Beruflich Dokumente
Kultur Dokumente
'\ , _...
Special Problems of
A1edicalStudents
Darlene L. Shaw
Danny Wedding
Peter B. Zeldow
Nancy Diehl
Let us emancípate the student, and givehim time and ..BOX 6~1 Specific s~essors in the basic scie~~e years ,,~, .
opportunity for theculd~ation'.~f mind, rus so that in . .T~e pressure .. .. ',"
his pupilage he' shall not .be a 'pGppet 'in' the h~nd~ of '. Emphasis on course exarninations md natiorial. board
others, but rather a self-relying ~nd reflecting being . . . exarninations : .' .. .....
Cornpetition for grades and c1ass rank
SIR WJll.lA.L\,1 OSLER '. .. Ó> ;:
F~áncial problerns .' ., ' •.•... ', ."
Amount of rote memorization .'.'
Ó: :
Ifyou listen c~~~nilly to what ~atients s~y, fuey will • Limited time for recreation árid eX~rcise .
Strain on social and intimare relationshíps
often tell you not.only what is wrong with the~ but also . Loneliness . '.. .'. '. .
what is wrong with you.
Fear of failure
WALKERPERCY . Prolonged dependence on parents orspouse
The decision to become a physician represents an irnpor- capacity for intimacy. Most medical students are young
tant commitment that produces profound personal effects adults who face these tasks. The medical school enviren-
and shapes many of life's events. Although medical school ment, however, may create stresses that impede achieve-
and residency training pro vide the knowledge and techni- ment of adulthood goals. For example, the seemingly lirn-
cal skills needed to practice medicine, they do not neces- itless material to be learned and the fierce competition for
sarily help anticipa te the positive and negative effects med- grades can de crease peer support and leave little time or
ical training and a career in medicine have on the persono energy for establishing intimate relationships.
In this chapter we discuss these effects and argue that med-
icine is a way of life, as well as a profession.
Specific Stressors in the Basic Science Years
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70 Part 1: The Physician and Society
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BOX 6:3 .Altitudes that influence the happiness of medical students and physicians*
t:~t~~thl<:.:. ..... . .....'. ".: .',. . Path 2 .. , .
L~':,'TheS~coping attitudes ,:"m not be very uSefuÚo you in medi- These eoping attitudes willIead to more long-term satisfac-
f:':- 'Cine,in the long 'nill. : - "" ... " o'. ',." . tions and eiIjoyrnent in medicine. .
,.
r.
f . The strong silentapproach. Don't tell oth~rs what you are .
thinking. . ". " , .. . .
Leam to listen to the feelíngsof others,'and to share your own..
. ~. .
Success means good grades and, later, wealth and material That's okay,b~t it doesn't compare to enjoying your work and
goods. .... ': .. people. . .
. Your needS must tak~ a sec~)Ddplace to ~~re impo~ant things . You must fill your own needs at the same time you are accorn-
in life. . plishing your other goals.
Your worth depends 00 what you accomplish. When you don't There is a source of self-worth that cannot be measured by
accomplish as much as others or as much as you can, you are your accornplishrnents, that is non-negotiable and fundamental.
basically inadequate ..
Mistakes are the result of ignorance, apathy, carelessness,and Mistakes aren't exactly okay,but they are a faet of life, even in
general basic worthlessness. medicine. Mistakes are your chief source of wisdom. Learn
from thern and don't make thern twice. Perfectionism leads to
burnout.
Critieism is a demonstration to the world of your inadequacy. Criticisrn isn't exactly pleasant, but get used to the idea that it
Defend, justify, explain, and attackl doesn't imply inadequacy. Learn to use it.
You are helpless in a world that controls your behavior. You are in charge of what you do; it's no use blarning anyone
else. What you do is up to you.
When you are feeling overwhe1med,lonely, anxious, depressed, There is nothing wrong with you; everyone has trouble coping
and can't study, it is up to you to "snap out of it," Be strong, and could use sorne help. It may be embarrassing to find that
work hard, and keep a stiff upper lip. It's just a rnatter of will- you don't know everything yet. A sense of self-worth that keeps
power. . you from getting help may lead to real trouble.
Results are more important than people. (Type A behavior is People are more important than results. (Type B behavior is
goal oriented.) "process" oriented.)
Thinking is the highest function. There is more to you than thinking. Don't let your feelings and
intuition atrophy; don't become an intellectual nerd.
* From Virshup, B. (1985). Coping in medical school. New York,NY:WW Norton. Used by perrnissioo.
both their commitment to medicine and their ability to spouse can begin to date others and discover that many of
cope with the amount to be learned. For the abandoned them are vivacious and interesting. Rituals (e. g., the act of
spouse a period of concern ex.ists about his or her physical putting on a stethoscope for the first time in the case of the
attractiveness and ability to once again establish a loving medical student) may be important in testing out newly
relationship. established roles.
