Does medical student debt lead to suicide?

Every year 300 to 400 physicians commit suicide. More than 10 percent of doctors are thought to have depression, a frequent precursor to suicide. Rates of depression and suicide among physicians are higher than in the general population. Many reasons including stress, heavy workload, sleep deprivation, lack of autonomy, and lack of outlets for personal care may contribute to higher vulnerability in doctors. High-profile suicides this past year by medical residents have led to a slew of articles on depression and suicide in physician. Curiously missing from the conversation is financial strain, particularly debt.

There is a strong connection between debt and depression/suicidal behaviors. A recent meta-analysis combining results from over 65 studies worldwide found that indebted individuals are nearly three times more likely to be depressed and almost six times more likely to have attempted or completed suicide. Importantly, a person’s financial concern and worry regarding their debt, rather than their amount of debt, is more strongly associated with worse mental health. In addition, debt is more important than income level for predicting mental illness.

Despite the importance of debt and financial worry, few studies have investigated their effect on physician depression and suicide. A number of studies show that higher debt leads to more burnout, a negative reaction to work-related or interpersonal stress. Burnout consists of three dimensions: emotional exhaustion, cynicism or depersonalization of others, and a reduced sense of personal accomplishment. A study of over 260 radiology residents found that a resident’s subjective financial strain was a stronger predictor of burnout than amount of debt. Another study of over 4,000 internal medicine residents found that more educational debt was associated with more depressive symptoms and cynicism about medicine. Burnout itself is a risk factor for depression and suicidal behaviors.

Concerns about finances likely begin during medical school. Medical students worry most about finances even more than academics. Despite an increase in financial worries during course of medical school, students with financial worries are less likely to seek counseling.

While it could be reasoned that a steady income beginning during residency should decrease worry, income is not directly associated with depression in residents. In addition, higher anticipated income does not seem to decrease risk of burnout among residents. Ultimately, the impact and meaning of income and debt in is the eye of the beholder. Unfortunately for many doctors their vision is myopic. Although most physicians earn enough money to climb out of debt, particularly after completing residency, financial strain can lead to poor mental health.

How can we address this problem?

The reasons people become depressed and commit suicide are complex, but we cannot ignore financial well-being. Despite the importance of financial well-being, the majority of medical residents have not received any training in financial planning or personal finance. Few finance courses exist in medical school and residency. The courses that exist do not account for the psychological aspects of debt such as financial strain.

Probing the root of financial strain is necessary to address individual resident needs. Financial well-being should be incorporated into wellness programs that are already available at many residency programs. Psychological treatments may help with financial worry, but mechanisms for help with debt itself are necessary. Currently, the median debt for medical graduates is $180,000 and continues to increase. The rate of increase in debt far outpaces increase in resident income, which has remained unchanged for decades after adjusting for inflation. Depending on their loan repayment plan, a physician may end up paying two or three times their original debt amount. Debt counseling and financial literacy courses, while helpful, are patchwork solutions for the systemic problem of debt in medicine.

Two promising options for medical graduates are the National Health Service Corps (NHSC) and the Armed Forces. The NHSC places primary care doctors in underserved settings (e.g., rural communities), in exchange for partial loan forgiveness. Unfortunately, the program is currently in jeopardy because Congress has not reauthorized funding to support it. Hopefully, the funding will be reauthorized before the fiscal year deadline on September 30th, 2015. Serving in the Armed Forces allows full loan repayment, but a medical resident has little say in where he lives and may be deployed to an armed conflict.

Another solution is to decrease the length of medical school or residency. Simply put, less debt accumulated during medical school and quicker transition to higher income after residency training translates to less debt. However, given that total resident work hours have been restricted during the first year of residency, shorter residency duration is unlikely. Shortening medical school is possible. In fact, a few schools are experimenting with three years instead of the traditional four years of medical school. Over time, shaving one year of medical school could lead to an individual net savings of $160,000 to 230,000.

Although these systematic changes will take time, they should be pursued. Right now, residency programs should aim to improve the individual financial well-being of their residents. No doctor should take his/her life because of financial worries or debt. Suicide is a loss for loved ones, community, and society. The health care system must take steps now to help doctors improve their well-being.

Kunmi Sobowale is a medical student.

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