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Ethical Use of Student Profiles to Predict and Prevent Development of Depression Symptoms During Medical School

Gengoux, Grace W., PhD; Roberts, Laura Weiss, MD, MA

doi: 10.1097/ACM.0000000000002436
Invited Commentaries

Research investigations have repeatedly shown that medical school can be a period of high stress and deteriorating mental health for many students. There is a critical need for systematic guidance on how to personalize prevention and treatment programming to help those students at highest risk. The authors of this Invited Commentary respond to the report by Dyrbye and colleagues, published in this issue of Academic Medicine, that proposes a prognostic index to predict risk of developing depression symptoms in medical students. The commentary authors applaud Dyrbye and her coauthors for their innovative approach; their findings provide substantial insights relevant to the critical goal of enhancing medical student well-being. However, evidence indicates that students who identify as members of racial, ethnic, sexual, and/or gender minority groups are at heightened risk of depression, so any program that profiles students in relation to their mental health symptoms must be proactive in ensuring that its efforts do not perpetuate stigma, marginalization, and discrimination for these underrepresented and potentially vulnerable groups. The commentary authors suggest practices for ethically implementing recommended wellness programs while maintaining an inclusive learning environment that respects personal privacy and incorporates transparent consent practices.

G.W. Gengoux is clinical associate professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California; ORCID: https://orcid.org/0000-0002-6942-9513.

L.W. Roberts is chairman and Katharine Dexter McCormick and Stanley McCormick Memorial Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California; ORCID: https://orcid.org/0000-0003-4270-253X.

Funding/Support: None reported.

Editor’s Note: This is an Invited Commentary on Dyrbye LN, Wittlin NM, Hardeman RR, et al. A prognostic index to identify the risk of developing depression symptoms among U.S. medical students derived from a national, four-year longitudinal study. Acad Med. 2019;94;217–226.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Laura Roberts, Department of Psychiatry and Behavioral Sciences, 401 Quarry Rd., Stanford, CA 94305; e-mail: lwroberts.author@gmail.com; Twitter: @_Roberts_Laura.

The human cost of not addressing poor mental health in medical students is substantial. Evidence suggests that about 28% of medical students globally show symptoms of depression1 and that symptoms can worsen over the course of medical school. Depression symptoms can be associated with anxiety, suicidal thoughts, and substance abuse—each of which carries its own additional health consequences. Students who identify as belonging to underrepresented ethnic, racial, sexual, and gender minority groups may be at particular risk.2–5 Depression symptoms can also contribute to functional impairment (e.g., difficulty with concentration, memory) and may be associated with long-term physical health effects, such as increased chance of cardiovascular disease, stroke, or obesity.6 Medical students experiencing depression or depression symptoms may not seek necessary care because of concerns about time, confidentiality, stigma, and potential repercussions for their careers.7 Students living with mental health issues are more likely to, at some point, drop out of medicine, which already has a fragile workforce. Those students with depression or depression symptoms who do remain in the field and eventually practice are at risk for burnout and continued declines in mental health, which, in turn, may lead to medical errors and lower-quality health care for patients.8

The benefits of remedying the widespread problem of poor medical student mental health would likely be extensive and influential. Students attend medical school to learn important academic content and clinical skills. Any efforts that make medical students more effective learners will help them become more skilled doctors as well. The majority of students attending medical school in the United States are young adults; learning to integrate meaningful work with self-care practices—including exercising, getting sufficient sleep, eating healthfully, and making time for personal relationships—will allow them to thrive throughout their adult lives. Although medical school has unique stressors, including near-constant exposure to new, challenging material and limited control over one’s daily schedule and workload, students will experience similar, and potentially even more potent, stressors as practicing physicians. The capacity to adapt to and effectively cope with the stresses of medical school may well have lifelong personal benefits for the physician-in-training. Moreover, given the increased focus on prevention and wellness in primary care and many other domains of medicine, enhancing wellness programming in medical school presents a unique opportunity to create synergy between student and patient needs. That is, integrating wellness programs for students with material about how they might incorporate wellness into patient care and the lifelong practice of medicine will substantially benefit future patients. For all these reasons, both understanding the factors that contribute to poor mental health outcomes for medical students and designing personalized approaches to support good health among physicians-in-training are critical needs in medical education.