Successful adaptation to transition involves a series of As new roles are assimilated and become increasingly
predictable stages. Initially individuals have to abandon comfortable, a need ex.ists to integrate those roles with an
many assumptions that may have once given meaning and individual's personal value system and Weltanschauung (a
direction to life. Medical students may have to let go of comprehensive conception ofthe world). Medical students
beliefs about personal and inteUectual superiority as they come to feel comfortable with their new role and confident
consistently find themselves in the bottom quarter of their in their abilities. The jilted spouse develops new and re-
class; the jilted spouse may have to reexamine core beliefs warding relationships and eventually finds a new love rela-
that are no Ionger adaptive (e. g., believing that only one tionship that is more rewarding than the distressed first
person can give happiness). This change produces a void marriage. Sorne attitudes that influence the happiness of
and new beliefs and attitudes have to be tested systernati- both medical students and physicians are listed in Box 6.3.
cally before they can be assimilated into an individual's In addition to attitudinal changes tha t can increase cop-
self-coricept. Students can learn that they are people of val- ing, stress management courses for medical students are
ue and worth despite their borderline grades. The jilted effective. For example, a I9-week study on self-hypnosis
Chapter 6: Special Problems of Medical Students 71
with medical students found associated increases in im- with women constituting an average of 46% of new entrants.
mune functions as measured by increases in number and During the last 10 to 20 years, much effort has also been
activity of natural killer cells. Another study found that first devoted to increasing the number of underrepresented mi-
year medicaI students who received a stress management norities (URM) admitted to medical schools, in order to
course, compared to non-attendees, were less anx.ious and have me di cal schooI matriculates better reflect the heteroge-
more satisfied with themselves, life, and their schooI per- neity of the U. S. population. In 1991, the AAMC established
formances. In addition, a well-controlled study published the 3000 by 2000 Project, aimed at doubIing the number of
in 1998 found that an 8-week meditation-based stress re- URMs adrnitted to medica! school by the year 2000. Unfor-
duction intervention for premedicaI and medical students tunately, court decisions not favoring affirmative action pro-
effectiveIy reduced anx.iety and psychologicaI distress, in- grams and other factors have hindered achievement of the
cluding decreased depression and increased empathy AAMC's goal.
seo res. Moreover, the beneficial results were observed even As medicaI school matricula tes have beco me a more het-
during an exam periodo erogeneous group, investigators have attempted to predict
success in medica! school. MCAT scores and overall under-
graduate GPAs have repeatedly been found to be good pre-
Predicting Success in Medical School dictors of medica! school performance as measured bymed-
ical school basic science GPAs and scores on the Natiorial
The first English-speaking woman physician was Dr. James Board of Medical Exarniners tests (e. g., R = .65). Scores on
Miranda Barry, who served in British Army hospitals between standardized tests and GPAs, however, have been notortously
1813 and 1865. Dr. Barry dressed and lived as aman and poor predictors of clinical performance. For exampIe, a study
was discovered to be a woman only after her death. In order published in 1997 found that cognitive ability as measured
to succeed as a physician, Dr. Barry had to obscure her real by undergraduate GPA and MCAT scores was onIy weakly
self and adopt the personality characteristics of aman. related to ward evaluations (R = .35).
In recent years, medica! school matriculates have become Consequently, many investigators have attempted to
a more diverse group. For exarnple, in the early 1970s, worn- identify personality characteristics predictive of success in
en constituted only 9% of applicants and 9% of entrants to rnedical school. A 1995 study showed that better perfor-
medica! schooIs. By contrast, the Association of American mance in medical schooI was correlated with being enthu-
Medica! Colleges (AAMC) reported that in 1999,45% of siastic, venturesome, self-opinionated, and driven. Class
medica! school applicants were wornen and, depending up- rank has been found to be associated with the traits of com - (
on the school, 26% to 64% of new entrants were wornen, pulsiveness and aggressiveness. Daily hassles and interper~
72 Part 1: The Physician and Society
-
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sonal conf1icts have also be en found to be significantly neg- need for effective preparatory and academic support ser-
atively correlated with mean grades on required third-year vices for al! students, and especially for those from disad-
clerkships. Two other groups of investigators have found a vantaged backgrounds.
curvilinear relationship between overall medical school
GPAs and anxiety. Achievement was maxinzized by a certain
leve! o[ anxiety, and anxiety above or below that leve! was
associated with decreased achievement. Indeed, a 1997 study MEDICINE AS A WAY OF LIFE
found that personality variables (e. g., tough mindedness
and emotional stability) were the primary predictors of Personality Characteristics of Medical Students
clinical performance. Not surprisingly, researchers have and Physicians
not been able to identify one or two personality traits that
predict al! medical school performance measures. Howev- Desirable personality characteristics. Several investigators
er, it seems clear that psychosocial attributes, perhaps akin have sought to identify personality characteristics desirable
to the concept of "emotional intelligence" (Goleman, in medical students and physicians. In one study, faculty
1995), contribute to success as a medical student and a and resident physicians valued a trait they labeled "tough-
professional. ness," which centered on enduran ce, perseveran ce, and
Another factor that seems to affect success in medical self-discipline. Sensitivity to others was also seen as a de-
school is coming from a socioeconomically or education- sirable trait for medical students. In another study, 42 rned- .
ally disadvantaged background, as is the case with many ical students were asked to rank 18 desirable traits. They
students who are from underrepresented minority popu- ranked honesty, responsibility, capability, and the ability to
lations. To examine this factor, an investigator recently love as the most desirable characteristics. Compulsivity is
(1998) cornpared the attrition rates of underrepresented another characteristic often identified as a valuable and
minority (URi\1) and nonminority (non-URM) students adaptive trait in physicians beca use it is believed to be as-
over a four-year period at a midwestern college of medi- sociated with carefully planned therapeutic regimens and
cine. The study found that among the 19% of URM stu- thoroughness in the diagnostic workup, including a will-
dents admitted (near the national average of minority ad- ingness to "go the extra rnile" to rule out arare disease.
