"
'\ , _...
Special Problems of
A1edicalStudents
Darlene L. Shaw
Danny Wedding
Peter B. Zeldow
Nancy Diehl
Let us emancípate the student, and givehim
opportunity for theculd~ation'.~f mind, rus so that in .
his pupilage he' shall not .be a 'pGppet 'in' the
others, but rather a self-relying ~nd reflecting
SIR WJll.lA.L\,1 OSLER '. .. Ó> ;:
Ifyou listen c~~~nilly to what ~atients s~y, fuey will •
often tell you not.only what is wrong with the~ but also .
what is wrong with you.
WALKERPERCY . Prolonged dependence on parents orspouse
The decision to become a physician represents an irnpor-
tant commitment that produces profound personal effects
and shapes many of life's events. Although medical school
and residency training pro vide the knowledge and techni-
cal skills needed to practice medicine, they do not neces-
sarily help anticipa te the positive and negative effects med-
ical training and a career in medicine have on the persono
In this chapter we discuss these effects and argue that med-
icine is a way of life, as well as a profession.
MEDICAL SCHOOL STRESS
Erik Erikson's psychosociál theory of development de-
scribes early adulthood as a time for strengthening the
identity that is usually attained during adolescente. This
identity ineludes individuals' establishing themselves as in-
dependent people, sepárate from parents. In addition,
young adults must pursue vocational goals and attain a
time and ..BOX 6~1 Specific s~essors in the basic scie~~e years ,,~, .
.T~e pressure .. .. ',"
h~nd~ of '. Emphasis on course exarninations md natiorial. board
being . . . exarninations : .' .. .....
Cornpetition for grades and c1ass rank
F~áncial problerns .' ., ' •.•... ', ."
Amount of rote memorization .'.'
Ó: :
Limited time for recreation árid eX~rcise .
Strain on social and intimare relationshíps
Loneliness . '.. .'. '. .
Fear of failure
capacity for intimacy. Most medical students are young
adults who face these tasks. The medical school enviren-
ment, however, may create stresses that impede achieve-
ment of adulthood goals. For example, the seemingly lirn-
itless material to be learned and the fierce competition for
grades can de crease peer support and leave little time or
energy for establishing intimate relationships.
Specific Stressors in the Basic Science Years
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 in-
credibly 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 prob-
lems, and competition for good grades are the primary,
stressors encountered in medica] schoo!. Other stressors
68 Part 1: The Physician and Society
in elude the tedium of rote memorization, loneliness, fear
of failure, and prolonged dependence on parents or spouse.
Box 6.1 summarizes the stressors medica! students encoun-
ter during the basi.c science years. Because of their perva-
siveness among medica! students, two problems, time pres- .
sure and fear of failure, deserve special attention.
Time pressure. One problem towers over all the rest of
medical students' concerns: too little time. Everi 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 man-
agement or who quickly learn to organize their lives in such
a way that everything gets at least sorne attention. In addi-
tion, 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
al! 50 pages ofbiochemistry assigned for the evening. They
quickly learn to prioritize their study time, and they block
off time for low-priority but stil! important activities.
(Washing your socks is not a high priority, but you can
postpone it only so long.)
Fear of failure. Feat of failure is another problem many
medical students encountet during the basic science years. Stu-
dents often seek counseling during the first weeks of medical
school, concerned about the massive amount of informa-
.tion to be mastered, their first peor 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 undergrad-
uate courses. It is a frightening experience when they find
themselves (along with 50% of their classmates) in the bot-
tom half of the class on the first examination or tVI'Oin
medical school. It is even more frightening when they con-
front failure for the first time. Yet even bright, hardworking,
and ambitious students fail an occasiona! 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,
do es 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
arnount of material to master, and there are simply not
enough hours in the day to master everything. In our expe-
rience, 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
schonl, In fact, many of them beco me 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 c1asses is a more significant
In the cancer ward, they fa ce the issue of imrninent
death; in the pediatric ward, they see children with
congenital defects die ofkidney infections; in emergen-
cy room s, 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 be-
ing shot in a senseless $13 robbery.
MAru..ENE M. COLEMAN, M.D.
criterion than c1ass rank and attempt to drive the point
home with a question: "What do you cal! the person who
graduates last in his or her c1ass from the very worst medical
school in the country?"
The answer is simple: "A doctor."
Specific Stressors in the Clinical Years
Sorne students who have been exceedingly capable in the
basic science c1assroom find themselves faltering as they
move into the junior year and confront the realities of clin-
ical medicine. Certainly, the third and fourth years of clin-
ical training differ greatly from classroom instruction in
that students must work collaboratively with a variety of
health care professiona!s, 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 interpersona! conflicts, typified by
nonsupportive and occasionally hostile relations between
faculty and students, are a significant source of stress dur-
ing the third and fourth years of medical school. Sorne of
the other specific stressors our students have encountered
during the c1inica! 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 stu-
dents' sense of self-efficacy improved significantly by the
BOX 6.2 Specificstressors in the clínical years
Interpersonal conflicts with faculty and felIow students .
Fear of increasing responsibilities and the potential conse-
quences ofbad decisions
Death of patients
Dealing with chroriic or terminally ill patients
Fear of infections such as AIDS .
Discornfort in discussíng personal and sexual issues
Discornfort in perforrning physical exams
Lonelíness and loss of frequent contact with Eriends on other
rotations
 -.
Chapter 6: Special Problems of Medical Students
le of their third year compared with their entry into
)1. Sorne of these stressors, however, result from hav-
_)confront the realiry of pain and suffering and the
ience of human existence, and these are continuing
s for physicians.
any students are attracted to medicine because of a gen-
desire to help others and are distressed in situations in
h they can do littIe to help. Unfortunately, patients with
er suffer and die; acquired immunodeficiency syn-
ne (AIDS) patients grow increasingly sick; and sorne old
ile become demented despite their physicians' best ef-
-, An important part of professional training in medicine
,the individual to accept the limitations ofhis or her craJt
the inevitability of pain, suffering, and death. Learning to
: with problems of this type without heavy reliance on
.lefense mechanisms of intellectualization and isolation
ffect may welI determine the extent to which the physi-
¡ avoids burnout and establishes a career that is mean-
ul and personally rewarding.
