Professionalism is critical to meeting the needs of patients and maintaining the public’s confidence in the medical profession.1 Although definitions of professionalism vary, physician integrity and accountability are widely acknowledged as core components.1,2 Integrity and accountability include maintaining appropriate relationships with patients, reporting impaired or incompetent colleagues, and managing conflicts of interests.1 Unfortunately, existing data have called into question the ability of some physicians to consistently handle these tasks appropriately. For example, a national study found that a third of physicians did not believe physicians are obligated to report an impaired or incompetent colleague.3 In that study, a third of physicians with personal knowledge of an impaired physician did not take any action.3 These beliefs and behaviors are in contrast to mandatory reporting statutes present in many states,3 the American Medical Association (AMA) code of ethics,4 and the Charter on Medical Professionalism.2
Additional data suggest that physician self-treatment and treatment of immediate family members, even for mental health problems, is widespread,5–8 despite statements by the AMA9 and others10–12 explaining why such behaviors indicate inappropriate professional actions and substandard care. The possibility of impaired professional objectivity, treating beyond area of expertise or training, and suboptimal dynamics in the patient–physician relationship (e.g., family members may fail to disclose sensitive information or be reluctant to decline a recommendation) are among the variety of reasons the AMA Code of Medical Ethics discourages self-prescribing or prescribing for family members.9 Together, these findings suggest that attitudes and behaviors within the medical culture often deviate from accepted professional standards.
Despite the importance of physician integrity and recognition of gaps between expected and actual behavior, little is known about medical students’ attitudes regarding appropriate prescribing behaviors as well as their personal responsibility to uphold the standards of the profession by reporting impaired colleagues, and what factors may influence these beliefs. Small studies conducted outside the United States suggest that acceptance of self-treatment is common among medical students in some countries, although it is not known how these attitudes extrapolate to U.S. medical students.5 With respect to reporting impaired colleagues, one U.S. study using vignettes depicting dilemmas about student impairment found that few medical students would report an ill colleague to medical school staff or other relevant authorities.13 No previous study, to our knowledge, has explored the relationship between medical students’ attitudes regarding these aspects of professionalism and measures of distress such as burnout, depression, and alcohol abuse/dependency.
On the basis of previous studies suggesting that distress is associated with decreased empathy14–17 and unprofessional behaviors and attitudes,17,18 we hypothesized that medical students experiencing professional burnout or personal distress (e.g., depression) would be more likely to endorse suboptimal prescribing practices and be less likely to report impaired colleagues. We further hypothesized that students personally experiencing symptoms of depression would be less likely to report colleagues impaired by similar mental health problems, while those personally struggling with alcohol abuse/dependence would be less likely to report colleagues impaired by alcohol or substance use.
Method
Participants and procedures
We have previously described the methods for this study elsewhere.19 Briefly, in 2012 we surveyed all 26,760 medical students who were listed in the Physician Masterfile (PMF) and who had given the AMA permission to contact them by e-mail. All accredited allopathic schools in the United States provide information on every matriculating student to the Association of American Medical Colleges (AAMC). The AAMC shares these data with the AMA, and the data become part of the PMF. Thus, the PMF contains nearly all medical students independent of AMA membership. We sent each medical student an e-mail message inviting them to participate in a study along with a link to the survey. Three reminders were sent over the ensuring two weeks. According to convention,20 we considered the roughly 12,500 medical students who opened at least one e-mail invitation to have received an invitation to participate in the study. Participation was voluntary, and all responses were anonymous. Completion of the survey implied consent, and we offered no incentives for participation. The Mayo Clinic institutional review board approved the study.
Study measures
Burnout, symptoms of depression, and symptoms of alcohol abuse or dependence.
We measured burnout using the Maslach Burnout Inventory (MBI).21 The MBI measures three burnout domains (emotional exhaustion [EE], depersonalization [DP], and low sense of personal accomplishment [PA]), which have been confirmed in factor analyses.21 For the current study, we categorized scores into low, intermediate, and high using established cutoffs.21 Because high scores on either the EE (≥27) or DP (≥10) scales can distinguish clinically burned-out from non-burned-out individuals, we considered those who scored high on either the EE or DP domain of burnout to have at least one manifestation of professional burnout.