missions) there was an attrition rate of approximately 16%, Given that sensitivity to others, horiesty, perseverance,
compared to a 4% attrition rate for non-URM students. and compulsivity are desirable traits for medical students
Moreover, students who withdrew because of academic dif- and physicians to possess, to what degree are these traits
ficulties comprised 75% of URM withdrawals and 57% of found among medical professionals? It appears that med-
non-URJ\tI withdrawals. Results such as these point to the ical students possess the characteristics of perseverance and
-. Chapter 6: Special Problems of Medical Students 73
subsequent overall mortality in their now late middle-aged the authors' experience with medical students, lead us to
S2mpie of physicians. These investigators discovered that three conclusions:
physicians whose hostility seores had been high 25 years ear-
lier were four to five times more likely to develop heart prob- 1. Over the course of the first 3 years of medical school,
lems during the ensuing years than those whose seores had· students become more Type A in their personality sryle.
been lower. A more recent longitudinal study of more than 2. As a group, they also become more mature, self-confi-
1,000 medical students found similar results. Students who dent, self-disciplined, extroverted, and hedonistic.
coped with tension by directing it inward, compared to 3. Education in medical schoolleads to improved commu-
those who used other coping mechanisms, were found to nication skills, but upon graduation, most students
have higher risk for early mortality (under age 55), even could benefit from further refinement of their interper-
when adjustments were made for age, smoking and choles- sonal skills.
terol.
Effect of medical school on personality. Two separate Although on the surface the increases in hedonism and
studies have reported an increase in Type A behavior in self-discipline appear contradictory, they reflect what
Australian medical students over the first 3 to 4 years of many medical students know: medical school teaches them
training in a 6-year curriculum. Similar increases in Type to work very hard and play equally hard.
A behavior occurred across 4 years of training in students
enrolled in an American medical school.
Other negative changes in students' personalities may Medical Marriages
also result from medical school training. Two studies dem-
onstrated a modest but unmistakable shift toward hedo- On any list of desirable professions for their child's spouse,
nism between the freshman and junior years of medical parents rank medicine at or near the topo The parent as-
school in two cohorts of students. More specifically, be- sumes the spouse's intelligence, education, income, and
tween their freshman and junior years medical students compassion will ensure a happy marriage. Unfortunately,
became less concerned with achievement and less intellec- this is not necessarily the case. On the positive side and con-
tually curious and became more impulsive, aggressive, and trary to popular opinion, physicians tend to stay in their nzar.-
interested in play. The authors attributed these changes to riages; and in fact, with a divorce rate of 29%, they have a
students' increasing dissatisfaction with their spartan edu- lower divorce rate than many other professions. Studies pub-
cational atmosphere. Other authors have reported that stu- lished in 1997 reported differential divorce rates with psy-
dents become significantly more self-indulgent, cynical, chiatrists having the highest rate (50%), followed by sur-
aggressive, and confrontational over the course of medical geons (33%), and pediatricians, internists, and pathologists
school. (23%). Among women physicians 70%-85% marry, and
On a more positive note, a longitudinal study found 50%-70% of these marry other physicians. Women derrna-
that Australian medical students in their sixth year of tologists are most likely to marry, and women emergency
study were more mature, emotionally stable, self-assured, room physicians and surgeons are least likely to marry. Fe-
self-disciplined, and extroverted than during their second male physicians have been found to have a higher divorce
year of training. A longitudinal study of 76 students in an rate than male physicians, though this appears to be an
American medical school found that students' self-per- artifact of specialty area and the higher divorce rate of
ceptions of warmth and helpfulness were stable over the women in the work force. A 1997 study found that women
course of training with no discernible trend toward cyn- physicians' divorce rate is lower than the rate for women in
icism or detachment from patients. In addition, a longi- the general population, consistent with earlier research that
tudinal controlled study published in 1997 showed that showed that women physicians' likelihood of divoree is
rather than losing interpersonal skills over the course of 23% lower compared to the general population of ern-
training, medical students who received education and ployed women. Physicians' divorces typically occur after
experience in this area can improve their skills. However, medical school or residency training, when the physieian
based on studies that show the average physician interrupts is 35 to 45 years of age.
his patient within 18 seconds of beginning the interview and Despite the longevity of physicians' marriage, in one
a study published as recently as 1997 which showed that study 47% of physicians reported having an unhappy mar-
90% of nurses report verbal abuse from a physician within riage. A recent (1999) study of over 650 physicians found
the past year, we know that it is important to continué to similar results in that approximately half reported high lev-
teach medical students and physicians to cornmunicate more els of marital satisfaetion. Other studies have found that
effectively. 25% to 47% of physicians have sought marital counseling
In surnmary, investigations of the effects of medical as a result of unhappiness, and an additional 21 % have
school training on students' personality characteristics seriously considered it. Still, even during residency, 40% of
have produced mixed results. These data, combined with residents report majar problems with their spouse. Of
Chapter 6: Special Problems of Medical Students 75
rhose who reported problems, 72% believed the problems stresses and satisfaction experienced in two-physician mar-
were caused by the residency, although only 21 % thought riages with those reported by couples in which only one of
their hospital work had been negatively affected by their the partners is a physician. In general, investigators have
marital problems. found no significant differences in the stressors reported
Sources of marital conflict. Several recent studies have by these two types of couples, and two-physician couples
investigated sources of conflict in physician marriages. One do not report either greater sharing or greater understand-
study analyzed questionnaires from 108 residents and found ing of work-related problems than the other couples. The
that they attributed their relationship stress to the large most recent investigation of dual-doctors' marriages was
number ofhours spent at the hospital, lack of athletic activ- published in 1999. Over 1200 physicians completed a sur-
iry, sleep deprivation, lack of family and social support, daily vey in order to directly compare two-physician marriages
chores.indebtedness, and the fact that the residents' spouses to marriages in which only one member was a physician.