/els 01 Stress
hough there is agreement regarding the sources of stress
medical students, there is little concurrence regarding
en the stress is most severe. One set of investigators
md that stress was highest at the start of school and just
.ore examinations and lowest midway in the third year.
hers have found that the pattern of stress that medical
.dents exhibited was dependent on the nature ~f stressor
ing studied, with the most common pattern being an
verted U-shape, indicating that time pressures, uncer-
.nty about career choice, and other problems were most
vere in the second and third years of medical schooI. Sev-
al recent studies have found that stress during medical
hcol is chronic and persistent rather than episodic.
There are also cont1icting results when medical students'
ress is compared with the stress experienced by other
-oups of students. One study found that 585 medical stu-
ents compared with 1,110 students in other health-related
elds reported significantly more stress on 35 of 83 ques-
ons, Other investigators, as recently as in 1997, have found
.iat law students and other graduate students report levels
,f stress similar to those of medical students, Medical stu-
lents enrolled in a traditionol currículum have been [ound to
-xperience significalltly more stress compared to students en-
ol/ed in a problem-based learning curriculum.
Several studies have determined that stress affects the
.mmunologic functioning of medical students. For exarn-
ple, in a 1999 study, medica!" students evidenced a signifi-
cant change in neuroimmune correlates from a baseline
(beginning of the academic year) to a stress condition (the
day before an exarn). During the stress condition, students
evidenced an increase in plasma cortisol levels and a sig-
nificant reduction of lymphocyte proliferation, IL-2 pro-
---.-~._
.._~ -
69
duction, and the percentage ofthe Iymphocyte CD19. Per-
haps due to stress, young physicians get minar illnesses
more frequently than expected. Moreover, they add to their
stress by continuing to work, despite being ilI, with, as re-
ported 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 sorne
investigators have reported that single students as a group
experience more severe stress than married students. Stud-
ies 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 patierits, their inability
to cure patierits, 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 pub-
lished in 1997 found that among female medie al students,
increased frequency of social contacts outside the school
environment was significantly predictive of increased dis-
tress. Evidence also indicares that the medical school envi-
ronment presents women with different problems and
chalIenges, including sexismo For example, surveys show
that up to 75% of female physicians report they have been
sexualIy harassed. Other studies have confirmed that worn-
en experience more difficulty in their interactions with fac-
ulty and hospital staff .
Coping with Transitions
In addition to presenting the student with a nurnber 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 occuts when a critical life event
(e. g., getting accepted into medical school) jolts an individu-
al's sense ofidentity 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 de-
spair (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 nzinimizing the significance of the evento This period of
minimization is followed by a period of selj-doubt. For
medical students this second stage often occurs about 7 or
8 weeks into the first semester when they begin to question (
70 Part 1: The Physician and Society

[-~::·.~I'"~::".:~:2·t?~:.~
.' ~;':-:-.
".t .~~. ::~::-' -... •• ._' '. ': ~."'::. t: o," •

~~.,
BOX 6:3 .Altitudes that influence the happiness of medical students and physicians*
t:~t~~thl<:.:. ..... . .....'. ".: .',. . Path 2 .. , .
L~':,'TheS~coping attitudes ,:"m not be very uSefuÚo you in medi- These eoping attitudes willIead to more long-term satisfac-
f:':- 'Cine,in the long 'nill. : - "" ... " o'. ',." . tions and eiIjoyrnent in medicine. .
,.
r.
f . The strong silentapproach. Don't tell oth~rs what you are .
thinking. . ". " , .. . .
Leam to listen to the feelíngsof others,'and to share your own..
. ~. .

Success means good grades and, later, wealth and material That's okay,b~t it doesn't compare to enjoying your work and
goods. .... ': .. people. . .

. Your needS must tak~ a sec~)Ddplace to ~~re impo~ant things . You must fill your own needs at the same time you are accorn-
in life. . plishing your other goals.

Your worth depends 00 what you accomplish. When you don't There is a source of self-worth that cannot be measured by
accomplish as much as others or as much as you can, you are your accornplishrnents, that is non-negotiable and fundamental.
basically inadequate ..

Mistakes are the result of ignorance, apathy, carelessness,and Mistakes aren't exactly okay,but they are a faet of life, even in
general basic worthlessness. medicine. Mistakes are your chief source of wisdom. Learn
from thern and don't make thern twice. Perfectionism leads to
burnout.

Critieism is a demonstration to the world of your inadequacy. Criticisrn isn't exactly pleasant, but get used to the idea that it
Defend, justify, explain, and attackl 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 blarning anyone
else. What you do is up to you.

When you are feeling overwhe1med,lonely, anxious, depressed, There is nothing wrong with you; everyone has trouble coping
and can't study, it is up to you to "snap out of it," Be strong, and could use sorne help. It may be embarrassing to find that
work hard, and keep a stiff upper lip. It's just a rnatter of will- you don't know everything yet. A sense of self-worth that keeps
power. . you from getting help may lead to real trouble.

Results are more important than people. (Type A behavior is People are more important than results. (Type B behavior is
goal oriented.) "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 perrnissioo.

both their commitment to medicine and their ability to spouse can begin to date others and discover that many of
cope with the amount to be learned. For the abandoned them are vivacious and interesting. Rituals (e. g., the act of
spouse a period of concern ex.ists about his or her physical putting on a stethoscope for the first time in the case of the
attractiveness and ability to once again establish a loving medical student) may be important in testing out newly
relationship. established roles.
