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Second-year med student Christopher Veal had just learned he failed a remediation course, necessitated because he had failed -- by just one point -- his final musculoskeletal exam.

Those failures were bad enough. Then, as a University of Vermont (UVM) dean was giving him this bad news, Veal heard the words he had dreaded. Two former classmates grimly told him: Whenever the dean asked this question, it was a signal he should consider quitting.

"Are you sure you really want to become a doctor?"

In an published Feb. 9 in Academic Medicine, Veal, now in his fourth year at UVM's Larner College of Medicine, described how crushed and terrified he felt. He hid in a stairwell, got down on his knees and cried. He most certainly did want to become a doctor.

Yet he had done the unthinkable. He had failed, and in doing so, had disgraced other Black students who hoped to become doctors, not to mention his family members who counted on him, he thought. Failure was something his mother said was never an option.

A plausible way out was suicide.

He walked to his car in the middle of a Burlington snowstorm -- it was January of 2018 -- and sat as the snow piled up on his windshield. He made a plan.

He would drive himself at high speed into a pole. "My family would assume my death was an accident in the heavy snow," he wrote.

A voice told him to call a close physician friend whose own son, once Veal's best friend, had died by suicide two years earlier, shocking everyone. She would understand. She had helped Veal generously with his med school tuition as well.

On the phone with Veal for a very long time, she convinced him to take a "time out" to get himself together, take some med school courses, and get some therapy. He did, and it saved him. Veal was back in medical school six months later.

A Call to Action

In his Academic Medicine commentary, Veal, 28, calls on medical school leaders to change their culture and adjust their programs to screen for suicidal ideation and mental health early on in student life. And to intervene if needed to help students manage pressures and stress.

Veal told 名媛直播 that he was inspired to write the piece after a tragedy late last June reignited his near suicide episode. A friend and fellow med student in his third year, also Black, took his own life.

It brought a flood of emotion, especially remorse. Veal felt he should have been more open with his friend about his own failure and depression -- to normalize it and convey that one can get help and feel better -- and that those despondent compulsions are temporary.

"I felt immense pain when he died because I knew how close I was [to suicide] when I was at his stage of education," Veal said. "I felt incredibly guilty because I didn't do more to tell people behind me, especially people of color like him, how bad things can get and how to prepare. ... I felt horrible that I didn't do that."

He sent an essay describing his own feelings and experiences to Larner's new dean, Richard Page, MD, who had launched numerous efforts to improve the school's mental health resources and curriculum, focusing on diversity and social justice.

But the dean needed to do more. "There was no plan for tutoring or mental health services," which "should be offered pro-actively to students based on their scores," Veal wrote to Page. He recommended crisis resources, such as those outlined by the American Foundation for Suicide Prevention (AFSP). The student who died "didn't have the support that saved me from myself two years before."

"Schools must also create a culture that normalizes the need for self-care," Veal told Page, "that includes vulnerability as part of our professionalism."

Veal's essay contained much of the content that appeared in Academic Medicine.

Dean promises change

Page promptly responded, pledging "to do all I can to provide the support you describe. We have to channel our collective feelings of guilt in the setting of ... death to provide a support structure that allows for each student's success."

Two days after Veal's commentary appeared in Academic Medicine, to the entire medical school thanking Veal for his "call to action" and included a link to the piece.

He pledged to develop a working group to assess current mental health services and make them more effective. He also is launching a suicide prevention campaign and will take further steps to provide safe and confidential assistance while adding many other services to advance mental health.

"Far too often individuals do not feel comfortable sharing their feelings, or reaching out for help, for fear of judgment or negative professional repercussion," Page wrote. "As such, those who need help the most may internalize thoughts and perceptions of their own failure while, at the same time, finding it unacceptable to perceive failure, or even to ask for help."

In an interview with 名媛直播, Page called Veal's experience "a near miss" and said student mental health is "a major issue." He considers Veal's article "to be both courageous and important because he's speaking up, and he is appropriately getting attention and helping to emphasize in an acute and an important way, that no matter how hard we work in this area, we can do better, and we must do better."

Among deans around the country, Veal's commentary has received a lot of attention. It was by the Harvard Medical School dean of student affairs, Fidencio Saldaña, MD.

Thomas Schwenk, MD, dean of the University of Nevada Reno School of Medicine, called Page's response "outstanding" and said he intends to use Veal's article "as required reading for our M2s, to whom I am speaking and teaching on this topic next week."

The idea that medical schools and students should make a point of encompassing self-care as a necessary part of being a professional clinician is significant, but somewhat ironic, Schwenk told 名媛直播 in an e-mail. Self-care should be "a simple human responsibility," but physicians work hard to compartmentalize. "Coming at this as part of our professional responsibility is the most engaging and most effective."

And Jonathan Ripp, MD, dean for wellbeing and resilience at Icahn School of Medicine at Mount Sinai in New York City, said that the approach to caring for a medical student with depression should be the same as the approach to his or her hypertension. Today, there are excellent treatments.

The 11.1%

Depression and suicidal ideation aren't uncommon among medical students, according to a in JAMA. It found depressive symptom prevalence was 27.2%. Of those who screened positive for depression, only 15.7% sought psychiatric help. And 11.1% of the students surveyed acknowledged thoughts of suicide.

Specialists told 名媛直播 that while there is , good estimates for how many students attempt to take their own lives or succeed before graduating is sorely lacking. But many physicians remember at least one, and some of those memories are quite graphic.

"There is no systematic tracking of medical student suicides," said Christine Moutier, MD, chief medical officer for the AFSP and a former dean of the University of California San Diego School of Medicine.

