Chapter 6: Special PartProblems 1: The Physician of Medical andStudents Society

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Special Problems of Medical Students

Darlene L. Shaw Danny Wedding Peter B. Zeldow Nancy Diehl Let us emancipate the student, and give him time and opportunity for the cultivation of his mind, so that in his pupilage he shall not be a puppet in the hands of others, but rather a self-relying and reflecting being. SIR WILLIAM OSLER

If you listen carefully to what patients say, they will often tell you not only what is wrong with them but also what is wrong with you. WALKER PERCY

The decision to become a physician represents an important commitment that produces profound personal effects and shapes many of life’s events. Although medical school and residency training provide the knowledge and technical skills needed to practice medicine, they do not necessarily help anticipate the positive and negative effects medical training and a career in medicine have on the person. In this chapter we discuss these effects and argue that medicine is a way of life, as well as a profession.

BOX 6.1 Specific stressors in the basic science years Time pressure Emphasis on course examinations and national board examinations Competition for grades and class rank Financial problems Amount of rote memorization Limited time for recreation and exercise Strain on social and intimate relationships Loneliness Fear of failure Prolonged dependence on parents or spouse

capacity for intimacy. Most medical students are young adults who face these tasks. The medical school environment, however, may create stresses that impede achievement of adulthood goals. For example, the seemingly limitless material to be learned and the fierce competition for grades can decrease peer support and leave little time or energy for establishing intimate relationships.

Specific Stressors in the Basic Science Years

MEDICAL SCHOOL STRESS Erik Erikson’s psychosocial theory of development describes early adulthood as a time for strengthening the identity that is usually attained during adolescence. This identity includes individuals’ establishing themselves as independent people, separate from parents. In addition, young adults must pursue vocational goals and attain a

With a touch of pride, many physicians describe their first year of medical school training as “a living hell.” Indeed, everyone involved would agree that medical school is incredibly stressful, a fact that is verified by the number of studies investigating the sources of medical students’ stress. Although the rank order of stressors differs from one study to another, time pressures, examinations, financial problems, and competition for good grades are the primary stressors encountered in medical school. Other stressors

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include the tedium of rote memorization, loneliness, fear of failure, and prolonged dependence on parents or spouse. Box 6.1 summarizes the stressors medical students encounter during the basic science years. Because of their pervasiveness among medical students, two problems, time pressure and fear of failure, deserve special attention. Time pressure. One problem towers over all the rest of medical students’ concerns: too little time. Even very bright students quickly find that there is too much to read and learn to allow for sloppy study habits. The students who succeed are those who know something about time management or who quickly learn to organize their lives in such a way that everything gets at least some attention. In addition, they develop a tolerance for learning without mastery. They give biochemistry its allocated 2 hours and then turn to the next scheduled topic, even if they have not mastered all 50 pages of biochemistry assigned for the evening. They quickly learn to prioritize their study time, and they block off time for low-priority but still important activities. (Washing your socks is not a high priority, but you can postpone it only so long.) Fear of failure. Fear of failure is another problem many medical students encounter during the basic science years. Students often seek counseling during the first weeks of medical school, concerned about the massive amount of information to be mastered, their first poor grades, or their doubts about their own adequacy and their choice of medicine as a profession. The problem often boils down to a simple fear: “I’m not smart enough to be in medical school.” Medical students are high achievers who have worked hard to earn a place in the freshman medical school class. They have frequently been class leaders in their undergraduate courses. It is a frightening experience when they find themselves (along with 50% of their classmates) in the bottom half of the class on the first examination or two in medical school. It is even more frightening when they confront failure for the first time. Yet even bright, hardworking, and ambitious students fail an occasional test and perhaps a class. The student who did not have a basic science major as an undergraduate may be particularly vulnerable to failure during the first year of medical school. A failure, however, does not mean that the student is not bright enough for medical school, that he or she is a “false positive,” or that the admissions committee made a mistake. It does reflect the fact that the basic science years consist of an overwhelming amount of material to master, and there are simply not enough hours in the day to master everything. In our experience, 95% of students who seek counseling for anxiety related to failure experiences in the freshman year go on to find their stride and cope very successfully with medical school. In fact, many of them become excellent clinicians and the graduates in whom we have the most pride. To cope with medical school most students must learn that earning a “C” in a course is acceptable. We emphasize to our students that passing classes is a more significant

In the cancer ward, they face the issue of imminent death; in the pediatric ward, they see children with congenital defects die of kidney infections; in emergency rooms, beautiful young 12-year-old children come in with venereal disease; and in the surgical wards they may interview people their own age paralyzed after being shot in a senseless $13 robbery.

MARLENE M. COLEMAN, M.D. criterion than class rank and attempt to drive the point home with a question: “What do you call the person who graduates last in his or her class from the very worst medical school in the country?” The answer is simple: “A doctor.”

Specific Stressors in the Clinical Years Some students who have been exceedingly capable in the basic science classroom find themselves faltering as they move into the junior year and confront the realities of clinical medicine. Certainly, the third and fourth years of clinical training differ greatly from classroom instruction in that students must work collaboratively with a variety of health care professionals, among whom they are the lowest in the pecking order. Given the students’ inexperience with the clinical work setting, it is not surprising that conflicts arise between them and the persons with whom they work and train. Indeed, such interpersonal conflicts, typified by nonsupportive and occasionally hostile relations between faculty and students, are a significant source of stress during the third and fourth years of medical school. Some of the other specific stressors our students have encountered during the clinical years of training are listed in Box 6.2. Most of the problems listed in Box 6.2 are time limited, and students rapidly acquire the skills necessary to function effectively on the wards. One study even found that students’ sense of self-efficacy improved significantly by the

BOX 6.2 Specific stressors in the clinical years Interpersonal conflicts with faculty and fellow students Fear of increasing responsibilities and the potential consequences of bad decisions Death of patients Dealing with chronic or terminally ill patients Fear of infections such as AIDS Discomfort in discussing personal and sexual issues Discomfort in performing physical exams Loneliness and loss of frequent contact with friends on other rotations

Chapter 6: Special Problems of Medical Students

middle of their third year compared with their entry into school. Some of these stressors, however, result from having to confront the reality of pain and suffering and the transience of human existence, and these are continuing issues for physicians. Many students are attracted to medicine because of a genuine desire to help others and are distressed in situations in which they can do little to help. Unfortunately, patients with cancer suffer and die; acquired immunodeficiency syndrome (AIDS) patients grow increasingly sick; and some old people become demented despite their physicians’ best efforts. An important part of professional training in medicine is for the individual to accept the limitations of his or her craft and the inevitability of pain, suffering, and death. Learning to cope with problems of this type without heavy reliance on the defense mechanisms of intellectualization and isolation of affect may well determine the extent to which the physician avoids burnout and establishes a career that is meaningful and personally rewarding.