Successful adaptation to transition involves a series of As new roles are assimilated and become increasingly
predictable stages. Initially individuals have to abandon comfortable, a need ex.ists to integrate those roles with an
many assumptions that may have once given meaning and individual's personal value system and Weltanschauung (a
direction to life. Medical students may have to let go of comprehensive conception ofthe world). Medical students
beliefs about personal and inteUectual superiority as they come to feel comfortable with their new role and confident
consistently find themselves in the bottom quarter of their in their abilities. The jilted spouse develops new and re-
class; the jilted spouse may have to reexamine core beliefs warding relationships and eventually finds a new love rela-
that are no Ionger adaptive (e. g., believing that only one tionship that is more rewarding than the distressed first
person can give happiness). This change produces a void marriage. Sorne attitudes that influence the happiness of
and new beliefs and attitudes have to be tested systernati- both medical students and physicians are listed in Box 6.3.
cally before they can be assimilated into an individual's In addition to attitudinal changes tha t can increase cop-
self-coricept. Students can learn that they are people of val- ing, stress management courses for medical students are
ue and worth despite their borderline grades. The jilted effective. For example, a I9-week study on self-hypnosis
 Chapter 6: Special Problems of Medical Students
with medical students found associated increases in im-
mune functions as measured by increases in number and
activity of natural killer cells. Another study found that first
year medicaI students who received a stress management
course, compared to non-attendees, were less anx.ious and
more satisfied with themselves, life, and their schooI per-
formances. In addition, a well-controlled study published
in 1998 found that an 8-week meditation-based stress re-
duction intervention for premedicaI and medical students
effectiveIy reduced anx.iety and psychologicaI distress, in-
cluding decreased depression and increased empathy
seo res. Moreover, the beneficial results were observed even
during an exam periodo
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 aman 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 aman.
In recent years, medica! school matriculates have become
a more diverse group. For exarnple, in the early 1970s, worn-
en constituted only 9% of applicants and 9% of entrants to
medica! schooIs. By contrast, the Association of American
Medica! Colleges (AAMC) reported that in 1999,45% of
medica! school applicants were wornen and, depending up-
on the school, 26% to 64% of new entrants were wornen,
71
Medica! Students at Work on a Cadaver,
1890 From the coUection of the Minne-
sota Historíca! Society, Minneapolis. Hu-
man dissection is a unique learning expe-
rienee that links every freshman medieal
student with previous generations of phy-
sicians.
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 mi-
norities (URM) admitted to medical schools, in order to
have me di cal schooI matriculates better reflect the heteroge-
neity of the U. S. population. In 1991, the AAMC established
the 3000 by 2000 Project, aimed at doubIing the number of
URMs adrnitted to medica! school by the year 2000. Unfor-
tunately, court decisions not favoring affirmative action pro-
grams and other factors have hindered achievement of the
AAMC's goal.
As medicaI school matricula tes have beco me a more het-
erogeneous group, investigators have attempted to predict
success in medica! school. MCAT scores and overall under-
graduate GPAs have repeatedly been found to be good pre-
dictors of medica! school performance as measured bymed-
ical school basic science GPAs and scores on the Natiorial
Board of Medical Exarniners tests (e. g., R = .65). Scores on
standardized tests and GPAs, however, have been notortously
poor predictors of clinical performance. For exampIe, a study
published in 1997 found that cognitive ability as measured
by undergraduate GPA and MCAT scores was onIy weakly
related to ward evaluations (R = .35).
Consequently, many investigators have attempted to
identify personality characteristics predictive of success in
rnedical school. A 1995 study showed that better perfor-
mance in medical schooI was correlated with being enthu-
siastic, venturesome, self-opinionated, and driven. Class
rank has been found to be associated with the traits of com - (
pulsiveness and aggressiveness. Daily hassles and interper~
72 Part 1: The Physician and Society
-
.•. .:.,
:;q~~~~
'. L;'( \
::~.:~~~-
sonal conf1icts have also be en found to be significantly neg-
atively 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 maxinzized by a certain
leve! o[ anxiety, and anxiety above or below that leve! 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 al! medical school performance measures. Howev-
er, 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 education-
ally disadvantaged background, as is the case with many
students who are from underrepresented minority popu-
lations. To examine this factor, an investigator recently
(1998) cornpared the attrition rates of underrepresented
minority (URi\1) and nonminority (non-URM) students
over a four-year period at a midwestern college of medi-
cine. The study found that among the 19% of URM stu-
dents admitted (near the national average of minority ad-
missions) 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 dif-
ficulties comprised 75% of URM withdrawals and 57% of
non-URJ\tI withdrawals. Results such as these point to the
Sir William Osler Lecturing to Medical
Students at Iohns Hopkins. Courtesy of
the National Library ofMedicine. Master
teachers have always been appreciated by
medical students. Note that almost aIl of
the students appear to be maleo
need for effective preparatory and academic support ser-
vices for al! students, and especially for those from disad-
vantaged 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 "tough-
ness," which centered on enduran ce, perseveran ce, and
self-discipline. Sensitivity to others was also seen as a de-
sirable trait for medical students. In another study, 42 rned- .
ical 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 beca use it is believed to be as-
sociated with carefully planned therapeutic regimens and
thoroughness in the diagnostic workup, including a will-
ingness to "go the extra rnile" to rule out arare disease.
Given that sensitivity to others, horiesty, 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 med-
ical students possess the characteristics of perseverance and
-. Chapter 6: Special Problems of Medical Students
Women physicians are differen~ their lives are different, their offices are
different, they practice medicine in a different way. With in creas ing num-
bers, they will change the way medicine is practiced. Courtesy of Dr.
ivlarjorie Sirridge.
sensitivity to others. A study of 246 medical students indi-
cated 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 conduded
that medical students are industrious, self-reliant, perfec-
tionistic, disciplined, inquiring, and sympathetic. Similarly,
a separa te study found that compulsive traits, induding
perfectionism, preoccupation with details, excessive devo-
tion 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 genera!ize
to all highly educated professionals. Lawyers, for example,
have been found to be much less compulsive than physi-
cians,
Several groups of authors have studied gender differenc-
es in medica! students' psychological characteristics. One
group found that female medical students had significantly
higher scores on scales measuring achievement orientation
and needs for autonomy, dorninance, and order. They
73
scored significantly lower than their male counterparts en
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 seo red
significantly higher on the intensity of loneliness scale and
women seo red significantly higher on the general anxiery,
test anxiery, and neuroticism scales. The authors cautioned,
however, that the magnitudes of the effect size estimates
were trivial. It is possible that admissions procedures in-
duding medical school admissions interviews lead to the
selection of an increasingly homogeneous group of stu-
derits.
Despite the difficulty researchers have had in consisterit-
ly identifying gender differences in personality traits
among medical students, it seems important to pursue this
line of research to understand better the personaliry factors
in medical students that predict future medical practice
styles and specialty choices, For example, women physi-
cians, compared to their ma/e counterparts, have been [ound
to communicate more positively with their patients, spend
more time with their patients, and render more preventive
careo In addition, women are more likely to enter people-
oriented specialties such as pediatrics, family medicine,
and psychiatry. Despite these well-established trends, it is
unclear what personaliry characteristics are associated with
specialty preference. For example, a recent study that
looked at personality characteristics of surgeons, anesthe-
siologists, and psychiatrists found no differences, and aU
groups evidenced compulsivity, decisiveness, and aggres-
sien.
