing to share some of my first-hand experiences and observations on medical school "stresses"? As long as suicide remains the second most common cause of death among medical students in the United States,' the question of motive deserves careful attention. But I suggest that we should be very cautious about making the leap from the fact of incidence to the notion (implicit in the phraseology of the inquiry sent to my class, and explicit in much of the discussion preceding the launching of the project) that "academic and personal stress" and "unsuitability for the profession" explain why medical students destroy themselves. In the first place, the statistics are not conclusive. While a study published in 1968 found the suicide rate among 85,299 students attending 50 medical schools in the United States between 1947 and 1967 to be "significantly higher" than among controls matched for age, sex, race and residence,' the director of a similar study underway in 1978 hazards the prediction that his final findings will not show any noteworthy discrepancy between the suicide rate of medical students in the United States and the control group (interview with Don A. Rockwell, MD, Department of Psychiatry, University of California, Davis, School of Medicine, June 1978). In any case, the suicide rate among graduate MD'S-at least 100 per year in the United States-is almost certainly higher than that among medical students.2 This suggests to me that we ought to be giving primary consideration to factors common to self-destructive student and graduate physicians. Could the suiThe author was a fourth-year medical student, Class of 1978, University of California, Davis, School of Medicine, when the article was submitted. She is now an intern in the Department of Medicine, Stamford Hospital, Stamford, Connecticut. Reprint requests to: Lynn W. Kitchen, MD, Dept. of Medicine, Stamford Hospital, Shelburne Road and West Broad Street, Stamford, CT 06902.
cidal persons among the two groups have more difficulty than their peers in coming to terms with the issue of their own mortality?3 Although it is part of the mythology of the medical profession that many of those who are motivated to undertake the study of medicine suffered serious personal illness as children or witnessed this phenomenon in another family member, I have encountered difficulty in documenting this in available literature. Moreover, my empirical conclusion based on four years of medical school has been that student physicians adjust surprisingly smoothly to our daily encounters with the ravages of incurable diseases on our patients. Halberstam's perceptive observation of us was that "far from becoming fixated on the pathology they study, they are likely to have considerable difficulty making any [overt] emotional connection between the patients they examine ... and the inevitable deterioration of their own bodies."4 There are at least five good reasons why this is so. First, medical students tend to be a young, energetic, physically robust group, with a sense of much useful work and productivity ahead of them. Second, lulled by the tidying, elegant phrases of the "voices of experience" on rounds, we exhaust ourselves in our quest to be perfect. Even as we scoff at the godly ways of our mentors, we gradually and unconsiously come to emulate their assured posturing. Third, in the early stages of training, student physicians rarely have long-term relationships with those they treat -in part because of the frequency of rotations, but also because so many patients in teaching hospitals are likely to be self-abusing and therefore not particularly likable persons. Fourth, the attending physicians attracted to academic medicine are often research-oriented rather than patient-oriented, -by which I mean that empathetic clinical role models are sometimes the exception rather than the rule. Fifth, should personal feelings about the death of a patient become troublesome, a student physician has the support of his THE WESTERN JOURNAL OF MEDICINE
441
SUICIDE AMONG MEDICAL STUDENTS
