The outside of UNC’s Emergency Room is pictured on Monday, April 15 2024. | Photo by Samuel Long
Story by Samuel Long
Graphic by Macon Porterfield
The time is 5 a.m. Sun Tark is garbed in blue scrubs and tennis shoes. She walks down the hospital corridor to check in on her patients, then creates a list containing vital tasks to complete for the day – something she and her peers called scut work.
She’s already been on the floor for 24 hours.
Luckily, Tark has time for a quick break. She sits for a bite to eat, as her last meal was hours ago. But the small pager she carries alerts her to an emergency – someone is in dire condition and needs her immediate attention. Then for 12 more hours, she and the other resident doctors at Vanderbilt University will resist unimaginable pressure with fleeting moments of downtime, substandard sleep and little room for error.
This shift took place in the late 1990s, while Tark was training to work in emergency medicine. On average, she clocked around 120 hours each week. That left her a maximum average of seven hours of daily sleep, though it was normal for residents to work around 36 hours in a row.
“They’d say, ‘oh, you get some days off,’ but no, we really didn’t,” Tark said. “We were always in the hospital and didn’t have a life. It was very difficult to have any kind of relationship or family life for sure.”
And Tark overheard stories of some residents bearing a similar lifestyle who, “shockingly,” broke.
Today, many of the conditions contributing to poor mental health for doctors have improved. But medical culture still contributes to higher rates of depression, anxiety and suicidal ideation among medical students, according to a 2023 article from the medical journal, Baylor University Medical Center Proceedings. The COVID-19 pandemic has only exasperated these concerns.
Many organizations have highlighted that the United States has a high rate of suicide among physicians — 300 to 400 die each year. But the mental difficulties among practitioners are not static; they fluctuate depending on external conditions.
Well-being concerns for physicians usually surface in medical schools, as medical students carry an increased burden of depression, anxiety and mental stress compared to nonmedical peers of the same age.
At the global scale, medical students’ prevalence rates for depression and anxiety are estimated at 27% and 36%, respectively. Data across several countries also suggests that medical students’ suicidal ideation rate is at 11% — an alarming statistic, according to the 2023 article.
In comparison, the World Health Organization estimates about 5% and 4% of people worldwide have depression and anxiety, respectively.
Corey Feist, CEO and co-founder of the Dr. Lorna Breen Heroes Foundation, said that medical students generally have stellar mental health conditions as they begin medical school. But after four years of training, their mental states fall far below that of similarly-aged peers.
These students are also more susceptible to burnout from rigorous academics, intense competition and high workloads, according to a 2023 study published in the National Library of Medicine. Though there are a wide range of burnout rates reported for medical students – 10% to 77% – it’s estimated that around half of them may suffer from the syndrome at some point during their schooling.
This may be partially due to medical school culture, Feist said. Medical students likely seek achievement to a higher degree than their peers due to the number of hurdles, such as difficult tests, they experience throughout school and training.
“There are certain professions, first responders, health care professionals, even the military who often combine their own identity with their profession,” he explained. “And so to take their profession is to, you know, to impact their identity.”
The foundation Feist works for was created after Dr. Lorna Breen, his sister-in-law, died by suicide April 26, 2020, during the onslaught of the COVID-19 pandemic. She had no prior mental health issues and no history of depression or anxiety. Her only significant risk factor was her occupation as a physician.
Her death sparked a national response from health care workers across the country, which emphasized the stigma of obtaining mental health care among health care workers as well as licensing questions that dissuade them from receiving treatment.
“Lorna was very concerned that she would have negative consequences on her ability to work because she obtained mental health treatment one time,” Feist said. “And that ultimately was the catalyst for her decision to take her life at the age of 49 when she was getting her MBA.”
But Breen’s story is not unique. Feist said he talks to the families of other physicians who have died by suicide almost every day.
Just one month ago, 34-year-old William West, who was completing his ophthalmology surgery residency at George Washington University Hospital, died by suicide March 1.
In response, the George Washington School of Medicine and Health Sciences residents’ and fellows’ union sent a letter to the George Washington University administration. The message demanded the university make the well-being of its residents a top priority and dismantle the culture of residency programs that discourages residents from prioritizing self-care.
Tark said during her time in medical school, which took place in the 1990s, students were determined to be as mentally strong as possible. It was a constant “weeding out” process.
“I hate to say it, but during my generation, yeah it was definitely stigmatized if you had to get mental help,” Tark said. “It was seen as a weakness.”
Darwish Alabyad, who is in his first year of residency at the Greater Baltimore Medical Center and will continue at the George Washington University Hospital, said he understands why residents have higher suicide rates.
“It makes sense to me and I don’t think it should. I don’t think that this amount of stress is necessary to train physicians,” he said.
