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医学生の悩みと医師の自殺リスク
画像 過去数十年間の研究によれば、医師の自殺率は一般より高く、男性で40%、女性では130%も高い。こうした違いを生み出す原因は医学校から始まる。医学生は入学時には他の学生に類似した精神衛生プロファイルを持っているが、卒業時には抑鬱・燃え尽き・その他の精神疾患となる確率が高くなる。健康管理アクセスは良いはずだが、多量飲酒などの問題のある対処の仕方をしてしまい、適切な治療を受けず、ある種の介入が必要だと認めることさえしない。
 こうした問題に対していくつかの理論が出されている。医学教育・研修・医療行為が社会的に隔絶されている。医師が自らに対して批判的なため、自らの病気を自ら避難する傾向がある。女医の自殺率の非常な高さは、職場での嫌がらせが原因である。
 こうした理論を基に多くの医学校での学生健康プログラムや秘密裏の精神衛生サービスが行われてきているが、医学生のデータはほとんど変化していない。若手医師の1/4がうつで苦しみ、半数以上が燃え尽きを経験し、10%以上が自殺企図を持っている。しかし、適切な介入や必要な洗練されたツールを持ち合わせていないし、その資金もない。
 2つの研究グループが、革新的な方法と資金援助を得て、米国医師会誌に研究成果を発表した。医学生の悩みと修学環境がいかにそれを養育し悪化させるかについて新たな知見を提供した。
 Dr. Dyrbye らは、プロフェッショナル対パーソナルという異なるタイプの悩みが、若手の医師の善悪判断の感覚に極めて異なる影響を及ぼしていると言う。2,500以上の医学生の調査で、感情的疲労や達成感の無さを示す燃え尽きは、プロフェッショナルな悩みであり、テストに嘘を答えやすく、患者の検査結果や診察で嘘を言いやすく、医師の役割について利他的でない見方をしやすくなる。反対に、個人的な悩みを心身の質が低下して抑鬱な学生が持ち、非プロフェッショナルな振る舞いや自己中心的な信念には影響を受けにくい。いくらかはオーバーラップするが、抑鬱とバーンアウトは2つの別物である。
 もう一つのミシガン大の研究では、抑鬱になりやすい医学生は周囲から不十分で不完全だと見られていると思いこんでしまう傾向があるという。
 医学校のみでなく卒後研修で良いポストを得るためにも競争に勝ち抜かなければならないため、欠点を認めることは厳しい状況になることを意味する。助けを求める人には多くの障害があり、どこか安全な場所を見つけることが困難となる。こうした「適者生存」の心的状態は、抑鬱や燃え尽きの学生のみでなく全ての医学生に影響を与える。
 介入をテストして悩みの要因分析を行うためには、より多くの長期研究が必要となる。現状では、医師と患者に膨大な負担をさせ続けることになる。
---------------------------
医学生の「燃え尽き」と治療への挑戦/米国
http://kurie.at.webry.info/200811/article_1.html
小児科医師の過労自殺、最高裁で和解/医師不足
http://kurie.at.webry.info/201007/article_9.html
麻酔科女医過労自殺 病院に賠償責任
http://kurie.at.webry.info/200705/article_55.html
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Medical Student Distress and the Risk of Doctor Suicide
By PAULINE W. CHEN, M.D.
Published: October 7, 2010
http://www.nytimes.com/2010/10/07/health/views/07chen.html

Martin Barraud

Several years ago, I learned that a physician in a town not too far from where I was practicing had committed suicide. Neither I nor my hospital colleagues knew him, but according to the story we heard, he was the father of young children, was respected by doctors and patients alike and had struggled privately with mental illness since medical school.

But it was not the details of his life that haunted us; it was the details of his death. He had locked himself in a room in the hospital, placed a large needle in his vein and injected himself with a drug that so effectively paralyzed his muscles he was unable to breathe.

Or call for help.

For days afterward, the doctor’s death came up repeatedly in conversations. We talked about the grief his family must have been experiencing and speculated on the extent of depression and self-loathing he must have experienced, but we dared not speak of, let alone imagine, the agony of his final moments.

Always, we ended up asking one another the same question: How could a doctor ― who most likely knew about what he was suffering from and about the treatments available ― never seek help?

For several decades now, studies have consistently shown that physicians have higher rates of suicide than the general population ― 40 percent higher for male doctors and a staggering 130 percent higher for female doctors. While research has traced the beginning of this tragic difference to the years spent in medical school, the contributing factors remain murky. Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout and other mental illnesses at higher rates. Despite better access to health care, they are more likely to cope by resorting to dysfunctional behaviors like excessive drinking and are less likely to receive the right care or even recognize that they need some kind of intervention.