team in developing and utilizing his defenses to deal with the loss. (It strikes me as significant that it is not at the student level but when these buffers are taken away that the suicide rate is highest-that is, among physicians in practice long enough to have been made painfully aware that medicine is a frontier art as a result of the deaths of parents, siblings, respected colleagues and patients who have become friends.5) In sum, I believe that we are on the wrong track in approaching the incidence of suicide in our profession as a problem that has an answer, and I doubt that many prospective suicidal persons can be somehow weeded out at the medical school admissions level.6'7 Ernst Becker, in his brilliant work The Denial of Death, characterized guilt and depression as the natural consequences of coming to terms with one's vulnerabilities.8 Indeed, suicidal tendencies in all persons usually follow some blow in self-esteem-whether in the area of interpersonal relationships, examination grades, or failing physical health. To the degree that the medical student and the physician he becomes is ruled by the demanding value system passed on from generation to generation in the medical profession, no amount of achievement will spare him from guilt at not being all that he has been conditioned to expect of himself. And what is suicidal ideation if it is not the aspiration to kill off the unfulfilled aspects of oneself, the aspects that render one inescapably imperfect, mortal? Perhaps the suicidal person's unconscious fantasy is that he will be able to exorcise his failures via the self-destructive act, but somehow survive to profit by this; he may be too angry-at his imperfect self and at a world which he views as demanding absolute perfection-to consider the finality of death.9 "Suicide," in the words of Camus, "is prepared within the silence of the heart."'0 This is likely to be especially true for those shaped according to a professional ethos that emphasizes the playing out of godly roles and discourages admissions (even to oneself, let alone a possible counsellor) of uncertainty or imperfection. Whether or not a person who experiences suicidal ideation actually chooses to kill himself depends on such factors as his insight, his ability to concede and explore his psychic pain, and his willingness (and luck) in establishing emotional intimacy with a psychotherapist or friend with whom he does not have to play charades. 442
NOVEMBER 1978 * 129 *- 5
Any malady quietly acknowledged and experienced-not compartmentalized, denied, or intellectualized away by the sufferer or those around him-becomes more manageable and bearable with time. Accordingly, the most reliable prophylactic against suicidal depression is to be found in the lonely, lifelong task of coming to grips with one's limitations and mortality, with what one can and cannot control in his life. It follows that the most productive way of discouraging self-destructive tendencies in medical students is to encourage them from the beginning of their training to embrace their humanity. The issues of suicide, death, dying and personal vulnerability ideally should not be delegated (with obvious implications) to departments of psychiatry, but dealt with by physician role models at all levels of the medical school hierarchy on a dayto-day basis. Too, more exploration in the medical school curricula of the therapeutic possibilities-for both parties-engendered by a solid doctor-patient relationship is warranted. For to the degree that the physician can derive satisfaction from his patients' faith in him as an empathetic, mature, competent person "on their side" of the battle, and utilize this faith as a potent healing tool, he will be better able to withstand his disappointment-whether experienced within himself or voiced by others-over human errors and his inability to perform "miracles."" These measures could result in a lowering of the suicide rate not only among student but also among graduate physicians. There is only one liberty, wrote Camus in his Notebooks: "to come to terms with death. After which, everything is possible." REFERENCES 1. Simon HJ: Mortality among medical students, 1947-1967. J Med Educ 43:1175-1182, Nov 1968 2. Sargent DA, Jenson VW, Petty TA, et al: Preventing physician suicide. JAMA 237:143-145, Jan 10, 1977 3. Vaillant GE, Sobawale NC, McArthur C: Some psychological vulnerabilities of physicians. N Engl J Med 287:372-375, Aug 23, 1974 4. Halberstam M, Lesher S: A Coronary Event. New York, JB Lippincott Co, 1976, p 41 5. Livingston PB, Zimet CN: Death anxiety, authoritarianism and choice of specialty in medical students. J Nerv Mental Dis 140:222-229, Mar 1965 6. Thomas CB: Suicide among us: Can we learn to prevent it? Johns Hopkins Med J 125:276-285, Nov 1969 7. Thomas CB: Suicide among us-II. Habits of nervous tension as potential predictors. Johns Hopkins Med J 129:190-201, Oct 1971 8. Becker E: The Denial of Death. New York, Free Press, 1975, p 212 9. Menninger KA: Man Against Himself. New York, Harcourt, Brace and World, Inc., 1938 10. Camus A: An Absurd Reasoning-The Myth of Sisyphus and Other Essays. New York, Vintage Books, 1953, p 4 11. Bressler B: Suicide and drug abuse in the medical community. Suicide Life Thr Behav 6:169-178, Fall 1976
From a Medical Student
