Caring for the Caregivers

For many medical school applicants, being a doctor means caring for people who need help and fulfilling dreams of serving the community. But about 400 physicians die every year by suicide, and almost 50 percent of medical students reported feeling emotionally exhausted and less empathetic toward their patients. Though they provide help for others, many physicians-in-training face barriers in getting help for themselves.

News reporter Shreya Aiyar, opinion columnist Miriam Bribiesca and photojournalist Daniel Alcazar chronicled the experiences and mental health of students at the top three University of California medical schools and what administrators are doing to help those students cope with stress, depression and thoughts of suicide.

Exhausting Expectations

Donna Egnatios picked up a phone call at 4:30 p.m. on June 22, 2015. Seconds later, she was told her 26-year-old son was dead.

The day before, Jeremy Egnatios, a third-year UC San Diego medical student, called his family to wish his dad a happy Father’s Day, to chat about his future residency plans and to tell them he loved them.

Until she read the note he left behind, Donna Egnatios didn’t recognize his veiled farewell for what it was – the result of almost 16 years coping with depression and bipolar disorder, and his belief that his illness would make it impossible for him to have the happy life he wanted as a physician with a family.

“It’s not fair that somebody who has a physical illness can just say ‘I’m sick today’ and no one questions it, but it’s not the same for someone with a mental illness,” said Donna Egnatios, paraphrasing from an email he composed but never sent. “He said, ‘It shouldn’t be any different than a diabetic who has a blood sugar of 500 who says I’m sick and I can’t come in today.’”

“It’s not fair that somebody who has a physical illness can just say ‘I’m sick today’ and no one questions it, but it’s not the same for someone with a mental illness.”

UC San Francisco, UCLA and UC San Diego are home to three top-ranked medical schools for research and primary care. Students here and around the country learn to care for patients, diagnose illness, prescribe appropriate medications and establish a rapport with their patients.

But medical students pay a price: Almost 50 percent of medical students surveyed for a 2014 study in the journal Academic Medicine reported experiencing burnout, compared to about 36 percent of age-matched college graduates. People who experience burnout are more likely to feel emotionally exhausted and express cynicism and detachment towards patients, according to the 22-item Maslach Burnout Inventory, a scale used to quantify and assess levels of burnout.

To fulfill their roles as caregivers, some medical students like Egnatios try to cope with emotional abuse and bury symptoms of mental illness, burnout or suicidal thoughts in the clinic.

The bottom of the ladder

Three years ago, Stephan Chiu enrolled in the David Geffen School of Medicine at UCLA as an enthusiastic student who wanted to change the world.

Chiu didn’t know what career he wanted to pursue as an undergraduate student at UCLA. But he had spent time shadowing physicians and volunteering in the campus Care Extenders program offered by UCLA Health, so medical school seemed like a good fit.

At Geffen, Chiu quickly fell in love with his medical school experiences, like practicing suturing up a wound.

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Stephan Chiu, a third-year UCLA David Geffen School of Medicine student, loved learning about medicine, suturing wounds and helping patients. But the clinic’s rigid hierarchy and harsh hours made him disillusioned – he said his supervising physicians often treated him dismissively and that he felt exhausted after waking up at 4 a.m. and staying on his feet all day.

“Sometimes, I get to do something really cool, like holding a person’s bowels in my hands,” Chiu said. “No one else gets to do that kind of stuff, like taking care of patients. It’s really cool.”

But in his third year, he became exhausted after he began rotating, or training in different specialties like pediatrics and neurology, at different hospitals like Kaiser Permanente Los Angeles Medical Center in Hollywood.

Rotations are a traditional part of medical school training, said Susan Rosen, a primary care provider and the medical director at UC San Francisco’s Student Health and Counseling. They expose medical students to the dozens of clinical specialties and help students gain experience for their future careers.

But the clinics’ strict hierarchies fed his disillusionment, said Chiu, who agreed to be interviewed on his only day off that month.

Attending physicians, who have completed their training and receive full physician salaries, sit atop the clinical ladder.

Resident and intern physicians – physicians who have completed medical school but have not finished training for their specialties – occupy the next rungs of the ladder, and medical students like Chiu cling to the bottom rung, Chiu said.

Chiu’s attending physicians often did not refer to him by name. Instead, Chiu said they called for “the med student” when they needed something, gave him the silent treatment or caught themselves before saying something dismissive.

“They’re always like, ‘Oh, I know the school tells me to treat you nice, so I’m not going to do anything mean to you,’” Chiu said.

During his first week of his general surgery rotation, Chiu accidentally contaminated his surgical gown by opening it up the wrong way. As a medical student, Chiu said he didn’t know much – he barely knew how to wear his gown and gloves properly, but was thrown into an environment where everybody around him was good at it already.