Undesirable personality characteristics, Other investi-
gators have identified less favorable traits in medical stu-
dents and physicians. For example, researchers at Harvard
Universiry found that 47 physicians, compared with 79 so-
cioeconomically matched controls were statistically more
likely to exhibit traits of dependency, pessimism, passivity,
and self-doubt. Another study noted that many medica/ stu-
dents exhibit a Type A persona/ity stylecharacterized by com-
petitiveness, hostility, time utgency, and excessive devotion to
work. Type A personality style and .excessive devotion to
work were documented in a survey ofl 00 randomly select-
ed physicians that found that only 10% regularly too k time
off to relax and only 16% read for pleasure, attended the-
ater or concerts, or viewed television as a pastirne. Only
11 % took vacations that were not linked to professional
activi tieso
One component of the Type A personality style, hostility,
has even been found to have a deleterious effect on physi-
cians' longevity. One group of researchers examined Min-
.nesota Multiphasic Personality Inventories (the MMPI;
see Chapter 20) that had been collected almost 30 years
earlier from University of North Carolina medica! stu-
dents, The investigators extracted scores on the CookMed-
ley Hostility Scale, an MMPI subscale, and used it to predict
74 Part 1: The Physician and Sociery
subsequent overall mortality in their now late middle-aged
S2mpie of physicians. These investigators discovered that
physicians whose hostility seores had been high 25 years ear-
lier were four to five times more likely to develop heart prob-
lems during the ensuing years than those whose seores 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 choles-
terol.
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 dem-
onstrated a modest but unmistakable shift toward hedo-
nism between the freshman and junior years of medical
school in two cohorts of students. More specifically, be-
tween their freshman and junior years medical students
became less concerned with achievement and less intellec-
tually curious and became more impulsive, aggressive, and
interested in play. The authors attributed these changes to
students' increasing dissatisfaction with their spartan edu-
cational atmosphere. Other authors have reported that stu-
dents 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-per-
ceptions of warmth and helpfulness were stable over the
course of training with no discernible trend toward cyn-
icism or detachment from patients. In addition, a longi-
tudinal 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 continué to
teach medical students and physicians to cornmunicate more
effectively.
In surnmary, 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 sryle.
2. As a group, they also become more mature, self-confi-
dent, self-disciplined, extroverted, and hedonistic.
3. Education in medical schoolleads to improved commu-
nication skills, but upon graduation, most students
could benefit from further refinement of their interper-
sonal 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 topo The parent as-
sumes 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 con-
trary to popular opinion, physicians tend to stay in their nzar.-
riages; and in fact, with a divorce rate of 29%, they have a
lower divorce rate than many other professions. Studies pub-
lished in 1997 reported differential divorce rates with psy-
chiatrists having the highest rate (50%), followed by sur-
geons (33%), and pediatricians, internists, and pathologists
(23%). Among women physicians 70%-85% marry, and
50%-70% of these marry other physicians. Women derrna-
tologists are most likely to marry, and women emergency
room physicians and surgeons are least likely to marry. Fe-
male 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 divoree is
23% lower compared to the general population of ern-
ployed women. Physicians' divorces typically occur after
medical school or residency training, when the physieian
is 35 to 45 years of age.
Despite the longevity of physicians' marriage, in one
study 47% of physicians reported having an unhappy mar-
riage. A recent (1999) study of over 650 physicians found
similar results in that approximately half reported high lev-
els of marital satisfaetion. 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 majar problems with their spouse. Of
 Chapter 6: Special Problems of Medical Students
rhose 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 ofhours spent at the hospital, lack of athletic activ-
iry, 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 lar the most common so urce 01 conflict reported in stud-
ies 01physicians' marriages is the physicians' tendency to work
long hours. Despite the popularity of this explanation, stud-
ies, including one published in 2000, have failed to establish
a significant correlation between divorce or marital dissat-
isfaction 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 com-
municatíon styles. The major concern 01 these physicians,
93% 01 whom were men, was that their spouses were not
interested in having sexual relations. The primary complaint
01 the spoLl5es was that thetr 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 ad-
justmen t 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 com-
plained about the fatigue of their mates, the lack of time
together, and the necessity to postpone gratification. The
husbands also felt overburdened with domestic responsi-
bilities and found conflicts with their own career demands
difficult to reconcile. Interestingly, in another study 75% of
women physicians reported perceived spousal support, al-
though only 15% of their husbands took significant re-
sponsibility for family or household chores.
Despite the increasing numbers of marriages between
two physicians, there is a paucíty of research comparing
75
stresses and satisfaction experienced in two-physician mar-
riages 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 understand-
ing 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 sur-
vey 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 individ-
ually). 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 experi-
enced conflict between their professional and family roles.
Benefits of marriage. Sorne researchers have long con-
sidered 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 satisfac-
tion. 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 [emale 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 th'at their relationship
with their spouse was very stressful. Sirnilarly, 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 cen-
ter, whereas growing up in a rural community was more likely
to tesult 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 I
have to spend with patients and colleagues, and to report
concerns about their ability to stay knowledgeable.
76 Part 1: The Physician and Society
A study published in 1998 based on the responses of
almost 2,170 physicians indicated that the factors that have
inf1uenced medical students' specialty choices have re-
mained remarkably consistent over the past 65 years, de-
spite the drama tic changes that have occurred in medicine
and medical care delivery systems oyer those decades. The
factorsmost consistently rated positive were: consistently
intellectual curiosity (e. g., "challenging diagnostic prob-
lerns"), altruism (e. g., "interest in helping people"), and
personal identity (e. g., "corisistent with personality; pos-
sess the required skills"). Negative factors such as "de-
mands on time" and "stress in the field" were also consis-
tently cited as important factors.
The demographic characteristics of persons who select a
spccific specialty appear to differ across specialties. For ex-
arnple, among 2,700 U. S. wornen physicians recently (1998)
surveycd, surgeons were younger and more likely to be
whitc, Unmarried, childless, and born in the U. S. Women
surgeons, compared to other wornen physicians, also
workcd more clinical hours and cal! nizhts but were not
more likcly to report they worked too much, '" had too much
work stress, or had less control over their work environment.