Said Schwenk, "We know nearly nothing" about medical student suicide rates, although "it appears to be a somewhat lower rate than the age-matched general population." However, miscoding of suicides among medical professionals "is likely frequent...again a reflection of the shame and stigma attached."

Medical school, Page said, "is always going to be hard.... But we can mitigate the stress. We can mitigate how hard it is and we can provide tools to deal with it, provide support when people need it to normalize the fact that mental health issues are not at all uncommon in medical school."

In his letter, Page acknowledged that not all students come to school with "the same degree of privilege," and that some underrepresented groups "may be subject to even greater stress and require enhanced (and therefore equitable) academic and psychological support."

Veal said it has been especially tough for him and many other ethnic minority students. He grew up in a low-income family in Detroit, "the Blackest city in the country," but now was attending medical school in "the whitest state in the country."

Despite the university's commitment to admit a diverse student mix, Veal said 11 students left during his first year, before Page became dean in 2018. Eight of them were people of color.

"I felt like I had a target on my back," he said. Veal is also gay, which he said added to feelings that he "didn't belong."

Plus, he had long hidden feelings of self-doubt and depression that his family culture refused to acknowledge. At one point he had called his grandmother to complain that some mornings, he barely wanted to get out of bed.

"She said, 'Chris, Blacks don't have depression.... Jim Crow is not a warm and fuzzy environment.'"

In hindsight, he said, "as Black Americans we were not given the privilege or luxury to complain about something like depression or anxiety. In the history of the U.S., depression and anxiety is a baseline for Black Americans."

Efforts like those at Larner are underway within medical schools around the country but at varying degrees.

Taking out the stigma

Licensing requirements are changing too, to ensure graduating medical students and renewing clinicians don't avoid seeking support or mental health counseling for fear it may block their ability to be licensed.

For starters, the Federation of State Medical Boards in 2018 recommended that each state medical board consider deleting any requirement that new or renewing license applicants disclose in their questionnaire responses to certain issues related to their mental health, addiction, or substance abuse. The idea is that if a clinician knows such a question must be answered truthfully, he or she may avoid seeking treatment.

So far, 39 state medical boards have revised questions addressing applicant health or previous treatment, and many already do not ask mental health questions on their licensing applications, said FSMB spokesman Joe Knickrehm.

In North Carolina, the medical board removed a question that asked licensees to disclose any medical conditions that might impair or limit their ability to practice. It was replaced "with an advisory statement of the board's expectation that licensees appropriately address personal health conditions, including mental health and substance use issues, without the need to disclose specific details," Knickrehm said.

The Washington Medical Commission no longer asks about specific mental health issues applicants have had in the past. Now, the agency asks only about current impairment, defined as within the past six months.

Medical schools have long been aware of the issue of suicidal ideation among their students, but the issue garnered more attention when two residents in New York City in 2014, Moutier said. Since then, every national medical and nursing organization, from the Accreditation Council for Graduate Medical Education to the Liaison Committee for Medical Education, has adopted language to address student mental health.

Those efforts were amplified after by suicide in 2018.

"They may pick a different word for it," Moutier said, such as wellness, resilience, burnout, or suicide prevention. "It's now the top priority for most, and yet that still doesn't mean that boots on the ground medical schools know how to ideally support medical students and to reduce suicide risk."

Moutier is the lead author of another (published alongside Veal's) calling for 20 policy changes, such as incorporation of the AFSP's interactive screening program and that medical educators assure that no student faces punitive consequences for seeking mental health support.

Jon Courand, MD, assistant dean for wellbeing for graduate medical education at the University of Texas in San Antonio, said many schools have stopped giving students numerical grades. At most schools, "the first two years are pass fail... It helps take away some of the competition between medical students, which is a big level of stress."

There is concern that the number of physicians who attempt suicide is on the increase, and it's important to understand, Courand said, that "the seeds of dying by suicide are sewn in medical school." At entry level, numerous studies show that med students are more well-adjusted and more adaptable than their age-matched peers going into engineering or business or being homemakers, but "something changes over their time in medical school. They become increasingly more burned out and jaded and depressed, and hence, a four-fold increase in the number of people in crisis."

Avoiding 'contagion'

What's also important is for the school to react quickly and appropriately when a student does die by suicide, Courand continued. Ten years ago, if a faculty member, resident, or med student died by suicide, "you may never hear about it, or if you did, it's a year later and you just heard someone died but you don't know why."

Now, with social media, word is out in minutes and often with misinformation. It's important to get out in front of it, to warn the community not to speculate on what might have happened, which "sometimes is very hurtful to their friends and family."

But it's also important to memorialize the individual in the right way to avoid what Courand called "contagion," which means more suicide attempts by others, a known phenomenon. "You have to aggressively get out there and offer mental health support...to be there 24/7" to prevent others from following that path. That means arranging memorials or establishing a scholarship fund for the college to remember the individual in positive ways.

One thing, though, is not a good idea: the urge to create a permanent physical memorial. "The fear is, wow, Johnny did this, and he's got a statue and a plaque and a little garden. I want that too," Courand said.

For Veal, the future is much brighter these days. He's looking forward to matching with a residency program on the West Coast and working with minority communities.

Last year, after several members of his family died from COVID, Veal got a call from a cousin asking him a haunting question: "Why do we keep dying?"

"I'm a fourth-year med student explaining to my cousin, the reason we're dying is because of horrible health policies and systemic racism, because of a health system we do not trust for very valid reasons, and because we have been suppressing our own emotions for so long."

The events of the last three years prompted Veal to change his career path from family medicine alone to psychiatry and family medicine. "That's primarily because I understand that people in my community do not have and are not getting adequate mental health resources ... and because of my grandmother's misunderstanding."

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