Interview: Suicide among medical students in Italy

esanum: Can we say that medical students, compared to other students, are more at risk of suffering from mental health problems?

This is an area that has been little explored so far. In recent years, probably due to the decrease in the number of doctors, there has been a reversal of this trend, and interest in the well-being of doctors and medical students has increased. On this subject, the scientific literature today offers no solid evidence. To be honest, the conclusions of studies often go in conflicting directions.

For example, research says that medical students are less often suspected of diagnoses for major depression, or generalised anxiety. However, at the same time, when suspicions emerge and are investigated, they are almost always confirmed. How can we interpret this finding?

There is still a great stigma attached to psychiatric illnesses, which weighs heavily on sufferers and their families. There is fear of prejudice, blame, isolation. Within the medical community, this stigma is amplified. The doctor with ongoing psychiatric suffering hardly ever reveals their symptoms. The same applies to medical students. Students know that their teachers, as doctors, might learn of their illness. Then there is the fear that, after graduation, the specialisation school or the medical association may become aware of their moment of difficulty, represented perhaps by a brief period of depression or anxiety.

In the medical field, universities, hospitals, professional associations, and training schools are all embryonic elements and determine often long-lasting relationships. As medical students think about their future, they fear that a psychiatric diagnosis will undermine their credibility with patients and colleagues.

The idea of having to preserve the public image of the doctor, as if they were a non-human figure, is widespread. Let's take, for example, an issue that is often talked about lately: burnout. It is spoken of in a generalised way, of course, without ever going into depth. Who, in the hospital, talks about it with colleagues? What research to date has gathered solid data to analyse the phenomenon and activate effective intervention plans? Physicians, for one, are reticent to talk about it, probably precisely because of this stigma experienced within the medical community.

esanum: If the stigma against psychiatric illnesses is so strong, does it make sense to activate psychological support services within universities and hospitals?

On its own, it does not seem to be an effective solution, although certainly motivated by good intentions. However, there are few universities in Italy today that guarantee constant and usable psychological support for their students. Those universities that do activate so-called listening desks hardly ever meet the actual needs of students.

First of all, there is the problem of anonymity. Can the university guarantee that the use of the service is then anonymous? A student who is not sure about anonymity, fearing that their lecturers may learn of their problem and judge them, will never use the service provided. For medical students, then, it is even more manifest.

If an engineering student is in crisis due to exams and therefore goes into depression, they can turn to doctors without fearing that their lecturers or future employers will know. This remains the case even after graduation. For a medical student to turn to a listening desk provided by the university is difficult, because the listener is their teacher or works closely with their teacher. For a 40-year old doctor, it is difficult to turn to a listening desk provided by the hospital, because the listener is a colleague.

If there is a need for a psychiatric examination, an in-depth examination, can the university contact the treating doctor or the health services in general? Does the university have this field of action? There is still a patchwork of work in this field, with no defined and shared modalities.

Not much, in my experience. For one thing, there is little talk about the problem - and if there is no talk about it, it is impossible to implement any initiative. When people do talk about the problem, often following yet another extreme case that we read about in the news, they do so by going into detail. Attention is focused on the individual, their personal situation, family, loved ones.

I believe, instead, that we must try to analyse the phenomenon with an overall look at the population level. The overall view can only be had by collecting data, analysing statistics and trends. The problem is that universities are reticent to provide data on their students suffering from psychiatric disorders and who attempt or commit suicide - very often they do not have this data. The death register is communal. The ISTAT, which is supposed to keep track of mortality trends, does not have data on the status of suicides, so we do not know how many of the suicide cases concern medical students, engineering students, language students, or others.

This being the case, awareness must first be raised at the level, if not of politics, then at least of health policy. This phenomenon must be observed, characterised and described. Without the analytical ability to observe events, one cannot think of intervention plans. Today, unfortunately, the initial pivot is missing.

We see the wake-up call of the student who commits suicide, of the lie that hides exams they never took. But we must go further: we must find the right magnifying glass to analyse the problem. Unfortunately, the will to do so is lacking.

We must not start with the listening desk opened by the university, but with a single national mortality register to collect data on this phenomenon. As is done, for example, for road accidents. First and foremost, we need a common and widespread way of collecting data to analyse the phenomenon. All health policy interventions, even at international level, start from here.

Instead, today we have fragmented data at various levels, which often do not even take into account foreigners studying in Italy. Without data, we cannot make any analytical reasoning.

esanum: The issue is not only Italian. Why, globally, is there a lack of will to collect data, analyse the problem and propose solutions?

The likely higher propensity for depressive syndromes and suicide among medical students has been highlighted by various studies, in different countries. All have concluded that more data are needed to analyse the phenomenon.

There are several reasons for this lack of data. Among the most important ones, in my opinion, is the issue of private universities. If this phenomenon is contained in Italy, it is widespread in the US. What private university can want to be transparent about this and risk losing appeal and customers? It is better for them to showcase ultra-performing students, excellent even in the art of folding the napkin at the table.

Universities are reticent to collect and share this data. Mortality registers are often unable to collect information comprehensively.

