The hidden curriculum of mental illness stigma in medical training

Sarah Tulk is an Ontario physician who recently finished her residency training in family medicine at McMaster University


“If only he had chosen a higher floor, we wouldn’t have had to come here!”

These were the words that came out of my preceptor’s mouth. I was a wide-eyed medical student, shadowing in orthopedic surgery. The patient was an older man who had sustained multiple fractures after attempting to end his life by jumping from an apartment building balcony. The trauma ward was full, so he was, inconveniently, located on a distant ward which meant his poor choice of departure level was now encroaching on our operating room time. In medical school, I learned that mental illness was shameful before I learned how to use a stethoscope.
There is no compassion for a failed suicide attempt.

 “If you ever find yourself feeling suicidal, make sure you go at least 10 floors up so as not to become a burden to society,” a pre-clerkship lecturer explained to my highly impressionable, eager-to-please classmates and me. This thoughtless comment was meant to highlight the decreased mortality—but astronomical morbidity—of jumps from anywhere lower than the 10th floor. The lecturer continued to explain how costly intensive care unit admissions and extensive rehabilitation are, particularly given that the chances of returning to be a “productive member of society” were low.  Failure to heed this advice and instead of contributing to medicine, one would cause a needless, costly drain to public funds. 
There is no compassion for a failed suicide attempt. Jump from well above the 10th floor. Don’t mess it up. Don’t become a burden.

The suggestion that the most substantial consequences of a failed suicide attempted is depletion of the health care budget delivers two strong messages:

1. your personal suffering does not matter; and

2. you are not entitled to receive the help afforded to the rest of the population.

I can only hope that somewhere in our fledgling trainee minds was a hint of questioning towards the lecturer’s statement; a seedling of an idea that (as the lecturer should have said)  if you find yourself thinking about killing yourself by any means, seek immediate help because you are experiencing a symptom of a serious illness that can be fatal if untreated.

In a twisted sense, another lecturer who instructed us on how to die by suicide using a rifle was nobler in intent, because the point of instruction was to ensure avoidance of undue suffering and not minimization of healthcare spending. The lecturer explained that to kill oneself with a rifle, it is important to use a broomstick to hit the trigger rather than the hands, so as to avoid a last-minute forward shift in the position of the barrel causing extensive facial and frontal lobe injury, but sparing critical brain areas and thus allowing for survival.
There is no compassion for a failed suicide attempt. Jump from well above the 10th floor. Don’t mess it up. Don’t become a burden.  Use a broomstick to hit the trigger.

“If they really wanted to do it, they wouldn’t have come here,” an emergency room (ER) preceptor said. “They’re just looking for attention.” Because if someone really wanted to kill themselves, why would they tell a physician, poised to spoil their plans? It didn’t make sense; clearly, it showed a lack of dedication to their suicide plan.

I held my tongue: don’t we tell patients that the ER is exactly the place to go if you fear you might die imminently? I’m not sure how the preceptor would have reacted had I applied the same logic to the patient with asthma in the next room, who must have also only wanted attention because clearly there was plenty of air for them to breath in there... it was as if they weren’t even trying to get better! Saying that a suicidal patient is not truly suicidal because they are seeking help teaches that it is okay to discredit psychiatric symptoms. It’s a lesson that can be difficult to unlearn.
There is no compassion for a failed suicide attempt. Jump from well above the 10th floor. Don’t mess it up. Don’t become a burden. Use a broomstick to hit the trigger. Suicidal patients don’t belong in the ER.

Unfortunately for medical students, the conscientiousness, obsessiveness and perfectionism that got them into medical school also impart an increased susceptibility to mental illness. Sadly, accessing treatment isn't simple. While wellness programs are, thankfully, becoming more and more common in Canadian medical schools, these programs are near to futile if we cannot break apart the stigma that prevent trainees from accessing them.

Just as a patient with diabetes can slip into a hypoglycemic coma in a candy store, a medical student can die by suicide surrounded by wellness day pamphlets. At a time in training when the word ‘CaRMS’ sends shivers down one’s spine, how can medical students be expected to seek help without any reassurance that there will not be adverse consequences?

There is compassion for mental illness. Don’t jump. Ask for help. You are not a burden. Put down the gun. Suicidal patients - including physician-patients - belong in the ER, or wherever treatment is available.

What learners hear matters not only to their approach to patients with mental illness, but to their own mental health as well. You never know what your learner is thinking:  if you use your influence to normalize mental health care, you just might save their life.



4 thoughts on “The hidden curriculum of mental illness stigma in medical training

  1. Beyond the cognitive concept of "reducing stigma" we are called upon to open our hearts - to ourselves, our colleagues and our patients. We are called upon to recognize our own traumatization and vulnerability. How do we do this? Do most wellness programs actually take us there? I don't think so. Nothing much has changed since I trained in the 1980s, but I believe something is happening, there's a disturbance beneath the surface. That's hopeful.
    Thank you for this thoughtful and heartfelt piece Sarah.

  2. Brian Gere

    Thanks for the excellent piece!
    We must be aware of the hidden bias in us all.
    Eg- the obese, homeless, " lazy or stupid ", psychotic, alcoholic, or "frequent flyer ".

    There is a well intentioned project to add resources to the 5 % who use up 66% of health care money..
    Hence called the 5/ 66 project. But this name is demeaning.
    The high needs & high acuity patient is exactly who we are meant to serve.
    We must be aware of cost, "choose wisely" but not succumb to the
    Political games.
    Otherwise, we become shallow and burned out providers.
    A moment of thought before entering the Hospital or clinic might help us all !

  3. S.Reid

    Thank you, thank you for this piece.
    Have just taken 3 days off to recover from the "normal" stress of bullying and verbal abuse in the OR.
    I am 60 years old.I am ready to quit.
    This lack of compassion and humanity for ourselves and others must stop.
    Please keep speaking out but also be aware that doing so will make you a potential target.
    Do please take care of yourself Sarah.

  4. Petra

    I will never forget the anger with which the ER nurses treated me after I made a serious attempt to die by suicide. The shame I felt was almost as harmful as the severe depression. Also not helpful - the comment "But you're beautiful", as if good looking people can't and shouldn't suffer from mental illness. Indeed, it was looking so "put together" that got me discharged several times, only to be re-admitted for the same improperly treated mental health condition. (You may notice that the anger is coming back as I write this). Well, yes. It took the medical system 10 years to properly diagnose and treat me for bipolar disorder.

    Thank you very much for this important piece, Sarah. You are a true advocate.


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