It is estimated that the United States will face a shortfall of nearly 120,000 physicians by 2030.¹ In light of these projected shortages, there is a pressing need to identify upstream factors that contribute to the loss of otherwise qualified students from the medical education pipeline. To date, studies of pipeline issues in premedical education have primarily focused on illuminating the mechanisms responsible for the disproportionate attrition of students belonging to racial and ethnic minority groups.^2-4 Other research on premedical education suggests that students are deterred from continuing their studies by a variety of considerations including the length of graduate medical training, trepidations about physicians’ long work hours, and the receipt of low grades in requisite coursework.⁵ Despite the notable contributions of these studies, much remains unknown about undergraduate premedical students and the factors that discourage their medical career aspirations.

A substantial body of empirical evidence indicates that graduate medical students experience high rates of depression, burnout, and suicidal ideation.^6-11 While these statistics are troubling in their own right, it is also the case that medical students who experience mental health problems are significantly more likely than their peers to seriously contemplate a departure from medical school.⁷ Consistent with these findings, research on the mental health of premedical students finds that premeds experience more depressive symptoms and higher levels of burnout than their non-premedical counterparts.^12,13 Yet, to date, it is unclear whether the mental health issues experienced by members of this group hold similar, negative consequences for their academic persistence. The answer to this question holds the potential to yield further insight into the psycho-social factors that predict leaks from the medical education pipeline at earlier points in the academic career.¹⁴

If mental health issues are negatively associated with medical career interest among premedical students, this association might not affect all premeds equally. Women in the United States experience internalizing forms of mental disorder (e.g., depression, generalized anxiety) more frequently than men.¹⁵ Corresponding with these broad social epidemiological patterns, past research indicates that premedical women are more susceptible than their male peers to both depression and burnout.^12,13 It follows that if depressive symptoms and burnout are associated with diminished medical career aspirations, premedical women may be especially at risk of losing interest in entering the medical profession. Indeed, this relationship may help shed further light on why women are less likely than men to apply to medical schools in the United States despite being substantially more likely than men to arrive on college campuses aspiring to careers in medicine.¹⁶

The aims of this study were: (1) to investigate whether depressive symptomology and burnout are associated with medical career interest among undergraduate premedical students, and (2) to examine whether the relationship between mental health and medical career interest varies by gender. In light of the preceding discussion, it was hypothesized that premedical students who experience higher levels of depressive symptomology and burnout would become less interested in pursuing a career in medicine. Additionally, it was hypothesized that the negative association between mental health issues and medical career interest would be exacerbated among premedical women, such that higher levels of depressive symptomology and burnout among this group would be associated with greater declines in medical career interest.

Efforts to understand the antecedents of premedical students’ declining interest in medicine are increasingly relevant in light of projected physician shortages in the United States. Following from research documenting high levels of depression¹²and burnout¹³among premedical students—factors that have been associated with thoughts of medical school departure among graduate medical students⁷—this study sought to examine whether these facets of mental health were associated with chang-es in medical career aspirations among premeds. Fur-thermore, because depressive symptoms and burnout are more common among premedical women compared to men,^12,13 a secondary aim of this study was to examine whether the association between mental health and medical career interest significantly varied by gender.

Using longitudinal survey data collected from early career premedical students at Indiana University, results showed that respondents who experienced more depressive symptoms and higher levels of burnout over the course of the academic year reported significant reductions in medical career interest. This finding broadly corresponds with research on graduate medical education, which indicates that medical students who experience greater burnout and depressive symptomology are more likely to seriously contemplate dropping out of medical school.⁷ The premedical track in the United States is an academically demanding pre-professional path characterized by intensive coursework in chemistry, biology, and physics, and competition with peers for one of a limited number of medical school seats in a given admissions cycle.^5,14,25Successful applicants to medical school frequently combine high grades in difficult coursework with a carefully curated list of time-consuming extracurricular activities.^26,27For some pre-meds, this combination of academic and social stressors may combine to erode their psychological well-being and weaken their resilience in the face of premedical track-related obstacles—a dynamic that could help to explain the relationship between higher levels of depressive symptoms/burnout and greater declines in medical career interest observed in this study.