A nurse harshly reprimanded Chiu, humiliating him in front of his resident physician, Chiu said. He realized his vision of being a doctor clashed with exhaustion from the long hours, stress and absence of support from clinical faculty and staff.

“I have all these sick patients, but I’m also really tired and I just want to go home to take care of myself,” Chiu said. “It sucks to say, but (I became) more cynical as the year went on.”

Rosen said first- and second-year medical students spend time with each other in large lecture-based classes, study together and talk about their problems.

But students can burn out more easily in their third years because they begin to work in clinics and take fewer classes with large groups of classmates, Rosen said. They can become isolated with different rotation times and locations than their friends, and they move from hospital to hospital when their rotations change.

Constantly moving from hospital to hospital can block students’ access to care and therapy, resulting in problems like social anxiety and frustration, said Lance Raynor, a mental health provider at UC San Francisco’s Student Health and Counseling.

Chiu said he felt the effects of isolation firsthand: He was not able to see his friends or family for days on end, and he also could not easily form meaningful relationships with his medical teams because he moved to a different team the next month.

“You’re perpetually on the bottom rung of the team, and you’re switching every month to a different team,” Chiu said. “It’s very stressful.”

Some medical students do not express frustration, stress and anxiety in case they are formally diagnosed with a mental illness that may go on their medical records, said Jessica Lloyd, the associate program director for the UCLA pediatric residency program.

Students may be frightened into thinking mental illness will affect their chances at competitive residency programs, Lloyd added. The California medical licensure application asks residency applicants to disclose any mental illness that could hinder their ability to treat patients, and states that it will decide if a student is eligible for a medical license based on the severity of the medical condition.

Lloyd said students’ stress in thinking about their futures and their lack of time to go to therapy appointments create barriers to care with no easy fix.

“We have to care for our caretakers now,” Lloyd said.

Caring for the caregiver

Jeremy Egnatios grew up watching his father move in and out of the hospital because of complications from a liver transplant.

Egnatios’ mother Donna Egnatios said he assumed a protective role when he realized his father could die at any moment, and he took his role of caring for her and his two sisters seriously.

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Donna Egnatios taught her son, Jeremy Egnatios, to always care for others, though he felt the symptoms of his bipolar disorder prevented him from believing he could be a physician. Nevertheless, his mother said Jeremy Egnatios was a caring person who helped his fellow students with their studying, saw patients at a student-run free clinic and worked at multiple research laboratories. He died by suicide in June 2015.

But Donna Egnatios said Jeremy Egnatios felt discouraged from pursuing his dream of caring for others because he believed his symptoms of depression and mania, associated with bipolar disorder, would prevent him from balancing them with his demanding physician schedule.

Egnatios withheld his symptoms from his family for years because he did not want to add to his parents’ stress, Donna Egnatios said. He was formally diagnosed with the disorder after his undergraduate years at Arizona State University.

“He wanted to cure people and take care of people (as a doctor),” Donna Egnatios said. “He wasn’t one to talk about his issues or problems.”

Though Jeremy Egnatios briefly attended pharmacy school, his mother said his pharmacy school professors recognized his intelligence and caring personality and pushed him to apply for medical school instead.

At UC San Diego, Jeremy Egnatios never hesitated to help other students with their schoolwork or through their own emotional slumps, Donna Egnatios said. He also juggled 10 projects at a student-run free clinic and worked on seven research projects, while studying for his exams.

Jerry Egnatios, Jeremy Egnatios’ father, said his son did not disclose his bipolar diagnosis to the university because he worried faculty and his peers would view him differently, or that the diagnosis would not fit his caregiver personality. Most of all, he feared the formal disclosure would affect his future employment as a resident physician, Donna Egnatios said.

Carolyn Kelly, associate dean for admissions and academic affairs, declined to comment on Jeremy Egnatios’ care through the university, citing the need to protect students’ personal and medical information.

Rosen said some medical students aren’t comfortable telling supervisors about their therapy sessions and appointments, fearing it may affect their performance grades and letters of recommendation for residency programs.

Jessica Chow, a fourth-year UC San Francisco medical student, said students are also afraid to take days off and mention mental and emotional hardship to their attending physicians. She added students don’t want to push more work onto their teams, or want others to think they are weak or shirking their responsibilities.

Donna Egnatios said Jeremy Egnatios began to lie to his attending physicians about why he could not show up to work – he would say he had a fever, instead of telling them that his depressive states prevented him from getting out of bed that day. “He never felt comfortable telling them he just was too depressed to go to school that day,” Donna Egnatios said.

