Numerous studies have found a high prevalence of psychological distress among medical students both in the United States and abroad.1,2 This distress may manifest in a variety of ways, including burnout, stress, depression, anxiety, poor mental or physical quality of life, or fatigue.3 Nearly half of U.S. medical students experience symptoms of burnout such as feeling emotionally exhausted, detached from patients, and that their efforts do not make a difference. Similar proportions have stress levels that are substantially higher than those of the age-matched general population and experience daytime sleepiness equivalent to that observed in patients requiring treatment for sleep apnea.3 When compared with the age-matched population, medical students have a strikingly higher prevalence of depression, with up to one-quarter exhibiting substantial depressive symptoms,4 and a higher rate of suicidal ideation.5 These various forms of distress often do not occur in isolation, however. Rather, students frequently suffer multiple forms simultaneously, making distress a multifaceted and individualized experience.3
Consequences of Distress
Distress among medical students has serious professional ramifications. Deterioration of mental health has damaging effects on medical students' empathy,6 interest in caring for underserved populations, ethical conduct, and professionalism.7 Further, students with burnout are less likely than those without burnout to hold altruistic views regarding physicians' responsibility to society and are more likely to seriously consider dropping out of medical school.8 This suggests that student distress may threaten the efficacy of efforts aimed at increasing medical students' interest in providing care to medically underserved populations and contribute to attrition from medical training, which has broader implications for the size of the physician workforce. In addition, distress can have profound personal consequences for students, including substance abuse, broken relationships, and suicidal ideation.5,9
Factors Associated With Distress
A variety of factors, both within and beyond the control of medical school administrators, contribute to distress among medical students. Evaluation/grading systems, learning environments, clerkship organization, resident role modeling, and faculty support are among the school-level factors that affect both medical students' mental health and their professional development.10–15 Beyond the immediate control of medical schools, major personal life events (e.g., personal or family illness, marriage, divorce) occur commonly among medical students and also strongly relate to the experience of burnout.4 Additionally, personal characteristics (e.g., having children, pursuing employment for income while in medical school) are associated with risk for dropping out8 and whether students can recover from distress once it occurs.11
Responding to Student Distress
Despite the high prevalence of distress and its potentially serious personal and professional ramifications, little is known about how to address the problem. The Liaison Committee on Medical Education (LCME) requires schools to have a student wellness program (Accreditation Standard MS-26),16 but guidelines on optimal format and content for such programs do not exist. Although well-intentioned efforts encouraging students to exercise, get more sleep, pursue good nutrition, and learn better approaches to stress management are pervasive, there is little evidence that these approaches are efficacious or have lasting benefits.
Against this backdrop, in this issue of Academic Medicine, Kushner and colleagues17 report the results of a novel, single-institution study in which students at the Northwestern University Feinberg School of Medicine (NUFSM) were required to use a cognitive behavioral approach to (1) identify a behavior they wished to improve, (2) monitor that baseline behavior, (3) learn about recommendations for the targeted behavior, (4) set personal goals, (5) implement a self-improvement plan, and (6) perform a self-assessment of effectiveness and identify factors that promoted or were barriers to achieving their goals. Students' behavioral choices included exercise, nutrition, and sleep, as well as more challenging dimensions such as study/work habits and mental/emotional health. Importantly, the study collected outcome data evaluating process and efficacy, including whether students achieved their goals, the factors they identified as facilitating or hindering success, and whether they would apply this behavioral change approach to other challenges in the future.
In this study,17 most students choose to focus on improving their exercise (44.6%), nutrition (27.4%), or sleep (15.2%) habits. Despite the high prevalence of distress among medical students, only 2.6% choose to focus directly on improving their mental/emotional health; this may have been due to concerns regarding confidentiality as well as the complex nature of this domain. (It is easier, for example, to increase the number of servings of fruits and vegetables consumed per day than to achieve better work-life balance). In aggregate, 80% of students felt they were healthier due to completing this cognitive behavioral exercise. Perhaps most important, students demonstrated insight into the factors that helped them achieve or kept them from achieving their goals, and more than 80% indicated they would use a cognitive behavioral approach to address future challenges.
