In April 2020, New York City resembled a ghost town with empty streets and shuttered businesses. In the days following Governor Andrew Cuomos stay-at-home order, the most populous city in the United States fell silent, except for the eerie echoes of loudspeakers urging individuals to maintain physical distance. Inside the citys emergency rooms and hospitals, however, healthcare workers were facing the worst experience of their careers. Forced to work with insufficient equipment, personnel, and space, New York Citys physicians were at the mercy of an illness they barely understood.

One of those physicians was Dr. Lorna Breen, an emergency medicine doctor at New York-Presbyterian Allen Hospital. Dr. Breen was a well-loved and respected clinician, but unable to cope with the incomprehensible agony of the pandemic at its height. She died by suicide in late April.

Stories like Dr. Breens are distressingly common even prior to the COVID-19 pandemic. A 2019 study asserts that the suicide rate is higher among doctors than in the general public, as are instances of depression. In the first year of postgraduate medical training, depressive symptoms increase 15.8% across resident physicians, and during residency training, anywhere between 20-45% of residents report symptoms of depression. Later on, depression and suicide remain as huge issues for physicians outside of their training.

Why? Obviously, physicians see and deal with a lot of trauma in their careers, so its not surprising that emotional discomfort is prevalent. Having to deal with death on a regular basis and having such an outward facing job leads to compassion fatigue, often leading to burnout and mental illness. At the same time, mental illness is a debilitating source of humiliation in medicine, often being perceived as a sign of weakness and an inability to handle the rigors of the profession.

Dr. Breens passing reignited a conversation surrounding well-being among physicians, but struggles with mental health often begin more than a decade before medical practice itself. Premedical students represent a sizable portion of the undergraduate population, and very early on in their careers, are accustomed to a cut-throat environment. [Mental health] is not viewed as a priority, says Heta Patel, a rising College senior studying Health and Societies, and a premedical student herself. Getting into a good medical school, doing well... those sorts of things are put first.

Its true. A 2010 study found that premeds, especially those who are female or Hispanic, exhibit signs of severe depression more frequently than non-premeds. Despite this prevalence, premeds are often reluctant to admit to these struggles, especially on their applications, out of fear of jeopardizing their chances of being accepted into a program. Its an open secret that programs are biased against applicants with a prior history of mental illness, and even though an applicant might see their illness as an experience crucial to their desire to serve others in a clinical context, many claim that its a surefire way to torpedo an application.

This attitude is prevalent throughout undergraduate medical education, which is often analogized to drinking from a firehose. The first two years of medical school are the preclinical years, where students take coursework in the basic science of medicine, but the rigor can be unlike anything experienced in college. For the most part, the preclinical medical school experience depends on where one trains. Ive had friends who were premed with me, went to different schools, and were really just working to the bone the first two years, says Matt Kubicki, a fourth-year medical student at the Perelman School of Medicine. Its mostly just a preclinical [curriculum]: study, take tests, do anatomy lab, that sort of thing.

Kubicki describes Penn as being more relaxed, even going as far as saying that his preclinical years were less stressful than his time as an undergraduate trying to get into medical school. He attributes this to the pass/fail grading system Penn utilizes when evaluating students in their preclinical years. At Penn our first semester is pass/fail, and even after that theres honors, but it doesnt really matter as much as the grades that we get during our clinical year, he says.

The third year of medical school is the clinical year, where students are able to escape the classroom and rotate in different clinical settings, gaining an understanding of how to practice medicine. While its undoubtedly exciting for many students to get their hands dirty, starting clinical year can be an adjustment that comes with its own set of mental health challenges.

The clinical year is universally hated among most med students, admits Kubicki. I mean it is exciting, youre finally getting to be in clinics, but unfortunately I think it needs to be overhauled a lot more. He describes the clinical year as when medical students are thrown into many different work settings with minimal guidance and constant evaluation. But the worst part? The isolation. When clinic time came, I just wasnt seeing anyone except my roommates, says Kubicki.

Ultimately, medical students work through those clinical rotations to become accepted into a residency program, a graduate medical education program where physicians train in their chosen subspecialty for an additional number of years after graduating medical school. Residents are likely to experience or have exacerbated difficulties in mental health. They face tremendous stress in their careers: substantial workloads, deprived sleep, and work-related compassion fatigue are common and expected. A 2018 study surveyed 18% of the resident physicians at an academic medical center in Chicago, IL, and 61% admitted that they could have benefited from psychiatric services, yet only 24% of those individuals actually solicited treatment. Major concerns for seeking care for mental health include a lack of time, fear of judgement from others, and fear of being unable to obtain licensure.

One of the biggest barriers to seeking mental health treatment among physicians is the fact that state medical licensure boards can ask invasive questions about psychiatric history, which the Department of Justice and numerous court decisions found violate the Americans with Disabilities Act. While the intrusiveness of some questioning has become muted due to legal recourse, some argue that they are still disconcertingly personal. Regardless, it dissuades many physicians from seeking treatment for fear of having such information become available. Notably, however, the mental health condition that receives the greatest scrutiny among physicians is substance abuse.

