If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Individual reprints of this article are not available. Address correspondence to Liselotte N. Dyrbye, MD, Division of Primary Care Internal Medicine, 200 First St SW, Rochester, MN 55905
The goal of medical education is to graduate knowledgeable, skillful, and professional physicians. The medical school curriculum has been developed to accomplish these ambitions; however, some aspects of training may have unintended negative effects on medical students' mental and emotional health that can undermine these values. Studies suggest that mental health worsens after students begin medical school and remains poor throughout training. On a personal level, this distress can contribute to substance abuse, broken relationships, suicide, and attrition from the profession. On a professional level, studies suggest that student distress contributes to cynicism and subsequently may affect students' care of patients, relationship with faculty, and ultimately the culture of the medical profession. In this article, we review the manifestations and causes of student distress, its potential adverse personal and professional consequences, and proposed institutional approaches to decrease student distress.
Medical schools are responsible for ensuring that graduates are knowledgeable, skillful, and professional.
To achieve these goals, medical schools typically use a curriculum of didactic lectures, modeling, supervised practice, mentoring, and hands-on experience to augment individual study. Unfortunately, some aspects of the training process have unintended negative consequences on students' personal health. Studies suggest that medical students experience a high incidence of personal distress,
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
It is critical for medical educators to understand the prevalence and causes of student distress, potential adverse personal and professional consequences, and institutional factors that can positively and negatively influence student health. In this article, we summarize the manifestations, causes, and consequences of student distress; propose how medical schools can address this problem; and outline areas where additional research is needed.
METHODS
The intent of this work was to summarize the central themes of medical student distress reported in the literature and to highlight selected studies exploring the prevalence, causes, and consequences of student distress as well as strategies to reduce student distress and promote well-being. Articles were identified by searching MEDLINE and PubMed for English language articles published between 1966 and 2004 with use of the search terms medical student AND depression, suicide, stress, burnout, distress, abuse, alcohol drinking, illicit drug usage, street drugs, substance-related disorders, ethics, professionalism, cynicism, cheating, debt, or academic performance. Additional studies were identified from the reference lists of these articles. Articles were reviewed critically by authors and included as appropriate to provide readers an overview of the research on medical student distress to date, with specific works featured based on the validity of methods used, the novelty of the research question, and the clarity of the findings. As such, this work is intended to be a summary rather than a systematic review that gives readers an understanding of the current literature on medical student distress.
MANIFESTATIONS OF STUDENT DISTRESS
Stress
Medical students experience substantial stress from the beginning of the training process.
Although some degree of stress is a normal part of medical training and can be a motivator for some individuals, not all students find stress constructive.
Strategies that center on disengagement, such as problem avoidance, wishful thinking, social withdrawal, and self-criticism, have negative consequences and correlate with depression, anxiety, and poor mental health.
In contrast, strategies that involve engagement, such as problem solving, positive re-interpretation, reliance on social support, and expression of emotion, enable students to respond in a manner that leads to adaptation,
Given that the aims of medical training include teaching graduates how to “promote health” and prepare for a career in an intellectually stimulating and socially meaningful profession, it is tempting to speculate that medical school would be a time of personal growth and enhanced health. Unfortunately, the contrary appears to be true, with numerous studies suggesting that students' mental health worsens during medical school.
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
In a study from the United Kingdom, more than one third of first-year students had poor mental health when measured with the General Health Questionnaire 12, which assesses anxiety and depression.
Another study from the United Kingdom of that year students found that the incidence of poor mental health on the General Health Questionnaire 12 doubled during the first year, increasing from 25% to 52%.
In a separate study, median Beck Depression Inventory scores increased 3-fold from the time of matriculation to the end of the second year, with 25% of students dysphoric, if not clinically depressed.
Two additional studies of US students confirm a peak in depression during the second year of medical school, with gradual improvement during the third and fourth year of training.
Despite the high prevalence of mental health-related concerns and ready access to mental health services, depressed medical students are no more likely than the general population to seek treatment for depression.
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
Barriers to use of mental health services include lack of time, perception of academic jeopardy, concern regarding confidentiality, the stigma of mental illness, and cost.
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
Burnout is another measure of poor mental health attributed to work-related stress. This syndrome of emotional exhaustion, depersonalization, and low personal accomplishment culminates in decreased effectiveness at work and is particularly common in individuals in the helping professions (teachers, nurses, social workers, etc).
The sources of stress for medical students vary by year in training. The first-year medical student is faced with the challenges of being uprooted from family and friends and adapting to a demanding new learning environment. Human cadaver dissection is a well-recognized stress for many students,
also characterize this transition. Attempting to master a large volume of information and joining a peer group of equal motivation and intelligence can be intimidating for young adults accustomed to rapid mastery of material and academic distinction. This challenge is amplified for students who struggle academically.