It is also noteworthy that NUFSM has defined personal wellness and self-care as a core competency for its students. Although neither the American Board of Internal Medicine's Physician Charter nor the Accreditation Council for Graduate Medical Education's core competencies contain an explicit self-care competency, both Canada's Royal College of Physicians and Surgeons and the United Kingdom's General Medical Council specify self-care as a core provision in their formal statements on physician competency.18,19 We strongly support this approach and believe that once the concept of self-care is formally recognized as a core competency for physicians, evidence-based curriculum and assessment will follow naturally. Establishing such a competency will also promote incorporating these initiatives into the formal curriculum (e.g., part of a required class, as described by Kushner and colleagues) rather than offering them as “volunteer” activities to be performed on personal time.
Beyond helping students develop and sustain health habits during medical school, training in self-care should facilitate acquisition of skills needed to assess personal well-being and promote resilience throughout the course of a medical career. Kushner and colleagues should be commended as early pioneers in this arena.
It should be emphasized that medical schools' responsibility to promote student wellness goes beyond teaching students self-care skills to promote resilience. Indeed, promulgating such activities without establishing an appropriate organizational culture and shaping the modifiable aspects of the learning environment that influence student well-being is likely to be viewed by students as setting a double standard, which will breed cynicism (e.g., the culture of medicine expects physicians to sacrifice everything to the greater good, but they should be sure to not let themselves get burned out).
One organizational factor that has been identified as a contributor to student stress is the grading schema. Findings from pilot studies suggest that pass/fail grading in the first and second years reduces stress and has a positive effect on students' well-being without adversely affecting their knowledge acquisition.13–15 Other potential target areas for school-level innovations include curriculomegaly, competitiveness, poorly structured clerkships, student abuse, and inadequate preparation of students for exposure to human suffering and ethical challenges. Addressing deficiencies in these areas is likely to improve the learning environment, facilitate the development of desired professional attributes, and promote student well-being.
Addressing the “hidden curriculum” embedded in the organizational culture is an even greater challenge for schools.20 The covert messages of this curriculum, often characterized by modeled cynicism by faculty and supervising residents, continue to assign a stigma to mental illness and convey the message that only the “weak” struggle or need help.21 Concerned about confidentiality and potential repercussions to academic standing and future employment, students in distress often do not seek help of their own initiative. Informing students about available mental health services, ensuring confidentiality, locating such services in convenient locations, and excusing students from class or clinical activities are important (and required by LCME Accreditation Standard MS-2716), but these steps may not be adequate to reach students in need. Schools should consider independently administered, active monitoring of students' emotional health, with referrals to appropriate mental health providers (who are not involved in medical education) when needed. They should also pursue efforts to devise a curricular schedule that builds in adequate personal time and promotes personal health.
Given the impact of distress on quality of care and resilience over the course of a career in medicine, self-care (including personal appraisal of well-being, wellness promotion, and recognition of when help is needed) should be recognized as a core competency for physicians. Achieving competency in this area is a shared responsibility of the physician/resident/medical student and the organizational environment in which he or she functions. Additional research, such as that reported by Kushner and colleagues, is needed to identify effective personal and organization-level strategies to reduce distress, identify and support struggling students, and promote well-being for the good of physicians, health care organizations, and the patients to whom they provide care.
3Dyrbye LN, Harper W, Durning S, et al. Patterns of distress in U.S. medical students. Med Teach. In press.
5Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334–341.
6Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22:177–183.
7Dyrbye LN, Massie FS Jr, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among U.S. medical students. JAMA. 2010;304:1173–1180.
9Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260:2521–2528.
10Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: A multi-center study. Med Educ. 2009;43:274–282.
11Dyrbye LN, Power DV, Massie FS, et al. Factors associated with resiliency and recovery from burnout: A prospective, multi-institutional study of U.S. medical students. Med Educ. 2010;44:1016–1026.
12Frank E, Carrera JS, Stratton T, Bickel J, Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: Longitudinal survey. BMJ. 2006;333:682.
13Reed DA, Dyrbye LN, Szydlo DW, Shanafelt TD. Pass-fail grading is associated with enhanced well-being among medical students: A multi-institutional study. J Gen Intern Med. 2009;24(suppl 1):132.
15Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass-fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc. 2006;81:1443–1448.
17Kushner RF, Kessler S, McGaghie WC. Using behavior change plans to improve medical student self-care. Acad Med. 2011;86;901–906.
19General Medical Council. The new doctor: Guidance on foundation training. 2009. www.gmc-uk.org/index.asp
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21Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304:1181–1190.