A 2009 study suggests that between 10-12% of physicians develop a substance abuse disorder during their careers, and the perceived social status of physicians often precludes them from getting help. Kubicki, who is interested in addiction medicine, submits that many of the traits that allow physicians to succeed actually put them at greater risk for developing drug or alcohol problems. A lot of medical students are used to being the know-it-alls who are high achievers... but where that can go wrong is if we suddenly start struggling, we are much less likely to ask for help, he says.

The doctors that ultimately do ask for help are placed into intense investigation. Special rehabilitation programs exist for physicians aiming to achieve sobriety, and relicensure always depends on the successful completion of these programs. It is, in a way, voluntary, but its not, says Penn Department of Psychiatry's Dr. Claudia Baldassano. Dr. Baldassano referred a patient of hers with an alcohol problem (who was a medical student at the time) to one such program. Penn Medicine would not allow this student to remain a student unless [they] enrolled voluntarily in this program. Dr. Baldassano noted that the patient was able to become sober, graduate, and begin residency, ultimately overcoming their problem and becoming a clinician.

The COVID-19 pandemic especially increases workload and stress for many physicians, and their mental health is at greater risk now than ever. Increased sanitation and distancing measures in hospitals make it difficult for doctors to spend time with one another like they once did. One of the best things about residency is the colleagues that you work with and the social connections that you get to build both inside and outside of the hospital, says Dr. Benjamin Lerman, a Pediatrics Resident at the Childrens Hospital of Philadelphia. At the height of the pandemic when we didnt know what the transmissibility of COVID was, we werent even allowed to be in the same room as each other, which was really socially isolating... that takes a mental toll when youre on call in the hospital for 28 hours.

Dr. Baldassano, who is also the Director of Penns Bipolar Outpatient Clinic, notes that she already received two new patient referralsboth of whom are physiciansas a direct result of the pandemic. One became manic in the setting of COVID-19 and increased work hours which led to disruption in sleep, she says. It... fomented what was probably an underlying bipolar disorder that... presented itself to the point where the person became so grandiose they thought they were going to be the one to solve the whole COVID problem.

Historically, medicine rarely discusses mental health within the ranks, but the overwhelming stress of the pandemic hasout of necessitymade administrators prioritize mental health at many levels of the healthcare world. Kubicki notes that in his opinion, Penn Medicine did a better job of addressing mental health concerns during the pandemic than they typically had before. It was kind of like because this was such a big shock to everyones systems, they just flat out from the beginning were like, Hey, if you need to talk about how the pandemic is affecting you, we got these resources all for you, he says. Penn Medicine recently introduced COBALT, a new mental health platform for physicians to receive confidential peer counseling and assistance coping with the trauma of the pandemic.

Even in the allied health professions, COVID-19 introduced broad discussions surrounding mental health where they did not exist before. The first time that ever happened was during coronavirus, says Jennifer Ben Nathan, an Emergency Medical Technician, referring to a supervisor offering to speak to EMTs stressed out from taking calls during the pandemic. Ben Nathan is a rising College sophomore and is working in Emergency Medical Services for 3.5 years now. She describes the culture in EMS as one that rarely discusses mental health, and that those conversations only arise in events of excessive trauma. They only kind of come up if something disturbing happens and we have to deal with it, but otherwise everyone kind of keeps quiet about it and you just kind of carry on, she says. How else are you going to do your job?

Physicians and administrators need to understand that being open, vulnerable, and fallible actually help doctors do their job. This shame associated with mental illness is simply incommensurate with the emotional toll that medicine inevitably takes on practitioners, but its ingrained into every aspect of medical training. If we want more people to enter medicine and operate to the best of their abilities, we have to acknowledge and honor the unimaginable sacrifices they make, and allow them to process trauma in a productive and healthy way.

The silver lining of the COVID-19 pandemic is that it forces a reckoning in medicine. It creates an environment so traumatic for many physicians, that for the first time, people in the field are willing to speak up and set aside stigmas for the sake of practitioners. The worst thing that can happen, however, is if we allow these discussions to regress post-pandemic, and return to a state where physicians once again fear admitting weakness and keep indulging in the tough culture medicine embodied. Changing that culture will require sustained involvement from administrators at every level of medicine, but especially in undergraduate medical education, where members of the next generation of physicians are being molded by one another.

The issue is that sustained involvement comes at a price. It costs money and it requires a structural investment, says Dr. Lerman. But, I think were moving in that direction, it just takes time.

VARUN SARASWATHULA is a rising College junior from Herndon, V.A. studying the Biological Basis of Behavior and Healthcare Management. His email is vsaras@sas.upenn.edu.

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Varun Saraswathula | Doctors are facing a silent mental health crisis and they need help - The Daily Pennsylvanian