Given the risks associated with medical student depression and the potential benefits of ameliorating depression symptoms in this population, the report by Dyrbye and colleagues9 on potentially identifying medical students vulnerable to depression is timely. In their study, “A Prognostic Index to Identify the Risk of Developing Depression Symptoms Among U.S. Medical Students Derived From a National, Four-Year Longitudinal Study,” published in this issue of Academic Medicine, Dyrbye and her coinvestigators have explored personal and medical school characteristics associated with increased depression symptoms in U.S. medical students.

Building on their extraordinary body of existing empirical work, Dyrbye and colleagues have developed and tested a “prognostic index that stratifies risk of developing depression symptoms” (Depression-PI).9 Their project engaged a large sample of medical students (n = 3,743) across 49 medical schools. The study’s results identified demographic factors, as well as psychological characteristics, associated with risk for depression. For example, students with depression symptoms at Year 4 of medical school were more likely to be nonwhite, single, born outside the United States, and from families with less income than the U.S. median household income. Higher stress, low social support, use of more negative coping behaviors, and depression symptoms in Year 1 were also strongly associated with increased risk of developing depression symptoms by the end of medical school.

The study is the first to propose and evaluate a model for predicting depression symptoms in medical students using a large longitudinal sample. The results promise to advance the science of medical student wellness by providing guidance regarding the students at the highest risk for developing depression, which, in turn, could lead to individualized programming to support these learners. Such an approach holds great potential for early identification and intervention for mental health issues, which, in turn, may reduce the burden of suffering experienced by students. At the same time, because individuals who have been shown to be at significant and heightened risk for depression during medical training also identify as belonging to nonmajority ethnic, racial, sexual, and gender groups,2–5 immense care must be taken to avoid perpetuating marginalization, stigma, and discrimination in profiling student risk and delivering targeted wellness interventions.

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Using Identified Risk Factors to Guide Curricular Programming

The student risk factors identified by Dyrbye and colleagues indicate that some subsets of students are likely to suffer more than others. Some of the risk factors Dyrbye and her coinvestigators have identified, such as negative coping behaviors, could be directly targeted with interventions. Existing evidence suggests that student psychological resources, such as feelings of self-efficacy and optimism, buffer perceived stress.10 Programs to bolster healthy coping behaviors in students may decrease the prevalence of depression symptoms. Vanderbilt School of Medicine has implemented a well-being curriculum focused specifically on the personal development of physicians-in-training11 as part of its comprehensive medical student wellness program. Mindfulness-based stress reduction and resilience training approaches have also shown promise.12 , 13 Notably, actively engaging students in identifying wellness priorities and in developing peer-led solutions is important for programs to be widely accepted and effective.12 , 14

Empirically derived demographic risk factors in Dyrbye and colleagues’ study highlight the fact that medical school may be uniquely stressful for students who identify as belonging to racial and ethnic minority groups. The diverse factors potentially contributing to this phenomenon warrant serious attention as a social justice issue. Medical schools have an obligation to make instruction—as well as the invitation to the medical profession—inclusive. In spite of critical progress in this area, enduring underrepresentation of individuals who identify as members of racial, ethnic, sexual, and gender minority groups persists in academic medicine. Institutional efforts to recruit and retain a diverse faculty to teach medical students must continue. Furthermore, continued refinement of promising diversity and inclusion initiatives that support the success of minority students throughout medical school is warranted.

Although we agree with Dyrbye and colleagues’ point that wellness programming should be offered to all students, we believe that special care is necessary to make programs and activities safe, relevant, and attuned for culturally diverse groups. An emerging critique of wellness programs in medicine suggests that the “well person,” by definition, is one who is “continually striving for self-improvement and better functioning”15—a definition that paradoxically reinforces the unwelcome normative ideal of physicians endeavoring at all times to be, or become, perfect.15 A deeper concern is that wellness programs in medicine may be predicated on a mind-set that devalues human variation rather than embracing inclusiveness and diversity. In light of such concerns, it is imperative for wellness programs directly targeting students at risk for depression, including those who identify as belonging to underrepresented groups, to not inadvertently cause harm. One example of a highly promising initiative is the comprehensive program run by the Office of Student Wellness at the University of California, Davis School of Medicine,16 which includes prevention, access to clinical treatment, and educational activities targeting not just students but faculty and family members as well. The program has adopted “cultural humility” as a key tenet in an effort to model mutually respectful relationships. The program has also deliberately recruited a diverse staff and incorporated cultural consultants to serve ethnic minority students more effectively.16