Researchers have offered several theories to explain these seemingly paradoxical findings. Some have faulted the increasing social isolation of medical education, training and practice. Others have pointed to the tendency for doctors to be highly critical of themselves and to blame themselves for their own illnesses. Still others, in light of the particularly high rates of suicide among female doctors, have suggested that workplace harassment may have a role.

Despite the many studies, theories and, more recently, student wellness programs and confidential mental health services offered by more and more medical schools, the grim statistics for medical students have hardly budged over the last generation. Up to a quarter of young doctors-to-be suffer from depression, more than half may be experiencing burnout, and a just more than 10 percent may be harboring thoughts of suicide.

These sobering numbers have remained unchanged in large part because our understanding of this issue has been hampered by inadequate research methodologies and insufficient financial support. We haven’t had the sophisticated tools needed to analyze the causes or appropriate interventions; and even if we did, we haven’t had the money to do anything with them.

Now two groups of researchers, using innovative methods and financed by medical school programs and departments with a keen interest in physician well-being, have published separate studies in The Journal of the American Medical Association that go beyond incidence statistics and theoretical considerations. Each study offers new findings about medical student distress and how the learning environment both fosters and exacerbates it. Read together, they offer disquieting views of the world in which tomorrow’s doctors are formed.

“There’s no arguing anymore over whether there’s a high prevalence of distress,” said Dr. Liselotte N. Dyrbye, lead author of one of the studies and an associate professor of medicine at the Mayo Clinic in Rochester, Minn. “What’s important now is that we hold a mirror up to ourselves and ask why this is happening, because it is clearly not what we medical educators have intended.”

Previous studies have linked medical student distress to unprofessional behavior. But, as Dr. Dyrbye and her colleagues show in their research, different types of distress ― professional versus personal ― can have very different effects on a young doctor’s sense of what is right and wrong.

Surveying more than 2,500 medical students across the country, the researchers found that students who suffered from professional distress, more commonly referred to as burnout, a constellation of emotional exhaustion, detachment and a low sense of accomplishment, were more likely to admit to cheating on tests, lying about the status of a patient’s laboratory tests or physical exam and espousing less altruistic views regarding their role as physicians. Conversely, students who suffered from personal distress, defined as poor mental or physical quality of life or depression, were not more susceptible to these unprofessional behaviors and self-centered beliefs.

“There certainly is some overlap,” Dr. Dyrbye said. “But depression and burnout are two separate entities.”

One result of erroneously conflating the two types of distress is stigmatization of mental illness. According to the second study, conducted by researchers from the University of Michigan in Ann Arbor, medical students who are depressed or prone to depression often believe they are viewed as inadequate and incompetent by those around them.

“They feel this from every direction ― from other medical students, faculty members, counselors, and even in their applications for residency training,” said the study’s lead author, Dr. Thomas L. Schwenk, a professor of family medicine at the University of Michigan. While depression can cause individuals to have negative and distorted views of their surroundings, “the culture of medical school makes these students also feel like they can’t be vulnerable or less than perfect.”

Given that students must compete with one another throughout medical school for postgraduate training positions, many have a difficult time admitting to any perceived weakness. For those who do and want help, there are more obstacles: with the sense that peers, faculty members and others are likely to judge distressed students as less competent, it is nearly impossible to find somewhere truly safe to turn.

But this “survival of the fittest” mentality can affect all medical students, not just those who are depressed or burned out. And it can affect patients by wearing away at a young doctor’s sense of empathy.

“If this is the way that students view each other,” Dr. Schwenk said, “how do they view their patients who are depressed or struggling with mental illness?”

More long-term studies are needed to test interventions and analyze the factors contributing to student distress. “We have to assume that starting in medical school, there’s a pipeline of experiences that leads to an increased risk of suicide,” Dr. Schwenk said. But without more evidence-based interventions, even the best intentions of medical educators will continue to do little to stem the tide of medical student distress and physician suicides.

That failure has already and will continue to come at a tremendous cost to doctors and patients. “I still believe that the people who are the most vulnerable are often the most empathic,” Dr. Dyrbye said. “They are the ones who get most attached and put the needs of the patient first.”

Dr. Dyrbye continued, “Until we know what really helps them and what works best, our learning environment will continue to eat away at our students’ empathy and altruism.”


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医学生の悩みと医師の自殺リスク/米国医療事情 医師の一分/BIGLOBEウェブリブログ
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