Medical student mental health has been a topic of study for many years. Saslow (1) was one of the first to examine the mental health of medical students. Since then, a seminal study by Dickstein et al. (2) highlighted the prevalence and type of psychiatric problems in medical students and found that 20% of medical students had sought psychiatric consultation. Loneliness and relationship difficulties were the two most commonly reported chief complaints; however, adjustment disorders, “V” codes, and mood disorders were the most prevalent diagnoses. A majority of students seeking assistance also expressed “role strain.” Various studies have since noted high stress levels (3–5), alcohol use (6), and rates of depression (7) in medical students.
Dyrbye et al. (8) recently found consistently higher overall levels of psychological distress in U.S. and Canadian medical students relative to both the general population and age-matched peers. Such distress may lead to impaired academic performance, increased alcohol intake, and various other psychological and physical morbidities, including suicide (9). Psychological distress typically worsens in the clinical years of medical training (7). Untreated problems not only have repercussions for patient care (10), but they may relate, at least in part, to risk of disciplinary problems in school as well as later practice (11), and may have implications for these students’ treatment of their patients (12).
For years, medical schools have had systems in place to provide either direct or referral services for students experiencing health-related problems. Unfortunately, although over 90% of students report the need for physical or mental health care during medical school (12–14), nearly half cite difficulties obtaining it (12). Typical barriers reported by students include the availability of health insurance, confidentiality, and career repercussions (12–15). Students seem especially sensitive to seeking care for mental health issues such as depression and chemical dependency (14, 15).
As a result of such findings most medical schools have instituted a host of policies and programs meant to address the physical and mental health of students. Systems have been established to provide not only evaluation and treatment services but also wellness programs to deal with these issues in a preventive manner (16). Many of these have focused on enhancing student well-being; defined as the ability to successfully balance professional and personal life through attention to one’s social, psychological, spiritual, and physical health (17). As further recognition of the importance of these issues, the Liaison Committee on Medical Education (LCME) for years has mandated that schools of medicine promote student well-being, provide preventive and therapeutic health services, and have an effective system of personal counseling in place to assist medical students.
Specifically, the LCME currently provides two medical student (MS) accreditation standards that address student mental health. The first is MS-26, which states “Each school must have an effective system of personal counseling for its students that includes programs to promote the well-being of students and facilitate their adjustment to the physical and emotional demands of medical school.” As noted, this standard has typically been addressed by developing school-supported wellness programs that may consist of speakers programs, small group discussions on various pertinent topics (e.g., stress management, relationships), health fairs, and other planned activities (e.g., picnics, ice skating parties) meant to encourage balance among students (16). In addition, schools have also encouraged students to use school-based or university-based counseling centers as well as psychiatric services when appropriate.
The second standard has two provisions. The first is MS-27, which states “Medical students must have access to preventive and therapeutic health services.” This standard has typically been met by providing services that include immunizations, preventive health services, and other germane diagnostic and treatment services that are usually provided by a student health clinic or similar entity. In 2004, the LCME amended this standard by adding a provision (MS-27A), which states the following: “The health professionals who provide psychiatric/psychological counseling or other sensitive health services to medical students must have no involvement in the academic evaluation or promotion of the students receiving those services.” The assumed intent of this provision is that students should neither be evaluated nor promoted by those with whom the student has had a dual relationship and thus could potentially be biased for or against the student.
Significant though it is, this recent elaboration of the accreditation standard is little noted by many professional organizations, much less a subject of either outcomes evaluation or research. Moreover, while the elaboration is not exclusive to psychiatry and psychiatrists, delimiting such faculty from the care of medical students is perhaps the most direct effect. Consequently, a brief review of basic considerations is a sensible initial approach to this complex conundrum in medical education and medical care.
Supportive Arguments for MS-27A
Student surveys support eliminating the involvement of health professionals who treat medical students for sensitive medical and psychiatric services from the student evaluation and promotion process. Roberts et al. (13) originally examined this issue and found that confidentiality and the desire to avoid dual-relationships were key impediments to students seeking care at their institution. More recent studies noted concerns with convenience, accessibility, cost, and confidentiality (12, 14, 15) regarding one’s health care and the preservation of confidentiality regarding fellow students’ illnesses (18).