A growing body of research has highlighted troubling rates of depression, burnout, and suicidal ideation among graduate medical students.^8-10 In response, researchers and administrators have argued that measures must be taken to address the mental health of this group. The findings of the present study suggest that similar attention must also be paid to the mental health of undergraduate premedical students. While colleges and universities in the United States increasingly offer academic advising tailored to the specific needs of premedical students, findings indicate that these services should be expanded to include a focus on students’ mental health. On campuses where mental health services exist, premedical advisors and faculty should coordinate with these offices for instruction in how to identify symptoms of depression and burnout among students. These efforts could be further strengthened by establishing a formal protocol for directing students identified as being at-risk for depression or burnout to treatment. Given the high degree of the stigma surrounding mental health issues found among medical trainees,¹⁰ this endeavor will undoubtedly require intensive efforts by academic counselors to normalize the use of mental health services during their meetings with premedical students.

Aligning with past research on premedical students,^12,13premedical women reported significantly higher levels of depressive symptoms and burnout than men at both survey waves in this study. Interaction models assessing whether the association between mental health issues and medical career interest varied by gender indicated that depressive symptoms were associated with greater declines in medical career interest among premedical women compared to men. Although women have only recently surpassed men in medical school admissions in the United States,²⁸ there is evidence from nationally representative data on freshmen at four-year colleges and universities that women have been more likely than men to arrive on college campuses aspiring to careers in medicine since 1994.¹⁶The stronger negative association between depressive symptoms and medical career aspirations among women may provide further insight into why roughly similar numbers of men and women apply to American medical schools each year despite women being considerably more likely to report an intention of applying to medical school as college freshmen.²⁹ Past research on women in science, technology, engineering, and mathematics finds that positive relationships with faculty, as well as close relationships with same-sex peers, can help to retain women in these fields.³⁰Consequently, mentor programs that pair premedical women with supportive faculty, or initiatives aimed at cultivating relationships among women enrolled in the same coursework, may help to sustain women’s medical career ambitions in the face of burgeoning mental health issues.

Findings from this study should be interpreted in light of several limitations. Most apparent are those stemming from the study’s low response rate and focus on a single research site. In terms of the former, declining response rates are increasingly common in survey research.^31,32 Although the honorarium offered to participants was increased to encourage participation; financial limitations ultimately placed a limit on further efforts to incentivize participation. Regarding the latter, the study’s focus on a large state university limits the generalizability of findings to other institutional settings. Indeed, while mental health issues may be associated with declining medical career interest among premeds at large public universities, it is plausible that this relationship may unfold differently at small liberal arts colleges or historically black universities where there are demonstrable differences in demographic composition, class size, and institutional missions. Response bias is another important issue to consider. Because demographic information for the students on the premedical listserv who chose not to participate in the study was not granted by Indiana University, it was not possible to discern whether there were substantive differences between premeds who elected to participate in the study and those who did not. Future studies should focus on research sites where demographic information on the premedical population is more thoroughly documented so statistical analyses can be weighted to account for respondent characteristics that predict selection into the sample.

Results from this prospective case study provide preliminary evidence that undergraduate premedical students who experience more depressive symptoms and higher levels of burnout become less interested in pursuing a career in medicine. The relationship between depressive symptoms and declining medical career interest was even more pronounced among premedical women compared to men. Albeit suggestive due to its small sample size and focus on a single research site, results from this study indicate that failure to provide adequate mental health services to undergraduate premedical students may lead to the siphoning of otherwise qualified premedical students from the medical education pipeline. These findings point to the need for a multi-site, nationally representative study of premedical education that can more definitively speak to the influence of mental health problems on undergraduates’ medical career aspirations.