We measured symptoms of depression using the two-item Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument.22 A positive depression screen is defined as a “yes” response to either of the two items. The PRIME-MD performs similarly to longer instruments,23 with a sensitivity of 86% to 96% and a specificity of 57% to 75% for major depressive disorder.22,23
We assessed symptoms of alcohol abuse/dependence using the Alcohol Use Disorders Identification Test version C (AUDIT-C). According to standard scoring, a score ≥5 for men or ≥4 for women on the AUDIT-C is considered to indicate symptoms of alcohol abuse or dependence.24,25
Measures of professional attitudes about appropriate prescribing and self-regulation.
We asked students to indicate whether they believed it is appropriate for physicians to write a prescription for an antibiotic to treat a bladder infection in a spouse; an antibiotic to treat a bladder infection in him- or herself; an antidepressant medication for a spouse; and an antidepressant medication for him- or herself. Such prescribing behaviors are not specifically prohibited under federal law, although they may be under some state laws or pharmacy statutes. Regardless, the AMA Code of Medical Ethics discourages self-prescribing or prescribing for family members.9 The American College of Physicians (ACP) Ethics Manual11 and the Guide to Good Medical Practice–USA10 make similar assertions. The AMA code does allow for self-treatment or treatment of family members in emergency situations, in isolated settings where there is no other qualified physician available, or for short-term, minor problems. Although a scenario could be imagined where it may be ethical for a physician to self-prescribe an antibiotic or prescribe an antibiotic for a spouse, the same cannot be said for antidepressants. In concordance with this assertion, the American Psychiatric Association ethics committee specifically discourages prescribing psychotropics outside a sound working relationship between a physician and his or her patient, which a physician cannot have with him- or herself or with a family member.12
Other survey questions inquired about attitudes representative of professional responsibility to support and report impaired colleagues. These items stemmed from the Charter on Medical Professionalism2 and were similar to previously published items assessing physicians’ support for professional norms.3,26 Specifically, we asked students to rate their level of agreement on a five-point Likert scale that medical students should be concerned about the health and wellness of fellow students; personally intervene/assist promptly when the health or wellness of a fellow student appears to have become compromised; report all instances of impairment among fellow medical students due to a mental health problem such as depression to medical school staff or other relevant authorities; and report all instances of impairment among fellow medical students due to alcohol or substance use to medical school staff or other relevant authorities.
Statistical analysis
We used standard descriptive summary statistics to characterize the sample. Differences by year in school, burnout, positive screen for depression, and positive screen for alcohol use or dependence were evaluated using chi-square test. All tests were two sided with type I error rates of 0.05. We performed multivariate logistic regression between each of the four prescribing behaviors and burnout and depression separately, controlling for age, sex, and year in school. We also used multivariate logistic regression to compare students’ attitudes toward reporting impaired colleagues and burnout, depression, and alcohol abuse/dependence, separately, controlling for age, sex, and year in school. In addition, we conducted multivariate logistic regression analyses to evaluate independent associations of age, sex, relationship status, year in school, burnout, and positive depression screen with agreeing it is appropriate to self-prescribe any medication (antibiotic or antidepressant), self-prescribe an antidepressant, prescribe any medication for a spouse, and prescribe an antidepressant for a spouse. Finally, we conducted multivariate logistic regression analyses to evaluate independent associations of age, sex, relationship status, year in school, burnout, positive depression screen, and alcohol abuse/dependence with agreeing that medical students should report all instances of impairment among fellow medical students due to mental health problems, and medical students should report all instances of impairment among fellow medical students due to alcohol or substance use to medical school staff or other relevant authorities. In multivariable analysis, we excluded observations with missing values for independent or predictor variables from the model. In univariate analyses, missing values were not included when comparing proportions or mean values. We conducted all analyses using SAS statistical software version 9.3 (SAS Institute, Inc., Cary, North Carolina).
Results
Among the roughly 12,500 medical students who opened the e-mail inviting them to participate in the study, 4,402 (35.2% participation rate) completed the survey. We have previously reported the demographic characteristics, MBI scores, and prevalence of depressive symptoms for the same group of medical students.19 Briefly, 1,972/4,376 (45.1%) were male, the median age was 25, most were single (2,859/4,380), and all years were represented (1,146/4,402 were first-year students, 1,385/4,402 were second-years, 840/4,402 were third-years, and 887/4,402 were fourth-years). The demographic characteristics (i.e., sex, age, year in training) of medical students were generally similar to all medical students listed in the PMF, although fewer participants were male (45.1% versus 52.7%). The mean EE, DP, and PA scores were 25.0, 7.0, and 36.0, respectively. The prevalence of high EE, high DP, and low PA scores were 44.6%, 37.9%, and 35.8%, respectively. More than half of medical students (58.2%) screened positive for symptoms of depression, and 1,411/4,354 (32.4%) had AUDIT-C scores suggesting alcohol abuse/dependence.