Thcir career satisfaction was similar to other women physi-
cians, and their satisfaction with their specialty was greater.
Career Satisfaction of Physicians
Allhough recen: 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
rcports of physician fraud in federally funded Medicare
Young Dador Courtesy of the National
Institute of Aging. Yaung physicians aften
feel uncamfattable caunseling patients old-
er than themselves.
and Medicaid programs. Physicians are no longer seen as
infallible.
Unfortunately, the public's changing view of medicine
has spread to the physicians thernselves. It has becorne fash-
ionable among physicians to bemoan their profession,
complaining increasingly about health maintenance orga-
nizations and preferred provider organizations (see Chap-
ter 3) and the intrusion of other business matters into their
practices. Physicians also cite diagnostic related groups, ris-
ing 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 result-
ed in sorne physicians discouraging students from entering
a career in medicine. In a survey of 1,200 students who
scored well on the Medica] 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 appli-
cants 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 per-
haps the percentage might have been lower if"were my child
interested in medicine" had been added to the questicn.
Despite the negative discourse about medicine as a ca-
reer, studies conducted as recently as 1999 show that the
majority of physicians are fairl), happy with their career
choice. For exarnple, 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 satis-
fied 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 gen-
eral pediatricians were gene rally 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
l1enerally satisfied with their careers (usually, almost al-
a
ways, 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 significan tiy affected by several factors, including work
control, specialty choice, practice type, and work1oad. Oth-
cr 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 mod-
erate to extreme satisfaction. The physicians were most sat-
isfied 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 jobo
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 ca re during the
course of their medica! education. Of the students who
seek psychiatric ca re, depending on the sample studied,
35% to 40% are found to have difficulty adjusting to sorne
aspect of school. Another significant proportion of stu-
dents seeking care (22%-40%) has a mood disturban ce,
usually depression. About 15% request assistance with
mar ita! problems.
Severa! factors affect students' willingness to seek psycho-·
logica! careo For example, a study published in 2000 by Dar-
77
Nothíng wíll 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
rnan, of the toil wom woman, with their joys, their 50"-
rows, and theit griefs. ..
SIR WILLlAM 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 psy-
chological treatment had higher levels of socially prescribed
perfectionism and held more negative attitudes about men-
tal health services than distressed students who were seeking
help. Studies such as these point to the importance of edu-
cating 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 experienc-
ing severe stress and seeking help for it are both "normal."
A significant proportion (10%-20%) of practicing physi-
cians at some time in their professionallife will have a signif-
icant psychiatric disorder. For example, a 1995 study found
that 13% of residents met diagnostic criteria for Post- Trau-
matic Stress Disorder. In another study, 34% of the mid-
dle-aged physicians in the sample had sought lOor 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. Cer-
tainly we could not expect that medical training provides
immunity from the psychological problems that beset all
other groups of people. The psychologicaI problems that
have been most frequently studied in rnedical 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 medica! students found that the
incidence of major depression during the first two years of
.school was 12%, with a lifetirne prevalence of 15% through
the second year of school. This later rate is three times great-
er than that for an age-matched control in the general pop-
ulation. Another study showed that the largest proportion
of students (25%) were symptomatic for depression near
78 Part 1: The Physician and Sociery
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 aboye the 80th percentile on a stan- .
dardized measure of depression. Although no gender differ-
ences 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 sep-
arate 1999 study found that although men and women med-
ical 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 additiori, students, espeeially
women, witli less good social support networks prior to enter-
ing were more prone to depression, even il they reported good
networks during medical sehoo/.
Several researchers have found that medical students do
not suffer from more psychiatric distress than other grad-
uate students. For exarnple, 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 mea-
sure of psychiatric distress, medical, dental, and nursing
students did not differ from one another on this rneasure,
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 anxi ety, high state depression, low dispositional
optirnism, and reliance on avoidant coping strategies pre-
dicted depression and anxiety toward the end of the first
year in medical school. In a separate 1997 study, socially
preseribed perjectionism and high scores on the imposter seale
(a seale that measures students'. beliels that they are less com-
petent than others believe they are and that they will one day
be diseovered as Ira uds) were the strongest predietors 01psy-
chiatrie 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 ap-
proximately 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 in-
terns had psychiatric disorders, 27% of interns had expe-
rienced at least ene episode of major depression at the con-
clusion of the first six months of training. The onset of
depression was significantly associated with a positive pa-
rental history of depression and high scores on tests of neu-
roticism; whereas sex, marital status, and workload were
not associated. In another study, a 28.7% prevalence rate
of depressive symptoms was noted for PGYl interns, with
the rate dropping during each successive year of training
to arate of 10.3% in PGY3 residents.
Although no well-designed studies of the rates of de-
pression among practicing male physicians have be en re-
ported, high rates 01 depression similar to those lar house
offieers have been reponed lar practieing [emale physicians.
One study, which used carefully defined diagnostic criteria,
established a lifetime prevalen ce rate of 39% for major de-
pression among 111 female physicians. This 39% preva-
lence rate is significantly higher than the 25% lifetirne risk
for depression that is commonly found in the general pop-
ulation of women. Another more recent (1999) study
found that 19.5% of women physicians sell-reported a his-
tory of depression. Depression was more common among
women physicians who were not partnered; were childless;
drank alcohol; had wotse 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 mucho Other studies have shown that
support [rom peers and work group cohesiveness mitigate
against depression in physieia '15.
Suicide Among Medical Students and Physicians
After accidents, suicide is the most common cause 01 death
among medieal 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 yeaL This rate was below the nation-
al rate for this age group and was lower than reported in
earlier studies of medical student suicide. The authors sug-
gest that perhaps counseling programs have contributed to
a decline in the suicide rates among medical students. Oth-
er studies have found that the suicide rate for female med-
ical students equals that of the men but is three to four
times higher than their female age-mates.
Suicide is also a serious problem aniong practicing phy-
sicians. Eaeh year physician suicide in the United States re-
moves [rom society a number 01physieians equal to the size
01 an average medieal sehool 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 over-
whelmingly white rnen, a subgroup with an especially high
base rate of suicide. More recent studies have [ound that male
physicians do not commit suicide much more [requently than
other men in the United States. In contrast, female physicians
have a suicide rate that is approximately two to [our times
that lar white nonphysician women 01 the same age.