Once in the clinical years of training, students often are separated from their peer-support group and frequently rotate to new work environments at different hospitals. Each rotation requires a unique medical knowledge base and skill set, which tends to highlight students' deficiencies rather than their progress.
An unstructured learning environment, lack of time for recreation, concerns about financial issues, long on-duty assignments, student abuse, and exposure to human suffering can be additional sources of distress during this period.
This “informal curriculum” conveys powerful messages about professional values, character, and norms. Unfortunately, depression, burnout, and stress are common among student supervisors
In 1 study of third- and fourth-year students, 98% of respondents reported observing physicians refer to patients in a derogatory fashion, and 60% reported witnessing unethical behavior toward a patient.
More than two thirds of students experienced guilt about their personal role in these episodes but felt forced to participate to “fit in” and receive a favorable evaluation. Others have made similar observations.
The “see one, do one, teach one” approach to learning invasive procedures, the demands to write notes about patients not personally examined, and a dehumanized approach to patients (“divide and conquer”) also can present ethical challenges to students who desire to be “team players” and who are influenced strongly by supervising physicians.
Most patients receive much of their health care toward the end of life, and medical students in the clinical years are confronted frequently with issues related to death and dying for the first time.
Unfortunately, the medical school curriculum often focuses exclusively on disease diagnosis and treatment and pays little attention to education about end-of-life issues and palliative care.
In light of the frequency with which students encounter patients at the end of life and the lack of student training in this area, it is no surprise that students are fearful, anxious, and hesitant to interact with dying patients.
Although issues related to death and dying often are presented during preclinical lectures, clinical training in the skills required to care for patients at the end of life is less common.
One study reported that although 100% of third-year students had cared for a terminally ill patient, only 41% had been present while an attending physician talked with a dying patient, and only 35% had ever discussed with an attending physician how to care for terminally ill patients.
In 1 study of more than 500 medical students, more than 40% reported that they had personally experienced abuse, with many stating that the experience was a major source of stress that affected them for a month or longer.
Although sources of stress related to the training experience have been the focus of most research on student distress, students also experience numerous personal life stressors common to individuals their age. In a study of more than 1000 medical students, many reported experiencing the death of a family member (15%), personal illness or injury (25%), or change of health in a relative (42%) within the past year.
Although these life events would be expected to adversely affect students' quality of life (QOL) and professional development, their effect has not been well studied. Other personal life events, such as marriage, appear to protect against distress. In the 1995 Association of American Medical Colleges graduation questionnaire, 30% of graduating medical students were married (a lower prevalence than reported in the age-matched general population),
and little is known about the mental health consequences of pregnancy or childrearing during medical school. Although childbirth and childrearing typically are considered positive life events, children add a level of complexity to students' lives,
In 1 study of second-year medical students, female students were more likely to be depressed if they had children, whereas no such relationship was observed among their male colleagues.
In 1 study, both grades in the preclinical years and clerkship examination scores could be predicted as well by psychosocial characteristics (anxiety, depression, loneliness, neuroticism, self-esteem, and stressful life events) as by Medical College Admissions Test scores.
Although theorized to have a negative influence, the effect of depression and burnout on academic performance in medical students has not been well studied.
Such negative attitudes may develop in response to students' environment and experiences. Although in the short term, attitudes such as cynicism may serve as a buffer against anxiety, fear of failure, and exposure to human suffering,
Medical student career intentions at the Christchurch School of Medicine: the New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE) survey of medical students pilot study: results part II.
Dishonesty in patient care activities, such as recording tasks not performed, reporting findings elicited by others, and lying about having ordered a test, often are motivated by fear and a desire to appear knowledgeable.
The perception of what defines academic integrity also differs by year in school. In 1 cross-sectional study, first-year students were more likely than more senior students to correctly identify case scenarios describing academic dishonesty as being unacceptable.
Students in later years of training were both less likely to consider the behaviors wrong and more likely to report that they had or would engage in the behaviors described.
Changes in binge drinking and related problems among American college students between 1993 and 1997: results of the Harvard School of Public Health College Alcohol Study.
Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students.
At one Midwest medical school, students' mean score on a validated assessment for alcohol dependence (Alcohol Use Disorders Identification Test) doubled during the first semester (P<.001), with 20% of students scoring above the cutoff for problematic drinking.
Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students.
