Research reported last year by St. Louis University School of Medicine revealed that by the end of the first year of medical school 26% of medical students are struggling with depression and at the end of the second year the prevalence is 32%. Another study reveals that 11% of medical students suffer from suicidal ideation. Medical school classes currently are about 50 % female students, and suicide among female medical students is 400% higher among them than among females in other professions. I have introduced legislation to seek answers to this tragedy, but so far at least one medical school in our state is opposing the proposal.
Below is an email I sent to the Lobbyist for Washington University Physicians who oppose HB 867 which calls for a research study regarding depression and suicide among our medical students. It calls for transparency by offering medical students the opportunity to voluntarily participate in a survey that will determine the prevalence of depression, and after a period of three years that data would be available to the public allowing students to have informed consent when choosing a medical school. Washington University School of Medicine did not testify in opposition to this bill when it was heard in Committee. In fact there was no testimony in opposition and there was over an hour of compelling testimony in favor including testimony from the President of the American Medical Student Association, physician experts, psychiatrists, and mental health organizations, and medical students studying in our state. This bill was voted “Do Pass” by unanimous vote of the Standing Committee on Health and Mental Health Policy. It is currently in the Select Committee on Social Services.
I posed four questions regarding their opposition to this groundbreaking, life saving proposal.
Dear Mr. Schlemeier,
I understand your reluctance to testify in opposition to HB 867 during the hearing recently, as there would likely have been withering questioning from committee members who would have wanted to know why Washington University opposes a multi-center collaborative research project with other Missouri medical schools to help reduce the prevalence of depression and suicide among medical students and physicians. Explaining the fact that Washington University worries that disclosing the the prevalence of depression and suicidal thoughts among the medical students at WUSM would impair its ability to recruit medical students would have been difficult indeed. Your task would have become even more difficult if the groundbreaking research published last year by St. Louis University School of Medicine would have been referenced which reveals that innovative changes to the academic program resulted in a reduction of depression among first year students from 27% to 11% while improving student performance on board exams.
It is my hope that the physicians and administration of Washington University School of Medicine will, upon reflection, embrace the concept of studying depression and suicide among medical students in our state in collaboration with the other medical schools in Missouri as facilitated by HB 867.
I would like to pose the following questions to those at Washington University who oppose HB 867 regarding the fundamental principles embodied in the draft of the bill referenced during the hearing:
1. Do prospective medical students have a right to know the prevalence of depression and suicidal thoughts among students in the school to which they are applying?
Discussion: HB 867 does require that the prevalence of depression among medical students be determined and made public annually, following an initial three year period during which time any changes decided upon by each medical school can be implemented. The concept of informed consent is a fundamental ethical and legal right in health care that physicians are taught at every level. By keeping the prevalence of depression and suicidal thoughts among the medical student population at a particular medical school a secret, prospective medical students are deprived of their basic right to informed consent when choosing to enter a medical school. The argument that such informed consent will keep Washington University School of Medicine from attracting high quality medical students is unfounded since St Louis University School of Medicine has published the results of their study revealing the prevalence of depression among students at their medical school in a recent study with no impact on the quality of the entering classes. In my opinion students considering WUSM or Harvard would have a higher opinion of the WUSM if they have begun research on the challenge of depression among medical students and I believe students would choose it preferentially over Harvard or any other institution that chooses to ignore the issue. Should we allow hospitals to keep their infection rate for knee replacement a secret because it may deter them from attracting patients to undergo the procedure? Let’s consider a hypothetical case of a pharmaceutical company seeking approval from the FDA for a new medication, and let’s say that it was found that of those who take the medication for two years, 30% become depressed and another 10% consider suicide. In such a case, the drug would probably not be approved, but if it were approved for use, the package insert for that medication would surely have to include a disclosure of that risk to patients. Why should it be any different for individuals exposing themselves to the very real risks of attending medical school, where the rate of suicide among female medical students and physicians is 400% higher than the rate of suicide among women who are not medical students or physicians.
The WUSTL Mission Statement declares that the University will: focus on meaningful measurable results for all of our endeavors, and it doesn’t say ‘unless Harvard doesn’t employ such measurements.’ WUSM should invite the Harvards of the world to participate, but failing that participation, it should take the lead along with the other medical schools in Missouri to shine the light where there is currently darkness.