Levels of Stress Although there is agreement regarding the sources of stress in medical students, there is little concurrence regarding when the stress is most severe. One set of investigators found that stress was highest at the start of school and just before examinations and lowest midway in the third year. Others have found that the pattern of stress that medical students exhibited was dependent on the nature of stressor being studied, with the most common pattern being an inverted U-shape, indicating that time pressures, uncertainty about career choice, and other problems were most severe in the second and third years of medical school. Several recent studies have found that stress during medical school is chronic and persistent rather than episodic. There are also conflicting results when medical students’ stress is compared with the stress experienced by other groups of students. One study found that 585 medical students compared with 1,110 students in other health-related fields reported significantly more stress on 35 of 83 questions. Other investigators, as recently as in 1997, have found that law students and other graduate students report levels of stress similar to those of medical students. Medical students enrolled in a traditional curriculum have been found to experience significantly more stress compared to students enrolled in a problem-based learning curriculum. Several studies have determined that stress affects the immunologic functioning of medical students. For example, in a 1999 study, medical students evidenced a significant change in neuroimmune correlates from a baseline (beginning of the academic year) to a stress condition (the day before an exam). During the stress condition, students evidenced an increase in plasma cortisol levels and a significant reduction of lymphocyte proliferation, IL-2 pro-

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duction, and the percentage of the lymphocyte CD19. Perhaps due to stress, young physicians get minor illnesses more frequently than expected. Moreover, they add to their stress by continuing to work, despite being ill, with, as reported in a 1997 study, 52% not taking time off and 81% coming to work when they are “unfit.” Female medical students consistently report more stress and more stress-related symptoms. White medical students, compared to students from underrepresented minorities, also report higher levels of stress. In addition, at least some investigators have reported that single students as a group experience more severe stress than married students. Studies also show that male and female medical students differ in sources of stress: women are more concerned about the responsibility inherent in the physician role, whereas men are distressed by relationships with patients, their inability to cure patients, and the threat of malpractice suits. Single female students may find that because they intimidate many male students, they do not have as large a pool of potential partners as their male classmates. Married female students may suffer from “role strain” when domestic tasks and their roles as wives conflict with their medical school duties and professional aspirations. Indeed, a study published in 1997 found that among female medical students, increased frequency of social contacts outside the school environment was significantly predictive of increased distress. Evidence also indicates that the medical school environment presents women with different problems and challenges, including sexism. For example, surveys show that up to 75% of female physicians report they have been sexually harassed. Other studies have confirmed that women experience more difficulty in their interactions with faculty and hospital staff.

Coping with Transitions In addition to presenting the student with a number of stressors, both entry into medical school and the change from the basic science years to the clinical years represent transitions and changes in the prevailing homeostasis in a student’s life. A transition occurs when a critical life event (e. g., getting accepted into medical school) jolts an individual’s sense of identity and requires that his or her behaviors and relationships change to manage the new situation successfully. Psychological research has provided a useful model for conceptualizing transition. The harbinger of change can be positive or negative and can produce either elation or despair (e. g., getting accepted into medical school or being deserted by your spouse). In either case the initial response is shock and immobilization. This inertia can be overcome by minimizing the significance of the event. This period of minimization is followed by a period of self-doubt. For medical students this second stage often occurs about 7 or 8 weeks into the first semester when they begin to question

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BOX 6.3 Attitudes that influence the happiness of medical students and physicians* Path 1 These coping attitudes will not be very useful to you in medicine, in the long run.

Path 2 These coping attitudes will lead to more long-term satisfactions and enjoyment in medicine.

The strong silent approach. Don’t tell others what you are thinking.

Learn to listen to the feelings of others, and to share your own.

Success means good grades and, later, wealth and material goods.

That’s okay, but it doesn’t compare to enjoying your work and people.

Your needs must take a second place to more important things in life.

You must fill your own needs at the same time you are accomplishing your other goals.

Your worth depends on what you accomplish. When you don’t accomplish as much as others or as much as you can, you are basically inadequate.

There is a source of self-worth that cannot be measured by your accomplishments, that is non-negotiable and fundamental.

Mistakes are the result of ignorance, apathy, carelessness, and general basic worthlessness.

Mistakes aren’t exactly okay, but they are a fact of life, even in medicine. Mistakes are your chief source of wisdom. Learn from them and don’t make them twice. Perfectionism leads to burnout.

Criticism is a demonstration to the world of your inadequacy. Defend, justify, explain, and attack!

Criticism isn’t exactly pleasant, but get used to the idea that it doesn’t imply inadequacy. Learn to use it.

You are helpless in a world that controls your behavior.

You are in charge of what you do; it’s no use blaming anyone else. What you do is up to you.

When you are feeling overwhelmed, lonely, anxious, depressed, and can’t study, it is up to you to “snap out of it.” Be strong, work hard, and keep a stiff upper lip. It’s just a matter of willpower.

There is nothing wrong with you; everyone has trouble coping and could use some help. It may be embarrassing to find that you don’t know everything yet. A sense of self-worth that keeps you from getting help may lead to real trouble.

Results are more important than people. (Type A behavior is goal oriented.)

People are more important than results. (Type B behavior is “process” oriented.)

Thinking is the highest function.

There is more to you than thinking. Don’t let your feelings and intuition atrophy; don’t become an intellectual nerd.

* From Virshup, B. (1985). Coping in medical school. New York, NY: WW Norton. Used by permission.

both their commitment to medicine and their ability to cope with the amount to be learned. For the abandoned spouse a period of concern exists about his or her physical attractiveness and ability to once again establish a loving relationship. Successful adaptation to transition involves a series of predictable stages. Initially individuals have to abandon many assumptions that may have once given meaning and direction to life. Medical students may have to let go of beliefs about personal and intellectual superiority as they consistently find themselves in the bottom quarter of their class; the jilted spouse may have to reexamine core beliefs that are no longer adaptive (e. g., believing that only one person can give happiness). This change produces a void and new beliefs and attitudes have to be tested systematically before they can be assimilated into an individual’s self-concept. Students can learn that they are people of value and worth despite their borderline grades. The jilted

spouse can begin to date others and discover that many of them are vivacious and interesting. Rituals (e. g., the act of putting on a stethoscope for the first time in the case of the medical student) may be important in testing out newly established roles. As new roles are assimilated and become increasingly comfortable, a need exists to integrate those roles with an individual’s personal value system and Weltanschauung (a comprehensive conception of the world). Medical students come to feel comfortable with their new role and confident in their abilities. The jilted spouse develops new and rewarding relationships and eventually finds a new love relationship that is more rewarding than the distressed first marriage. Some attitudes that influence the happiness of both medical students and physicians are listed in Box 6.3. In addition to attitudinal changes that can increase coping, stress management courses for medical students are effective. For example, a 19-week study on self-hypnosis

Chapter 6: Special Problems of Medical Students

71 Medical Students at Work on a Cadaver, 1890 From the collection of the Minnesota Historical Society, Minneapolis. Human dissection is a unique learning experience that links every freshman medical student with previous generations of physicians.

with medical students found associated increases in immune functions as measured by increases in number and activity of natural killer cells. Another study found that first year medical students who received a stress management course, compared to non-attendees, were less anxious and more satisfied with themselves, life, and their school performances. In addition, a well-controlled study published in 1998 found that an 8-week meditation-based stress reduction intervention for premedical and medical students effectively reduced anxiety and psychological distress, including decreased depression and increased empathy scores. Moreover, the beneficial results were observed even during an exam period.

Predicting Success in Medical School The first English-speaking woman physician was Dr. James Miranda Barry, who served in British Army hospitals between 1813 and 1865. Dr. Barry dressed and lived as a man and was discovered to be a woman only after her death. In order to succeed as a physician, Dr. Barry had to obscure her real self and adopt the personality characteristics of a man. In recent years, medical school matriculates have become a more diverse group. For example, in the early 1970s, women constituted only 9% of applicants and 9% of entrants to medical schools. By contrast, the Association of American Medical Colleges (AAMC) reported that in 1999, 45% of medical school applicants were women and, depending upon the school, 26% to 64% of new entrants were women,

with women constituting an average of 46% of new entrants. During the last 10 to 20 years, much effort has also been devoted to increasing the number of underrepresented minorities (URM) admitted to medical schools, in order to have medical school matriculates better reflect the heterogeneity of the U. S. population. In 1991, the AAMC established the 3000 by 2000 Project, aimed at doubling the number of URMs admitted to medical school by the year 2000. Unfortunately, court decisions not favoring affirmative action programs and other factors have hindered achievement of the AAMC’s goal. As medical school matriculates have become a more heterogeneous group, investigators have attempted to predict success in medical school. MCAT scores and overall undergraduate GPAs have repeatedly been found to be good predictors of medical school performance as measured by medical school basic science GPAs and scores on the National Board of Medical Examiners tests (e. g., R = .65). Scores on standardized tests and GPAs, however, have been notoriously poor predictors of clinical performance. For example, a study published in 1997 found that cognitive ability as measured by undergraduate GPA and MCAT scores was only weakly related to ward evaluations (R = .35). Consequently, many investigators have attempted to identify personality characteristics predictive of success in medical school. A 1995 study showed that better performance in medical school was correlated with being enthusiastic, venturesome, self-opinionated, and driven. Class rank has been found to be associated with the traits of compulsiveness and aggressiveness. Daily hassles and interper-