Jeremy Egnatios attempted suicide in March 2014, injecting himself with an overdose of insulin, and was transported to a UC San Diego-affiliated hospital. Donna Egnatios said UC San Diego deemed him temporarily unfit for medical school based on its technical standards, which state candidates must have the physical and emotional stamina to function under stressful situations.

Donna Egnatios said only a few people knew of her son’s bipolar disorder diagnosis after his suicide attempt – Kelly and a few of his close friends.

Egnatios’ physicians placed him into intense therapy and psychiatric rehabilitation sessions, and Donna Egnatios said he learned to cope with his mood swings by painting, establishing regular sleep patterns and writing poetry.

When he was discharged, Jeremy Egnatios was six months behind the rest of his classmates. The university let him return, though, and he was given the option to catch up because of his extensive research in laboratories and experience with the student-run clinic.

At the end of his third year, Egnatios rotated through a psychiatry clinic – he spoke with patients who said their physicians locked them in wards and quarantined them for hours at a time. In his note, Egnatios wrote that he became terrified of meeting the same fate, of having medical school taken away from him because he couldn’t control his mood swings, Donna Egnatios said.

Jeremy Egnatios died by suicide in June. His sister Tara Egnatios found his credit card, driver’s license, checkbook and car keys sitting on his kitchen counter. A note nearby said to keep the cash, pay the rent and not worry about anything.

Donna Egnatios said Jeremy Egnatios left a legacy of care and kindness at UC San Diego. The comments left on Egnatios’ obituary page, many from fellow students and professors, mentioned instances like his offering to help younger students study for their exams, though he had his own exams coming up, or supporting other students through their periods of anxiety or depression.

“If his death can help other people speak up and let the schools know they’re struggling, I think those kind of things might make a difference,” Donna Egnatios said. “(Jeremy Egnatios) didn’t get there, but there are enough other people that can make it through and finish what he started.”

Healing from the stress

Daniel Herrador disliked the mask of false happiness he had to wear when he was having a bad day.

The third-year UC San Francisco medical student was usually a cheerful, enthusiastic student who would throw himself into clinical rotations with gusto. He would participate in hands-on workshops, wearing thick, prickly gloves to understand how an elderly patient with nerve damage ties shoelaces, and regularly asked how his resident and attending physicians how he could help with tricky cases.

But when Herrador couldn’t keep a smile on his face, like after an argument with his romantic partner or when he was sleep-deprived, he found it impossible to be at his best for a medical team who depended on – and graded – him.

Herrador said a bonus of trying hard in clinic, in addition to learning valuable information about patient care, was receiving honors, or an honorable distinction on the student’s evaluation at the end of a rotation.

“Somebody who gets honors doesn’t ever show he’s not engaged that day,” Herrador said.

To relieve the stress, Herrador said he attends as many practices for his softball team as he can. Herrador added he’s missed games because of weekend hospital shifts and doesn’t know whether he can continue with the team during residency, but he promised himself he would focus on one non-medical activity when medical school became tough.

Raynor said he also believes in letting students briefly distract themselves from medical school for a change in pace. He added some UC San Francisco students have never even toured the city – though they’ve lived in the city for two or three quarters, they haven’t seen the Bay Bridge light up or gone to Golden Gate Park.

As part of therapy, he assigns students to visit landmarks like Coit Tower on top of Telegraph Hill in San Francisco during free weekends. Rosen, who also sees medical students to address their complaints of burnout, said when the students come back, they have broken their routine long enough to feel refreshed about going back to their studies or clinical work.

Nick Orozco, a fourth-year UC San Francisco student, turns to meditation to destress. Roxanne Vasquez, a fourth-year UCLA medical student and well-being representative on the medical student council, plans socializing workshops and participates in big sibling-little sibling events, in which students are grouped into families.

For Herrador, it’s the bigger picture that matters – finding comfort in his identity and remembering who he is throughout the stress of medical school. He wears a small rainbow stripe at the bottom of his medical badge, symbolizing his identification with the lesbian, gay, bisexual and transgender community.

Some of his LGBT classmates refuse to wear the stripe because Herrador said they fear discrimination by supervisors or patients. Herrador, however, said he finds solace in turning to his identity, partner, softball team and friends during difficult and stressful times.

“Doctors are expected to never get sick,” Herrador said. “We’re expected to never take time off, to always give, give, give. But at the same time, we’re people too.”

A Hidden Culture of Medical Student Mistreatment

You’re not a true Bruin if half your friends weren’t pre-med students when they started at UCLA, only to realize it wasn’t for them. But for those that do make it, medical school represents another beast altogether.

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(Courtney Tran/Daily Bruin)

The first two years of medical school are difficult, to say the least. Students constantly need to digest tons of information, learn to navigate an entirely new social scene and are suddenly expected to also master their social skills once their clinical rotations begin.

