An estimated 15% of physicians will at one point in their careers become impaired (1). This is detrimental to the field of medicine, since impaired physicians are more likely to lose their licenses and careers, and to patients, since impaired physicians deliver suboptimal care (1, 2). In the past 20 years, attention has been given to helping the impaired physician (3, 4), but less attention has been paid to preventing impairment and increasing the overall well-being of physicians (5, 6). One aspect of this is the promotion of positive self-care, which involves personal attention to proper diet, exercise, sleep habits, health care, and psychological well-being, and can begin early in medical training. (As described in this article, positive self-care does not involve self-prescribing or self-diagnosis.) This article will review current literature on medical student health, provide suggestions for changes that medical schools can make to promote positive medical student self-care and overall wellness, and discuss future areas of research.
Current State of Medical Student Health Care
Medical students face an array of health problems. In one study 90% of medical students reported needing medical care while in medical school (5). Although many health care needs may be routine, medical students appear to be more vulnerable than the general population to some illnesses (6–9). For example, a longitudinal study of medical students throughout their 4-year training period found that at least 12% of students showed considerable depressive symptoms at any given time (7) and suicide is the second leading cause of medical student death (8). Medical students also experience high levels of stress, which adversely affects academic performance, professionalism, and health (6). In fact, a recent longitudinal study found that stress symptoms, such as fatigue, irritability, depression, and anxiety, significantly increased over a 6 year period of medical training (9). Research has shown that other professional and graduate level students face high rates of depression and anxiety as well (10, 11), so the apparent vulnerability of medical students could be attributable to the demands of higher education. However, it is clear that medical students have higher rates of overall psychological distress than both the general public and age-matched peers (12).
In addition to having numerous health concerns, medical students are hesitant to seek medical treatment, and they perceive many barriers to seeking health care (13). In one study, 55% of medical students revealed that they had not sought medical treatment, even when needed, during medical school (14). Major reasons for these barriers to health care appear to be confidentiality concerns and fear of academic jeopardy or other negative consequences, particularly when seeking help for stigmatizing illnesses (14, 15). These illnesses appear to be the same illnesses that generally cause impairment: mental illness, drug and alcohol abuse, and stress-related illness. Medical students may attempt to address serious health problems themselves rather than seeking appropriate health care. When medical students do seek care, they often opt for informal “curbside” care and bypass general practitioners for direct referrals to specialists (16).
Suboptimal self-care results in more than possible future impairment; it also results in missed opportunities for preventing burnout and increasing job satisfaction (17–20). Also, doctors who themselves practice good self-care are more likely to educate and encourage their patients to practice healthy lifestyles and positive self-care (21). Much may be gained from improving medical students’ self-care practices.
Many gaps exist in the literature on medical student wellness. While we know why some students do not seek care, we do not know which students are not seeking care, or risk factors associated with not seeking care. We also do not know which policies and practices act as barriers for medical students seeking health care or what factors could improve students’ willingness to seek health care. Despite these areas of uncertainty, the consequences of the status quo are serious enough that medical schools should explore innovative strategies for increasing student wellness now rather than waiting for more research.
Wellness Promotion Programs
Introducing an educational program into medical student curricula aimed at improving student wellness and health care seeking practices is one way to remind medical students that an essential part of becoming a doctor is taking care of oneself. A few pilot programs have had some success at individual schools (22–25). For example, Case Western Reserve University School of Medicine offered a voluntary wellness elective for first and second year students involving education by physicians on medical student impairment, relaxation techniques, and coping strategies (24). The elective was evaluated via essay review and a questionnaire administered after the elective concluded. These lectures received strongly positive reviews in both the essays and the questionnaire with respondents agreeing that the elective helped them prioritize their personal health and well-being. However, it is possible that the strong positive response was due to selection bias since it was a voluntary program. Also, positive feedback on a questionnaire may not correlate with actual increased positive wellness behavior, so the true value of the program is hard to judge.
Investigators at the Indiana University School of Medicine used a survey to assess wellness and health habits of medical students and then randomly assigned a group of students to receive a “self-awareness intervention” consisting of written feedback on their current health habits (25). Other students volunteered to take part in a “self-care intervention” involving 1.5 hours of lecture and discussion on wellness and positive health habits. A post-intervention survey to assess health habits later in the next semester found that the “self-awareness intervention” group felt significantly less “sleepy” than the control group and the “self-care intervention” group took fewer naps and had an easier time falling asleep than the control group. However, alcohol consumption and depression ratings were not affected, and it is possible that low sample size and selection bias in one or both groups may account for these differences.