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Part 1: The Physician and Society Sir William Osler Lecturing to Medical Students at Johns Hopkins. Courtesy of the National Library of Medicine. Master teachers have always been appreciated by medical students. Note that almost all of the students appear to be male.

sonal conflicts have also been found to be significantly negatively correlated with mean grades on required third-year clerkships. Two other groups of investigators have found a curvilinear relationship between overall medical school GPAs and anxiety. Achievement was maximized by a certain level of anxiety, and anxiety above or below that level was associated with decreased achievement. Indeed, a 1997 study found that personality variables (e. g., tough mindedness and emotional stability) were the primary predictors of clinical performance. Not surprisingly, researchers have not been able to identify one or two personality traits that predict all medical school performance measures. However, it seems clear that psychosocial attributes, perhaps akin to the concept of “emotional intelligence” (Goleman, 1995), contribute to success as a medical student and a professional. Another factor that seems to affect success in medical school is coming from a socioeconomically or educationally disadvantaged background, as is the case with many students who are from underrepresented minority populations. To examine this factor, an investigator recently (1998) compared the attrition rates of underrepresented minority (URM) and nonminority (non-URM) students over a four-year period at a midwestern college of medicine. The study found that among the 19% of URM students admitted (near the national average of minority admissions) there was an attrition rate of approximately 16%, compared to a 4% attrition rate for non-URM students. Moreover, students who withdrew because of academic difficulties comprised 75% of URM withdrawals and 57% of non-URM withdrawals. Results such as these point to the

need for effective preparatory and academic support services for all students, and especially for those from disadvantaged backgrounds.

MEDICINE AS A WAY OF LIFE Personality Characteristics of Medical Students and Physicians Desirable personality characteristics. Several investigators have sought to identify personality characteristics desirable in medical students and physicians. In one study, faculty and resident physicians valued a trait they labeled “toughness,” which centered on endurance, perseverance, and self-discipline. Sensitivity to others was also seen as a desirable trait for medical students. In another study, 42 medical students were asked to rank 18 desirable traits. They ranked honesty, responsibility, capability, and the ability to love as the most desirable characteristics. Compulsivity is another characteristic often identified as a valuable and adaptive trait in physicians because it is believed to be associated with carefully planned therapeutic regimens and thoroughness in the diagnostic workup, including a willingness to “go the extra mile” to rule out a rare disease. Given that sensitivity to others, honesty, perseverance, and compulsivity are desirable traits for medical students and physicians to possess, to what degree are these traits found among medical professionals? It appears that medical students possess the characteristics of perseverance and

Chapter 6: Special Problems of Medical Students

Women physicians are different, their lives are different, their offices are different, they practice medicine in a different way. With increasing numbers, they will change the way medicine is practiced. Courtesy of Dr. Marjorie Sirridge.

sensitivity to others. A study of 246 medical students indicated that medical students, as a group, scored higher than other students on several personality variables, achieving their highest scores on measures of endurance, nurturance, and need for achievement. Those same authors concluded that medical students are industrious, self-reliant, perfectionistic, disciplined, inquiring, and sympathetic. Similarly, a separate study found that compulsive traits, including perfectionism, preoccupation with details, excessive devotion to work, and extreme conscientiousness, were present in 100 randomly selected physicians, all of whom declared themselves to be compulsive personalities. Moreover, this high incidence of compulsivity does not seem to generalize to all highly educated professionals. Lawyers, for example, have been found to be much less compulsive than physicians. Several groups of authors have studied gender differences in medical students’ psychological characteristics. One group found that female medical students had significantly higher scores on scales measuring achievement orientation and needs for autonomy, dominance, and order. They

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scored significantly lower than their male counterparts on scales measuring needs for affiliation. A recent (1999) study of a large sample of medical students (743 men and 414 women) found that although men and women students were similar on 8 of 12 psychosocial measures, men scored significantly higher on the intensity of loneliness scale and women scored significantly higher on the general anxiety, test anxiety, and neuroticism scales. The authors cautioned, however, that the magnitudes of the effect size estimates were trivial. It is possible that admissions procedures including medical school admissions interviews lead to the selection of an increasingly homogeneous group of students. Despite the difficulty researchers have had in consistently identifying gender differences in personality traits among medical students, it seems important to pursue this line of research to understand better the personality factors in medical students that predict future medical practice styles and specialty choices. For example, women physicians, compared to their male counterparts, have been found to communicate more positively with their patients, spend more time with their patients, and render more preventive care. In addition, women are more likely to enter peopleoriented specialties such as pediatrics, family medicine, and psychiatry. Despite these well-established trends, it is unclear what personality characteristics are associated with specialty preference. For example, a recent study that looked at personality characteristics of surgeons, anesthesiologists, and psychiatrists found no differences, and all groups evidenced compulsivity, decisiveness, and aggression. Undesirable personality characteristics. Other investigators have identified less favorable traits in medical students and physicians. For example, researchers at Harvard University found that 47 physicians, compared with 79 socioeconomically matched controls were statistically more likely to exhibit traits of dependency, pessimism, passivity, and self-doubt. Another study noted that many medical students exhibit a Type A personality style characterized by competitiveness, hostility, time urgency, and excessive devotion to work. Type A personality style and excessive devotion to work were documented in a survey of 100 randomly selected physicians that found that only 10% regularly took time off to relax and only 16% read for pleasure, attended theater or concerts, or viewed television as a pastime. Only 11% took vacations that were not linked to professional activities. One component of the Type A personality style, hostility, has even been found to have a deleterious effect on physicians’ longevity. One group of researchers examined Minnesota Multiphasic Personality Inventories (the MMPI; see Chapter 20) that had been collected almost 30 years earlier from University of North Carolina medical students. The investigators extracted scores on the Cook Medley Hostility Scale, an MMPI subscale, and used it to predict

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subsequent overall mortality in their now late middle-aged sample of physicians. These investigators discovered that physicians whose hostility scores had been high 25 years earlier were four to five times more likely to develop heart problems during the ensuing years than those whose scores had been lower. A more recent longitudinal study of more than 1,000 medical students found similar results. Students who coped with tension by directing it inward, compared to those who used other coping mechanisms, were found to have higher risk for early mortality (under age 55), even when adjustments were made for age, smoking and cholesterol. Effect of medical school on personality. Two separate studies have reported an increase in Type A behavior in Australian medical students over the first 3 to 4 years of training in a 6-year curriculum. Similar increases in Type A behavior occurred across 4 years of training in students enrolled in an American medical school. Other negative changes in students’ personalities may also result from medical school training. Two studies demonstrated a modest but unmistakable shift toward hedonism between the freshman and junior years of medical school in two cohorts of students. More specifically, between their freshman and junior years medical students became less concerned with achievement and less intellectually curious and became more impulsive, aggressive, and interested in play. The authors attributed these changes to students’ increasing dissatisfaction with their spartan educational atmosphere. Other authors have reported that students become significantly more self-indulgent, cynical, aggressive, and confrontational over the course of medical school. On a more positive note, a longitudinal study found that Australian medical students in their sixth year of study were more mature, emotionally stable, self-assured, self-disciplined, and extroverted than during their second year of training. A longitudinal study of 76 students in an American medical school found that students’ self-perceptions of warmth and helpfulness were stable over the course of training with no discernible trend toward cynicism or detachment from patients. In addition, a longitudinal controlled study published in 1997 showed that rather than losing interpersonal skills over the course of training, medical students who received education and experience in this area can improve their skills. However, based on studies that show the average physician interrupts his patient within 18 seconds of beginning the interview and a study published as recently as 1997 which showed that 90% of nurses report verbal abuse from a physician within the past year, we know that it is important to continue to teach medical students and physicians to communicate more effectively. In summary, investigations of the effects of medical school training on students’ personality characteristics have produced mixed results. These data, combined with

the authors’ experience with medical students, lead us to three conclusions: 1. Over the course of the first 3 years of medical school, students become more Type A in their personality style. 2. As a group, they also become more mature, self-confident, self-disciplined, extroverted, and hedonistic. 3. Education in medical school leads to improved communication skills, but upon graduation, most students could benefit from further refinement of their interpersonal skills. Although on the surface the increases in hedonism and self-discipline appear contradictory, they reflect what many medical students know: medical school teaches them to work very hard and play equally hard.