As student wellness is increasingly considered a key priority and as more and more medical schools are offering integrated student wellness programs, leaders have called for not only helping students cope with “inevitable distress” during medical school but also making the medical school experience itself less distressing.17 Some challenge is inevitable in the course of becoming a physician. Caring for people at the extremes of life—that is, helping people who are suffering to bear their burdens—is a hard task. Nonetheless, some aspects of medical school may be unnecessarily stressful, and these could be redesigned. The process of becoming a physician should foster students’ capacity for understanding and supporting others with maturity, kindness, and compassion—rather than their ability to compete and be tough. For example, Stanford recently developed a “zero tolerance” program to prevent mistreatment of medical students.18 Additionally, one of us (L.W.R.) attended an exceptional medical school many years ago with a pass–fail grading system that reduced many of the unnecessary negative experiences of medical training (e.g., worrying about grades and class ranking) and allowed students to support one another’s growth professionally and personally. More recently, grading modifications that might promote cooperative learning over competitiveness have been proposed14—as have other potential curricular changes designed to improve student mental health and well-being (e.g., problem-based learning, longitudinal electives, resilience and mindfulness instruction).17 Such innovations will require alignment of undergraduate and graduate medical education, as well as a significant shift in mind-set; nevertheless, such ideas are worthy of consideration, especially if they increase health and well-being in medical students from diverse backgrounds.

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Avoiding Adverse Consequences From Student Profiling

The idea of profiling students to deliver targeted interventions, even if these interventions are likely to be effective, raises ethical concerns that warrant serious attention. These concerns include considerations about what types of data are collected, who has access to these data, and how these data are used in decisions regarding access to prevention and intervention programs. Evidence suggests that students may already be highly sensitive to issues of confidentiality and that they may already worry about the negative professional repercussions of seeking care for mental health concerns during medical school.7 , 19 , 20 Such concerns are especially acute in certain medical schools, as reflected both in the findings of studies of medical student health care and in the results of the graduate questionnaire administered annually by the Association of American Medical Colleges, which reveal widely varying policies and cultures of mistreatment in U.S. medical schools.21 Similarly, studies of physicians in practice and in residency training reveal that physicians avoid necessary care because they fear losing their licenses, professional standing, and/or career opportunities.22 , 23 Recent public attention to the unauthorized use of personal data24,25 further highlights how seriously medical schools must take the issue of consent and privacy. In the highly competitive medical school environment, the stakes are especially high. For these reasons, any approach to providing targeted treatments on the basis of individual potential vulnerabilities or risk factors must meet a high standard of respect for privacy and must avoid marginalizing, stigmatizing, or perpetuating discrimination against students who identify as members of groups underrepresented in medicine.

Dyrbye and colleagues have explicitly recommended against the use of the Depression-PI in screening medical school applicants. Those students who may possess greater risk of developing depression symptoms deserve equal access to medical school admissions. Any efforts to exclude those students could exacerbate disparities already in existence and reduce diversity in detrimental ways. In fact, students who have personal experiences overcoming adversity may bring unique strengths to the profession and could become particularly compassionate doctors.

As program leaders and directors develop, implement, and enhance programs for students already enrolled in medical school, they must respect each learner’s privacy in deciding who needs the most help. To guard against unintended discrimination, a diverse set of stakeholders should engage in program design. In addition, program leaders will need to carefully balance resources dedicated to identifying students at risk with resources for expanding access to interventions that have been proven to be, or are highly likely to be, effective. Community partnerships that allow students to access off-site resources for prevention and treatment may be beneficial.

Strong and transparent consent practices can also guard against unexpected risks to individual privacy, but these may not be sufficient. In our view, consistent and transparent program policies and procedures, which are essential for building student trust, must be established in advance if the idea of stratifying and identifying students by risk is adopted. Students should be informed at each step about how their personal data might be used, and they must always retain the right either to decline to answer a particular question or participate in any survey if they do not feel comfortable with the disclosure. Even for students identified as at risk, participation in each step of available wellness programming will require informed consent.

Well-being is of great personal importance to the nearly 120,000 medical students currently enrolled in MD or DO programs in the United States. Health and well-being are also integrally related to quality of care and patient safety. Healthier medical students may become healthier doctors who are better positioned to provide high-quality care for their patients. In the process of advancing systemic supports for student wellness, privacy and the right to self-determination (especially for vulnerable student populations) must be honored. A cautious, respectful, individualized prevention approach, which integrates wellness themes into the fabric of medical school instruction and gives medical students the power to opt in to targeted programs, has the potential to substantially alter the medical school experience for many students who are suffering.

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References

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© 2019 by the Association of American Medical Colleges