worked long hours. Other authors have noted additional Twenty-two percent of the male physicians and 44% of the
sources of conflict in physician marriages, including chronic female physicians were married to physicians. Men and
fatigue, decreased sexual interest, and feelings of alienation women in dual-doctor marriages differed significantly
and loneliness in the nonmedical spouse. from other married physicians in that they more frequently
By lar the most common so urce 01 conflict reported in stud- enjoyed shared work interests with their spouses and had
ies 01physicians' marriages is the physicians' tendency to work higher family incomes (although they earned less individ-
long hours. Despite the popularity of this explanation, stud- ually). The two types of couples were not different from
ies, including one published in 2000, have failed to establish one another in the frequency with which they achieved
a significant correlation between divorce or marital dissat- their career goals or the frequency with which they experi-
isfaction and long hours of work in either physicians or enced conflict between their professional and family roles.
medical students. Similarly, another study found that lack Benefits of marriage. Sorne researchers have long con-
of time because of practice demands was a complaint that sidered marriage to have a positive effect on male medical
served to externalize conflicts inherent in the relationship, students, and marital satisfaction has repeatedly been
falsely attributing failure to factors outside the marriage. found among physicians to be a predictor of job satisfac-
tion. One study found that men who were married when
Accordingly, those researchers found that the real conflicts
they entered medical school were less likely to fail or drop
in medical marriages revolve around differences in the
out than unmarried male students. Female residents have
partners' needs for intimacy, disparate perceptions of the
also reported positive benefits from marriage, including a
problems in the relationship and in each other, and com-
sense of emotional security and intimacy. Unfortunately, at
municatíon styles. The major concern 01 these physicians,
least two studies suggest that [emale medical students may
93% 01 whom were men, was that their spouses were not
receive less support from their spouses than male students.
interested in having sexual relations. The primary complaint
The more rigorous of these studies found that among 334
01 the spoLl5es was that thetr physician partners did not talk
medical students, 17% of married women compared with
to them enough. Interestingly, for both the physicians and
only 6% of married men indicated th'at their relationship
their spouses, complaints of "doesn't support or empathize
with their spouse was very stressful. Sirnilarly, although
with me" and "doesn't listen to me" were common. This
31 % of the men indicated their wives were moderately or
finding is consistent with two more recent (1999) studies
very supportive, only 19% of the women described. their
that found that marital satisfaction and psychological ad- husbands' behavior that way. . '.
justmen t were predicted by spousal support, not by stress
or the number of hours worked.
Although earlier investigations of medical marriages
dealt almost exclusively with male physicians and their Practice Setting and Specialty Choice
wives, recent studies examined dual-doctor marriages. One
study analyzed interviews with female interns and residents Several characteristics of medical students affect specialty
and their spouses. The husbands of these residents com- choice and practice setting. For example, a study published
plained about the fatigue of their mates, the lack of time in 1998 found that growing up in an inner-city community
together, and the necessity to postpone gratification. The was significantly associated with practicing in an urban cen-
husbands also felt overburdened with domestic responsi- ter, whereas growing up in a rural community was more likely
bilities and found conflicts with their own career demands to tesult in practicing in a rural center. In addition, women
difficult to reconcile. Interestingly, in another study 75% of are more likely than men to be in generalist or primary care
women physicians reported perceived spousal support, al- fields, to be in a group rather than a solo practice, to have
though only 15% of their husbands took significant re- practices with a high proportion of managed care patients,
sponsibility for family or household chores. to report dissatisfaction with the short amount of time they I
Despite the increasing numbers of marriages between have to spend with patients and colleagues, and to report
two physicians, there is a paucíty of research comparing concerns about their ability to stay knowledgeable.
76 Part 1: The Physician and Society
A study published in 1998 based on the responses of and Medicaid programs. Physicians are no longer seen as
almost 2,170 physicians indicated that the factors that have infallible.
inf1uenced medical students' specialty choices have re- Unfortunately, the public's changing view of medicine
mained remarkably consistent over the past 65 years, de- has spread to the physicians thernselves. It has becorne fash-
spite the drama tic changes that have occurred in medicine ionable among physicians to bemoan their profession,
and medical care delivery systems oyer those decades. The complaining increasingly about health maintenance orga-
factorsmost consistently rated positive were: consistently nizations and preferred provider organizations (see Chap-
intellectual curiosity (e. g., "challenging diagnostic prob- ter 3) and the intrusion of other business matters into their
lerns"), altruism (e. g., "interest in helping people"), and practices. Physicians also cite diagnostic related groups, ris-
personal identity (e. g., "corisistent with personality; pos- ing numbers of malpractice suits and declining rates of
sess the required skills"). Negative factors such as "de- reimbursement from insurance companies as harbingers
mands on time" and "stress in the field" were also consis- of the ruin of medicine as a career.
tently cited as important factors. Negative attitudes about a career in medicine have result-
The demographic characteristics of persons who select a ed in sorne physicians discouraging students from entering
spccific specialty appear to differ across specialties. For ex- a career in medicine. In a survey of 1,200 students who
arnple, among 2,700 U. S. wornen physicians recently (1998) scored well on the Medica] College Admission Test but did
surveycd, surgeons were younger and more likely to be not apply to medical school, 25% reported that a practicing
whitc, Unmarried, childless, and born in the U. S. Women physician had discouraged them from seeking a career in
surgeons, compared to other wornen physicians, also medicine. Another survey indicated 33% to 40% of appli-
workcd more clinical hours and cal! nizhts but were not cants had been discouraged from going to medical school by
more likcly to report they worked too much, '" had too much a physician. When queried, 44% of physicians reported that
work stress, or had less control over their work environment. they would not encourage their child to pursue a career in
Thcir career satisfaction was similar to other women physi- medicine, although a subsequent study suggested that per-
cians, and their satisfaction with their specialty was greater. haps the percentage might have been lower if"were my child
interested in medicine" had been added to the questicn.