Prescribing attitudes
Most students (57.7%) believed it was acceptable for physicians to write a prescription for an antibiotic to treat a bladder infection in a spouse, and over a third (34.5%) thought it acceptable for a physician to self-prescribe an antibiotic. Fewer students agreed that it is acceptable for physicians to prescribe an antidepressant for their spouse (8.6%) or to self-prescribe (4.9%) an antidepressant. Students in their clinical years (years 3 and 4) were slightly more likely to indicate that each inappropriate prescribing behavior was acceptable than preclinical students (years 1 and 2; see Supplemental Digital Table 1 https://links.lww.com/ACADMED/A253).
After controlling for age, sex, and year in school, students with burnout or with symptoms of depression were significantly more likely to indicate that each of the inappropriate prescribing behaviors was acceptable (Table 1). For example, students with burnout had a more than 50% increased odds of indicating that self-prescribing antidepressants was acceptable (OR 1.51 [95% CI 1.12–2.05]) than students without burnout. Similarly, students who screened positive for symptoms of depression were nearly 50% more likely to indicate that they believed that self-prescribing antidepressants was acceptable (OR 1.48 [95% CI 1.10–2.00]).
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Table 1: Relationships Between Burnout, Symptoms of Depression, and Beliefs About Appropriate Prescribing Behaviors Among a National Sample of U.S. Medical Students, 2012
Results of multivariable analysis (separate model for each prescribing practice evaluated) examining independent relationships between age, sex, relationship status, year in school, burnout, and positive depression screen with each prescribing behavior are shown in Table 2. Burnout remained independently associated with endorsing three of the four inappropriate prescribing behaviors, while depression was independently associated with endorsing two of the four inappropriate prescribing behaviors. Sex and year in school also remained independent predictors. Female medical students were substantially less likely to endorse each prescribing behavior than male students. Third- and fourth-year students were more likely than first-year students to endorse an inappropriate prescribing behavior.
Table 2: Multivariable Analysis of Factors Independently Associated With Agreeing That It Is Appropriate to Self-Prescribe or Prescribe for a Spouse Among a National Sample of U.S. Medical Students, 2012
Attitudes toward reporting impairment
Nearly all agreed that medical students should be concerned about the health and wellness of fellow students (95.6%), and most agreed that they should personally intervene when the health or wellness of a fellow student appears to have become compromised (81.7%). In contrast, less than half (47.5%) endorsed that medical students should report all instances of impairment among fellow medical students due to mental health problems (e.g., depression) to medical school staff or other relevant authorities. A slightly higher proportion of medical students indicated that medical students should report impairment among fellow students due to alcohol or substance abuse (58.7%). The discrepancy between reporting impairment due to mental health problems and alcohol or substance abuse was more pronounced among students later in training than those earlier in training (see Supplemental Digital Table 2 for details https://links.lww.com/ACADMED/A253).
Students with burnout or depressive symptoms were less likely to agree they had a personal responsibility to support and/or report impaired colleagues, although the magnitude of these differences was generally small (Table 3). Students personally experiencing burnout (OR 0.79 [95% CI 0.70–0.90]) or depressive symptoms (OR 0.71 [95% CI 0.63–0.80]) were 20% to 30% less likely to believe that medical students should report colleagues who were impaired by mental health problems. Students who had symptoms of alcohol abuse/dependence (OR 0.53 [95% CI 0.46–0.60]) were substantially less likely to believe that medical students should report colleagues with impairment due to alcohol or substance abuse.
