Excessive alcohol consumption in the United States is a serious public health problem. Each year, harmful drinking claims nearly 88,000 lives and exacts a $223 billion toll on the U.S. economy. The costs result mostly from losses in workplace productivity, health care expenses, motor vehicle crashes, and law enforcement and other criminal justice expenses related to excessive alcohol consumption.1 Multiple risk factors among the general adult population have been identified for alcohol abuse/dependence, including younger age, being unmarried, male sex, mood disorders, family history of alcohol abuse/dependence, and lower income.2
A recent national study of U.S. physicians found that 12.9% of male physicians and 21.4% of female physicians met diagnostic criteria for alcohol abuse/dependence.3 Excessive consumption of alcohol is also common among U.S. medical students.4–7 In physicians, alcohol abuse/dependence was strongly associated with younger age and dimensions of distress including burnout, depression, and decreased quality of life (QOL).3,8 Previous research indicates that these manifestations of distress are also common among U.S. medical students.9,10 Yet, to our knowledge, no previous study has explored the relationship between the presence of alcohol abuse/dependence and distress among medical students.
The methods used in this study have been previously reported.9 Briefly, in 2012 we surveyed all 26,760 medical students listed in the American Medical Association’s (AMA’s) Physician Masterfile (PMF) who had given the AMA permission to contact them by e-mail. We sent each medical student an e-mail message inviting them to participate. According to convention,11 we considered the 12,500 medical students who opened at least one e-mail to have received an invitation to participate in the study. Participation was voluntary, and responses were anonymous. No compensation was provided. The Mayo Clinic institutional review board approved the study.
The survey included questions about basic demographic items (age, sex, relationship status, year of training) and self-reported estimate of current educational debt. Response options for questions were multiple-choice or Likert scale. Measures of alcohol abuse/dependence, burnout, depression, suicidality, quality of life, and fatigue were also included.
We used the Alcohol Use Disorders Identification Test (AUDIT-C) screening tool to identify those respondents with alcohol abuse/dependence. The full-length AUDIT was developed by the World Health Organization as a primary care screening tool to identify harmful drinking.12,13 The AUDIT-C is a short screening tool derived from the full-length AUDIT and has been shown to be just as sensitive in identifying those with alcohol abuse/dependence.14 The AUDIT-C scores range from 0 to 12. We identified participants as screening positive for alcohol abuse/dependence by having an AUDIT-C score ≥ 3 for females (sensitivity 0.66, specificity 0.94) and ≥ 4 for males (sensitivity 0.86, specificity 0.72).14
The Maslach Burnout Inventory (MBI) is a 22-item questionnaire that has been shown to be valid and reliable in assessing burnout and that has become the standard questionnaire used for its assessment.15,16 The MBI evaluates three domains of burnout: emotional exhaustion, depersonalization, and personal accomplishment. Consistent with convention,8 those respondents who scored high on either the emotional exhaustion (≥ 27) or depersonalization (≥ 10) domain of burnout were considered to have at least one manifestation of professional burnout, and were thus identified as experiencing burnout. Score from the personal accomplishment subscale is not used to categorize individuals as having burnout.
Depression and suicidality.
The two-item PRIME-MD (Primary Care Evaluation of Mental Disorders) depression screen was used to identify depression. This two-item screen has been found to be as valid and reliable as longer screening questionnaires.17,18 We assessed suicidality with a one-item screen, asking “During the past 12 months, have you had thoughts of taking your own life?” This item has been used in previous studies of physicians and medical students.3,10,19,20
QOL and fatigue.
All participants rated their overall, mental, emotional, and physical QOL over the week prior to completing the survey on a single standardized linear analogue self-assessment scale for each domain of QOL (0 = “As bad as it can be”; 10 = “As good as it can be”). This scale has established validity in a variety of medical conditions and populations.21–24 In addition, participants rated their level of fatigue on a similar standardized linear analogue scale (where lower scores indicate higher fatigue). We considered those who recorded a score of 5 or less to have high fatigue.21
We used standard descriptive statistics and chi-square test, Fisher exact test, or Wilcoxon/two-sample t test procedures as appropriate. We conducted multivariate logistic regression procedures for two purposes: first, to adjust the P values for comparisons of variables of interest and alcohol abuse for age, gender, and relationship status; and second, to identify factors independently associated with an increased risk of alcohol abuse/dependence. In the modeling process, we included the following independent variables: relationship status, sex, age, year of training, educational debt, burnout, depression, overall QOL, suicidal ideation, and fatigue. All analyses were performed using SAS statistical software version 9.2 (SAS Institute, Cary, North Carolina).
