January 4, 2020 · medicine opinion personal ·

On Flexible and Fixed Identities

I wanted to write about a topic that has repeatedly been on my mind, specifically about how medical students define their identities, and how their well-being can be affected by identity. To give some context, a few weeks ago, I was shocked to hear about a 3rd year medical student who committed suicide at the University of Ottawa. This follows two other suicides in the past few years, a University of Toronto 2nd year medical student, and a McMaster University medical graduate who was denied a residency spot for two years. There has been a lot more information in the media surrounding the McMaster graduate, Robert Chu, so I'll be focusing more on him. Chu is described as a tenacious individual with high standards and goals, someone who regularly sets up flowcharts of goals to complete. Chu had imagined himself becoming a radiologist, so during medical school he had tailored his training and research towards matching to radiology, one of Canada's most competitive specialties. Chu applied for residency positions in 2016 and 2017, but was not matched both times with little insight from the resident matching service as to why. During his second attempt, Chu was unfairly denied a psychiatry residency because they felt Chu was "not so committed" to psychiatry due to his radiology research in the past.

Before residency, life appeared to be going as planned for Chu; he had completed his 4 year undergrad in 3 years, was accepted to medical school at a younger age than most, and had published in radiology journals. So what could have caused the suicide? According to Chu's family, Chu had not been showing any signs of depression, despair, or withdrawal. But in his letter to the public, it becomes clear that Chu was frustrated and "sick" of the residency system, saying that his medical education has been "useless", and that his diligent studies, his practice, and medical debt have "all been for naught". Although I only have a limited view of Chu, I believe his seemingly "all or nothing" thinking, a trait many tenacious and resilient people hold, has led him to believe there was no hope in becoming the doctor he thought he would be. By subsequently taking his life, Chu was showing that he was no longer willing to negotiate with society regarding these issues. Chu was justified in his belief that he deserved to match to a residency, but perhaps a flexible identity that embraced change and failure could have prevented this tragedy from occurring.

Unfortunately, failure of any sort has very little place in medicine, whether it is during the intense pressure as a doctor in medical scenarios, the gruelling medical school application process, or due to the difficulties experienced by unmatched graduates. The ultracompetitiveness of medicine helps strengthen this notion by attracting people who don't view failure as an option, and that have resiliency almost to a fault. During my undergraduate studies, I've met more than a few life science students who were hyperfocused on medicine as a career, claiming to have a "backup" plan while in reality having a fixed identity on becoming a doctor. To further illustrate, accepted medical students will preach to applicants to never lose hope, that they too will make it one day if they keep trying. As expected, these highly persevering people tend to put in huge amounts of time and effort into becoming "well-rounded applicants", and are thus quite likely to get accepted into medical schools. However, being accepted to medical school is only half the struggle, as many of my peers were surprised to learn. In fact, the pursuit of a career in medicine is a never-ending treadmill with more competitive applications constantly on the horizon, such as research, residency matching, fellowship, etc.

The question is, how do medical students handle serious roadblocks in this arduous path, especially if they don't view failure as an option?

It is unclear what the circumstances were for the other two suicides, but I wonder if the students' self-perceived identities played a role, influenced by external pressures such as parents and peers, or by their own beliefs and personality traits. Unfortunately, these suicides are part of the larger cracks showing in medicine: on average, doctor suicide and burnout rates are two to three times higher than the rates of other professions. A quick search highlights a Medscape 2019 study claiming that 44% of all physicians in the US are burnt out, and that 1 in 7 have contemplated suicide. In all these cases, I believe we as a medical community have failed to create an environment that fosters well-being and care, and have failed to deeply understand our medical students and professionals. Currently, we are in great need for system-wide changes to alleviate these painful issues of burnout and suicide. Both the Canadian Medical Association and the Canadian Federation of Medical Students have acknowledged these serious issues, and are currently advocating for policy changes.

In the meantime, I have some more personal suggestions that can help prevent the dangers of fixed identities:

First, diversify your identity, similar to making a smart economic investment. You wouldn't want your identity hinging on an single opaque regulatory system, so develop parts of your identity that are independent of each other. Find hobbies, relationships, research, or volunteering opportunities that help define you.

Second, try to test your ideas and plans early and often, making sure that there aren't discrepancies between what you imagine an activity to be like and what it actually is. Seek out shadowing, mentoring, or whatever you need to truly understand. An analogy I borrow from software engineering, is the danger of Waterfall development and the success of Agile development. Waterfall means an entire product is completed without any testing or trialing, and this results in very high failure rates. In contrast, Agile focuses on continual improvement through constant feedback, and is able to adapt to small failures and changes.

Finally, shift your identity into trying to be the best version of yourself, someone who follows passion and core values. Having an identity based on more abstract ideas allows for more leniency and prevents thinking in absolutes. For example, my interest in research stems from my value towards long-term contributions to society, a value that provides me with a lot of flexibility in my life choices. Since life doesn't always work out the way you want it to, be fair and honest to yourself, embrace failure, and stay flexible.