Or, as Nicholas Orozco, a fourth-year medical student at UC San Francisco medical school, said, “They often describe it in medical school as trying to drink water from a fire hydrant.”

But unlike the undergraduate experience, where there is some variation in class difficulty, medical school only gets tougher. By the time a student reaches third-year clinical rotations, stress can reach critical levels.

But chances are, you won’t hear much about this – which isn’t unusual. Overworking seems to be part of the culture instilled from the beginning of medical school and many seem unwilling to talk, as if they’ll violate some sort of unwritten code. Hence, breakdowns, burnout and mistreatment are topics rarely mentioned when thinking about medical school and the path toward becoming a doctor.

Overworking seems to be part of the culture instilled from the beginning of medical school, and many seem unwilling to talk, as if they’ll violate some sort of unwritten code.

But it doesn’t have to be this way. Burnout and depression among medical students can be prevented if medical schools acknowledge the stigma around mental health issues and work with staff to ensure that medical students are being treated appropriately.

One solution would be to just cap working hours altogether, including those of third-year students. In 2003 resident hours were capped to 80 hours a week because of increasing burnout rates. But when it comes to third-year medical students, no weekly cap is specified.

But even if there is a cap, an attitude adjustment needs to come as well. For instance, Stephan Chiu, a third-year medical student at the David Geffen School of Medicine at UCLA, spoke about the harsh treatment he received while in rotations. He was humiliated in front of his entire team and often scolded by nurses for making mistakes on procedures he wasn’t taught in the first place.

“You have no idea what you’re doing, and nobody takes the time to teach you,” Chiu said. “The first week or two, I was a mess. Nurses were constantly telling me to get out of the way. ... They accept you because you’re there, but they treat you like a ghost.”

Nurses were constantly telling me to get out of the way... they accept you because you’re there, but they treat you like a ghost.

Daniel Herrador, a third-year UC San Francisco medical student, who also had a similar experience, said he feels invisible the majority of the time during medical rotations.

“Third-year medical students are off to the side. It is getting better, but there have been situations where people don’t really address you by your name, or they don’t even try. ... Either you are expected to perform 150 percent, or they won’t remember that you’re even there,” he added.

This derogatory treatment can start a downward spiral, especially when students might be struggling with other problems already. Susan Rosen, a primary care provider and medical director at UC San Francisco Student Health and Counseling, said many students who seek mental health counseling are dealing with personal problems that range from family issues to romantic relationships.

This cutthroat culture in medical school isn’t a surprise. For decades, previous generations have perceived burnout as disgraceful and, while acceptance for students’ limitations has improved, many students are still ashamed to admit they need help.

“I think the stigma is less now than it used to be, and there is a lot more emphasis now that it is okay to come in and say you are burned out. That would not have been acceptable when I was in medical school. You wouldn’t say you were burnt out. That meant you weren’t tough enough,” said Dr. Margaret Stuber, assistant dean for well-being and career development for the David Geffen School of Medicine, after being asked about her experience in medical school.

And broader societal shifts aren’t helping.

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Nicholas Orozco, a UCLA alumni and a fourth-year medical student at UCSF, was part of a joint medical school program between UC Berkeley and UCSF. Orozco is specializing in emergency medicine. He hopes to give back to his community after being stationed at the USC Medical Center.

The medical health system is in short supply of care providers, and to fulfill this demand means that communication becomes an afterthought, leaving instances of abuse unnoticed. Especially now after President Obama’s health care law has been implemented, medical school functions more like a machine that spits out medical students. Hence, fulfilling this shortage of primary doctors naturally leads to a fast-paced environment where personal problems are ignored, pushing students into the shadows. Essentially, lack of intimate conversations in such a fast-moving culture harbors a perfect breeding ground for mistreatment.

It’s true that medical schools are trying to address the lack of dialogue on mental health through mental programs and campaigns, such as the “It’s Okay To ...” campaign at UC San Francisco, Counseling and Psychological Services at UCLA and “Out of the Shadows” walk at UC San Diego, but it’s not enough.

These programs and events are undoubtedly important, but the root of this epidemic can only be tackled if physicians and working doctors are also made aware of the commonality of mistreatment and burnout among medical students. A solution to this disconnect between medical students and physicians, again, lies in not only caring after staff but also creating procedures to facilitate honest communication within a medical team. These procedures would promote high integration of medical students within the team roles.

Medical school is challenging for many students, but the majority of the time, preventing maltreatment from occurring is harder than it seems, particularly when current efforts focus on physicians rather than early on. Reaching out to faculty members is encouraged at all medical schools, but the reality of this actually happening is still in its developing stages.