Medical Marriages On any list of desirable professions for their child’s spouse, parents rank medicine at or near the top. The parent assumes the spouse’s intelligence, education, income, and compassion will ensure a happy marriage. Unfortunately, this is not necessarily the case. On the positive side and contrary to popular opinion, physicians tend to stay in their marriages; and in fact, with a divorce rate of 29%, they have a lower divorce rate than many other professions. Studies published in 1997 reported differential divorce rates with psychiatrists having the highest rate (50%), followed by surgeons (33%), and pediatricians, internists, and pathologists (23%). Among women physicians 70%–85% marry, and 50%–70% of these marry other physicians. Women dermatologists are most likely to marry, and women emergency room physicians and surgeons are least likely to marry. Female physicians have been found to have a higher divorce rate than male physicians, though this appears to be an artifact of specialty area and the higher divorce rate of women in the work force. A 1997 study found that women physicians’ divorce rate is lower than the rate for women in the general population, consistent with earlier research that showed that women physicians’ likelihood of divorce is 23% lower compared to the general population of employed women. Physicians’ divorces typically occur after medical school or residency training, when the physician is 35 to 45 years of age. Despite the longevity of physicians’ marriage, in one study 47% of physicians reported having an unhappy marriage. A recent (1999) study of over 650 physicians found similar results in that approximately half reported high levels of marital satisfaction. Other studies have found that 25% to 47% of physicians have sought marital counseling as a result of unhappiness, and an additional 21% have seriously considered it. Still, even during residency, 40% of residents report major problems with their spouse. Of

Chapter 6: Special Problems of Medical Students

those who reported problems, 72% believed the problems were caused by the residency, although only 21% thought their hospital work had been negatively affected by their marital problems. Sources of marital conflict. Several recent studies have investigated sources of conflict in physician marriages. One study analyzed questionnaires from 108 residents and found that they attributed their relationship stress to the large number of hours spent at the hospital, lack of athletic activity, sleep deprivation, lack of family and social support, daily chores, indebtedness, and the fact that the residents’ spouses worked long hours. Other authors have noted additional sources of conflict in physician marriages, including chronic fatigue, decreased sexual interest, and feelings of alienation and loneliness in the nonmedical spouse. By far the most common source of conflict reported in studies of physicians’ marriages is the physicians’ tendency to work long hours. Despite the popularity of this explanation, studies, including one published in 2000, have failed to establish a significant correlation between divorce or marital dissatisfaction and long hours of work in either physicians or medical students. Similarly, another study found that lack of time because of practice demands was a complaint that served to externalize conflicts inherent in the relationship, falsely attributing failure to factors outside the marriage. Accordingly, those researchers found that the real conflicts in medical marriages revolve around differences in the partners’ needs for intimacy, disparate perceptions of the problems in the relationship and in each other, and communication styles. The major concern of these physicians, 93% of whom were men, was that their spouses were not interested in having sexual relations. The primary complaint of the spouses was that their physician partners did not talk to them enough. Interestingly, for both the physicians and their spouses, complaints of “doesn’t support or empathize with me” and “doesn’t listen to me” were common. This finding is consistent with two more recent (1999) studies that found that marital satisfaction and psychological adjustment were predicted by spousal support, not by stress or the number of hours worked. Although earlier investigations of medical marriages dealt almost exclusively with male physicians and their wives, recent studies examined dual-doctor marriages. One study analyzed interviews with female interns and residents and their spouses. The husbands of these residents complained about the fatigue of their mates, the lack of time together, and the necessity to postpone gratification. The husbands also felt overburdened with domestic responsibilities and found conflicts with their own career demands difficult to reconcile. Interestingly, in another study 75% of women physicians reported perceived spousal support, although only 15% of their husbands took significant responsibility for family or household chores. Despite the increasing numbers of marriages between two physicians, there is a paucity of research comparing

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stresses and satisfaction experienced in two-physician marriages with those reported by couples in which only one of the partners is a physician. In general, investigators have found no significant differences in the stressors reported by these two types of couples, and two-physician couples do not report either greater sharing or greater understanding of work-related problems than the other couples. The most recent investigation of dual-doctors’ marriages was published in 1999. Over 1200 physicians completed a survey in order to directly compare two-physician marriages to marriages in which only one member was a physician. Twenty-two percent of the male physicians and 44% of the female physicians were married to physicians. Men and women in dual-doctor marriages differed significantly from other married physicians in that they more frequently enjoyed shared work interests with their spouses and had higher family incomes (although they earned less individually). The two types of couples were not different from one another in the frequency with which they achieved their career goals or the frequency with which they experienced conflict between their professional and family roles. Benefits of marriage. Some researchers have long considered marriage to have a positive effect on male medical students, and marital satisfaction has repeatedly been found among physicians to be a predictor of job satisfaction. One study found that men who were married when they entered medical school were less likely to fail or drop out than unmarried male students. Female residents have also reported positive benefits from marriage, including a sense of emotional security and intimacy. Unfortunately, at least two studies suggest that female medical students may receive less support from their spouses than male students. The more rigorous of these studies found that among 334 medical students, 17% of married women compared with only 6% of married men indicated that their relationship with their spouse was very stressful. Similarly, although 31% of the men indicated their wives were moderately or very supportive, only 19% of the women described their husbands’ behavior that way.

Practice Setting and Specialty Choice Several characteristics of medical students affect specialty choice and practice setting. For example, a study published in 1998 found that growing up in an inner-city community was significantly associated with practicing in an urban center, whereas growing up in a rural community was more likely to result in practicing in a rural center. In addition, women are more likely than men to be in generalist or primary care fields, to be in a group rather than a solo practice, to have practices with a high proportion of managed care patients, to report dissatisfaction with the short amount of time they have to spend with patients and colleagues, and to report concerns about their ability to stay knowledgeable.

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Part 1: The Physician and Society Young Doctor Courtesy of the National Institute of Aging. Young physicians often feel uncomfortable counseling patients older than themselves.

A study published in 1998 based on the responses of almost 2,170 physicians indicated that the factors that have influenced medical students’ specialty choices have remained remarkably consistent over the past 65 years, despite the dramatic changes that have occurred in medicine and medical care delivery systems over those decades. The factorsmost consistently rated positive were: consistently intellectual curiosity (e. g., “challenging diagnostic problems”), altruism (e. g., “interest in helping people”), and personal identity (e. g., “consistent with personality; possess the required skills”). Negative factors such as “demands on time” and “stress in the field” were also consistently cited as important factors. The demographic characteristics of persons who select a specific specialty appear to differ across specialties. For example, among 2,700 U. S. women physicians recently (1998) surveyed, surgeons were younger and more likely to be white, unmarried, childless, and born in the U. S. Women surgeons, compared to other women physicians, also worked more clinical hours and call nights but were not more likely to report they worked too much, had too much work stress, or had less control over their work environment. Their career satisfaction was similar to other women physicians, and their satisfaction with their specialty was greater.