Suicide Among Medical Students LYNN W. KITCHEN, MD, Stamford, Connecticut FOLLOWING THE SUICIDE of a student at my medical school, a committee was created to "look into the psychiatric care of medical students." Along with my fellow classmates, I received a letter from the committee chairman: would I be willing to share some of my first-hand experiences and observations on medical school "stresses"? As long as suicide remains the second most common cause of death among medical students in the United States,' the question of motive deserves careful attention. But I suggest that we should be very cautious about making the leap from the fact of incidence to the notion (implicit in the phraseology of the inquiry sent to my class, and explicit in much of the discussion preceding the launching of the project) that "academic and personal stress" and "unsuitability for the profession" explain why medical students destroy themselves. In the first place, the statistics are not conclusive. While a study published in 1968 found the suicide rate among 85,299 students attending 50 medical schools in the United States between 1947 and 1967 to be "significantly higher" than among controls matched for age, sex, race and residence,' the director of a similar study underway in 1978 hazards the prediction that his final findings will not show any noteworthy discrepancy between the suicide rate of medical students in the United States and the control group (interview with Don A. Rockwell, MD, Department of Psychiatry, University of California, Davis, School of Medicine, June 1978). In any case, the suicide rate among graduate MD'S-at least 100 per year in the United States-is almost certainly higher than that among medical students.2 This suggests to me that we ought to be giving primary consideration to factors common to self-destructive student and graduate physicians. Could the suiThe author was a fourth-year medical student, Class of 1978, University of California, Davis, School of Medicine, when the article was submitted. She is now an intern in the Department of Medicine, Stamford Hospital, Stamford, Connecticut. Reprint requests to: Lynn W. Kitchen, MD, Dept. of Medicine, Stamford Hospital, Shelburne Road and West Broad Street, Stamford, CT 06902.
cidal persons among the two groups have more difficulty than their peers in coming to terms with the issue of their own mortality?3 Although it is part of the mythology of the medical profession that many of those who are motivated to undertake the study of medicine suffered serious personal illness as children or witnessed this phenomenon in another family member, I have encountered difficulty in documenting this in available literature. Moreover, my empirical conclusion based on four years of medical school has been that student physicians adjust surprisingly smoothly to our daily encounters with the ravages of incurable diseases on our patients. Halberstam's perceptive observation of us was that "far from becoming fixated on the pathology they study, they are likely to have considerable difficulty making any [overt] emotional connection between the patients they examine ... and the inevitable deterioration of their own bodies."4 There are at least five good reasons why this is so. First, medical students tend to be a young, energetic, physically robust group, with a sense of much useful work and productivity ahead of them. Second, lulled by the tidying, elegant phrases of the "voices of experience" on rounds, we exhaust ourselves in our quest to be perfect. Even as we scoff at the godly ways of our mentors, we gradually and unconsiously come to emulate their assured posturing. Third, in the early stages of training, student physicians rarely have long-term relationships with those they treat -in part because of the frequency of rotations, but also because so many patients in teaching hospitals are likely to be self-abusing and therefore not particularly likable persons. Fourth, the attending physicians attracted to academic medicine are often research-oriented rather than patient-oriented, -by which I mean that empathetic clinical role models are sometimes the exception rather than the rule. Fifth, should personal feelings about the death of a patient become troublesome, a student physician has the support of his THE WESTERN JOURNAL OF MEDICINE
441
SUICIDE AMONG MEDICAL STUDENTS
