Unbearable weight of the white coat: The mental health crisis in our medical colleges

Illustration: TBS

Sajib Baroi, a student at Sher-e-Bangla Medical College in Barishal, recently took his own life.

Bite Sized: Why medical college in Bangladesh is becoming a mental health crisis

Reports suggest he had been struggling with intense academic pressure and was falling behind in his studies. While his batchmates had already started their internships, Sajib was still in his third year, which deeply affected his mental health.

"I'm tired of fighting with myself. I need some rest. Please forgive me. I couldn't return the love I received," Sajib wrote in a note he left behind. Incidentally, this suicide bears an eerie resemblance to that of another medical student a few years ago.

In 2022, another Baroi — this time Manik Baroi from a private medical college in the capital — also took his own life. Before doing so, he left a note that read: "No one is responsible for my death. I am committing suicide due to personal despair. I failed in medical school and couldn't fulfil my dream of becoming a writer…" 

Currently, there are no comprehensive statistics on how many medical students commit suicide in Bangladesh each year.

The non-governmental organisation Aachol Foundation, which researches student suicides, focused specifically on suicides among medical students only in the year 2021. According to their report, at least 101 university students died by suicide in Bangladesh that year, 12 of whom were medical students. This indicates that a significant proportion of university student suicides came from medical institutions.

A study by Miliva Mozaffar, a faculty member of the Biochemistry Department at Uttara Medical College for Women and Hospital, found that around 24% of medical students in Bangladesh have contemplated suicide at some point during their academic life.

Another recent study by researchers at Dinajpur Medical College published in January this year identified a complex interplay of academic, personal, and professional stressors as key reasons behind suicides among medical students and doctors in Bangladesh, including academic pressure, exam failures, mental illness, family and relationship problems, job dissatisfaction and workplace challenges.

The situation is similarly alarming in neighbouring India. A report released in May this year revealed that over the past five years, 119 medical students across India died by suicide — among them, 64 were undergraduate (MBBS) students and 55 were postgraduate (MD/MS) students.

Senior doctors in India have pointed to extreme academic pressure, long and exhausting duty hours, inadequate rest, and a hostile work environment as key factors contributing to student burnout.

"There is no denying the link between intense academic pressure, frequent exams, sky-high expectations, and burnout," said Dr G Srinivas, Vice-Chairman of the Telangana State Medical Council (TSMC).

"There is a definite need for stricter anti-harassment and anti-ragging policies in medical colleges, ensuring that the working hours of PG doctors are not overextended and that young MBBS and PG medical students receive proper mentorship," he added.

Yet, the fact that the number of medical student suicides in Bangladesh is still not recorded annually, let alone studied for underlying causes, reflects how little attention this issue receives in our country.

Conversations with medical students and experts suggest that the situation is indeed dire due to academic pressures and internship-related struggles.

A H M Nayeem, an intern doctor at Sir Salimullah Medical College, explained that medical students in Bangladesh are required to study 11 subjects in total. Anatomy, taught from the very first year, is considered the most difficult and demanding subject.

"After perhaps a few relaxed days during the first week, the cycle of item exams, or daily assessment, begins," Nayeem said. "These continue consistently from the first year through to the fifth and remain a constant source of anxiety for students."

He noted that one of the major stressors is that the minimum pass mark in any medical exam is 60%. In oral exams, where evaluating performance objectively can be tricky, even minor mistakes may result in failure.

Missing or failing an item exam often triggers a vicious cycle, as understanding future topics becomes increasingly difficult without clearing earlier ones. And if a teacher is uncooperative, the chances of recovering from such setbacks diminish drastically.

"After three to four months, based on the successful completion of item exams, card exams are held," Nayeem explained.

"A student must pass a specific number of card exams to qualify for the term finals. Similarly, passing a set number of term finals is required to be eligible for the professional exams, which are held four times during the five-year course."

Professional exams introduce an entirely new level of stress. While students are generally familiar with what their own teachers might ask, these exams also involve an external examiner, whose questions and expectations are often unpredictable and can heavily influence the outcome.

"For instance, one of the external examiners in our Forensic Medicine exam was a professor who had reportedly conducted the autopsy of actor Salman Shah," Nayeem recalled. "He would ask extremely detailed questions about autopsy procedures, and a single misstep could mean failing the exam."

As a result, even after studying diligently throughout the year, students often have to exert an almost inhuman amount of effort just to pass their professional exams.

And once all four professional exams are cleared, the internship phase begins. While the official workload for interns is set at 72 hours per week, in practice, medical students often end up working significantly more than that.

Rezwan Rahman Sadid, an intern doctor from Rajshahi Medical College, elaborated on the structure and workload within public medical colleges.

According to him, the medicine department alone receives around 300 patients every day. From 8am to 2pm, about 30 to 35 personnel — including senior doctors, interns, and mid-level doctors — are on duty to attend to these patients.

However, after 2pm and throughout the night, only a few intern doctors remain to manage all of them, making the workload overwhelmingly difficult.

"There is barely a moment to catch our breath. We are expected to take full responsibility and carry out every task ourselves during a time in our lives that was meant for learning, not for bearing such burdens alone," Sadid said.

He added that surgeries conducted during the day often last four to six hours, and intern doctors are required to participate in them as well. Although the official duty hours are 12 per day, in reality, they often work 16 to 18 hours. Some interns do not even get a weekly day off.

"Despite such exhaustive work, we receive a monthly salary of only Tk20,000, which is unacceptable by any standard, anywhere in the world," Sadid noted with frustration.

On top of everything, there is the constant anxiety about the future. What will they do after the internship? If they wish to pursue further studies, where will the money come from? If they want to start earning, when will they find time to prepare? These thoughts linger persistently in their minds.

One of the key reasons behind the overwhelming pressure on intern doctors is the acute shortage of physicians in the country. To address this crisis, intern doctors have been staging protests since the beginning of this year.

Among their five-point demands, one of the most urgent was the immediate recruitment of 10,000 doctors to fill vacant positions across the healthcare system.

They also called for the formation of a separate health commission and demanded that new recruits be appointed in the sixth grade, as was the practice earlier. Furthermore, the intern doctors stressed that 4,000 to 5,000 doctors should be recruited annually to ensure stability in the healthcare sector.

However, the Healthcare Reform Commission's report did not provide any concrete direction on how to respond to these demands, and in many cases, the recommendations were seen as impractical.

For example, Sadid pointed out that despite the well-known manpower crisis in public hospitals, the report recommended that doctors spend at least 10 minutes with each patient, a guideline that is virtually impossible to follow under current circumstances.

"In doing so, the report fails to acknowledge the practical realities of both the healthcare system and medical education," Sadid noted.

Psychiatrist S M Yasir Arafat, assistant professor at Bangladesh Specialized Hospital, believes that safeguarding the mental health of medical students requires addressing the academic pressure they endure.

At the same time, he emphasised that suicide is an extremely complex issue. It is rare for someone to die by suicide solely due to academic stress. Other factors, such as financial hardship, relationship struggles, uncertainty about the future, and a lack of social life, often play significant roles.

"Nonetheless, academic pressure may act as a trigger," he explained. "Moreover, academic stress frequently forces students to compromise their social lives and other aspects of well-being."

Arafat also challenges the notion that extreme academic or internship pressure is necessary, as it prepares medical students to cope better with the demands of their profession.

"That's an absurd idea. Nowhere else in the world is such thinking considered acceptable. There is more to life than just academics. It's unrealistic to expect that doctors should have no life outside their profession.

"And this very mindset is why even medical students view mental health issues as a stigma and hesitate to seek professional help. Breaking this stigma is crucial," he added.