Implementing change in a culture that has instilled toughness and a sense of competition for years can be hard. However, simply accepting the way things are now and dismissing abuse and fatigue as common will only yield physicians who are more prone to experience burnout.

These attitudes defeat the main purpose of becoming a doctor, which is to help and aid people in need.

While it is not only the mindset of incoming medical students, new physicians and installed doctors that should be changed and analyzed, the University of California medical school system should, at the very least, begin a conversation among all UC medical schools on how to improve and implement programs for mental wellness among students who will carry the future of health care.

Past the screen of silence

SAN FRANCISCO – A sheet of plain brown butcher paper covers a lobby wall of University of California San Francisco’s Student Health and Counseling clinic. In the center are the permanent-marker words “It’s okay to ...,” surrounded by scribbled responses by students and faculty.

“It’s okay to not be at the top of your class.”

“It’s okay to get a B.”

“It’s okay to go to a movie on a Wednesday night.”

Similar signs cover walls all around the UCSF campuses, reminding the university’s near-3,000 graduate and preprofessional students to pause and reflect on self-care amid the daily grind of performing experiments and training at pharmacy, dentistry and medical clinics.

Medical students and physicians are particularly at risk for burnout and depression because of demanding clinical schedules, according to a 2003 Journal of the American Medical Association study that examined the risk of suicide and depression in the medical field.

Thirteen years later, universities and hospitals around the country invest more in mental health and physician well-being, but the conversation surrounding mental health is not yet standard, said Dr. Susan Rosen, a primary care provider and medical director of the UCSF Student Health and Counseling clinic.

About 400 physicians – the rough equivalent of one medical school’s total population – die by suicide each year. To emphasize self-care and empower students to reach out for help, universities like UCSF, UCLA and UC San Diego plan and implement their own programs to prevent burnout and promote well-being in medical students.

Spotting problems

Jessica Chow dragged herself to class, beset by family troubles when she should have been focusing on medical school.

Chow, a fourth-year student at UCSF School of Medicine, said she could not prioritize school – she began having trouble studying and balancing the material with her personal issues.

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Jessica Chow, a fourth-year UCSF School of Medicine student, began seeing a therapist after her professor noticed her struggling behind in class. She said she was grateful for his advice because his reaching out showed her he cared.

She knew she was stressed, but didn’t know what to do or where to turn.

Chow said one of her mentors noticed her struggling in class. After pulling her aside, he advised her to see a counselor.

“He cared about my classmates and me, and that’s why he brought it up,” Chow said.

But Rosen said spotting a struggling student is usually very difficult: Medical students do not usually express their frustration because they are used to being at the top of their classes, and often believe that struggling is tantamount to failure.

Third- and fourth-year medical students are particularly at risk for falling under the radar because they train at different hospitals, said Vittorio Comelli, assistant director of the UCSF Medical Student Well-Being Program.

The Medical Student Well-Being Program, located on the university’s Parnassus campus, works exclusively with medical students, faculty and staff. The Student Health and Counseling clinic, located four miles west on the Mission Bay campus, is open to all UCSF graduate and preprofessional students.

Third-year medical students move from place to place so often that they can’t make lasting relationships that allow supervisors to observe problems, said Lance Raynor, a mental health provider at UCSF’s Student Health and Counseling clinic.

Comelli said third-year students can come to his clinic and workshops at the Parnassus campus during the day, but he creates special evening appointment times to accommodate their busy schedules. He also plans to create a clinical hour to travel to their different hospitals every week.

“Our focus is for students to constantly remember to take care of themselves, because that’s the first thing they forget,” Comelli said.

The UC San Diego School of Medicine uses an online diagnostic system called the Healer Education Assessment and Referral Program to seek out and screen at-risk medical students who may not have time or energy to travel from hospitals in the greater San Diego area to the main campus.

“Our focus is for students to constantly remember to take care of themselves, because that’s the first thing they forget.”

The 10-minute online questionnaire asks students to rate their symptoms of depression, burnout and exhaustion on a “not at all” to “most or all of the time” scale, and can give students a way to anonymously contact a mental health provider, said Dr. Carolyn Kelly, UC San Diego School of Medicine’s associate dean for admissions and student affairs.

Officials at the UCLA David Geffen School of Medicine do not use and have no plans to implement similar online programs, said Margaret Stuber, the school’s assistant dean of well-being and career development.

Medical students at UCLA can schedule appointments at Counseling and Psychological Services, an on-campus facility. They also have the option of seeing Paula Stoessel, a UCLA medical school-affiliated psychologist independent of CAPS who screens more than 700 medical students and 1,000 residents and fellows and matches them to outside providers for treatment.