Career Satisfaction of Physicians Although recent polls indicate that medicine is still the most honored profession, the public’s respect for physicians has clearly been eroded by well-publicized malpractice suits and reports of physician fraud in federally funded Medicare

and Medicaid programs. Physicians are no longer seen as infallible. Unfortunately, the public’s changing view of medicine has spread to the physicians themselves. It has become fashionable among physicians to bemoan their profession, complaining increasingly about health maintenance organizations and preferred provider organizations (see Chapter 3) and the intrusion of other business matters into their practices. Physicians also cite diagnostic related groups, rising numbers of malpractice suits and declining rates of reimbursement from insurance companies as harbingers of the ruin of medicine as a career. Negative attitudes about a career in medicine have resulted in some physicians discouraging students from entering a career in medicine. In a survey of 1,200 students who scored well on the Medical College Admission Test but did not apply to medical school, 25% reported that a practicing physician had discouraged them from seeking a career in medicine. Another survey indicated 33% to 40% of applicants had been discouraged from going to medical school by a physician. When queried, 44% of physicians reported that they would not encourage their child to pursue a career in medicine, although a subsequent study suggested that perhaps the percentage might have been lower if “were my child interested in medicine” had been added to the question. Despite the negative discourse about medicine as a career, studies conducted as recently as 1999 show that the majority of physicians are fairly happy with their career choice. For example, a study published in 1998 of nearly 800 male and female physicians across a variety of medical specialties and practice settings found that 73% were satisfied with their overall practice and most were satisfied with their income. Physicians in private practice were most sat-

Chapter 6: Special Problems of Medical Students

isfied with their overall practice and office resources. Among primary care physicians, the family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their practice. Similar results were found in a 1999 survey of a nationally representative group of nearly 2,700 women physicians which revealed that 84% were generally satisfied with their careers (usually, almost always, or always satisfied). However, 31% would maybe, probably, or definitely not choose to be a physician again, and 38% would maybe, probably, or definitely prefer to change their specialty. As in the earlier study of men and women, among the women surveyed, career satisfaction was significantly affected by several factors, including work control, specialty choice, practice type, and workload. Other studies have shown that autonomy, relationships with colleagues and patients, resources, status, personality traits, and time away from work predict job satisfaction among physicians. In a direct comparison between fee-for-service and capitation, a 1999 study showed that physicians were much more satisfied with a fee-for-service delivery system. To determine which aspects of their jobs physicians find satisfying, a study asked 211 physicians to rate their degree of satisfaction on 13 job-related variables. The study found that overt dissatisfaction was rare, and the average rating on each of the items was in the range that indicated moderate to extreme satisfaction. The physicians were most satisfied with the diversity of patients under their care, their ability to derive personal gratification from patient care, and their intellectual stimulation. They were least satisfied with their prospects for increasing success in the future, with 21% indicating they were not very satisfied or very dissatisfied with that aspect of their job.

PSYCHOLOGICAL PROBLEMS IN MEDICAL STUDENTS AND PHYSICIANS Although the majority of medical students and physicians cope successfully with the demands of their lives, as many as 30% develop psychological problems. Despite these high rates of distress, studies have shown that only 8% to 15% of medical students seek psychiatric care during the course of their medical education. Of the students who seek psychiatric care, depending on the sample studied, 35% to 40% are found to have difficulty adjusting to some aspect of school. Another significant proportion of students seeking care (22%–40%) has a mood disturbance, usually depression. About 15% request assistance with marital problems. Several factors affect students’ willingness to seek psychological care. For example, a study published in 2000 by Dar-

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Nothing will sustain you more potently than the power to recognize in your humdrum routine . . . the true poetry of life—the poetry of the commonplace, of the ordinary man, of the toil worn woman, with their joys, their sorrows, and their griefs.

SIR WILLIAM OSLER’S advice to medical students (circa 1905)

lene Shaw and her colleagues found that students expressed concern about the stigma of seeking professional help. In addition, distressed students who were not receiving psychological treatment had higher levels of socially prescribed perfectionism and held more negative attitudes about mental health services than distressed students who were seeking help. Studies such as these point to the importance of educating medical students about research that has established the effectiveness of psychotherapy and marital therapy. It is also important that medical students be informed about the ethics of confidentiality, which govern university counseling centers. Lastly, students should understand that experiencing severe stress and seeking help for it are both “normal.” A significant proportion (10%–20%) of practicing physicians at some time in their professional life will have a significant psychiatric disorder. For example, a 1995 study found that 13% of residents met diagnostic criteria for Post-Traumatic Stress Disorder. In another study, 34% of the middle-aged physicians in the sample had sought 10 or more outpatient visits for psychiatric care, a proportion that was significantly higher than that for a matched control group. In this study 17% of physicians vs. 6% of the controls had required psychiatric hospitalization. The statistics regarding the use of psychiatric services by medical students and physicians are not surprising. Certainly we could not expect that medical training provides immunity from the psychological problems that beset all other groups of people. The psychological problems that have been most frequently studied in medical students and physicians are depression, suicide, and substance abuse.

Depression Several empirical studies have documented what most medical students already know: medical school can be a depressing place. One study of 304 medical students found that the incidence of major depression during the first two years of school was 12%, with a lifetime prevalence of 15% through the second year of school. This later rate is three times greater than that for an age-matched control in the general population. Another study showed that the largest proportion of students (25%) were symptomatic for depression near

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the end of the second year. Strikingly similar results were found in a recent (1997) longitudinal study which found that although entering medical students had similar rates of depression as the general population, by year two 39% and by year four 31% scored above the 80th percentile on a standardized measure of depression. Although no gender differences were found at baseline, women experienced higher rates of depression than men at year two and at year four. Increases in perceived stress were significant predictors of increased depression scores in both men and women. A separate 1999 study found that although men and women medical students are equally likely to experience stressful life events (e. g., 38% death of a family member in past 12 months; 39% financial problems), women who experienced these events appraised them as more negative and as having a greater impact on them. In addition, students, especially women, with less good social support networks prior to entering were more prone to depression, even if they reported good networks during medical school. Several researchers have found that medical students do not suffer from more psychiatric distress than other graduate students. For example, a study published in 1998 by Darlene Shaw and her colleagues found that although 28% (2.5 times the number found in the normal population) of students scored in the clinical range on a standardized measure of psychiatric distress, medical, dental, and nursing students did not differ from one another on this measure, and pharmacy students were more distressed than each of these groups. Several investigators have sought to identify personality characteristics and other factors that predict psychiatric distress among medical students. A 1997 study found that poorer undergraduate academic performance, high trait and state anxiety, high state depression, low dispositional optimism, and reliance on avoidant coping strategies predicted depression and anxiety toward the end of the first year in medical school. In a separate 1997 study, socially prescribed perfectionism and high scores on the imposter scale (a scale that measures students’ beliefs that they are less competent than others believe they are and that they will one day be discovered as frauds) were the strongest predictors of psychiatric distress among medical students. The relatively high rates of depression found among medical students continue into the internship year. With surprising consistency, studies have demonstrated that approximately 30% of interns in the first postgraduate year (PGY1) of training suffer from depressive syndromes. One such study found that although only 10% of entering interns had psychiatric disorders, 27% of interns had experienced at least one episode of major depression at the conclusion of the first six months of training. The onset of depression was significantly associated with a positive parental history of depression and high scores on tests of neuroticism; whereas sex, marital status, and workload were not associated. In another study, a 28.7% prevalence rate

of depressive symptoms was noted for PGY1 interns, with the rate dropping during each successive year of training to a rate of 10.3% in PGY3 residents. Although no well-designed studies of the rates of depression among practicing male physicians have been reported, high rates of depression similar to those for house officers have been reported for practicing female physicians. One study, which used carefully defined diagnostic criteria, established a lifetime prevalence rate of 39% for major depression among 111 female physicians. This 39% prevalence rate is significantly higher than the 25% lifetime risk for depression that is commonly found in the general population of women. Another more recent (1999) study found that 19.5% of women physicians self-reported a history of depression. Depression was more common among women physicians who were not partnered; were childless; drank alcohol; had worse health; had more stress at home; had a history of substance abuse, an eating disorder, or another psychiatric illness; had less control at work; had high job stress; were dissatisfied with their career; and who reported working too much. Other studies have shown that support from peers and work group cohesiveness mitigate against depression in physicians.