Table 3: Relationships Between Burnout, Symptoms of Depression, Symptoms of Alcohol Abuse or Dependence, and Attitudes Toward Supporting and Reporting Impaired Colleagues Among a National Sample of U.S. Medical Students, 2012
On multivariable analysis, positive depression screen (OR 0.72 [95% CI 0.63–0.82]), symptoms of alcohol abuse (OR 0.65 [0.57–0.75]), and more advanced year in school (see Table 4) were independently associated with lower odds of believing that medical students should report impairment among fellow medical students due to mental health problems. Burnout (OR 0.870 [95% CI 0.77–0.99]), alcohol abuse/dependence (OR 0.55 [95% 0.48–0.63]), and being partnered (versus married; OR 0.77 [95% CI 0.63–0.94]) were independently associated with lower odds of believing that medical students should report impairment among fellow medical students due to alcohol or substance abuse. Third- and fourth-year students (versus first-year students) and female students (OR 1.38 [95% CI 1.22–1.57]) were more likely to believe that medical students should report impairment among fellow medical students due to alcohol or substance.
Table 4: Multivariable Analysis of Factors Independently Associated With Attitudes Regarding Personal Responsibilities to Support Colleagues and Report Impairment Among a National Sample of U.S. Medical Students, 2012
Discussion
The duty of each physician to adhere to appropriate professional behavior and report impaired colleagues is critical to the integrity of the profession. In this large national study, we found a high prevalence of students who inappropriately believed it was acceptable for physicians to self-prescribe antibiotics or prescribe them for a spouse. A smaller but substantial proportion of students thought it was acceptable for physicians to self-prescribe antidepressants or prescribe antidepressants for their spouse, both behaviors clearly in conflict with established professional expectations.9–12 These beliefs were more common among students in the later years of training who are closer to having prescribing privileges. Although our findings show that students were concerned about each other’s health and wellness and believed that they have a personal responsibility to support each other, they frequently did not think that they have a personal responsibility to report an impaired colleague. Notably, beliefs about the duty to report impaired colleagues appear to be influenced by an individual medical student’s own distress and personal alcohol use. Although the sense of responsibility to support each other is encouraging, these findings suggest that students may choose to shield impaired colleagues rather than simultaneously supporting them and taking professional action to protect patients.
This study also furthers our understanding of relationships between attributes of professionalism and burnout. Students with burnout were more likely to agree that each of the inappropriate prescribing behaviors was acceptable, a finding that persisted for three of four prescribing scenarios after controlling for age, sex, relationship status, year in school, and positive depression screen. Students with burnout were also less likely to believe that they had a personal responsibility to support the health and wellness of colleagues or to report colleagues with impairment due to alcohol or substance use. These relationships between burnout and students’ beliefs about appropriate prescribing behaviors and duties regarding impaired colleagues are important because burnout is prevalent not only among medical students18,27 but also physicians.28–30 If burnout has a similar effect on these professional attitudes among practicing physicians, burnout may at least partially explain suboptimal physician participation in the process of reporting impaired colleagues3 and self-prescribing tendencies.5–8
By asking medical students in the early years of training, who may not have been exposed to accepted professional standards for prescribing behaviors, about their attitudes toward self-prescribing and prescribing for a spouse, we gained insight into how the medical school environment and professional culture may bear some responsibility for the high prevalence of suboptimal beliefs in these areas among more advanced medical students. Through the apprenticeship model of education, students are acculturated into an environment in which up to 50% of physicians self-prescribe5–8 and more than a third with direct knowledge of a physician who is incompetent to practice medicine do not report colleagues to the relevant authority.3,26 This may explain why students further along in their training were more likely to endorse suboptimal prescribing behaviors than students closer to the beginning of medical training. The relationship between year in training and beliefs about reporting impaired colleagues is more complex. Students in the later years of training were less likely than first-year students to believe that they should report colleagues who are impaired by mental health problems (e.g., depression) but more likely to support reporting colleagues impaired by alcohol or substance abuse. Whether this difference is due to greater fear of students with depression being discriminated against by residency directors or attending physicians, differing perceptions of degree of professional impairment from alcohol or substance abuse problems than depression, or other factors is worthy of further exploration.