2. Will Washington University School of Medicine agree to help design and participate in the “Show Me Compassionate Medical Education Research Project” in collaboration with the 5 other medical schools in Missouri using evidence based medicine principles to seek to better understand depression, suicide and other related conditions among medical students and seek to find ways to modify the medical educational program to limit the damage to the mental health and well being of medical students, reduce the risk of suicide and seek to remove barriers to the early availability of appropriate support and treatment for medical students?
Discussion: A bedrock principle of the practice of medicine that is taught in every medical school in the United States is that treatment needs to be evidence based. In order to have evidence of treatment effectiveness there needs to be a measure of the condition being treated. If one does not measure, it is not possible to practice evidence based medicine. The multi-center study of medical student well being in our state possible under HB 867 would be innovative, ground breaking, and would fill a huge gap in the understanding of the national tragedy that exists regarding the high incidence of depression and suicide among our medical students and physicians. WUMS and all other medical schools in our state should embrace this opportunity.
The WUSM Vision Statement includes the following:
The University will:
•enhance our intellectual and technological environment to foster exceptionally creative research and education, and
•apply advances in research and medicine to the betterment of the human condition locally and globally,
What better way is there to put these guiding principles to work than to seek to relieve the misery being experienced by students right under the very noses of the faculty at Washington University School of Medicine and other medical schools in our state and across the nation?
3. Does Washington University School of Medicine believe that the mental health of its medical students, particularly as it relates to the prevalence of depression and suicidal thoughts is an important parameter to know, and does the University recognize such prevalence as a valid measure of the performance of a medical school, in addition to academic achievement on board exams?
Discussion: Should medical schools be evaluated solely by the academic scores of the students who attend and graduate from the medical school, or should it be asked at what cost to the mental health and well being of the students are those board scores achieved? The prevalence of depression at St. Louis University School of Medicine at the end of the 2nd year was 32% before any changes were made to the educational process, after which it was cut in half. The prevalence of depression at WUSM could be higher or lower than that- but no one knows what the prevalence actually is. The effectiveness of a physician is negatively influenced when the physician suffers from depression. Therefore even if the board scores of students are high, the effectiveness of physicians-in-training and newly graduated physicians so affected would be sub par and if the rate of depression among them is high, there would be a measurable impact on the public health resulting from failure to identify and address the true prevalence of these conditions among medical students. Therefore, since the prevalence of depression and suicidal thoughts among medical students upon entry into medical school is the same as the general population, and after one or two years in medical school such prevalence is known to be much higher than non medical students, and since there is likely variability of this prevalence among medical schools, and since this is a parameter that is within the capability of each medical school to address in its own way, it is reasonable to include a measure of the prevalence of depression among its students when one considers performance measures of a medial school.
The WUSTL Mission Statement declares that the University shall:
Judge ourselves by the most exacting standards, and:
Washington University’s faculty and staff strive to enhance the lives and livelihoods of students, the people of the greater St. Louis community, the country, and the world. Adding a mental health performance measure to the performance evaluation of medical schools is a more exacting standard that has tremendous potential to enhance the lives of students and the patients treated by these physicians-in-training in St. Louis, the country, and the world.
4. Does Washington University School of Medicine acknowledge that treatment programs available to medical students for depression and suicidal thoughts through the University may not be trusted by medical students due to fear of negative impact on their professional advancement and that this prevents some students from seeking support and treatment when they are in need of such services?
Discussion: During the hearing on HB 867 compelling evidence was produced that in fact many medical students mistrust the programs currently in place at medical schools and that they will seek care more readily if the care is provided outside of the purview of the medical school or university. A psychiatrist who currently has a daughter in medical school in Missouri testified that she has received a number of requests for assistance from classmates of her daughter who became aware that their classmate’s mother was a psychiatrist. Due to the fact that licensing applications and applications for BNDD and DEA prescribing privileges as well as hospital staff applications, and insurance credentialing inquire about a physician’s history of having sought mental health care, medical students are hesitant to ask for help from sources associated with the medical school or the student health service associated with the university. Therefore, the current approach in use at most medical schools, which relies heavily on identifying and offering treatment services to students struggling with depression, is inherently insufficient and suboptimal. Seeking ways to remove barriers to asking for help is necessary.