In a study of graduating students from 8 US medical schools, 29% of students reported that their alcohol consumption increased during medical school, with more than 20% reporting at least 1 episode of binge drinking (5 or more drinks in 1 sitting) in the past 30 days.
In a survey of 2046 senior students at 23 medical schools, the reported incidence of marijuana (10%), cocaine (2.8%), tranquilizer (2.3%), heroin/opiate (1.1%), psychedelic (0.7%), amphetamine (0.3%), and barbiturate (0.2%) use in the last 30 days was concerning.
Although the suicide rate for female students during this period equaled that of their male colleagues, it was 3 to 4 times higher than age-matched women in the general population.
an estimated 8 to 25 attempted suicides occur for each suicide death, reflecting the concern that completed suicides represent only a fraction of the extreme distress manifested by suicidal ideation, planning, and attempts among medical students.
The risk of student suicide appears higher in the clinical years. Among senior Norwegian medical students, 14% reported having suicidal thoughts within the past year, and 6% had planned to commit suicide during medical school. Such suicidal thoughts persist into postgraduate training
but the factors that prompt medical students to act on their plan have not been studied. Among physicians, suicide attempts are more likely among those who are single, female, depressed, have other psychiatric illness, or struggle with drug or alcohol dependency.
REDUCING STUDENT DISTRESS: IDEAS FOR MEDICAL SCHOOLS AND MEDICAL EDUCATORS
Understanding the causes and consequences of student distress is important (Figure 1), but medical schools need to go beyond identifying distress and strive to promote well-being for all students. Well-being is distinct from the mere absence of distress and includes achieving a high QOL in multiple domains (physical health, mental health, emotional health, spiritual health, etc).
Promoting and nuturing well-being during medical school and equipping graduates with the skills necessary to recognize personal distress, to determine when they need to seek assistance, and to develop strategies to promote their own well-being is essential to promoting professionalism and laying the foundation for resilience through the course of a career.
FIGURE 1Proposed model of causes and consequences of student distress.
The Association of American Medical Colleges urges medical schools to establish relationships between faculty members and students to promote a positive learning environment.
Physicians for the Twenty-First Century: The GPEP Report: Report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. Association of American Medical Colleges,
Washington, DC1984
Although relationships with faculty undoubtedly assist students, student-led support programs may provide an even stronger source of support and promote positive strategies for coping with stress.
Senior medical students may more easily relate to challenges faced by junior students, and “buddy programs” designed to promote mentorship of junior students by senior students appear to lower student stress.
The evaluation system used to assess student performance also can have a powerful effect on the learning environment. The A-F grading scheme, used to classify performance, often creates a competitive environment that promotes anxiety and peer competition rather than collaborative learning. Researchers at the University of Michigan evaluated the effect of changing to a pass-fail grading system on student performance and satisfaction.
Compared with previous classes, students' performance on tests in basic science courses were unchanged, suggesting students' motivation for subject mastery was not affected by the change in the evaluation system. In contrast, students' satisfaction with the evaluation system and learning environment improved with the pass-fail approach. Although some authors have reported that residency program directors prefer candidates evaluated with use of traditional grades,
others have reported that the pass-fail grading system does not influence students' likelihood of matching with a highly ranked postgraduate training program.
Thus, fostering a nurturing environment for students in part may depend on promoting the well-being of residents and faculty. Unfortunately, burnout and cynicism are common among residents and practicing physicians and can adversely affect professional modeling.
Faculty development programs need to both address staff satisfaction and confront problematic behavior such as disrespect, hostility, and rudeness, which are often ignored.
Allowing students to contribute to curriculum development can benefit both students and administrators and give students a sense of ownership in their educational experience. Students bring unique perspectives to curriculum committees including insight regarding redundancies in the curriculum, feedback on effective and ineffective teaching methods, and ideas about areas for new curriculum development (alternative medicine, end-of-life care, ethics, genomics, etc). Because students rotate among various hospitals in the training system, they also can provide insight regarding variations in the care of patients, workload, culture, and teaching style among hospitals and identify the most effective experiences.
and once struggling students are identified, they need individualized support. Deans must not only make students aware of the available resources, but also address barriers to care. Because of the stigma of mental illness, many medical students are not comfortable seeking care for mental health problems from their own institution and prefer to receive off-site care.
Collaborative Research Group on Medical Student Health Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools.
Creating an ombudsman program, offering career counseling, and providing students off-campus confidential resources covered by the student health insurance plan are critical. Descriptions of successful mental health programs for medical students may serve as models.
Stress-management programs that inform students about the effects of stress on physiological and psychological functioning and teach students how to plan, prioritize, identify sources of stress, and cope with stress
61057-4&id=gr1.gif){kind=link}