Suicide Among Medical Students and Physicians After accidents, suicide is the most common cause of death among medical students. A survey published in 1996 of 101 (80%) U. S. medical schools found that between 1989 and 1994, a total of 15 students committed suicide; Fourteen of the suicides were men, 8 of whom used a firearm and 6 of whom overdosed. Forty percent of the reported suicides occurred in the junior year. This rate was below the national rate for this age group and was lower than reported in earlier studies of medical student suicide. The authors suggest that perhaps counseling programs have contributed to a decline in the suicide rates among medical students. Other studies have found that the suicide rate for female medical students equals that of the men but is three to four times higher than their female age-mates. Suicide is also a serious problem among practicing physicians. Each year physician suicide in the United States removes from society a number of physicians equal to the size of an average medical school graduating class. Early studies suggested physician suicide rates were approximately twice the rate for the general population. That finding, however, reflected the fact that physicians of the day were overwhelmingly white men, a subgroup with an especially high base rate of suicide. More recent studies have found that male physicians do not commit suicide much more frequently than other men in the United States. In contrast, female physicians have a suicide rate that is approximately two to four times that for white nonphysician women of the same age. Factors associated with physician suicide and suicide at-

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turbed, and alcohol or drugs were thought to be a significant factor in 40% of these suicides. Another study that compared physician suicides with an age- and sex-matched control group of physicians who died of other causes found significantly more physicians who committed suicide had chronic mental disorders, psychiatric hospitalizations, previous suicide attempts, and outpatient care by a mental health professional. The greatest differences between the two groups was in their use of drugs and alcohol; significantly more of the suicide group (34% vs. 14% of controls) were believed to have had a drug problem and/or problems associated with their use of alcohol at some time in their lives. Finally, significantly more physicians in the suicide group compared with the controls had been physically violent toward their spouses (36% vs. 11%), and the suicide group was believed to have received and to have given significantly less emotional support from and to family members and friends. A recent study (1999) of 2,700 women physicians found that 1.5% self-reported a suicide attempt. Those with a history of alcohol abuse or dependence, sexual abuse, domestic violence, poor current mental health, a family history of psychiatric disorders, U. S. birth, and non-Asian heritage were significantly more likely to report suicide attempts or depression.

Physician Struggling with Death for Life Courtesy of the National Library of Medicine. Although the image is appealing, physicians who adopt grandiose self-images are at high risk to burn out and become frustrated and embittered.

tempts. A classic study conducted in the 1960s falsely concluded (due to methodological and statistical flaws) that rates of physician suicides differed across medical specialties. Subsequent investigators, however, found that the differences in suicide rates across different medical specialties were not statistically significant among U. S. physicians. Other reports regarding physicians suicide indicate no specialty predominance in England, and general surgeons have the highest suicide rate among physicians in Sweden. Several investigators have studied the role of personality variables in medical student suicide. One research group reported that nine medical students who committed suicide compared with medical student controls had significantly higher ratings on psychological tests that had measured hostility, depression, negativism, suspiciousness, dependency, and impulsivity. Other studies have suggested that physicians who kill themselves suffer from depression and substance abuse. A classic study based on interviews with surviving family members reported that three fourths of 249 physicians who committed suicide were described as depressed or dis-

ALCOHOL, DRUGS, AND THE MEDICAL PROFESSION The character of Hawkeye Pierce in the movie and television series “M.A.S.H.” typifies the popular stereotype of the hardworking and hard-drinking physician who uses alcohol as a coping mechanism for dealing with the stress of long hours and a demanding surgery schedule. Although the portrayal makes for good comedy, alcohol abuse can have devastating effects. Alcohol is involved in 50% of motor vehicle deaths, 67% of murders, and 33% of suicides. For physicians, the combination of heavy drinking and medical practice can lead to patient harm, loss of a medical license, and personal tragedy. Alcoholism and other forms of substance abuse occur across all groups of individuals regardless of social class, education, or occupation. However, some authors have speculated that physicians may have unusually high rates of substance abuse. One of the earliest assertions to this effect appeared in the Journal of the American Medical Association in 1894 when a physician wrote, “It is a fact— striking though sad—that more cases of morphinism are met with among medical men than in all other professions combined.” More recent authors have continued to claim that physicians have a higher prevalence of drug problems than other occupational groups. Some have called drug addiction an occupational hazard for physicians, and still oth-

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ers have suggested that physicians are at higher risk for drug use because 20% to 25% of them are adult children of alcoholics.

Substance Use by Medical Students and Physicians In addition to all of the speculation about drug use among physicians, many investigations of the actual prevalence of drug use among physicians and medical students have been conducted. The most comprehensive study of substance use among medical students analyzed the responses of 589 fourth-year students to an anonymous questionnaire administered at 13 medical schools in different regions of the United States. In that study, for each of 11 substances, students reported whether they had used that substance ever in their lifetime, in the past year, in the previous 30 days, or daily (defined as 20 or more times in the previous month). Alcohol was the most widely used drug, with 88% of the medical students reporting alcohol use in the month before the study. Marijuana was the second most frequently used substance, with 17% reporting use in the previous month. Cocaine ranked third in frequency of use, with 6% of students reporting use in the previous month. Not surprisingly, only 9% of students reported smoking cigarettes in the previous month. Similar rates of substance use were reported in a longitudinal study of 170 medical students approximately ten years later in 1997. Most medical students (92%–95%) reported using alcohol at least once in the prior year, and marijuana was the illicit drug used most by students (22%–29%) in the past year. Benzodiazepine use in the past year was reported by 2%–6% of medical students. Medical students’ use of licit and illicit drugs was comparable to that of their chronological peers and prior studies of medical students. Surprisingly, although some students (4%–9%) appeared to be at risk for alcohol dependence, no student came to the attention of the school administration due to problems associated with substance use. Moreover, although 13% to 17% students were aware of a classmate’s problem, half of students who were aware of a student’s problem failed to take any action. Heavy drinking (defined as five or more drinks in a 24-hour period) was reported by 14%–22% of students. This study and a study by one of the present authors found that students with a family history of alcohol abuse had a significantly increased risk for developing alcohol-related problems. Other studies have addressed whether medical students use various substances at a rate higher than a national sample of their peers. With respect to alcohol use, when compared with more than 2,500 age- and sex-matched controls, medical students had higher rates of alcohol use in the previous month than college or high school graduates, although the lifetime prevalence (95%–97%) was very similar for the medical student and control groups. Lifetime

prevalence of marijuana use for medical students was also very similar to their peers from the national sample, but when marijuana use in the previous month was compared, medical students had significantly lower rates of use (17%) than college (21%) or high school (27%) graduates. A similar finding was reported for daily use of marijuana, with only 1% of male and female medical students reporting daily use compared with male (5.5%) and female (2%) college graduates and male (11%) and female (15%) high school graduates. Cocaine showed a similar pattern, with the medical students being significantly less likely and the high school students significantly more likely than the college graduates to use this substance in the previous year or month. Cigarettes showed the most dramatic differences in that only 4% of male and 5% of female medical students smoke daily compared with 40% of male and 34% of female high school graduates of a similar age. In summary, compared with their peers nationally, medical students reported less use of marijuana, cocaine, cigarettes, and several other substances (e. g., LSD, barbiturates, and amphetamines). However, their use of tranquilizers and alcohol was slightly higher than that of their cohorts. No similarly good data exist comparing substance use among physicians and their peers. Studies that do look at this issue report conflicting results. Although a 1991 study found no significant differences in the drinking patterns of physicians compared with age-matched controls, other investigators have suggested that as physicians age, they are more likely than the general population to evidence alcohol-related problems. A 1999 study examined the anonymous self-reported past year use of several substances among more than 5,400 physicians from twelve specialties. The statistical model controlled for demographic and other characteristics that might explain observed specialty differences. Emergency room physicians used more illicit drugs; psychiatrists used more benzodiazepines; and anesthesiologists used more major opiates. Comparatively, pediatricians had overall lower use rates, as did surgeons, except for tobacco smoking. Self-reported substance abuse and dependence were highest among psychiatrists and emergency room physicians and lowest among surgeons.