With respect to mental health problems, Tija et al. (19) found a variety of factors contributing to students’ hesitancy to seek mental health treatment. Specifically, 53.8% of students noted a lack of time, 23.1% of students cited the stigma of using mental health services, 23.1% cited the fear of the negative impact on career, and another 23.1% cited a fear that a diagnosis would enter the academic record. Additional students were fearful they would be recognized by a colleague associated with the mental health center or that treatment would not help. A previous study by Givens and Tija (20) likewise found that major barriers for seeking treatment for depression among medical students included confidentiality (37%), stigmatization (30%), and fear of documentation in the academic record (24%), among others.
In addition to addressing student reservations regarding health care accessibility, the implementation of MS-27A may also prevent potential conflicts related to therapeutic boundary issues inherent in dual relationships. Boundaries provide the foundation for a safe and trusting relationship characterized by openness and respect. Faculty-providers in dual relationships are certainly seen as being in a more powerful position than their more vulnerable student-patients and, as such, have the clinical imperative to guard over autonomy, neutrality, and objectivity (21), thus, limiting the potential to negatively affect other aspects of the students’ lives (22). For example, having information about a student’s history of substance dependency and related legal problems may influence the faculty member’s grading of that student or the faculty member’s proclivity to promote that student to the next level of education. Eliminating the possibility of this conflict provides some assurance to the student that he or she will be “protected” from such influences, resulting in more openness in the therapeutic relationship and/or more fairness in the evaluation and promotion process. Prohibiting this dual relationship will also inhibit any student contestation regarding the evaluation or promotion process.
In summary, over 90% of students become ill and need health care during medical school. Unfortunately, a variety of barriers, such as accessibility, cost, confidentiality, and academic jeopardy related to the formation of dual relationships inhibit students’ tendency to obtain proper care. In order to address these concerns, Given and Tija (20) echo the recommendations of Roberts and colleagues (13) by suggesting that mental health services should be “confidential, available to all students, easily accessible, and well advertised…the point of contact should be separate from the academic affairs and dean’s offices and that long-term counseling should be available if necessary.” MS-27A removes a significant barrier to treatment by eliminating potential conflicts associated with dual therapeutic relationships and ensuring that students may seek and then receive medical care and psychiatric services in a safe and confidential venue. If removal of these barriers allows students to seek treatment in a more timely fashion, then MS-27A serves its intended purpose.
Although this revision of the LCME guidelines appears to be an important step toward the elimination of barriers to medical students seeking optimal medical treatment, one must wonder if in doing so we have “thrown the baby out with the bathwater.” Several problems are inherent in this provision and may actually limit students’ accessibility to optimum care.
Eliminating access to psychiatry faculty who may evaluate or promote a student clearly deprives that student of his or her autonomy to select a treating psychiatrist best suited for his or her care. Similarly, this provision may limit students’ access to those persons most qualified to treat a given condition. Academic psychiatrists within the home institution, particularly those with national or international expertise on a given disease, may be the most qualified to treat a given student. Not allowing such access may do more harm than good in regards to patient care and well being.
Academic faculty may also be best suited to understand the many issues that medical students face. In the case of psychiatric care, certain dual relationships may, in fact, have value in therapeutic work. It has been noted that visibility and involvement in a community, in this case the medical training community, increase approachability and lessen suspiciousness toward the provider and, thus, may indirectly enhance clinical efficacy (21).
The standard also allows little latitude for other important access issues, including sometime Byzantine bureaucracies of insurance “carve-out,” limited panels, and all the rest. So, too, students who matriculated to schools in rural areas often have few, if any, alternatives to faculty experts, which is especially problematic in the arrangement of psychiatric care. Because of these factors, it may be incumbent on the psychiatrist to enter into a dual relationship, based on the principle of nonmaleficence, if doing so is less harmful than not (22).