As hypothesized, students personally experiencing symptoms of depression were less likely believe that medical students should report colleagues impaired by mental health problems. Similarly, students with alcohol abuse/dependence were less likely to believe they had a duty to report colleagues impaired by alcohol or substance use. These findings may relate to personal experiences with stigma regarding these conditions (e.g., personally experiencing negative consequences after revealing depression or seeking treatment) or a greater perception of self-stigma (e.g., if depressed then I have inadequate coping skills), treatment stigma (e.g., people view others less favorably if they have been treated for depression), or public stigma (e.g., people believe depressed people are inferior).31,32 The latter possibility is supported by findings from a previous single-institution study where students with greater Patient Health Questionnaire-9 (PHQ-9) scores were more likely to endorse stigma items than students with lower PHQ-9 scores.31
How should medical schools respond? First, our findings suggest that medical students may benefit from explicit curricula on appropriate prescribing practices, how professional impairment threatens quality of care, the importance of self-regulation to the profession, and how to appropriately intervene and support colleagues. Second, the higher prevalence of suboptimal prescribing and reporting behaviors among students with greater exposure to prescribers (physicians, residents) suggests that medical schools may need to work with physician groups, accrediting organizations, academic medical centers, and hospitals to accelerate efforts to educate the medical community about appropriate prescribing and the importance of self-regulation.3 Third, the hidden curriculum that fosters greater reluctance to report colleagues impaired from mental health problems than alcohol or substance abuse needs to be addressed. Fourth, the low prevalence of students willing to report impairment of colleagues due to mental health or alcohol/substance use problems coupled with low rates of self-initiated help-seeking behaviors33,34 support the calls for screening medical students for distress,35 student wellness programming, innovative curricula focused on self-care, and other school-level initiatives.35–37 Lastly, we found some interesting differences by sex, with female medical students having 30% to 47% lower odds of suboptimal attitudes about prescribing and professional responsibilities to report, that merit further study.
This study has a number of limitations. First, only a limited number of prescribing and reporting behaviors representative of professionalism were assessed. Second, the study assessed student beliefs rather than self-reported or observed behavior, which raises the potential of recall bias and reporting bias. Although we could have asked whether they had personally intervened to assist a colleague whose health appeared to have become compromised or had reported an impaired colleague, such an approach is vulnerable to opportunity bias (e.g., students who had not reported an impaired colleague may not have had the opportunity or may not have adhered to accepted professional standards). Third, medical students cannot prescribe medications; we do not know if the relationships found will persist among physicians. Fourth, as a cross-sectional study, this study cannot determine whether the relationships found are causal. A longitudinal study would provide a more definitive answer to the question about causation and directionality. Fifth, the response rate was 35% among students who received an invitation to participate in the study. Such a response rate is typical of national survey studies of physicians and medical students.18,38–40 We do not know if students with distress were more likely to complete the survey because the topic was relevant to them, or if they were less motivated to fill out the survey. To evaluate nonresponse bias,41 we compared demographics of our responders with the full population of U.S. medical students and found the groups quite comparable, although our sample was slightly biased toward female students. This minor demographic difference is unlikely to substantially influence our results because the relationship between burnout and attitudes toward prescribing practices and reporting impaired colleagues persisted on multivariable analysis after controlling for sex and other characteristics. We also compared the prevalence of burnout and positive depression screening among our responders with other data sources and found rates similar to what has been previously reported in studies with higher participation rates.18,26 These findings lend support that responders in this study were representative.
Strengths of the study include the use of the PMF, a complete registry of all U.S. medical students attending allopathic schools, to obtain a large sample size that included students in all years of training attending diverse medical schools distributed across the United States; a sample of respondents representative of U.S. medical students42; use of validated metrics to measure burnout, depressive symptoms, and alcohol dependency/abuse; and inclusion of items derived from the AMA Code of Medical Ethics,9 the ACP Ethics Manual,11 the Guide to Good Medical Practice–USA,10 the American Psychiatric Association ethics committee,12 the Charter on Medical Professionalism,2 and other previously published items assessing physicians’ support for professional norms.3,26
In summary, our findings indicate that suboptimal attitudes about professional responsibilities to report impairment and prescribing behaviors are common among medical students. Burnout was independently associated with suboptimal attitudes about regarding impaired colleagues and appropriate prescribing. Students personally dealing with depression or substance use problems were less likely to appropriately address impairment in colleagues dealing with the same issue. Collectively, these findings indicate that burnout and other forms of distress impede students’ abilities to fulfill their professional responsibilities.10,26 Efforts to cultivate professionalism in future physicians may benefit from a more explicit curriculum regarding appropriate prescribing and how to handle impaired colleagues as well as greater attention to medical student well-being.
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