Despite the negative discourse about medicine as a ca-
reer, studies conducted as recently as 1999 show that the
Career Satisfaction of Physicians majority of physicians are fairl), happy with their career
choice. For exarnple, a study published in 1998 of nearly
Allhough recen: polls indicate that medicine is still the most 800 male and female physicians across a variety of medical
honored profession, the public's respect for physicians has specialties and practice settings found that 73% were satis-
clearly been eroded by well-publicized malpractice suits and fied with their overall practice and most were satisfied with
rcports of physician fraud in federally funded Medicare their income. Physicians in private practice were most sat-
;,
Chapter 6: Special Problems of Medical Students 77
isfied with their overall practice and office resources.
Among primary care physicians, the family practitioners Nothíng wíll sustain you more potently than the power
and general internists were generally less satisfied, and gen- to recognize in your humdrum routine ... the true poetry
eral pediatricians were gene rally more satisfied with most of life-the poetry of the commonplace, of the ordinary
aspects of their practice. Similar results were found in a rnan, of the toil wom woman, with their joys, their 50"-
1999 survey of a nationally representative group of nearly rows, and theit griefs. ..
2,700 women physicians which revealed that 84% were
l1enerally satisfied with their careers (usually, almost al-
a
ways, or always satisfied). However, 31 % would maybe, SIR WILLlAM OSLER'S advice to medical students
probably, or definitely not choose to be a physician again, (circa 1905)
and 38% would maybe, probably, or definitely prefer to
change their specialty. As in the earlier study of men and
women, among the women surveyed, career satisfaction lene Shaw and her colleagues found that students expressed
was significan tiy affected by several factors, including work concern about the stigma of seeking professional help. In
control, specialty choice, practice type, and work1oad. Oth- addition, distressed students who were not receiving psy-
cr studies have shown that autonomy, relationships with chological treatment had higher levels of socially prescribed
colleagues and patients, resources, status, personality traits, perfectionism and held more negative attitudes about men-
and time away from work predict job satisfaction among tal health services than distressed students who were seeking
physicians. In a direct comparison between fee-for-service help. Studies such as these point to the importance of edu-
and capitation, a 1999 study showed that physicians were cating medical students about research that has established
much more satisfied with a fee-for-service delivery system. the effectiveness of psychotherapy and marital therapy. It is
To determine which aspects of their jobs physicians find also important that medical students be informed about the :
satisfying, a study asked 211 physicians to rate their degree ethics of confidentiality, which govern university counseling
of satisfaction on 13 job-related variables. The study found centers. Lastly, students should understand that experienc-
that overt dissatisfaction was rare, and the average rating ing severe stress and seeking help for it are both "normal."
on each of the items was in the range that indicated mod- A significant proportion (10%-20%) of practicing physi-
erate to extreme satisfaction. The physicians were most sat- cians at some time in their professionallife will have a signif-
isfied with the diversity of patients under their care, their icant psychiatric disorder. For example, a 1995 study found
ability to derive personal gratification from patient care, that 13% of residents met diagnostic criteria for Post- Trau-
and their intellectual stimulation. They were least satisfied matic Stress Disorder. In another study, 34% of the mid-
with their prospects for increasing success in the future, dle-aged physicians in the sample had sought lOor more
with 21 % indicating they were not very satisfied or very outpatient visits for psychiatric care, a proportion that was
dissatisfied with that aspect of their jobo significantly higher than that for a matched control group.
In this study 17% of physicians vs. 6% of the controls had
required psychiatric hospitalization.
The statistics regarding the use of psychiatric services by
PSYCHOLOGICAL PROBLEMS medical students and physicians are not surprising. Cer-
tainly we could not expect that medical training provides
IN MEDICAL STUDENTS immunity from the psychological problems that beset all
AND PHYSICIANS other groups of people. The psychologicaI problems that
have been most frequently studied in rnedical students and
Although the majority of medical students and physicians physicians are depression, suicide, and substance abuse.
cope successfully with the demands of their lives, as many
as 30% develop psychological problems. Despite these
high rates of distress, studies have shown that only 8% to Depression
15% of medical students seek psychiatric ca re during the
course of their medica! education. Of the students who Several empirical studies have documented what most medical
seek psychiatric ca re, depending on the sample studied, students already know: medical school can be a depressing
35% to 40% are found to have difficulty adjusting to sorne place. One study of 304 medica! students found that the
aspect of school. Another significant proportion of stu- incidence of major depression during the first two years of
dents seeking care (22%-40%) has a mood disturban ce, .school was 12%, with a lifetirne prevalence of 15% through
usually depression. About 15% request assistance with the second year of school. This later rate is three times great-
mar ita! problems. er than that for an age-matched control in the general pop-
Severa! factors affect students' willingness to seek psycho-· ulation. Another study showed that the largest proportion
logica! careo For example, a study published in 2000 by Dar- of students (25%) were symptomatic for depression near
78 Part 1: The Physician and Sociery
the end of the second year. Strikingly similar results were of depressive symptoms was noted for PGYl interns, with
found in a recent (1997) longitudinal study which found the rate dropping during each successive year of training
that although entering medical students had similar rates of to arate of 10.3% in PGY3 residents.
depression as the general population, by year two 39% and Although no well-designed studies of the rates of de-
by year four 31 % scored aboye the 80th percentile on a stan- . pression among practicing male physicians have be en re-
dardized measure of depression. Although no gender differ- ported, high rates 01 depression similar to those lar house
ences were found at baseline, women experienced higher offieers have been reponed lar practieing [emale physicians.