Of the exactly 12,500 medical students who opened the e-mail invitation to participate, 4,402 completed surveys (35.2% response rate; 4,354 completed the AUDIT-C). The demographic characteristics of those who completed surveys have been previously reported.9 Age and year of training were similar to the 66,461 medical students listed in the PMF; however, our participants were less likely to be male (1,972/4,354 [45.3%] versus 35,031/66,461 [52.7%]).
Of the 4,354 students who completed the AUDIT-C, 1,411 (32.4%) met criteria for alcohol abuse/dependence. Rates of burnout, depressive symptoms, suicidal ideation, and QOL have been previously reported.9 In aggregate, 3,389/4,218 (80%) had burnout, alcohol abuse/dependence, or depressive symptoms at the time of the survey, and 2,964/4,221 (70%) students had burnout, alcohol abuse/dependence, and/or suicidal ideation present at the time of the survey. The prevalence of students experiencing burnout, alcohol abuse/dependence, depression, and suicidal ideation is illustrated in Figures 1 and 2.
The relationships between demographic characteristics and alcohol abuse/dependence are shown in Table 1. Age, relationship status, and educational debt each demonstrated a statistically significant association with alcohol abuse/dependence. Specifically, alcohol abuse/dependence was more likely in those who were younger (P = .04), were single (P < .001), or owed > $100,000 in educational debt (P < .01). Although alcohol abuse/dependence appeared to be more common during the first two years of medical school, this trend did not reach statistical significance (P = .06). Unlike for the adult U.S. population1 and physicians,3,8,20 no association between sex and alcohol abuse/dependence was observed.
Associations between alcohol abuse/dependence and burnout, depression, recent suicidal ideation, QOL, and fatigue are shown in Table 2. Alcohol abuse/dependence was more common among medical students with burnout (P = .01), high emotional exhaustion (P < .01), high depersonalization (P < .001), and depression (P = .01). No relationship was found between suicidal ideation within the last 12 months and alcohol abuse/dependence. Alcohol abuse/dependence was more common among those with lower mental (P = .03) and emotional (P = .016) QOL, while no association between alcohol abuse/dependence and other QOL dimensions (e.g., physical, overall, fatigue) were observed. Finally, we performed multivariate stepwise logistic regression using relationship status, sex, age, year in school, burnout, overall QOL, recent suicidal ideation, and fatigue as independent variables (Table 3). Alcohol abuse/dependence remained independently associated with burnout (OR 1.20, P < .01). Other factors independently associated with alcohol abuse/dependence included being single (versus married, OR 1.89, P < .001), being younger (for each five years younger, OR 1.15, P = .01), and having educational debt more than $50,000 ($50,000–$100,000 versus less than $50,000, OR 1.21, P = .03; > $100,000 versus < $50,000, OR 1.27, P < .01).
Alcohol abuse/dependence was strongly associated with several dimensions of distress in this national study of U.S. medical students. Approximately one-third (32.4%) of those students who completed the AUDIT-C met diagnostic criteria for alcohol abuse/dependence. In comparison, only 15.6% of a sample of U.S. college-educated 22- to 34-year-olds met similar criteria.25 Furthermore, the rate observed in our sample was almost twice what was previously reported among participating surgeons,8 a national sample of U.S. physicians,3,20 and that found in U.S. adult population.1,26 We found a higher prevalence of alcohol abuse/dependence among medical students with burnout, depression, and low mental and emotional QOL than for those without.
