In recent years, multiple studies exploring medical student mental health highlight the increased frequency and severity of emotional problems during physicians' formative years. Although these studies demonstrate a clear burden on medical students, we have not achieved a broader understanding of malleable factors in student wellness, and, thus, effective interventions to promote wellness are lagging behind. The development of evidence-based preventive and clinical programs in academic centers requires an appropriate focus on overall medical student wellness, encompassing academic and institutional elements. Successful models of student wellness programs exist (1); however, best-practices in this area have not yet been developed. A systematic review of studies among U.S. and Canadian medical students showed a higher prevalence of anxiety and depression among these students than in their age-matched peers (2). Even more worrisome, 11% of students in a longitudinal cohort from seven medical schools admitted to having had suicidal thoughts in the previous year (3). Over time, medical student health centers have seen an increased utilization of services (4, 5). It is unclear whether this is due to a higher prevalence and/or severity of mental disorders, increased identification of disorders, improved availability of services, reduced stigma, or a combination of these factors. This commentary will review factors that may contribute to student distress and discuss suggestions for effective interventions to address these. Our purpose is to provoke thought and debate about student wellness and to inspire action through the development of evidence-based interventions to improve wellness at medical schools across the country.
Contributing Factors and Strategies for Culture Change
Factors contributing to students' mental health difficulties during medical school may be individual (intrapersonal and interpersonal) and/or environmental (institutional; see Table 1). These may include preexisting or de novo medical and/or mental illness; academic difficulties; emotional intelligence (EI) deficits (being unaware of one's own or others' emotions and having limited ability to effectively communicate and work with others); intolerable stress due to high workload, with high performance expectations and exposure to human suffering; confronting the hierarchical culture of medicine, including intergenerational clashes; neglect of social support networks, leading to isolation; and interpersonal stressors (e.g., a family member's illness, divorce, separation, long-distance relationships, and financial pressures) (6, 7). The following sections outline factors contributing to student distress, paired with potential strategies for addressing them. In some cases, solutions have been described in the literature. Additional suggestions are presented, based on our institutions' experiences.
TABLE 1.Contributing Factors and Suggested Interventions to Address Student Distress
Whereas some students arrive at medical school with personal histories of psychiatric disorders, others experience new-onset illnesses during the course of training (6). Medical students face significant pressures, including adjustment to the competitive school environment; working among an equally competent and driven group of peers; frequent rotations between clinical sites and teams, taxing one's ability to adapt; and a large educational debt burden (7). These considerable stressors may exacerbate underlying vulnerability for disorders such as depression, anxiety disorders, and addiction. Students with an earlier history of anxiety and/or depression often experience recurrences. Similar to their age-related peers, students may present with substance abuse or dependence. Up to 20% of first-year students admit to excessive alcohol intake; 3%–10% of students report illicit drug use; and 10% have used prescription stimulants in their lifetime for nonmedical purposes, most often to enhance academic performance (7–9). Although rare in medical school (5% in a recent survey), attention-deficit hyperactivity disorder may be unmasked by the tremendous increase in academic workload (8). Other students may struggle with eating disorders; impulse-control disorders, such as gambling; or engage in risky sexual behaviors (9). Less commonly, psychotic and bipolar disorders may emerge during medical training.
Additional factors that may hinder a student's growth are personality structure and latent conflicts regarding authority, which interfere with optimal learning (5). At times, students are fulfilling their parents' dream of becoming physicians. This prevents them from fully engaging, and they may unconsciously sabotage themselves by procrastinating filing paperwork, paying fees, sitting for exams, or engaging in other passive-resistant behaviors. Psychotherapy can help students face and resolve these conflicts, so that they can become more meaningfully involved and committed to their personal and professional growth (5).
Inadequate academic performance is recognized as a risk factor for developing depression or anxiety in medical students, but it can also be a consequence of an underlying mental illness (4). A functional academic advising system is a salient component of career counseling in every medical school. If any learning disabilities are identified, accommodations are recommended. Communication between academic advisers and mental health professionals is at times necessary (although unidirectional, because of confidentiality concerns) in order to optimize student support.
Emotional-Intelligence (EI) Deficits
EI deficits are difficult to identify and remediate, since the current medical curriculum does not place much emphasis on these skills. Students with social-awareness deficits manifesting as poor interactions with patients or other members of the medical team may encounter difficulties in the professionalism arena. Professionalism curricula and empathy training through journaling, role-playing, reflective exercises, and modeling of doctor–patient interactions by peers and faculty advisers can be helpful (10). Individual psychotherapy is also beneficial, allowing the students to learn more about themselves in a safe, nonthreatening environment.