rates of depression than men at year two and at year four. One study, which used carefully defined diagnostic criteria,
Increases in perceived stress were significant predictors of established a lifetime prevalen ce rate of 39% for major de-
increased depression scores in both men and women. A sep- pression among 111 female physicians. This 39% preva-
arate 1999 study found that although men and women med- lence rate is significantly higher than the 25% lifetirne risk
ical students are equally likely to experience stressful life for depression that is commonly found in the general pop-
events (e. g., 38% death of a family member in past 12 ulation of women. Another more recent (1999) study
months; 39% financial problems), women who experienced found that 19.5% of women physicians sell-reported a his-
these events appraised them as more negative and as having tory of depression. Depression was more common among
a greater impact on them. In additiori, students, espeeially women physicians who were not partnered; were childless;
women, witli less good social support networks prior to enter- drank alcohol; had wotse health; had more stress at home;
ing were more prone to depression, even il they reported good had a history of substance abuse, an eating disorder, or
networks during medical sehoo/. another psychiatric illness; had less control at work; had
Several researchers have found that medical students do high job stress; were dissatisfied with their career; and who
not suffer from more psychiatric distress than other grad- reported working too mucho Other studies have shown that
uate students. For exarnple, a study published in 1998 by support [rom peers and work group cohesiveness mitigate
Darlene Shaw and her colleagues found that although 28% against depression in physieia '15.
(2.5 times the number found in the normal population) of
students scored in the clinical range on a standardized mea-
sure of psychiatric distress, medical, dental, and nursing Suicide Among Medical Students and Physicians
students did not differ from one another on this rneasure,
and pharmacy students were more distressed than each of After accidents, suicide is the most common cause 01 death
these groups. among medieal students. A survey published in 1996 of 101
Several investigators have sought to identify personality (80%) U. S. medical schools found that between 1989 and
characteristics and other factors that predict psychiatric 1994, a total of 15 students committed suicide; Fourteen of
distress among medical students. A 1997 study found that the suicides were men, 8 of whom used a firearm and 6 of
poorer undergraduate academic performance, high trait whom overdosed. Forty percent of the reported suicides
and state anxi ety, high state depression, low dispositional occurred in the junior yeaL This rate was below the nation-
optirnism, and reliance on avoidant coping strategies pre- al rate for this age group and was lower than reported in
dicted depression and anxiety toward the end of the first earlier studies of medical student suicide. The authors sug-
year in medical school. In a separate 1997 study, socially gest that perhaps counseling programs have contributed to
preseribed perjectionism and high scores on the imposter seale a decline in the suicide rates among medical students. Oth-
(a seale that measures students'. beliels that they are less com- er studies have found that the suicide rate for female med-
petent than others believe they are and that they will one day ical students equals that of the men but is three to four
be diseovered as Ira uds) were the strongest predietors 01psy- times higher than their female age-mates.
chiatrie distress among medical students. Suicide is also a serious problem aniong practicing phy-
The relatively high rates of depression found among sicians. Eaeh year physician suicide in the United States re-
medical students continue into the internship year. With moves [rom society a number 01physieians equal to the size
surprising consistency, studies have demonstrated that ap- 01 an average medieal sehool graduating class. Early studies
proximately 30% of interns in the first postgraduate year suggested physician suicide rates were approximately twice
(PGY1) of training suffer from depressive syndromes. One the rate for the general population. That finding, however,
such study found that although only 10% of entering in- reflected the fact that physicians of the day were over-
terns had psychiatric disorders, 27% of interns had expe- whelmingly white rnen, a subgroup with an especially high
rienced at least ene episode of major depression at the con- base rate of suicide. More recent studies have [ound that male
clusion of the first six months of training. The onset of physicians do not commit suicide much more [requently than
depression was significantly associated with a positive pa- other men in the United States. In contrast, female physicians
rental history of depression and high scores on tests of neu- have a suicide rate that is approximately two to [our times
roticism; whereas sex, marital status, and workload were that lar white nonphysician women 01 the same age.
not associated. In another study, a 28.7% prevalence rate Factors associated with physician suicide and suicide at-
Chapter 6: Special Problems of Medica] Students 79
turbed, and alcohol or drugs were thought to be a signifi-
cant factor in 40% of these suicides. Another study that
compared physician suicides with an age- and sex-matched
control group of physicians who died of other causes found
significantly more physicians who committed suicide had
chronic mental disorders, psychiatric hospitalizations, pre-
vious suicide atternpts, and outpatient care by a mental
health professional. The greatest differences between the two
groups was in their use of drugs and alcohol; significantly
more of the suicide group (34% vs. 14% of controls) were
believed to have had a drug problem and/or problems as-
sociated with their use of alcohol at sorne time in their lives.
Finally, significantly more physicians in the suicide group
cornpared with the controls had been physically violent
toward their spouses (36% vs. 11%), and the suicide group
was believed to have received and to have given significantly
less emotional support from and to family members and
friends. A recent study (1999) of 2,700 women physicians
found that 1.5% self-reported a suicide attempt. Those
with a history of alcohol abuse or dependence, sexual
abuse, domes tic violence, poor current mental health, a
family history of psychiatric disorders, U. S. birth, and
non-Asían heritage were significantly more likely to report
suicide attempts or depression.