Substance Abuse by Medical Students and Physicians Studies that have investigated the prevalence of substance abuse (as opposed to substance use) among medical students have found that 11% to 23% of medical students are excessive drinkers, 6.5% are at high risk for substance abuse, 18% abuse alcohol sometime during medical school, and 3% are dependent on psychoactive substances other than alcohol. Although somewhat alarming, these

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percentages do not signify prevalence rates that are significantly higher than those found in their same-age peers. Only three studies have directly compared rates of substance abuse among physicians with rates among other occupational groups. Each of these three, however, found no significant differences between the rates for physicians vs. other groups. The prevalence of these problems among physicians is similar to that in the U. S. population in general. Encouraging as these findings are, a significant percentage of physicians are likely to abuse alcohol or drugs. This finding is of particular concern, because an impaired physician can wreak untold harm on the patients in his or her care. In addition, physicians who become alcohol dependent suffer mightily. For example, a study of 100 alcoholic women (95 physicians and five medical students) found that 32% were separated or divorced, 53% had at least one alcoholic parent, 8% said both parents were alcoholic, 22% had suffered domestic violence, 32% had been arrested for alcohol-related offenses, 34% had attempted suicide, 15% had been sued for professional liability, and 71% had received inpatient treatment for alcohol dependence. In response to concerns about problems caused by impaired physicians and with the encouragement of the American Medical Association, the state medical societies in each of the 50 states have formed Impaired Physician Programs, often referred to as Physician Assistance Programs, designed to help impaired physicians receive appropriate treatment. A similar movement is afoot on medical school campuses where administrators are recognizing their responsibility to establish clear guidelines and policies defining appropriate professional behavior regarding alcohol and drug use by students. In addition, the federal government has recognized the need for such policies and recently mandated that institutions of higher education have in place policies and programs relating to substance abuse. Medical schools, however, seem poorly equipped to fulfill that federal mandate. For example, although a recent study found that all medical schools responding to a survey (N equal 114) had psychological counseling available to students, one third of the schools indicated that these services are not adequate. In a separate survey only 22% of medical schools responding to a questionnaire indicated that they have a written policy relating to medical student impairment. Certainly, if the problem of substance abuse and other psychological disorders among medical students and physicians is to be adequately addressed, medical schools must develop programs aimed at prevention, early identification, and rehabilitation.

SUMMARY Medicine is a profession with multiple rewards and some risks. On the average these risks appear comparable with

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those encountered in other high-stress occupations that require long and intensive preparation. Contrary to popular mythology, medical marriages are stable and the divorce rate for physicians is relatively low; however, many medical marriages are unhappy, and long work hours and patient demands can easily become an excuse for avoiding the difficult job of confronting marital problems. Psychological problems and substance abuse also exist in a significant number of physicians, and female medical students and physicians in particular have high rates of stress and suicide as they cope with conflicting societal roles. It is imperative that both medical students and physicians be aware of the risks inherent in medical education and the physician role and vigilant about early identification of any problems that may develop. In our experience, clearly identifying a problem and “owning” it places one at least halfway toward the eventual solution.

CASE STUDY Jack Hunter, a 22-year-old graduate of a midwestern statesupported university, is currently enrolled as a first-year medical student at a prestigious university in the northeast United States. Although he excelled as an undergraduate, Jack is very concerned about his ability to compete successfully in medical school. He feels overwhelmed by the volume of material he has to read and memorize and finds he is envious of some of his former college classmates who enrolled in medical schools that use a problem-based learning curriculum. Jack wants eventually to specialize in ophthalmology. He is aware that acceptance into those residency programs is extraordinarily competitive and only the very top students are accepted. As he sits in class, he finds himself worrying about whether he will be able to perform well enough on the United States Medical Licensing Examination (USMLE) to warrant consideration by ophthalmology residency programs. Yet another source of stress is his relationship with his girlfriend back home, who is becoming bored with her job as a nurse’s aid and is hoping to join him soon so they can marry at the end of his first year in medical school. Jack spends all of his time studying. He is limiting himself to 5 hours of sleep each night and has stopped exercising. Although several of his classmates have suggested that he join their study group, he has declined their offer because he fears he does not grasp the material well enough to keep up with their pace. He feels uneasy and anxious around many of his classmates and he sits alone during lectures. His only sources of support are nightly phone conversations with his girlfriend and “beer busts” with a couple of classmates after each major exam and on weekends.

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Questions • In what ways are Jack’s stressors representative of the concerns many students have? • In what ways are Jack’s stressors different? • What aspects of Jack’s presentation are of particular concern to you? • If you were Jack’s primary care physician, what additional information would you try to elicit from him? What would you counsel him to do?

Discussion Jack’s concerns about time pressures and mastery of material are representative of the stressors experienced by many medical students. He is also experiencing the imposter phenomenon in that he fears he is not as skilled as others think he is. He is future oriented and “borrowing trouble” in that he is worrying about future events about which he has no control, except by doing his best in his current classes. By focusing on these future events, he is adding to his stress and likely limiting his current effectiveness. Jack’s coping mechanisms are flawed in that he is isolating himself socially, rather than seeking support within the school environment. Moreover, although his relationship with his girlfriend provides some support, it is also a source of stress in that their educational levels are divergent and perhaps they have different goals for the near future (marriage vs academic achievement). It is important to gain additional information about Jack’s alcohol and drug use (both past and present) and his family history of substance use/abuse. As Jack’s primary care physician, it would be appropriate to refer him to a stress management course for medical students or to individual psychotherapy at a counseling and psychological services center. Almost all universities provide confidential psychological services for medical students, and surveys of students who use these centers routinely report high levels of benefit and satisfaction with the service they receive.

Additional Case History By the end of Jack’s first year in medical school, he is performing in the top third of his class, though he remains disappointed with his grades. He constantly feels anxious and pressed for time, and he is becoming increasingly irritable and hostile. He also feels torn between spending more time studying and providing his girlfriend with the nightly phone calls she relies upon. Although he is not using any illicit drugs, his drinking has escalated, and he is now consuming 6–12 beers at parties on most Friday and Saturday nights. At his girlfriend’s insistence, he seeks counseling from the university-based psychological center on his campus, where he is relieved to learn that his contact will be

held in strict confidence, and no one in his academic program will be notified. At the counseling center, Jack’s psychologist learns that Jack is the first person in his family to graduate from college. His mother works at the local Sears store, and his father is a welder who is alcoholic. Jack is the oldest of three children.

Questions • What aspects of Jack’s current functioning are of concern? • How is his anxiety likely affecting his academic performance? • What do you think about his current alcohol consumption, and what additional information do you need to better assess it? • What risk factors for alcohol abuse does Jack currently exhibit? • What other psychological disorders is he at risk for? • What type of psychological treatment is appropriate for Jack?

Discussion Jack is exhibiting characteristics of a Type A personality and his hostility is particularly problematic. His anxiety is interfering with his academic performance. His alcohol consumption, although not dissimilar from that of approximately 10–20% of his peers, is of concern, especially given his family history of alcohol abuse. It would be important to determine whether Jack is experiencing symptoms of alcohol abuse or dependence (see Chapter 18), including loss of control over his drinking and unwanted consequences such as driving while impaired. Jack is also at risk for depression (see Chapter 28) and should be assessed for this. The mental health professional treating Jack would undoubtedly provide him with emotional support and help him to develop more effective coping skills. It would also be appropriate to help Jack to evaluate his use of alcohol and set appropriate goals for limiting his alcohol consumption. A cognitive-behavioral approach to treatment would be effective.