While Alabyad was a medical student at the Morehouse School of Medicine in Atlanta, his father passed away. After a talk with his advisor, he determined it would likely be feasible to take time off to support his family and still graduate on time.
But if he wanted to come off as competitive as possible while applying to residency, his best option was to stay in school. Alabyad’s interest, radiology, is a competitive specialty compared to other areas of medicine. He wanted to make sure he wouldn’t have any problems achieving his goals. So he stayed.
Even before knowing he wanted to go into radiology, Alabyad said he put a lot of pressure on himself because he didn’t want to perform below his potential. After finishing his daily work in the hospital, he would be engrossed in his studies.
Between their time as an undergraduate and the start of their residency, medical students generally take three large tests – the Medical College Admission Test, better known as the MCAT, and the first two steps of the United States Medical Licensing Examination, or board exams. The MCAT contains over six hours of test content. Step 1 and Step 2 of the USMLE take eight and nine hours to complete, respectively.
Salomon Ariza, between starting his undergraduate degree in 2013 and his now third year in the UNC School of Medicine, said these tests have been one of his largest sources of stress – so he has to take time for himself in order to stay healthy.
“Those times I’m really needing to make sure I’m on top of stuff, taking breaks and working out and looking after myself,” he said. “It’s around those times where I definitely get more anxious and I really need to make sure I’m looking after my mental health.”
Step 2 of the USMLE is usually taken at the beginning of the fourth year of medical school, after a student completes their third-year clinical rotations. In order to match into competitive medical specialties, students have to hit a certain benchmark, Ariza explained.
This test, as well as Step 1, are often considered the most important exams a medical student will complete as they advance through their medical career. Residency programs are notably interested in using a student’s Step 2 score to decide on admissions.
Ariza completed his bachelor’s degree in 2017. During the next few years, he took on different roles in areas of primary care before returning to his studies as a medical student at the UNC School of Medicine in 2021.
Now in the middle of his clinical rotations, Ariza said he works in the New Hanover Regional Hospital in Wilmington full time and averages around two hours of studying per day – clocking between 55 to 59 hours of work each week.
Alabyad said he spent around 60 hours per week working his ICU rotation at the Morehouse School of Medicine. This rotation occurred during the height of the COVID-19 pandemic, which contributed to higher levels of burnout among all workers in the health care industry.
He said even the attending physicians, who were in charge, were still figuring out the best treatment plans for critically ill COVID patients. That process continuously evolved during his ICU rotation and Alabyad barely had time for breaks.
But luckily, even at the height of his stress during the pandemic, he said had a lot of people he could talk to. Two confidential therapy sessions and a free subscription to the Headspace meditation app were provided to Alabyad and other students free of charge by the Morehouse School of Medicine.
“I feel like we’ve talked about so many kinds of stressors, so many different things that can make you feel overwhelmed in different ways,” he said. “But I think the strategies and the skills that you develop while dealing with those stressors, those are the things that can be universal and can be applied in different situations in different scenarios.”
Although Tark said getting treatment for mental health was seen as a weakness in the 1990s when she was a resident, she said she believes attitudes have changed. Now, there are rules in many hospitals limiting a resident’s time in the hospital to 80 hours per week.
While working as an attending physician at WakeMed Raleigh Campus in the 2000s, Tark saw the effects of those changes.
“The number of residents that were coming through that were actually getting married and having families as they’re going through residency, I was shocked,” she said. “I’m telling you, oh my gosh, if you were pregnant during my time, it was like ‘forget it’.”
Recent medical school graduates have told Tark that current students have much more access to mental health resources than when she was completing her degrees.
For example, Ariza said the UNC School of Medicine has implemented well-being days and facilitated an environment that promotes reaching out to resources when students are struggling with their health. There is less stigma surrounding mental health, he said.
Ariza explained the residents and attending physicians he works with in Wilmington are very understanding people. When students come to them with difficulties, they’re receptive and willing to iron out the problems.
“A lot of what physicians are facing and what medical students are facing in the medical field has come to the forefront,” Rohini Kousalya Siva, president of the American Medical Students Association, said. “I think what has improved is that we’re talking about it a lot more.”
In 2022, President Joe Biden signed the Dr. Lorna Breen Health Care Provider Protection Act into law. The act mandated that the Department of Health and Humans Services run a campaign and provide grants to promote well-being and resilience among health care workers.
The American Medical Students Association and the Dr. Lorna Breen Heroes Foundation have also worked with a variety of state medical boards to change “overly broad and invasive” mental health questions on licensure and credentialing applications.
Siva said this progress is heartwarming.
“When I look at it as coming from an association or organization, I know we have a lot of work to do,” Siva said. “But I also know there are a lot more partners in it with us and that gives me a lot of hope.”