Factors associated with physician suicide and suicide at-
 Chapter 6: Special Problems of Medica] Students
Physician Struggling with Death for Life Courtesy of the NationaI
Library of Medicine. Although the image is appealing, physicians who
adopt grundiose self-images are al high risk lo burn out and become [rus-
• trated and embittered.
tempts. A classic study conducted in the 1960s falsely con-
cluded (due to methodological and statistical flaws) that
rates of physician suicides differed across medica! special-
tieso Subsequent investigators, however, found that the dif-
ferences in suicide rates across different medical specialties
were not statistícally significant among· U. S. physicians.
Other reports regarding physicians suicide indicate no spe-
cialty predominance in England, and general surgeons have
the highest suicide rate arnong physicians in Sweden.
Several investigators have studied the role of personality
variables in medical student suicide. One research group
reported that nine medica! students who committed sui-
cide compared with medica! student controls had signifi-
cantly higher ratings on psychologica! tests that had mea-
sured hostility, depression, negativism, suspiciousness, de-
pendency, 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 farnily
members reported that three fourths of249 physicians who
committed suicide were described as depressed or dis-
79
turbed, and alcohol or drugs were thought to be a signifi-
cant 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, pre-
vious suicide atternpts, 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 as-
sociated with their use of alcohol at sorne time in their lives.
Finally, significantly more physicians in the suicide group
cornpared 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, domes tic violence, poor current mental health, a
family history of psychiatric disorders, U. S. birth, and
non-Asían heritage were significantly more likely to report
suicide attempts or depression.
ALCOHOL, DRUGS, AND THE
MEDICAL PROFESSION
The character of Hawkeye Pierce in the movie and televi-
sion series "M.A.S.H." typifies the popular stereotype of
the hardworking and hard-drinking physician who uses al-
cohol as a coping mechanism for dealing with the stress of
long hours and a demanding surgery schedule. Although
the portraya! makes for good comedy, alcohol abuse can
have devastating effects. Alcohol is involved in 50% of mo-
tor vehicle deaths, 67% of murders,.and 33% of suicides.
For physicians, the combination of heavy drinking and
medie al practice can lead to patient harrn, loss of a rnedical
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, sorne authors have
speculated that physicians may have unusually high rates
of substance abuse. One of the earliest assertions to this
effect appeared in the [ournal of the American Medical As-
sociation in 1894 when a physician wrote, "It is a fact~
striking though sad-that more cases of morphinism are
. met with among medica! 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 occupationa! groups. Sorne have called drug ad-
diction an occupationa! hazard for physicians, and still oth-
80 Part 1: The Physician and Society
ers have suggested that physicians are at higher risk for drug
u~e because 20% to 25% of them are adult children of al-
coholics.
Substance Use by Medical Students and Physicians
In addition to al! of the speculation about drug use among
physicians, many investigations of the actual prevalen ce 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 anonyrnous questionnaire ad-
ministered at 13 medical schools in different regions of the
United States. In that study, for each of 11 substances, stu-
dents 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 sur-
prisingly, only 9% of students reported smoking cigarettes
in the previous month.
Similar rates of substance use were reported in a longi-
tudinal study of 170 medical students approximately ten
years later in 1997. Most medical students (92%-95%) re-
ported using alcohol at least once in the prior year, and
marijuana was the il!icit drug used most by students
(22%-29%) in the past yeaL Benzodiazepine use in the past
year was reported by 2%-é/o of medical students. Medical
students' use oflicit and illicit drugs was comparable to that
of their chronological peers and prior studies of medical
students. Surprisingly, although sorne students (4%-9%)
appeared to be at risk for alcohol dependence, no student
carne to the attention of the school administration due to
problems associated with substance use. Moreover, al-
though 13% to 17% students were m-vare of a classmate's
problem, half of students who were aware of a student's prob-
lem 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 farnily history
of alcohol abuse had a significantly increased risk for de-
veloping alcohol-related problems.
Other studies have addressed whether medical students
use various substances at arate higher than a national sarn-
ple of their peers. With respect to alcohol use, when corn-
pared with more than 2,500 age- and sex-matched controls,
medical students had higher rates of alcohol use in the pre-
vious month than college or high school graduares, al-
though the lifetime prevalence (95%-97%) was very simi-
lar 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 sarnple, but
when marijuana use in the previous month was cornpared,
medica! students had significantly lower rates of use (17%)
than college (21 %) or high school (27%) graduates. A sim-
ilar finding was reported for daily use of marijuana, with
only 1% of rnale and female medical students reporting
daily use compared with male (5.5%) and female (2%) c01-
1ege graduates and male (11 %) and female (15%) high
school graduates. Cocaine showed a similar pattern, with
the medica! students being significantly 1ess likely and the
high school students significantly more likely than the c01-
1ege graduates to use this substance in the previous year or
month. Cigarettes showed the most drama tic differences in
that only 4% of male and 5% of female medica! students
smoke daily compared with 40% of male and 34% of fe-
male high school graduates of a similar age. In summary,
compared with their peers nationally, me di cal students re-
ported less use of marijuana, cocaine, cigarettes, and sev-
eral other substances (e. g., LSD, barbiturates, and arnphet-
amines). 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 in-
vestigators have suggested that as physicians age, they are
more likely than the general population to evidence aleo-
hol-related problems.
A 1999 study examined the anonyrnous 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 smok-
ing. Self-reported substance abuse and dependence were
highest among psychiatrists and emergency room physi-
cians 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 stu-
dents 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
 Chapter 6: Special Problems of Medical Students
percentages do not signify prevalence rates that are signif-
icantly higher than those found in their same-age peers.
Only three studies have directly compared rates of sub-
stance abuse among physicians with rates among other oc-
cupational groups. Each of these three, however, found no
significant differences between the rates for physicians vs.
other groups. The prevalence of these problems among phy-
sicians is similar to that in the U. S. population in general.
Encouraging as these findings are, a significant percent-
age of physicians are likely to abuse alcohol or drugs. This
finding is of particular concern, because an impaired phy-
sician can wreak untold harm on the patients in his or her
careo In addition, physicians who become alcohol depend-
ent suffer mightily. For exarnple, 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 re-
ceived inpatient treatment for alcohol dependence.