Roxanne Vasquez, a fourth-year student at the school of medicine, said some students told her they never get matched with outside providers. Because Stoessel is only one person, she may not be able to find them suitable therapists because of her limited number of contacts.

Symptoms of disenchantment, depression and anxiety can become more potent over the course of a couple weeks, she added. She hopes four or five more staff will be hired in the near future to help screen patients and broaden the scope of referrals.

Stoessel denied multiple requests for an interview, saying she was unavailable.

“I just want to sleep in, I just want to see my friends. I haven’t seen a friendly face in a week.”

During Stephan Chiu’s general surgery rotation, he said he felt isolated and confused. The third-year medical student often lacked a support system when he was rotating off-campus: He couldn’t see his family and friends because of the intense workload and 18-hour workdays.

“There are a lot of days during the rotation when ... I’m exhausted,” Chiu said. “I just want to sleep in, I just want to see my friends. I haven’t seen a friendly face in a week.”

Finding a safe space

When Callan Fockele’s husband needed an emergency surgery, she didn’t think she could take a day off because of the time demands of her inpatient internal medicine rotation.

But Fockele, a fourth-year UCSF medical student, worked with a supportive team who encouraged her to take two days off to care for her husband. She added her supervising physicians even sent her text messages asking how she and her husband were doing.

Fockele said her empowering experience with her internal medicine team members, who told her they related with her situation and encouraged her decision, was an exception to the norm. Usually, she felt uncomfortable asking for time off to care for herself or her loved ones, because some of her other teams gave off unspoken vibes that her absence would let them down.

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Callan Fockele, a fourth-year UCSF medical student, said she usually felt uncomfortable asking for time off because of unspoken feelings from her physician supervisors that she would be burdening the team. She did, however, get to take two days off to care for her husband after a surgery.

“The culture of medicine is team-oriented – we’re all in this together,” Fockele said. “If I were to not show up one day, it would disturb the everyday workflow, and let (the team) down.”

Chow said she thinks creating a more comfortable work environment involves empowering students and faculty to reach out to each other and feel safe in discussing their problems.

Rosen said she tries to put students’ struggles into perspective by educating faculty about the warning signs of depression and burnout in medical students and asking them to contribute to the “It’s okay to ...” poster project.

The project aims to tell students that struggling or feeling overwhelmed is acceptable, Rosen said. She added when she reached out to current faculty members to write their thoughts on the posters, many of them told her they had either consulted a psychologist in the past or are currently in therapy.

“We’re not only communicating a message to students, but to other faculty who aren’t paying attention,” Rosen said. “It’s saying (going to a counselor) is okay to do and that it’s a normal part of self-care.”

At UC San Diego, third-year medical student Jeremy Egnatios’ death by suicide in June 2015 brought an outpouring of support from students, staff and faculty for those battling the symptoms of mental illness, Kelly said.

Many of those who attended his memorial came together again four months later to participate in the Out of the Darkness walk in San Diego, sponsored by the American Foundation for Suicide Prevention, Kelly said. Kelly invited the Egnatios family to the walk, said Donna Egnatios, Jeremy Egnatios’ mother, and dedicated to walk to his memory.

Donna Egnatios said she was surprised when one of the speakers spoke so candidly about her own experiences with bipolar disorder and her lack of will to survive. The speaker reminded her eerily of Jeremy Egnatios’, who would often speak about the soaring ups and crushing downs that accompanied his bipolar disorder.

Tina Egnatios, Jeremy Egnatios’ younger sister, and her mother remembered sitting in shock at her honesty, but were also grateful the speaker helped them know they were not alone and that she explained her everyday experiences with the disorder.

“Everything she said was almost identical to what he wrote to us,” Donna said. “We knew what she was saying was true.”

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UCSF provides mental health services for all of its graduate and pre-professional students at its Student Health and Counseling clinics. Dr. Susan Rosen, a primary care provider and the medical director of the clinic, said one of her goals is to make the conversation about mental health more accepted.

Well-being groups at UCLA also encourage dialogue about burnout and depression among students and faculty, said Prerna Gupta, a third-year student at the Geffen School of Medicine. In each well-being group, students and a faculty member meet every few months as their schedules permit to check in amid the chaos of studying and caring for patients.

Chiu and his fellow group members, who meet once a month, exchanged stories about how their visions for the future changed because of the exhaustion that accompanies medical school. He said some students who wanted to become surgeons got a reality check during their rotations: They became mentally and physically exhausted after going through weeks of waking up at 4 a.m., staying on their feet all day and only returning home close to midnight.

Hearing his group members’ struggles helped him realize he was not alone, Chiu said.

Each group’s dynamic is different, but the intimate environment helps create a safe space to vent about struggles and problems, said Evan Shih, a third-year UCLA medical student.