Another issue concerns the limitation on types of professionals who treat students for mental health and sensitive medical issues. Why has the LCME singled out psychiatric conditions, along with a very few other medical conditions, as being uniquely “sensitive”? If faculty confidentiality and potential bias is a concern, why not require that all medical services be so delimited? For example, primary care physicians are often the first to see patients or students with mental health problems (23, 24).
Conversely, if the LCME is to allow any medical faculty to serve in roles of dual agency as treater-teachers, ought not they who have the most sophisticated training in identifying and ameliorating interpersonal biases be the first so entrusted? The current proscription carries with it an ambivalent, even stigmatizing, formulation of academic psychiatrists and their work ethos.
Roberts and colleagues (12) have shown that despite student reservations regarding the potential adverse consequences of obtaining health care within one’s institution, 63% of medical students (77% of clinical students) seek informal consultation for health-related problems. Whereas a large percentage of these consults are likely for nonsensitive medical advice, personal experience suggests that a significant amount are for sensitive medical and psychiatric services from faculty whom students trust. Allowing students to receive treatment from their faculty for these sensitive issues may make the covert overt, resulting in more formal and thorough treatment.
In summary, students may benefit from having access to psychiatric faculty who may eventually be involved in their evaluation and promotion process. Benefits may include expertise, familiarity with the particular medical school culture, and accessibility. In addition, despite the laudable nature of the LCME recommendations, no causal connection between students’ fears and faculty status per se is elicited in these studies. The recommendations may reflect more generic resistance to anxiety about mental health services rather than specific misgivings about care rendered by faculty. In light of these many issues, it seems prudent to allow both faculty and student to determine such risks and benefits on a case-by-case basis as opposed to allowing LCME pedagogic standards to consistently trump the mental health care needs of students.
Ultimately, the purpose of any policy concerning medical student health should focus on what is best for the overall health of students. Recent surveys show that over 90% of students need health care while in medical school, including 47% who have mental health or substance-related problems (15). The literature suggests that many students prefer to have health insurance that allows off-site care due to concerns over confidentiality and academic jeopardy (12–15).
MS-27A attempts to address these concerns by suggesting that “health professionals who provide psychiatric/psychological counseling or other sensitive health services to medical students must have no involvement in the academic evaluation or promotion of students receiving those services.” One assumes that this provision would reduce fears of confidentiality, faculty stigmatization, and “contamination” of the student’s academic record, and enhance students’ access to and outcome associated with mental health treatment. However, no evidence currently exists regarding the impact of this LCME provision on student use of these services.
For the future, the role of academic psychiatry faculty in the evaluation and treatment of medical students is an area of concern upon which a variety of professional organizations should review and offer wisdom. Such organizations presumably include, but are not limited to, the Association of Academic Chairs of Departments in Psychiatry, Association for Academic Psychiatry, Association of Directors of Medical Student Education in Psychiatry, American Association of Directors of Psychiatric Residency Training, APA, and the American College of Psychiatrists. The LCME is to be applauded for its requirement that students have ready access to high quality, confidential psychiatric and mental health care, ideally without direct referral via Deans’ Offices. However, the preoccupation with psychiatric services is worrisome given the wide range of faculty in other departments who, as teachers-treaters, may become dual agents for certain students. Moreover, the best policies and practices in this important interface are by no means yet established and, in fact, need much more thorough consensus, evaluation, and research to ensure the greater health of our junior colleagues in medical schools.
Until then, a policy that ensures accessibility and encourages students to obtain care for psychiatric and other sensitive medical services from providers who have “no involvement in the academic evaluation or promotion of the students receiving those services” seems prudent. However, there may be occasions when treatment is recommended by a health care professional within one’s institution and who may eventually evaluate the student due to factors such as accessibility, expertise, or preference. Under these conditions, it is incumbent on the institution and faculty member to establish safeguards and appropriate internal policies to protect the student from the potential malfeasance that may occur as part of that dual relationship. These would help to ensure that the ultimate priority remains the patient’s (i.e., student’s) mental health and well being.
Future discussion and research should address the impact of the LCME MS-27A standard on students’ use of health care services. In addition, research should focus on alternative systems for providing preventive and therapeutic services that improve accessibility and overall care in this vulnerable group.