ers have suggested that physicians are at higher risk for drug prevalence of marijuana use for medical students was also
u~e because 20% to 25% of them are adult children of al- very similar to their peers from the national sarnple, but
coholics. when marijuana use in the previous month was cornpared,
medica! students had significantly lower rates of use (17%)
than college (21 %) or high school (27%) graduates. A sim-
Substance Use by Medical Students and Physicians ilar finding was reported for daily use of marijuana, with
only 1% of rnale and female medical students reporting
In addition to al! of the speculation about drug use among daily use compared with male (5.5%) and female (2%) c01-
physicians, many investigations of the actual prevalen ce of 1ege graduates and male (11 %) and female (15%) high
drug use among physicians and medical students have been school graduates. Cocaine showed a similar pattern, with
conducted. The most comprehensive study of substance the medica! students being significantly 1ess likely and the
use among medical students analyzed the responses of 589 high school students significantly more likely than the c01-
fourth-year students to an anonyrnous questionnaire ad- 1ege graduates to use this substance in the previous year or
ministered at 13 medical schools in different regions of the month. Cigarettes showed the most drama tic differences in
United States. In that study, for each of 11 substances, stu- that only 4% of male and 5% of female medica! students
dents reported whether they had used that substance ever smoke daily compared with 40% of male and 34% of fe-
in their lifetime, in the past year, in the previous 30 days, male high school graduates of a similar age. In summary,
or daily (defined as 20 or more times in the previous compared with their peers nationally, me di cal students re-
month). Alcohol was the most widely used drug, with 88% ported less use of marijuana, cocaine, cigarettes, and sev-
of the medical students reporting alcohol use in the month eral other substances (e. g., LSD, barbiturates, and arnphet-
before the study. Marijuana was the second most frequently amines). However, their use of tranquilizers and alcohol
used substance, with 17% reporting use in the previous was slightly higher than that of their cohorts.
month. Cocaine ranked third in frequency of use, with 6% No similarly good data exist comparing substance use
of students reporting use in the previous month. Not sur- among physicians and their peers. Studies that do look at
prisingly, only 9% of students reported smoking cigarettes this issue report conflicting results. Although a 1991 study
in the previous month. found no significant differences in the drinking patterns of
Similar rates of substance use were reported in a longi- physicians compared with age-matched controls, other in-
tudinal study of 170 medical students approximately ten vestigators have suggested that as physicians age, they are
years later in 1997. Most medical students (92%-95%) re- more likely than the general population to evidence aleo-
ported using alcohol at least once in the prior year, and hol-related problems.
marijuana was the il!icit drug used most by students A 1999 study examined the anonyrnous self-reported
(22%-29%) in the past yeaL Benzodiazepine use in the past past year use of several substances among more than 5,400
year was reported by 2%-é/o of medical students. Medical physicians from twelve specialties. The statistical model
students' use oflicit and illicit drugs was comparable to that controlled for demographic and other characteristics that
of their chronological peers and prior studies of medical might explain observed specialty differences. Emergency
students. Surprisingly, although sorne students (4%-9%) room physicians used more illicit drugs; psychiatrists used
appeared to be at risk for alcohol dependence, no student more benzodiazepines; and anesthesiologists used more
carne to the attention of the school administration due to major opiates. Comparatively, pediatricians had overall
problems associated with substance use. Moreover, al- lower use rates, as did surgeons, except for tobacco smok-
though 13% to 17% students were m-vare of a classmate's ing. Self-reported substance abuse and dependence were
problem, half of students who were aware of a student's prob- highest among psychiatrists and emergency room physi-
lem failed to take any action. Heavy drinking (defined as five cians and lowest among surgeons.
or more drinks in a 24-hour period) was reported by
14%-22% of students. This study and a study by one of the
present authors found that students with a farnily history
of alcohol abuse had a significantly increased risk for de- Substance Abuse by Medical Students and
veloping alcohol-related problems. Physicians
Other studies have addressed whether medical students
use various substances at arate higher than a national sarn- Studies that have investigated the prevalence of substance
ple of their peers. With respect to alcohol use, when corn- abuse (as opposed to substance use) among medical stu-
pared with more than 2,500 age- and sex-matched controls, dents have found that 11% to 23% of medical students are
medical students had higher rates of alcohol use in the pre- excessive drinkers, 6.5% are at high risk for substance
vious month than college or high school graduares, al- abuse, 18% abuse alcohol sometime during medical
though the lifetime prevalence (95%-97%) was very simi- school, and 3% are dependent on psychoactive substances
lar for the medical student and control groups. Lifetime other than alcohol. Although somewhat alarming, these
Chapter 6: Special Problems of Medical Students 81
percentages do not signify prevalence rates that are signif- those encountered in other high-stress occupations that re-
icantly higher than those found in their same-age peers. quire long and intensive preparation. Contrary to popular
Only three studies have directly compared rates of sub- mythology, medical marriages are stable and the divorce rate
stance abuse among physicians with rates among other oc- for physicians is relatively low; however, many medical mar-
cupational groups. Each of these three, however, found no riages are unhappy, and long work hours and patient de-
significant differences between the rates for physicians vs. mands can easily become an excuse for avoiding the diffi-
other groups. The prevalence of these problems among phy- cult job of confronting marital problems. Psychological
sicians is similar to that in the U. S. population in general. problems and substance abuse also exist in a significant
Encouraging as these findings are, a significant percent- number of physicians, and female medical students and
age of physicians are likely to abuse alcohol or drugs. This physicians in particular have high rates of stress and suicide
finding is of particular concern, because an impaired phy- as they cope with conflicting societal roles. It is imperative
sician can wreak untold harm on the patients in his or her that both medical students and physicians be aware of the
careo In addition, physicians who become alcohol depend- risks inherent in medical education and the physician role
ent suffer mightily. For exarnple, a study of 100 alcoholic and vigilant about early identification of any problems that
women (95 physicians and five medical students) found may develop. In our experience, clearly identifying a prob-
that 32% were separated or divorced, 53% had at least one lern and "owning" it places one at least halfway toward the
alcoholic parent, 8% said both parents were alcoholic, 22% eventual solution.
had suffered domestic violence, 32% had been arrested for
alcohol-related offenses, 34% had attempted suicide, 15%
had been sued for professional liability, and 71% had re-
ceived inpatient treatment for alcohol dependence.