Additional Case History Throughout the fall semester of Jack’s second year in medical school, he attends counseling only sporadically, and he drops out of therapy prior to his fall semester final exams. During counseling, Jack maintains that his drinking is not a problem, pointing out that if it were, he would not be able to stay in the upper third of his class. As he becomes increasingly withdrawn socially, two of his classmates become concerned about his drinking and approach one of

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their professors who indicates that as long as Jack is performing well in school, what he does outside of class is “his business.” Jack’s drinking continues to increase in frequency. He begins drinking on some weeknights, and he experiences several blackouts. For example, on two occasions after a night of drinking he awakens at home but cannot recall how he got there. In addition, while out drinking one night, he is arrested for public intoxication. In the spring semester, he fails his pharmacology course and his physical diagnosis course, making him eligible for dismissal from medical school. When the Dean of Students calls Jack in to discuss his academic problems, in order to avoid dismissal from school, Jack reluctantly admits that his drinking might have had a detrimental effect on his academic performance. The Dean refers Jack for mandatory treatment of his alcohol dependence.

Questions • What is the defense mechanism (see Chapter 8) that Jack is exhibiting in regard to his drinking? • Is it usual for a student who has a drinking problem to continue to perform well academically? • What is an appropriate course of action for friends or faculty to take when they are concerned about a student? • Should the medical school dismiss Jack because of his drinking problem? • What course of action would most Deans take?

Discussion When Jack points to his good academic performance as evidence that he does not have an alcohol problem, he is exhibiting denial. It is not unusual for students to initially maintain good academic performance, despite excessive alcohol use. Indeed, studies have shown that many alcoholic physicians graduated in the top 10% of their class. Friends and faculty who are concerned about a student for any reason, including his/her alcohol use, should first approach the student in a supportive way and express their concerns directly. If need be, they should insist the student seek professional help and inform an appropriate academic official. When academic officers such as a Dean become aware of a student’s substance abuse, they typically take a supportive stance and facilitate the student’s receiving appropriate treatment. In most instances, dismissal from school is pursued only when all other options have failed, including the student’s receiving one or more leaves of absence to receive appropriate treatment.

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SUGGESTED READINGS Bourne, E.J. (1995). The anxiety & phobia workbook. Oakland, CA: New Harbinger Publications. Many medical students suffer from simple phobias, including fears related to the gross anatomy lab, needle phobias, and blood phobias. This excellent workbook provides step-by-step procedures and exercises for overcoming problems with phobias, panic attacks, and anxieties. In addition to providing instruction in cognitive and behavioral techniques for overcoming phobias, it also employs a holistic approach, in that it addresses issues such as assertiveness, self-esteem, and spirituality. Davis, M., Eshelman, E., & McKay, M. (1995). The relaxation and stress reduction workbook. Oakland, CA: New Harbinger Publications. This outstanding workbook is designed as a self-help tool to teach students stress management and relaxation techniques. It increases students’ awareness of their personal reaction to stress and reviews numerous stress-reduction techniques, including progressive relaxation, meditation, and visualization. It also provides effective instruction in other related topics such as diaphragmatic breathing, thought stopping, and how to deal with irrational beliefs and negative self-talk. Ellis, D.B. (1985). Becoming a master student. Rapid City, ND: College Survival, Inc. This book is loaded with hundreds of nuts-and-bolts techniques to help students to be more successful learners. It offers effective solutions to many problems students face, including dosing off during lectures, procrastinating, planning their time, and taking tests. It teaches techniques aimed at improving memory, reading skills, goal setting, and numerous other skills needed to succeed as a student. Ey, S., Henning, K.R., & Shaw, D.L. (2000).Attitudes and factors related to seeking mental health treatment among medical and dental students. Journal of College Student Psychotherapy 14(3): 23–39 This article, which reports the results of an anonymous questionnaire completed by 315 medical and dental students, examines the factors which keep many students from seeking help from a mental health professional. It points to the importance of educating students about how emotional distress can impact academic performance and indicates that when students are informed about the availability of university-based counseling services, they should also receive information that normalizes treatment seeking. Goleman, D.P. (1995). Emotional intelligence New York, NY: Bantam Press High I.Q. is no guarantee of success or happiness. Drawing on neuroscience research, the author postulates that emotional intelligence (defined as self-awareness, altruism, motivation and empathy) is the strongest predicator of professional and personal success. Greenberger, D. & Padesky, C. (1995). Mind over mood. New York, NY: Guilford Press. Cognitive therapy is the fastest growing form of psychotherapy and has been proven to be effective in numerous controlled research studies. This book distills the wisdom and science of cognitive psychotherapy, teaches readers the central principles that have made cognitive therapy successful and provides explicit instructions that will help students to apply these principles in their day-to-day lives. It helps students understand the connections between their thoughts, moods, and behaviors and teaches techniques helpful in managing depression, anxiety, and anger. It is an

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excellent resource for students who are experiencing “normal” stress or mood problems. Heitler, S. (1997). The power of two: Secrets to a strong & loving marriage. Oakland, CA: New Harbinger Publications. This excellent book is for anyone who is now or hopes to someday be married. It provides clear instructions in how to communicate better with your partner, including teaching the skills needed to talk, listen, and resolve conflicts more effectively. It also provides instruction in how to express and receive anger and how to arrive at shared decisions in an efficient and caring fashion. Hendrix, H. (1988). Getting the love you want. New York, NY: Henry Holt & Co. This remarkable book serves as a primer for helping individuals understand the psychological dynamics inherent in virtually all romantic relationships and marriages. Although some of the terminology borders on “psychobabble,” the book helps couples to identify feelings and behaviors left over from childhood that inevitably lead them to experience conflict. It provides a series of step-by-step exercises that help couples to become a source of mutual support to one another. In our experience, many couples have found this book invaluable in helping them to understand and heal their relationships. Henning, K., Ey, S., & Shaw, D. (2000). Perfectionism, the imposter phenomenon, and psychological adjustment in medical, dental, nursing, and pharmacy students. Journal of Medical Education, 32, 456–464. This article examines the personality characteristics which are related to psychological distress experienced by medical, dental, nursing, and pharmacy students. McKay, M., Fanning, P., & Paleg, K. (1994). Couple skills: Making your relationship work. Oakland, CA: New Harbinger Publications. This brief book provides step-by-step instruction in communication skills that will enhance virtually any couple’s ability to communicate with one another and negotiate solutions to the conflicts they are experiencing. Myers, M.F. (1988). Doctor’s marriages: A look at the problems and their solutions. New York, NY: Plenum. This book is an intelligent and thorough account of the issues of special interest to medical students. Reiser, D.E., & Rosen, D.H. (1985). Medicine as a human experience. Rockville, MD: Aspen. Primarily a book about the physician-patient relationship, this text provides an excellent account of medicine from a humanistic perspective without degenerating into any of the “psychobabble” that sometimes afflicts such writings. It includes a fine introductory chapter for medical students about life on the wards. Virshup, B. (1985). Coping in medical school. New York, NY: WW Norton.

* See p. 459 for Answer Key and discussion.

This is a fascinating little book full of practical advice for medical students.

USMLE REVIEW* 1. Success in medical school is positively related with all of the following EXCEPT: A. Undergraduate grade-point average B. MCAT scores C. Compulsiveness D. Emotional intelligence or stability E. Underrepresented minority status 2. Research has shown that, compared to their male counterparts, female physicians tend to be more likely to do all of the following EXCEPT: A. Specialize in pediatrics B. Spend more time with patients C. Marry another physician D. Have a type A personality E. Communicate positively with patients 3. Match the specialty with the substance its members are most likely to abuse: 1. Psychiatrist 2. Anesthesiologist 3. Surgeons 4. Emergency room physicians A. Benzodiazepines B. Opiates C. Illicit drugs D. Tobacco 4. The variable most closely associated with deciding to practice medicine in an urban center is: A. Intellectual curiosity B. Growing up in an inner-city C. Altruism D. Gender E. Marital status 5. Most studies of job satisfaction in physicians show: A. General satisfaction B. Overt dissatisfaction C. A majority would change specialty D. Dissatisfaction with income E. Preference for managed care environments