“There’s barely any talk of anything medical,” Shih said. “They’re just making sure everything’s okay – kind of like a home base.”

Creating change

Vasquez couldn’t believe how many times the Geffen School of Medicine rejected her pitches to improve well-being programs.

Vasquez is a well-being representative on the medical school student council that plans and hosts events to promote wellness and balance in medical students. This year, she and the eight other well-being representatives spent weeks brainstorming how they could keep third- and fourth-year medical students in touch with each other during their core and elective rotations.

Vasquez said they suggested creating networks on Facebook, Instagram and Snapchat to allow medical students to chat without having to meet in person.

However, Vasquez said she didn’t realize how many legal barriers she had to overcome – for instance, if a medical student made a comment with the intent to self-harm or attempt suicide, the liability would be placed on the school.

“It takes a while for stuff to get done,” Vasquez said.

Kian Asanad, a second-year Geffen School of Medicine student, said faculty members often discuss general ideas with students at schoolwide town hall meetings.

Clarence Braddock, vice dean for education, said he worked with the school of medicine, CAPS and Health System teams to plan a satellite CAPS center to be located in the Center for Health Sciences building.

But Braddock said the funding, staffing, exact location and opening date for the satellite CAPS center have not yet been determined.

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For Dr. Margaret Stuber, access to mental health can always be improved. The UCLA David Geffen School of Medicine assistant dean of well-being and career development works with students to assess the demand and use of existing programs, and will implement peer counseling programs for students.

CAPS and Stoessel’s services do not share medical students’ records, to ensure confidentiality, Stuber said. But Rosen, whose clinic exchanges records with Comelli’s program, said sharing information between similar services is crucial to avoid prescribing conflicting treatment.

“There are times when their providers might not be available,” Rosen said. “If a student is in crisis, they’ll often come into our clinic when (the Medical Student Well-being Program) providers are not available.”

Braddock said he does not know what Stoessel’s clinical responsibilities are or how many patients she treats. Stuber added faculty members gauge need by what they observe in students, but do not have any idea of Stoessel’s workload.

She said students walking into her office in tears, crying in class or failing exams would prompt administration to pitch new programs, or talk with CAPS or other schools about their mental health programs for more ideas.

“We’ll have a feeling that there’s unmet need,” Stuber said.

However, Rosen said officials who do not know how many students need help cannot expand services without knowledge of the current situation.

Rosen said UCSF’s Student Health and Counseling services is modeling its structure after UC Berkeley’s CAPS program, which places CAPS mental health providers in different schools such as Berkeley Law and Berkeley Engineering.

Training CAPS staff members to be school-specific liaisons allows them to become experts at gauging each school’s culture and gaining students’ trust, said Jeffrey Prince, director of UC Berkeley’s CAPS.

For example, Rosen said a liaison to the UCSF medical school could anticipate a springtime rush of second-year medical students, around the time of national standardized exams, and could refer students for further care if serious problems arise.

Prince said continuously seeing a familiar face in a familiar location such as the medical school allows students to become less afraid to seek help.

But for now, Prince said putting up encouraging posters around the UCSF campus helps normalize some of the pressures students feel to perform at an impossibly high standard.

“Medical school shouldn’t be so stressful that it’s only the survival of the fittest,” Rosen said.

Improving mental health services for medical students is imperative

The University of California medical system is falling short when it comes to mental health resources for medical students; it's not taking care of its own caretakers.

To deal with the overwhelming amount of stress their jobs require, medical students often first turn to family for comfort. However, family can only help so much, leaving physicians-in-training with very few options to alleviate their stress.

At UCLA, the most obvious source of help would be Counseling and Psychological Services. Unfortunately, while CAPS is a great resource for most students, programs specifically for medical students are nonexistent. There is a vast difference in experience between medical students and undergraduates, and these groups have differing counseling needs. CAPS, however, is currently not equipped to handle these differences.

Unfortunately, while CAPS is a great resource for most students, programs specifically for medical students are nonexistent.

The sole reliance on CAPS at various medical schools is unrealistic, and has thus far been unsuccessful. Data from 2014 indicates the UCLA medical student body is made up of around 745 students, out of which only about 14 percent make use of mental health services at CAPS. These numbers, provided by UCLA, are low in comparison to the high stress medical students endure throughout their medical career.

Some schools have developed programs to complement existing mental health resources and have made them better for medical students. For instance, UCSF has created the Medical Student Well-being Program, offering medical students who are always on the go sometimes next-day appointments as well as flexible hours that work around their schedule. Meanwhile, UC Berkeley has developed a satellite program that encourages communication by providing mental health professionals specific to departments that students can identify with.