In addition, building on the recent work done by St Louis University School of Medicine, further research is necessary regarding whether it is possible to reduce the prevalence of depression among medical students by changing the academic program, thereby getting at the root causes, rather than just attempting to bind up the wounds of those who silently attempt to endure the medical education process. HB 867 also asks our medical schools to study the effect of current application processes noted above for medical students and physicians as it relates to establishing barriers to asking for help, and to make recommendations for any advisable changes that may be needed regarding the statutes, rules, regulations and common practices that govern or influence the practice of medicine in our state.
Below I have copied the Mission and Vision Statements of Washington University and Washington University School of Medicine for your reference, followed by some closing remarks:
WUSM Mission and Vision
Washington University School of Medicine will lead in advancing human health through the best clinical care, innovative research and the education of tomorrow’s leaders in biomedicine in a culture that supports diversity, inclusion, critical thinking and creativity.
In leading the advancement of human health, Washington University School of Medicine will: •cultivate excellence and collegiality within an inclusive community
•attract and develop a diverse, talented, academic workforce
•lead the revolution in biomedicine
•enhance our intellectual and technological environment to foster exceptionally creative research and education
•develop and maintain excellent clinical programs to provide outstanding care
•observe the highest standards of ethics, integrity and compassionate care
•apply advances in research and medicine to the betterment of the human condition locally and globally
Washington University’s mission is to discover and disseminate knowledge, and protect the freedom of inquiry through research, teaching and learning.
Washington University creates an environment to encourage and support an ethos of wide-ranging exploration. Washington University’s faculty and staff strive to enhance the lives and livelihoods of students, the people of the greater St. Louis community, the country, and the world.
Our goals are:
•to welcome students, faculty, and staff from all backgrounds to create an inclusive community that is welcoming, nurturing, and intellectually rigorous;
•to foster excellence in our teaching, research, scholarship, and service;
•to prepare students with attitudes, skills, and habits of lifelong learning and leadership thereby enabling them to be productive members of a global society; and
•to be an institution that excels by its accomplishments in our home community, St. Louis, as well as in the nation and the world.
To this end we intend:
•to judge ourselves by the most exacting standards;
•to attract people of great ability from diverse backgrounds;
•to encourage faculty and students to be bold, independent, and creative thinkers;
•to provide an exemplary, respectful, and responsive environment for living, teaching, learning, and working for present and future generations; and
•to focus on meaningful measurable results for all of our endeavors.
HB 867 establishes an anonymous and voluntary mechanism for screening medical students for depression, providing students and their families an opportunity for informed consent, and it provides a framework for our Missouri medical schools to design and conduct groundbreaking research regarding the widespread and tragic prevalence of depression and suicide among our medical students. It also provides students the option of asking for help real time, even immediately if necessary. I have not heard any convincing argument that this research is not necessary, nor have I witnessed any credible medical research that sought to keep the resulting data secret.
It is my hope that Missouri’s medical schools will lead the way in addressing the national tragedy that is medical student depression and suicide. I remain committed to working with all of our medical schools, other stakeholders, and my colleagues in the legislature regarding this issue and am open to any reasonable compromise, as the many modifications to the original bill demonstrate. However, I will not endorse the status quo, nor will I agree to keep such data a secret. All interested parties had the opportunity to provide testimony in favor or against during the hearing, and will have another opportunity during Senate hearings. I am willing to have ongoing dialogue. The contention that my presentation at the hearing misrepresented the essential provisions of the bill is just not true. I have video of the hearing that can be compared to the provisions of the draft of the bill to which I referred during the hearing that will back that up. I would suggest that interested representatives of Washington University and WUSM, and representatives from any other medical schools or groups or individuals come to Jefferson City to discuss this further face to face. I also request that those who remain opposed to HB 867, after considering the foregoing information, respond to the questions posed in this document in writing.
The many organizations and individuals that appeared and testified in favor of HB 867 for well over an hour is a matter of public record. They included, representatives from the American Medical Student Association, medical students, physician experts in physician suicide, psychiatrists, and mental health professional organizations. There were a great many individuals who wanted to testify in favor but who feared retaliation if they chose to do so. If I had allowed anonymous testimony a great deal more testimony in favor would have resulted. If there are constructive suggestions that would result Washington University becoming a champion for this initiative, bring them forward, I am eager to hear them and to work together. If however, your only suggestions relate to avoiding transparency, be prepared for resistance to that concept.
State Representative Dr. Keith J. Frederick
Missouri’s 121st District