The learning environment is an essential ingredient of the academic experience, and the students' perceptions are shaped by interactions with peers, faculty, residents, nurses, and staff. These experiences may adversely influence the emotional development of emerging physicians (11). Unfortunately, medical educators, themselves, were trained in an atmosphere of frequent belittling and humiliation, and this negativity may be involuntarily perpetuated. An impressive 50%–80% of students report having felt abused or taken advantage of (7). It is important to educate all faculty and residents on appropriate feedback and evaluation strategies. Faculty-development programs also help enhance supervisory and teaching skills. Policies with clear repercussions in the event of student mistreatment are delineated at some institutions.
Despite availability of mental health services for medical students, significant barriers to care still exist. The Liaison Committee on Medical Education mandates that health professionals providing psychiatric/psychological counseling or other sensitive health services to medical students have no involvement in the academic evaluation or promotion of the students receiving those services. Many students fear that disclosing personal illness or psychological struggles to medical school officials might jeopardize their academic progress or chances of getting into residencies of their choice. Furthermore, approximately half of 955 students at 9 medical schools stated that they would be reluctant to report a colleague's illness. These attitudes varied across schools, demonstrating that the overall institutional culture regarding wellness had a great influence on students' perceptions and behaviors (12).
Informing students of policies for maintaining the privacy of their personal health records and respecting the boundaries between academic processes and mental health services are essential steps toward establishing an atmosphere of trust. Presentations at student orientation and every year thereafter, hand-out materials, and websites are, in our experience, helpful modalities to reach students who may be experiencing distress. Another useful approach is to train peer-counselors, who may more readily recognize the signs of a struggling peer and who collaborate with the counseling center staff to provide appropriate services to the student in need.
Cultivating a culture of excellence and compassion, where students are taught to take care of themselves while balancing altruism for their patients, is not easy. Encouraging medical students (and, more importantly, their residents and faculty advisers) to be self-aware; to practice healthy study, sleep, and exercise habits; and to de-stress in healthy ways, represents a monumental shift in the traditional culture of medicine. Also, those who choose to seek appropriate care for personal illness should be admired and respected because this is an important ingredient of physicians' professionalism. Institutional culture changes require clear communication, relentless dedication to a vision, consolidating improvements, and long-range planning. We recommend an integrated effort, involving all learners and educators. Effective educational forums include panel discussions with physicians and students who have been afflicted with psychiatric illness or showing video presentations, such as “Struggling in Silence” (available from the American Foundation for Suicide Prevention [www.afsp.org]), both of which can help demystify mental illness in health-providers. In many academic institutions, physician well-being programs help faculty and residents access necessary resources and maintain their emotional balance, while providing high-quality patient care and teaching. The University of California Davis School of Medicine has recently launched a student wellness program, complementing mental health services already in existence. The program's educational core consists of an annual lecture from a distinguished speaker, a series of workshops (some developed uniquely for students; others involving residents and staff), a mindfulness-based stress-reduction course, presentations and podcasts, as well as integration of wellness topics in the existing curriculum (http://www.ucdmc.ucdavis.edu/mdprogram/student_wellness/index.html). Also, faculty development and staff training on mental health topics are offered.
Cultural diversity is an important aspect of the institutional culture. The authors recommend utilizing a cultural consultant to help design interventions and shape programs that sensitively address the needs of underrepresented minority students. A cultural consultant is a champion of cultural diversity, who may be a faculty member at the institution and can educate others. Along the same lines, outside mentors and consultants can provide confidential advice that is extremely valuable in difficult situations. Most importantly, involving students in committees that design wellness programs (1) and collecting stakeholders' feedback consistently will help direct efforts to areas of improvement that may not be visible in a top-down view.
Student wellness should be a priority for all medical schools. Despite available mental-health services, students still encounter barriers to care. Developing student wellness programs based on stakeholders' input and feedback is vital. Effective student-wellness programs identify and address risk factors for mental illness, offer education for all learners and faculty, facilitate access to appropriate services, and strive to promote an overall atmosphere of excellence and compassion. Institutional culture changes are difficult to achieve, but necessary in order to help develop physicians who are well-balanced, healthy, and happy, while serving patients to the best of their abilities. Future research directions may include investigating professionalism lapses in students and graduates from schools with established wellness programs, rates of preferred program residency matches in students who have utilized counseling services, and other academic-performance outcomes as related to early identification of emotional difficulties. Investing in our students' mental health today will reap benefits for health care and the broader society tomorrow.