We cannot even collect data from the media. There are several recommendations not to spread the news about suicide cases because, on this there is certain evidence, when a suicidal act is highlighted in the media, immediately afterwards there is an increase in cases (we talk about copycat suicides). The media play a very important role in the attractiveness of the suicide phenomenon. In the USA, we often see real waves of psychiatric diagnoses and even suicides after a suicidal act. Often the waves are local, very intense, tending to die out in the short term.

esanum: Might the medical student have a greater propensity to commit suicide more because of subjective issues or more because of contextual issues?

We can say, observing and generalising, that the two elements, the medical student and the medical school, when they coexist, are equally important in triggering specific dynamics that can undermine the student's mental health.

We know that the medical student is likely to fit into a certain personality type, albeit with various subtypes. Let us imagine, for instance, that the typical personality of the medical student is characterised by dynamics related to success, social status, leadership. An academic environment that does not take into account these particular characteristics of its students, that does not inform, that does not educate, is obviously bound to create stressful situations.

Probably another type of person would not have the same degree of suffering, but what interests us is to see the world as it is today. The idea of university psychology, of a university intervention tout-court loses its meaning when we realise that students are very different from each other, they have different desires and needs.

esanum: So, could a new medical degree course that somehow models itself on the general characteristics of its students be the most effective intervention to improve student well-being?

Exactly. We must avoid the ivory tower, the closed university far removed from the needs of students. The course of study must be designed for the student, always offering alternatives to best develop individual aptitudes and abilities.

Personally, I think that this element is more relevant for Medicine than for other degree courses, because for Medicine students there is a strong intermingling between the academic and the work path. Those who study Literature, for example, have little chance that their university professor will become their superior in the workplace or that, in some way, he/she will interact with (and perhaps determine) their future working sphere.

For the medical student this is not the case. The figure of the doctor is particular, it has several intersecting plans of action. Medical students are aware of this, they know that the relationship with their professors will not end with graduation. For others, the idea of gritting one's teeth during university and then closing the parenthesis and opening a new one, that of work, may be worthwhile. For doctors, there is a future perspective of interaction with the academic world during graduate school, continuing education, and research activities. The doctor, from the time he or she is a student, is faced with a mixture of different aspects: the educational, professional and social worlds are all one, with associated competitive and lasting power dynamics.

I think so. The subject of burnout among physicians is a complex one. it is an area of research that I am working on, together with other colleagues, with quite a few difficulties. The first, which may seem trivial, is the scope of the term 'burnout'. When one speaks of burnout one always speaks of it in the work context. For doctors there is a period when one is a doctor but at the same time a student, the period of specialisation. Can the term burnout be used in this phase of mixing study and work? Can the term burnout be used for medical students?

Speaking of doctors, one has to consider the idea of an identity that is not separate from the profession - the doctor is a doctor all the time, even when he/she sleeps. How is this identity managed? How is it taught, how is it transmitted?

The Hippocratic oath tells us to treat those who teach us to be doctors as family members. The idea of the group, of the family, of identity has been rooted in the Western medical tradition for over two thousand years. The idea of the doctor playing a special role in society is also ancient and, probably, the burden of this is already felt when one starts studying medicine. In my opinion, we have to start from here to analyse the phenomenon of burnout among doctors. Perhaps it is not the idea we all have of the doctor that needs to be corrected, but the way future doctors assimilate it, first and foremost at university.

esanum: The COVID-19 pandemic has changed (and is changing) the balance and dynamics in several areas of healthcare. What are the new elements affecting young doctors, from a mental health perspective?

There is a tendency among young doctors to separate the professional sphere more from the other components of their lives. We have no data on this, only perceptions. An important element underlying this new trend is the mutation of the specialisation course, which is increasingly turning from a training course into a real career path. To this we can add the change in the cultural context in which the figure of the doctor is placed today compared to the past, hence the change in society's idea of the doctor. And perhaps the digital revolution that we are experiencing has also brought about new awareness.

But, of course, in Italy this phenomenon increased after 2020 when, because of the COVID-19 pandemic, many young doctors, newly qualified, went to work to manage the health emergency. Since 2020, newly qualified doctors have been thrown into the fray due to the pandemic and the shortage of personnel. They have worked, interacted with patients, diagnosed elbow to elbow with older and more experienced colleagues. This allowed them to internalise a personal professional figure, an idea of a doctor far removed from the one born in speciality schools and universities.

Those who entered specialty school today did not enter it as recent graduates without any professional experience. Most of the young residents today are in specialty school with some field experience behind them. This has changed the dynamics, probably exacerbating the intergenerational conflict.

In the light of this and other factors that are contributing to a change in the role and perception of the doctor in society, specialisation schools probably also need to be redesigned, taking into account the doctors who attend them today.

As with medical students, the mental well-being of trainees requires, in the first instance, a precise analysis of their specific characteristics and needs.

Tarchi L, Moretti M, Osculati AMM, Politi P, Damiani S. The Hippocratic Risk: Epidemiology of Suicide in a Sample of Medical Undergraduates. Psychiatr Q. 2021 Jun;92(2):715-720. doi: 10.1007/s11126-020-09844-0. Epub 2020 Sep 7. PMID: 32895751; PMCID: PMC8110500.
(Only in Italian) Tarchi L. La sindrome di Ippocrate. L’eco del nulla. 13/10/2020
Hippocratic Oath (ancient text)

Interview: Suicide among medical students in Italy

Students worldwide are at high risk of poor mental well-being, depression, or suicidal ideation and behaviour. Medical students may represent the most at-risk group.