As shown by these examples, wellness education could be provided through a variety of means. Research suggests that the specific format of educational programs is not the predictive factor for success (22–25). Instead, sharing information about medical student health problems and suggesting ways to cope with the unique challenges that medical school presents seemed to be most critical (22–25).
Educating attending physicians and residents on the importance of their own well-being and that of medical students could also promote positive self-care among medical students. For example, attending physicians and residents who are taught about the importance of positive self-care could model such behavior for medical students. Also, attending physicians and residents could be taught the importance of fostering a healthy teaching environment and encouraged to discuss wellness issues with students—for example, by advising medical students to take appropriate breaks on the job, take time off when they are ill, and schedule medical appointments rather than engaging in curbside medical care.
Educating medical students about positive self-care is a reasonable starting point in the effort to increase student wellness, but medical schools must also make access to health care and preventive medicine easily available. A support service offering off-site, independent care, similar to an employee assistance program, has reportedly been increasingly utilized at the University of South Florida since 1997. That may indicate medical student satisfaction with the program (26) although no postcare follow-up data has been gathered thus far. The design of the program is attractive, though, because unlike many of the current systems in medical schools, this type of service could be used by students facing a broad range of issues with less confidentiality risks (26). The cost of the program has been estimated at 7 cents per day (about $25.00 a year) per person enrolled, which, while not high, may still be prohibitive for many schools.
Keeping students informed about the availability of services is key to a successful support program for students. Many schools introduce wellness programs at orientation, but newsletters or e-mails about the programs at high stress times for students could serve as timely reminders. The advantage of a newsletter reminding students to schedule regular doctors’ appointments, offering tips on stress management, and endorsing the importance of student health is that it is a relatively easy and a very cost-effective way to promote existing programs. It could serve by itself as an effective tool for encouraging medical students to prioritize their health.
“Free” Improvements: Policy and Attitude Changes
In an era of tight academic budgets, implementing new educational programs or overhauling a current student support system may not be an option for many medical schools. But medical schools can still make positive changes to promote medical student health by making their policies more student-health friendly. For instance, because many students fear academic jeopardy when seeking health care, policies should be written so that students who seek care for stigmatizing illnesses receive protection from negative assessment based on those problems. Attendings and residents should be informed that evaluations of students should be based solely on performance and should not be influenced by knowledge of stigmatizing illnesses.
Another low-cost policy would be to suggest that students establish a primary care physician (PCP) at matriculation. Students could be urged to see their PCP regularly to discuss stress and mental health issues as well as physical health problems (6). Medical schools could also make proactive changes to student schedules—in addition to accredidation authorities’ work hour limits, schools could make an effort to provide adequate time for relaxation and recuperation. For example, students could receive a day off from classes after exams in the nonclinical years and 2 days off between rotations in the clinical years. Schools could also choose to give students major holidays off even in the clinical years, limit the number of overnight shifts in a month, and strictly enforce work hour limits. Written policies giving students time off for medical appointments or procedures during the clinical years also could make seeking care more feasible for students with unpredictable and hectic schedules.
Lastly, medical schools could write a statement on the value of medical student, resident, and faculty wellness. At the very least, this could begin a change in attitude among the academic medical community and serve as inspiration for the future.
Prior research has shown that medical training itself may contribute to student mental illness and stress. Investigators have also begun to explore some of the reasons medical students do not focus on personal wellness needs and health care. Research has not yet demonstrated the best way to deal with these problems. Research is also needed to understand whether positive self-care affects students’ physical and mental health, later career satisfaction, and patient care effectiveness. Finally, no multicenter randomized controlled wellness-intervention studies have been performed to date. Such studies to compare the effectiveness of educational initiatives, support programs, and/or policy changes would be optimal.
Medical school is a high stress time for students, reflected by increased incidence of mental illness, suicide, substance abuse, and burnout. Compounding this problem is the finding that medical students are hesitant to seek adequate medical care because they fear academic jeopardy and often feel guilty taking time to focus on personal wellness. Medical schools are uniquely positioned to alleviate these problems because they educate, support, and even provide health care for medical students. Efforts such as increased education on health and wellness issues, broad support programs aimed at preventing impairment and helping struggling students, and changes in school policies to encourage positive self-care are all steps medical schools can take to increase healthy personal care habits among medical students. Action now to promote healthy students could result later in healthier doctors, which might benefit not only the medical field as a whole, but also patients through better physician patient care practices.