In response to concerns about problems caused by irn-
paired physicians and with the encouragement of the Amer-
ican Medical Association, the state medical societies in each
of the 50 states have formed Impaired Physician Prograrns,
often referred to as Physician Assistance Programs, de-
signed to help impaired physicians receive appropriate treat-
ment.
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 recog-
nized the need for such policies and recently mandated that
institutions of higher education have in place poJicies and
programs relating to substance abuse. Medical schools,
however, seem poorly equipped to fulfill that federal rnan-
date. For example, although a recent study found that al!
medical schools responding to a survey (N equal l l-t) had
psychological counseling available to students, one third of
the schools indicated that these services are not adequate. In
a sepárate survey only 22% of rnedical 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 disor-
ders among medical students and physicians is to be ade-
quately addressed, medie al schools must develop programs
aimed at prevention, ear1y identification, and rehabilitation.
.around many of his classmates and he sits alone during
SUM1\1ARY
Medicine is a profession with multiple rewards and some
risks. On the average these risks appear comparable with
81
those encountered in other high-stress occupations that re-
quire long and intensive preparation. Contrary to popular
mythology, medical marriages are stable and the divorce rate
for physicians is relatively low; however, many medical mar-
riages are unhappy, and long work hours and patient de-
mands can easily become an excuse for avoiding the diffi-
cult 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 prob-
lern and "owning" it places one at least halfway toward the
eventual solution.
CASESTUDY
Jack Hunter, a 22-year-old graduate of a midwestern state-
supported university, is currently enrolled as a first-year
medical student at a prestigious university in the northeast
United States. Although he excel!ed as an undergraduate,
Jack is veryconcerned about his ability to compete success-
fuIly in medical schooJ. He feels overwhelmed by the vol-
ume of material he has to read and memorize and finds he
is envious of some of his former college classmates who
enroIled in medical schools that use a problem-based
learning curriculum. Iack wants eventually to speciaJize in
ophthalmology. He is aware that acceptance into those res-
idency 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 Licens-
ing 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 hop-
ing to join him soon so they can marry at the end of his
first year in medical school.
Iack spends all of his time studying. He is limiting him-
self to 5 hours of sleep each night and has stopped exercis-
ing. Although several of his classmates have suggested that
he join their study group, he has declined their offer be-
cause he fears he do es not grasp the material well enough
to keep up with their pace. He feels uneasy and anxious
lectures. His only sources of support are nightly phone
conversations with his girlfriend and "beer busts" with a
couple of classmates after each major exarn and on week-
ends.
82 Part 1: The Physician and Society
Questions
• I In what ways are [ack's stressors representative of the con-
cerns many students have?
In what ways are [ack's stressots differellt?
What aspects of [ack's presentation are of particular con-
cetn to you?
If you were [ack's primary care pnysician, what additional
information would you try to elicit fr011! him? What would
you counsel him to do?
Discussion
Iack's concerns about time pressures and mastery of mate-
rial are representative of the stressors experienced by many
medica] students. He is also experiencing the imposter phe-
nomenon 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 c1asses. By
focusing on these future events, he is adding to his stress
and likely Iimiting his current effectiveness. Iack's coping
mechanisms are flawed in that he is isolating himself so-
cially, rather than seeking support within the school envi-
ronment. Moreover, although his relationship with his girl-
friend provides sorne support, it is also a so urce of stress in
that their educationallevels are divergent and perhaps they
have different goals for the near future (marriage vs aca-
demic achievement). It is important to gain additional in-
formation about Iack's alcohol and drug use (both past and
present) and his family history of substance use/abuse. As
Iack's primary ca re physician, it would be appropriate to
refer him to a stress management course for medical stu-
dents or to individual psychotherapy al a counseling and
psychological services center. A/m05t al! universities provide
conjidential psychological ser vices for medica! students, and
surveys oj students who use these centets routinely report high
le veis ofbenefit and satisfaction wttli the ser vice they receive.
Additional Case History
By the end of Iack's first year in medical school, he is per-
forming in the top third of his class, though he remains
disappointed with his grades. He constantly feels anx.ious
and pressed for time, and he is becoming increasingly irri-
table 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 con-
suming 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 cam-
pus, where he is relieved to learn that his contact will be
held in strict confidence, and no one in his academic pro-
gram will be notified. At the counseling center, Iack's psy-
chologist learns that Iack is the first person in his family to
graduate frorn college. His mother works at the local Sears
sto re, and his father is a welder who is alcoholic. Iack is the
oldest of three children.
Questions
What aspects of [ack's current [unctioning are of concern?
How is his anxiety likely affecting his academic perfor-
mance?
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 [ack currently ex-
hibit?
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 anx.iety is
interfering with his academic performance. His alcohol
consumption, although not dissirnilar frorn that of approx-
imately 10-20% ofhis peers, is of concern, especially given
his family history of alcohol abuse. It would be important
to determine whether Iack is experiencing symptoms of
alcohol abuse or dependence (see Chapter 18), including
loss of control over his drinking and unwanted cense-
quences 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 Iack to evaluate his use of alco-
hol and set appropriate goals for limiting his alcohol con-
sumption. A cognitive-behavioral approach to treatment
would be effective.
Additional Case History
Throughout the fall semester of Iack's second year in med-
ical school, he attends counseling only sporadically, and he
drops out of therapy prior to his fal! semester final exams.
During counseling, Iack 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 beco mes in-
creasingly withdrawn social!y, rwo of his c1assmates be-
come concerned about his drinking and approach one of
, I
~ ; Chapter 6: Special Problems
their professors who indicates that as long as Iack is per-
forming well in school, what he does outside of c1ass is "his
business." Iack's drinking continues to increase in frequen-
cy. He begins drinking on some weeknights, and he expe-
riences several blackouts. For example, on two occasions
after a night of drinking he awakens at home but cannot
recal! how he got there. In addition, while out drinking one
night, he is arrested for public intoxication.
In the spring sernester, he fails his pharmacology course
and his physical diagnosis course, making hirn eligible for
dismissal from medical school. When the Dean of Students
calls Iack in to discuss his academic problerns, in order to
avoid dismissal from school, Iack reluctantly admits that
his drinking might have had a detrimental effect on his
academic performance. The Dean refers Iack for mandato-
ry treatment of his alcohol dependence.