team in developing and utilizing his defenses to deal with the loss. (It strikes me as significant that it is not at the student level but when these buffers are taken away that the suicide rate is highest-that is, among physicians in practice long enough to have been made painfully aware that medicine is a frontier art as a result of the deaths of parents, siblings, respected colleagues and patients who have become friends.5) In sum, I believe that we are on the wrong track in approaching the incidence of suicide in our profession as a problem that has an answer, and I doubt that many prospective suicidal persons can be somehow weeded out at the medical school admissions level.6'7 Ernst Becker, in his brilliant work The Denial of Death, characterized guilt and depression as the natural consequences of coming to terms with one's vulnerabilities.8 Indeed, suicidal tendencies in all persons usually follow some blow in self-esteem-whether in the area of interpersonal relationships, examination grades, or failing physical health. To the degree that the medical student and the physician he becomes is ruled by the demanding value system passed on from generation to generation in the medical profession, no amount of achievement will spare him from guilt at not being all that he has been conditioned to expect of himself. And what is suicidal ideation if it is not the aspiration to kill off the unfulfilled aspects of oneself, the aspects that render one inescapably imperfect, mortal? Perhaps the suicidal person's unconscious fantasy is that he will be able to exorcise his failures via the self-destructive act, but somehow survive to profit by this; he may be too angry-at his imperfect self and at a world which he views as demanding absolute perfection-to consider the finality of death.9 "Suicide," in the words of Camus, "is prepared within the silence of the heart."'0 This is likely to be especially true for those shaped according to a professional ethos that emphasizes the playing out of godly roles and discourages admissions (even to oneself, let alone a possible counsellor) of uncertainty or imperfection. Whether or not a person who experiences suicidal ideation actually chooses to kill himself depends on such factors as his insight, his ability to concede and explore his psychic pain, and his willingness (and luck) in establishing emotional intimacy with a psychotherapist or friend with whom he does not have to play charades. 442
NOVEMBER 1978 * 129 *- 5
Any malady quietly acknowledged and experienced-not compartmentalized, denied, or intellectualized away by the sufferer or those around him-becomes more manageable and bearable with time. Accordingly, the most reliable prophylactic against suicidal depression is to be found in the lonely, lifelong task of coming to grips with one's limitations and mortality, with what one can and cannot control in his life. It follows that the most productive way of discouraging self-destructive tendencies in medical students is to encourage them from the beginning of their training to embrace their humanity. The issues of suicide, death, dying and personal vulnerability ideally should not be delegated (with obvious implications) to departments of psychiatry, but dealt with by physician role models at all levels of the medical school hierarchy on a dayto-day basis. Too, more exploration in the medical school curricula of the therapeutic possibilities-for both parties-engendered by a solid doctor-patient relationship is warranted. For to the degree that the physician can derive satisfaction from his patients' faith in him as an empathetic, mature, competent person "on their side" of the battle, and utilize this faith as a potent healing tool, he will be better able to withstand his disappointment-whether experienced within himself or voiced by others-over human errors and his inability to perform "miracles."" These measures could result in a lowering of the suicide rate not only among student but also among graduate physicians. There is only one liberty, wrote Camus in his Notebooks: "to come to terms with death. After which, everything is possible." REFERENCES 1. Simon HJ: Mortality among medical students, 1947-1967. J Med Educ 43:1175-1182, Nov 1968 2. Sargent DA, Jenson VW, Petty TA, et al: Preventing physician suicide. JAMA 237:143-145, Jan 10, 1977 3. Vaillant GE, Sobawale NC, McArthur C: Some psychological vulnerabilities of physicians. N Engl J Med 287:372-375, Aug 23, 1974 4. Halberstam M, Lesher S: A Coronary Event. New York, JB Lippincott Co, 1976, p 41 5. Livingston PB, Zimet CN: Death anxiety, authoritarianism and choice of specialty in medical students. J Nerv Mental Dis 140:222-229, Mar 1965 6. Thomas CB: Suicide among us: Can we learn to prevent it? Johns Hopkins Med J 125:276-285, Nov 1969 7. Thomas CB: Suicide among us-II. Habits of nervous tension as potential predictors. Johns Hopkins Med J 129:190-201, Oct 1971 8. Becker E: The Denial of Death. New York, Free Press, 1975, p 212 9. Menninger KA: Man Against Himself. New York, Harcourt, Brace and World, Inc., 1938 10. Camus A: An Absurd Reasoning-The Myth of Sisyphus and Other Essays. New York, Vintage Books, 1953, p 4 11. Bressler B: Suicide and drug abuse in the medical community. Suicide Life Thr Behav 6:169-178, Fall 1976