In response to concerns about problems caused by irn-
CASESTUDY
paired physicians and with the encouragement of the Amer-
ican Medical Association, the state medical societies in each Jack Hunter, a 22-year-old graduate of a midwestern state-
of the 50 states have formed Impaired Physician Prograrns, supported university, is currently enrolled as a first-year
often referred to as Physician Assistance Programs, de- medical student at a prestigious university in the northeast
signed to help impaired physicians receive appropriate treat- United States. Although he excel!ed as an undergraduate,
ment. Jack is veryconcerned about his ability to compete success-
A similar movement is afoot on medical school campuses fuIly in medical schooJ. He feels overwhelmed by the vol-
where administrators are recognizing their responsibility to ume of material he has to read and memorize and finds he
establish clear guidelines and policies defining appropriate is envious of some of his former college classmates who
professional behavior regarding alcohol and drug use by enroIled in medical schools that use a problem-based
students. In addition, the federal government has recog- learning curriculum. Iack wants eventually to speciaJize in
nized the need for such policies and recently mandated that ophthalmology. He is aware that acceptance into those res-
institutions of higher education have in place poJicies and idency programs is extraordinarily competitive and only
programs relating to substance abuse. Medical schools, the very top students are accepted. As he sits in class, he
however, seem poorly equipped to fulfill that federal rnan- finds himself worrying about whether he will be able to
date. For example, although a recent study found that al! perform well enough on the United States Medical Licens-
medical schools responding to a survey (N equal l l-t) had ing Examination (USMLE) to warrant consideration by
psychological counseling available to students, one third of ophthalmology residency programs. Yet another source of
the schools indicated that these services are not adequate. In stress is his relationship with his girlfriend back home, who
a sepárate survey only 22% of rnedical schools responding is becoming bored with her job as a nurse's aid and is hop-
to a questionnaire indicated that they have a written policy ing to join him soon so they can marry at the end of his
relating to medical student impairment. Certainly, if the first year in medical school.
problem of substance abuse and other psychological disor- Iack spends all of his time studying. He is limiting him-
ders among medical students and physicians is to be ade- self to 5 hours of sleep each night and has stopped exercis-
quately addressed, medie al schools must develop programs ing. Although several of his classmates have suggested that
aimed at prevention, ear1y identification, and rehabilitation. he join their study group, he has declined their offer be-
cause he fears he do es not grasp the material well enough
to keep up with their pace. He feels uneasy and anxious
.around many of his classmates and he sits alone during
SUM1\1ARY lectures. His only sources of support are nightly phone
conversations with his girlfriend and "beer busts" with a
Medicine is a profession with multiple rewards and some couple of classmates after each major exarn and on week-
risks. On the average these risks appear comparable with ends.
82 Part 1: The Physician and Society
excellent resource for students who are experiencing "normal" This is a fascinating little book full of practical advice for rnedical
stress or mood problems. students.
Heitler, S. (1997). The power of two: Secrets to a strong é- loving mar-
riage. Oakland, CA: New Harbinger Publications.
This excellent book is for anyone whóís now or hopes to someday
be married. It provides clear instructions in how to cornmunicate
better with your partner, including teaching the skills needed ro
talk.Iisten, and resolve conflicts more effectively. It also provides
instruction in how to express and receive anger and how to arrive
at shared decisions in an efficient and caring fashion.
Hendrix, H. (1988). Getting the lave you want. New York. NY: Henry
Holt & Co.
This rernarkable book serves as a primer for helping individuals
understand the psychological dynamics inherent in virtually aU
romantic relationships and marriages. Although sorne of the ter-
minology borders on "psychobabble," the book helps couples to
identify feelings and behaviors left over from childhood that in-
evitably Iead them to experience conf1ict. It provides a series of
step-by-step exercises that help couples to beco me a source of
mutual support to one another. In our experience, many eouples
have found this book invaluable in helping them tounderstand
and heal their relationships.
Henning. K .• Ey, S.. & Shaw, D. (2000). Perfectionisrn, the irnposter
phenornenon, and psychological adjustment in rnedical, dental.
nursing. and pharmacy students.foumal ofMedical Education, 32.
456--464.
This article examines the personality characteristics which are
reJated to psychological distress experienced by medical, dental.
nursing. and pharmacy studerits.
McKay, M.. Fanning, P., .& Palcg, K. (1994). Couple ski lis: Makillg your
relationship work. Oakland, CA: New Harbinger Publieations.
This briefbook provides step-by-stcp instruction in communica-
tion skiUs that will enhance virtually any couplc's abiliry to corn-
municate with one another and negotiate solutions to the con-
fliets they are experiencing.
Myers, M.E (1988).Doctor's marriages: A loo]: at the problems and their
solutions. New York, NY: Plenum.
This book is an intelligent and thorough account of the issues of
special interest to medical studcnts.
Reiser, D.E .• & Rosen. D.H. (1985). Medicine as a human experience.
Rockville, MD: Aspen.
Primarily a book about the physieian-patient relationship, this
text provides an excellent aeeount of medicine from 'a humanistic
perspective without dcgenerating into an)' of the "psychobabble"
that sometirnes afflicts such writings, It includes a fine introduc-
tory chapter for medica! students about Jife on the wards, '
Virshup, B. (1985). Copillg in medica! school. New York. Nr: WV\'
Norton.