Questions
What is the defense mechanism (see Chapter 8) that [ack
is exhibiting in regard to his drinkillg?
15 it usual for a student who has a drinking problem to
continue to perform well acadernically?
What is an appropriate course of action for friends or fac-
ulty to take when they are concerned abo~lt a studenti
Should the medical school dismtss [ack beca use of his
drinking problem?
What course of action would most Deans take?
Discussion
When Iack points to his good academic performance as
evidence that he does not have an alcohol problern, he is
exhibiting denial. It is not unusual for students to initially
maintain good academic performance, despite excessive al-
cohol use. Indeed, studies have shown that many alcoholic
physicians graduated in the top 1000 of their class. F riends
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 pro-
fessional 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 fromschool is pur-
sued only when al! other options have failed, including the
student's receiving one or more leaves of absence to receive
appropriate treatment.
of Medical Students 83"
SUGGESTED READINGS
Bournc, E.J. (1995). The anxiety 6- phobia workbook. Oakland, CA:
Ncw Harbinger Publications .
.\!any 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 proce-
dures and exercises for overcoming problems with phobias, panic
attacks, and anxieties.ln addition to providing instruction in cog-
nitive and behavioral techniques for overcoming phobias, it also
employs a holistic approach, in that it addresses issues such as
assertiveness, self-esteem, and spiritualiry.
Davis, M., Eshelrnan, E., & McKay, M. (1995). The relaxation and stress
reduction workbook. Oak1and, CA: New Harbinger Publications.
This outstanding workbook is designed as a sclf-help tool to teach
srudents stress management and relaxation techniques.It increases
students' awareness of their personal reaction to stress and reviews
numerous stress-reduction techniques, including progressive re-
laxation, meditation, and visualization. lt also provides effective
instruction in other related topics such as diaphragmatic breathing,
thought stopping, and how to de al with irrational beliefs and ne-
gative self-talk.
Ellis, O.B. (1985). Becoming a master student. Rapid Ciry, NO: College
Survival,lne.
This book is.loaded with hundreds of nuts-and-bolts techniques
to help students to be more successfullearners. lt 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
skiUs, goal setting, and numerous other skills needed to succeed as
a student.
Ey, S., Herining, K.R., & Shaw, O.L. (2000). Attitudes and factors related
to seeking mental health treatment among medical and dental stu-
dents. [ournal o] College 5wdwt Psychotherapy 14(3): 23-39
This article, which reports the results of an anonyrnous question-
naire completed by 315 medical and dental students, examines the
factors which keep many students from seeking help from a mental
health professional. lt points to the importance of educating stu-
dents about how ernotional distress can impact academic perform-
ance and indicates that when students are informed about the
availabiliry of universiry-based counseling services, they should
also receive information that normalizes treatment seeking.
Goleman, D.P. (1995). Emotional inteíligence New York, NY: Bantam
Press '
High l.Q. is no guarantee of success or: happiness, Drawing on
neuroscience research, the author postulares that ernotionul intel-
ligence (defined as self-awareness, altruism, motivation and ern-
pathy) is the strongest predicator of professional and personal
success.
Greenberger, O. & Padesky, C. (1995).IVfilld OI'U mood. New York, NY:
Guilford Press.
Cognitive therapy is the fastest growing form of psychotherapy
and has been proven to be effective in nurnerous controlled re-
search studies. This book distiUs the wisdom and science of cog-
nitive psychotherapy, teaches readers the central principies that
have rnade cognitive therapy successful and provides explicit in-
structions that will help students to apply these principies in their
day-to-day lives, It helps students understand the connections
berween their thoughts, rnoods, and behaviors and teaches tech-
niques helpful in managing depression, anxiery, and anger.lt is an
 :
.. "_'
~. ~~~-.
. tl, ~,' ~
Part 1: The Physician and Society

excellent resource for students who are experiencing "normal" This is a fascinating little book full of practical advice for rnedical
stress or mood problems. students.
Heitler, S. (1997). The power of two: Secrets to a strong é- loving mar-
riage. Oakland, CA: New Harbinger Publications.
This excellent book is for anyone whóís now or hopes to someday
be married. It provides clear instructions in how to cornmunicate
better with your partner, including teaching the skills needed ro
talk.Iisten, 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 lave you want. New York. NY: Henry
Holt & Co.
This rernarkable book serves as a primer for helping individuals
understand the psychological dynamics inherent in virtually aU
romantic relationships and marriages. Although sorne of the ter-
minology borders on "psychobabble," the book helps couples to
identify feelings and behaviors left over from childhood that in-
evitably Iead them to experience conf1ict. It provides a series of
step-by-step exercises that help couples to beco me a source of
mutual support to one another. In our experience, many eouples
have found this book invaluable in helping them tounderstand
and heal their relationships.
Henning. K .• Ey, S.. & Shaw, D. (2000). Perfectionisrn, the irnposter
phenornenon, and psychological adjustment in rnedical, dental.
nursing. and pharmacy students.foumal ofMedical Education, 32.
456--464.
This article examines the personality characteristics which are
reJated to psychological distress experienced by medical, dental.
nursing. and pharmacy studerits.
McKay, M.. Fanning, P., .& Palcg, K. (1994). Couple ski lis: Makillg your
relationship work. Oakland, CA: New Harbinger Publieations.
This briefbook provides step-by-stcp instruction in communica-
tion skiUs that will enhance virtually any couplc's abiliry to corn-
municate with one another and negotiate solutions to the con-
fliets they are experiencing.
Myers, M.E (1988).Doctor's marriages: A loo]: 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 studcnts.
Reiser, D.E .• & Rosen. D.H. (1985). Medicine as a human experience.
Rockville, MD: Aspen.
Primarily a book about the physieian-patient relationship, this
text provides an excellent aeeount of medicine from 'a humanistic
perspective without dcgenerating into an)' of the "psychobabble"
that sometirnes afflicts such writings, It includes a fine introduc-
tory chapter for medica! students about Jife on the wards, '
Virshup, B. (1985). Copillg in medica! school. New York. Nr: WV\'
Norton.

* See p. 457 for Answer Key and discussion.