Medical students with alcohol abuse/dependence in our study were more likely to be younger, single, and have higher educational debt. Younger age and single relationship status are both known risk factors for problematic alcohol use among medical students5 as well as in the general population.2,25 To our knowledge, no previous studies have evaluated the relationship between alcohol abuse/dependence and educational debt for medical students, although greater debt has been previously associated with an increased risk of alcohol abuse/dependence among the general population.27,28 Our findings suggesting that educational debt may increase the risk of alcohol abuse/dependence are particularly concerning considering that medical educational debt has risen sharply over the past several decades. From 1995 to 2014, the average cost of attendance at private medical schools increased by 209%, while the cost at public medical schools increased 286% over the same time period.29 In 2014, the average medical student graduated with $180,000 of debt.30 The escalating cost of medical school needs to be more effectively addressed, especially if health care reform and reimbursement changes lead to reduced earning potential in some specialty areas. If educational debt continues to rise in the face of lower earnings, the psychological toll of educational debt may become even more severe.
The prevalence of suicidal ideation in this cohort (9.4%) was similar to that found in a previous multi-institutional study of medical students10 and higher than individuals of similar age in the general U.S. population (5.7% among 18- to 29-year-olds).31 Suicidal ideation was not more commonly endorsed by those with alcohol abuse/dependence. Alcohol, however, increases impulsivity and the risk of completed suicide32–34 as well as other self-injurious impulsive behaviors.35,36 In this study, 35.8% (147/411) of those students with suicidal ideation had coexistent alcohol abuse/dependence—a dangerous combination.
Our study provides further evidence that distress among medical students warrants serious attention. A multifaceted approach to reducing alcohol use, ameliorating burnout, and reducing the cost of medical education is needed. Schools should put into place student wellness curricula to help students understand the prevalence and consequences of mental health problems among physicians in-training and in-practice, self-assess their well-being, develop strategies to enhance their resilience, manage educational debt, and seek help when needed. Mindfulness programming and facilitated small-group discussions are among approaches shown to be helpful.37,38 In addition to such training, medical schools should work to identify and remediate factors within the learning environment contributing to high levels of stress and burnout.39–44 Also, schools need to address barriers to students seeking care for substance abuse and mental health services.19,45 Interventions undertaken should be rigorously evaluated and disseminated to facilitate amelioration of distress among medical students. In addition, national efforts are needed to curb the dramatic increase in the cost of medical school, including consideration of state and federal expansion of financing for medical education.46,47 Loan repayment deferment, low-interest loans, and innovative debt reconciliation or forgiveness programs have also been suggested.48
Our study has a number of limitations. First, our response rate was 35.2%. Students who responded to our survey may have had more or less burnout or alcohol use compared with nonresponders. However, the rate of burnout seen in our sample was similar to rates seen in previous studies, suggesting that it is representative.9,10,49 Our response rate is also typical of national survey samples of physicians and medical students.8,49,50 Also, our sample included fewer males than those listed in the PMF. All other demographic variables were similar. This slight difference in sex is unlikely to have accounted for any systematic differences, as the relationship between burnout and alcohol abuse/dependence persisted on multivariate analysis after controlling for sex.
A second limitation is the cross-sectional design. We cannot determine causality or directionality of the relationships among our variables. Although the associations were statistically significant, we do not know whether alcohol abuse/dependence causes burnout or vice versa. A longitudinal study is needed to provide a more definitive answer to the question about causation and directionality. Third, we chose to use the AUDIT-C for our screening instrument for alcohol abuse/dependence and used a cutoff score of ≥ 3 for females (sensitivity 0.66, specificity 0.94) and ≥ 4 for males (sensitivity 0.86, specificity 0.72). If we had used higher cutoff scores, our sensitivity would have increased, but at a cost to specificity. Fourth, time frames for our measures differed. For example, symptoms of depression were elicited over the month prior to survey completion, whereas quality-of-life measures were asked over the week prior. Finally, we depended on self-reported educational debt and included a limited set of personal variables.
The rate of alcohol abuse/dependence in this cohort of U.S. medical students was higher than for similarly aged peers not attending medical school. Alcohol abuse/dependence among medical students was strongly associated with burnout, higher educational debt, and personal characteristics (i.e., younger age and single relationship status). A multifaceted approach to address alcohol use, ameliorate burnout, and reduce the cost of medical education is needed.
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