UCLA needs to be more proactive in tackling the serious problems of burnout and depression in its medical school by following UCSF’s and UC Berkeley’s models. By providing the medical student body with more targeted programs, students will be able to better their lives and preserve their sanity before it’s too late.

The reason CAPS is not effective as the sole program serving the mental health needs of medical students is that it forces students to wait long periods before being seen, while also juggling their schedules in hopes of squeezing inflexible appointment times. Not improving access to mental counseling can harm students who are distressed and require mental assistance as soon as possible.

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UCSF also has a separate program for medical students, faculty and staff, called the Medical Student Well-Being Program. Vittorio Comelli, the assistant director of the program, targets events, workshops and appointment times to the schedules of third-years spread out across the city of San Francisco.

In efforts to prevent this, UCLA has had talks about implementing a satellite program along with CAPS, but it’s barely in its beginning stages. Only one meeting has been carried out about this matter.

“We are not there yet,” said Dr. Margaret Stuber, assistant dean for career development and well-being at the David Geffen School of Medicine. “It’s something that we have started talking about. The medical school always had some services that we offer in parallel with CAPS so that there is another way of dealing with (issue of mental health).”

However, the parallel services with CAPS are obviously ineffective, given that UCLA’s mental health services have a UC Student Association mental health grade of a C+. Even when there are two doctors available to see students at the medical school – Paula Stoessel, who screens students and Bruce Kagan, who treats them – their duties are completely isolated from CAPS. This means students can be prescribed conflicting treatments because there is no mutual conversation between the medical school and CAPS.

Surprisingly, the answer to UCLA’s problem might come from UC Berkeley, which doesn’t even have a medical school.

The school has established satellite locations throughout the campus where there are mental health providers doing clinical and outreaching consultation work. This means one person is stationed in a department or school and can tailor services to students within that school.

The duties of these mental health providers are clear and focused. Their work is mainly geared at providing services to the needs of specific groups, allowing them to host appropriate workshops and provide more effective individual counseling.

Jeffrey Prince, director of counseling and psychological services at UC Berkeley and the director of student mental health at UCSF, said that there are about 10 satellite locations within Berkeley. In those locations, each psychologist offers drop-in counseling, also known as “Let’s Talk” hours, which, unlike therapy sessions, do not require mass amounts of paperwork to begin a formal counseling relationship.

This program not only offers a quick opportunity for students to check on their mental health status, but also fosters a closer relationship between a staff member and a student, ultimately encouraging students to seek more formal counseling if necessary.

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(Devin Le/Daily Bruin)

Giving medical students the opportunity to speak with someone who is familiar with the culture of medical school is vital because mental health professionals who are cognizant of medical school calendars can reach out to students during times when they know students will be prone to high levels of stress.

Yet this doesn’t seem to be happening at other top UC medical schools.

Thankfully, there are also programs other than UC Berkeley’s that UCLA and others can learn from. While UCSF is not an “ordinary” university, because of its sole emphasis on professional schools, it can still act as a template for how schools can provide better support to their medical students.

Vittorio Comelli, a UCSF psychologist, works closely with medical students at UCSF by providing a mental health program that is geared solely for their needs. Comelli is the assistant director of the Medical Student Well-being Program, which unlike other mental health programs at UC’s, is constructed specifically to serve the mental health of medical students.

This program has a 15-year history and was made to offer medical students services where they could be seen and helped quickly. Comelli spends the majority of his time either speaking with medical students or trying to reach out to them.

“Medical students who come into the Medical Student Well-being Program have one-third more satisfaction with their mental health compared to national numbers,” said Comelli. “We are only focused on them. We are very intimately connected to their professional lives.”

By implementing similar programs as the ones at UCSF and UC Berkeley, UCLA can cultivate a mindset focused on mental wellness that is geared specifically for medical students.

Granted, there are costs associated with establishing a program of similar size and caliber. However, the resources are there. According to documents from the UC Office of the President, Ronald Reagan UCLA Medical Center makes $2.25 billion in revenue, $100 million of which is profit.

UCLA can implement the changes gradually, and should not use a lack of funding or space as an excuse. By locating a small amount of profit every year to create and develop mental health programs, the university will benefit from its investment.

There is no such thing as offering perfect mental health resources to all students, but there is a lot of room for improvement.

Having better geared programs for medical students that are reachable and timely can have a great impact on student wellness. UCLA medical school as well as other schools need to expand outside of CAPS and think more about their professional school population.

There is no such thing as offering perfect mental health resources to all students, but there is a lot of room for improvement. Providing a point person at every major school within a university who focuses on mental health services can be a step closer to fixing this broken system.

The majority of the UC system is currently hoping everyone will fit into one mold, but they simply can’t. Our future doctors deserve better.