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“Sometimes it heals, often it soothes, it always listens. This well-known adage of doctors illustrates the reality of their profession: a daily confrontation with difficult situations, with illness, sometimes with helplessness and death… And if “the doctor’s first medicine is the doctor himself”, it may happen that he is too. affected, even more so in the current context of shortages and great tensions in the health system.
These difficulties, which seem systemic, particularly affect users, but caregivers are not spared. Difficulties and feelings of exhaustion can then increase, particularly among students and young doctors, who find themselves in the position of having to compensate for system failures alongside other health professionals.
The issue of medical student mental health came to the fore with the publication of a meta-analysis in 2016 in the prestigious JAMA magazine. This study collected data from almost 200 publications and estimated that 27% of medical students suffered from depressive symptoms and 11% suicidal thoughts. He also highlighted the lack of French data on the subject, as there was only one French study, published in 2014.
Worrying data from France
In response, the French medical student associations ANEMF (National Association of Medical Students of France), ISNAR-IMG (Autonomous National Inter-Union Representative of General Medicine Interns) and ISNI (National Inter Union of Interns), along with ISNCCA ( The National Inter-Union of Clinical Leader Assistants, now renamed “Young Doctors”) conducted a survey in 2017. The latter found the presence of anxiety symptoms in 62% of students, depressive symptoms in 28% of students and suicidal ideation in 23%. . Necessary, this survey had methodological limitations that we have already discussed.
After him, the Ministers of Health and Higher Education commissioned a report from Dr. Marra (psychiatrist accompanying students for more than 15 years at Paris Sorbonne University and then at Créteil University), published in 2018, and which led to the creation of the National Support Center for the Quality of Life of Health Students (CNA) chaired by this specialist until 2021.
However, the situation of young students and doctors remains worrying. Thus, a 2019 study found that 93.7% of them “reported having been exposed at least once to hospital violence and 41.7% to moral harassment. Almost 80% of interns and young chefs say they work more than 48 hours a week. In addition, the suicide rate among inmates, estimated from suicides recorded by the media, was three times higher than that of the general population of the same age (33 per 100,000 vs. 11 per 100,000 between 25 and 34 years). However, there are no reliable data on the subject.
The pandemic has once again highlighted the worrying mental health situation of future doctors. By weakening a health system under great strain, the health crisis has brought suffering to light in a context where the malaise of medical students already seemed prevalent. The CNA, in addition to its missions of training, investigation, organization of a national network and support for students, has repeatedly alerted the authorities on the subject and issued recommendations that have not yet been complied with.
A 2021 Medical Student Mental Health Survey
In this difficult context, the student associations (ANEMF, ISNAR-IMG and ISNI) decided at the end of 2020 to carry out a new survey on the mental health of medical students and young doctors. This survey was conducted from May 17 to June 27, 2021, with the support of the French Conference of Deans of Medicine. The results were presented at a symposium in the National Assembly in October 2021]and led to a publication in a scientific journal in March 2022.
The questionnaire included several validated tools from the scientific literature to measure the presence of depressive or anxious symptoms at the time of the survey, a characterized depressive episode in the last 12 months, and the presence of burnout syndrome.
Burnout is a syndrome described by the psychiatrist Freundenberg in 1974 on the professional exhaustion of caregivers. It was later popularized by the psychologist Maslach, who developed a burnout scale (Maslach Burnout Index, MBI) comprising three subscales: emotional exhaustion, depersonalization, and personal achievement). The MBI was then adapted for different populations.
The survey used the student version of the MBI for the second and third year and the nursing version for the other students (external and internal). The presence of suicidal thoughts in the last 12 months was also evaluated, as well as humiliation or sexual and gender-based violence (SGBV) during the studies. Around 12,000 students responded, or 15% of all medical students in France. The findings of this study are particularly worrying.
First, compared to the 2017 survey, 75% of students had anxiety symptoms in the last seven days (+13%) and 39% had depressive symptoms (+11%). Then, one in four young students or doctors suffered from depression during the year and almost one in five students had had suicidal thoughts. From the fourth year, when students are immersed in the hospital system, two out of three future doctors are in burnout.
Exposure to different forms of violence in the hospital setting raises questions: one in four students declares having been a victim of humiliation or sexual harassment, and 4% of future doctors have suffered a sexual assault, in most cases! at the hospital! Finally, in terms of working conditions, more than half of the interns say they work more than 50 hours a week, despite the fact that the legal maximum is 48 hours.
A public health problem
Since the problem is old, a lot of work has been devoted to possible solutions. One of the objectives of the CNA was to contribute to institutional changes and the development of support structures for students in each medical school. It offered recommendations to develop mental health support and prevention measures for health students.
Following the context, the government decided to “evolve” the CNA into a body under the dual supervision of the general directorates of the Ministries of Higher Education and Health within the framework of the national plan against sexist and sexual violence.
We can already question the semantic shift from a concern for the “quality of life” of future caregivers to that of the fight against “male chauvinist and sexual violence” which, although essential, is only one aspect of the multiple psychosocial risks that threaten the quality of life of health students. And if the institutionalization of the missions of the old CNA and its de facto extension to all students is praiseworthy, fair and necessary, the truth is that health students present specific problems in relation to the difficulties of the health system.
Caregiver mental health issues are no longer addressed.
The 2021 study finds a series of factors associated with the risk of depression in relation to the hospital environment on which action can be taken: economic precariousness, excessive working hours, exposure to violence, especially gender and sexual violence… Most of these statements have already been made by ANEMF, ISNI and ISNAR-IMG.
A problem getting worse?
Through these two surveys in 2017 and 2021, the question about the worsening mental health of future doctors arises and we hope that the next national study will evaluate the actions implemented to improve the well-being of medical students. However, acting does not imply proposing any measure without thinking. The issue is complex and must take into account both the complexities of the system and the specificities of the actors:
In this, any action must be the subject of a long-term evaluation, in order to guarantee the effectiveness of the proposed measure and the interest of the students.
Solutions cannot be invented former nihilo but they arise from a work of reflection taking into account the global nature of the problems. They cannot be reduced to mere trade union demands or legitimate legal actions. Those who decide technical measures or legislate in response to problems that appear in the news, sometimes run the risk of disconnecting from the complexity of the situations, or even promoting actions on some components of the system. Except to show that these targeted interventions are enough to move the system towards a more desirable state, one must be cautious and remember this other adage “the more things change, the more they stay the same”.
These measures of change, necessary in the current state, require multiple skills: psychological, psychiatric, technical, administrative, educational, medical and ethical and must be above all at the service of patients, students, future doctors and, finallyof the society.
Also: if you experience psychological distress, you can find resources and advice and contact professionals by calling 3114.