Medical students study hard with the intention of making people well. Yasmina Dadi asks if medicine is making you sick

Countless hours spent in the library, harsh exams, competition, stress, and a small to non-existent income for several years, sums up everyday life for many medical students. Studying itself can be stressful, but researchers have found specific health effects of medical school, including high levels of anxiety and depression.

A longitudinal study that examined psychological distress in first year medical students found that medical students' anxiety levels were higher than for other university students in autumn and spring. The percentage of medical students reporting depression also doubled over the school year.¹

Esa Leinonen, a professor of psychiatry in the University of Tampere, Finland, studied medical students' stress factors in the '90s.^{2 3} He says the reasons behind medical students' high levels of stress are complex. Student's own psychological traits, such as competitiveness and meticulousness, as well as the external aspects of the studies contribute.

Leinonen says, "Medical students felt that the most stressful aspect in their studies was the fear of making mistakes, feelings of inadequacy, and fear of unemployment. We also found that responsibilities caused anguish to upper class students, and meeting seriously ill and dying patients caused distress to younger students. Noticeably, female students felt more stressed about their studies than men."

Poor treatment that students might experience at medical school can also affect students' wellbeing. A US study found that medical students are commonly abused verbally during medical school training. These episodes made students cynical about academic life and the medical profession. Some students even confessed that the abuse made them consider quitting medical school.⁴ Another US study found that the abuse that students face is an important cause of stress.⁵

Recently, researchers interviewed UK medical students about their experiences and perceptions of the quality of teaching received during their undergraduate training. They found that an element of humiliation also occurs in teaching in the United Kingdom.⁶

In the study, one student said, "I've found my first rotation was very stressful, humiliating, I worked and read because of fear, because I felt targeted and that was just miserable."

The stress that medical students experience can lead to self destructive behaviour, and some students try to cope with the stress by drinking alcohol. This, of course, can worsen their situation.

Leinonen explains, "Previous studies have found that doctors drink too much. In our own research we found that medical students' alcohol use increased significantly as students advanced in their studies. The use of alcohol as a stress reliever starts apparently at university. This kind of behaviour is most common in men."

Sadly in many cases, medical students fail to seek necessary care for depression, anxiety, and stress. According to Kari Pylkkänen, a psychiatrist in the student health centre in Helsinki, medical students do not use healthcare facilities as much as other students: "We have noticed that medical students have a higher threshold than other students for seeking help for psychological problems."

But before you consider changing your course for the sake of your wellbeing, it is not all bad. Leinonen explains, "Even though stress manifested as tiredness for half of the medical students and three out of four felt occasionally irritated, more than half of the students estimated their physical and psychological health as good."

Also, contrary to common belief, medical students do not experience more health anxiety as a consequence of being exposed to a medical education. A recent study found that medical students actually worry less about their health than other students.⁷

Furthermore, a study done at Queen's University, Belfast, found that medical and science students live longer than any other students. The researchers followed up health records collected from male students at Glasgow University between 1948 and 1968. They discovered that medical student were the least likely to die young, despite being the heaviest smokers at university.

The researchers believe that the reason for this is that a medical degree is more likely than an arts degree to result in a permanent employment and good income, which could affect health in later life. Even though doctors smoked more than anyone else as students, they also wished to quit the habit more than other students. This would explain why the lawyers tended to die young, despite being likely to have affluent lifestyles--they smoked almost as heavily as the medics at university, but kept on smoking.

But before you start to ignore all health related advice--the study also found that medical students were the most likely to die from alcohol related deaths.⁸

Yasmina Dadi, third year emdical student, University of Helsinki
Email: yasmina222001@yahoo.com


studentBMJ 2005;13:1-44 January ISSN 0966-6494

1. Vitaliano PP, Maiuro RD, Russo J, Mitchell ES. Medical student distress: a longitudinal study. J Nerv Ment Dis 1989;177:70-6.
2. Leinonen E, Nevala K, Lehto O, Nieminen P, Isohanhi M Lääketieteen opiskelijoiden stressin aiheuttajat ja oireet. Suom Laakaril 1995;50:2459.
3. Nevala K, Leinonen E, Pokkinen V, Nieminen P, Isohanhi M. Lääketieteen opiskelijoiden stressiä tasapainottavat tekijät. Suom Laakaril 1996;51:316.
4. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study of medical student ‘abuse’: student perceptions of mistreatment and misconduct in medical school. JAMA 1990;263:533-7.
5. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA 1990;263:527-32.
6. Lempp H, Seale C. ‘Hidden’ curriculum of humiliation in medical school.BMJ 2004;329:770-3.
7. 7. Singh G, Hankins M, Weinman JA. Does medical school cause health anxiety and worry in medical students? Med Educ 2004;38:479-81.
8. 8. McCarron P, Okasha M, McEwen J, Smith GD. Association between course of study at university and cause-specific mortality. J R Soc Med 2003;96:384-8.

Medical students and health professionals have been identified as being at high risk for alcohol abuse and substance abuse as well as many psychiatric disorders like depression, bipolar disorder, cognitive impairment and many more, the figures of which if delved into would be alarming. A recent study ⁽¹⁾ demonstrated the prevalence of regular alcohol intake as 30% and of smoking as 20% in 263 medical students covered in the study. This was observed more in males than in females.

Since the problem is far from being solved and has always been growing in an unrestrained manner due to factors like stress and competition that come as an unasked by-product of this profession, it is only logical to think of a programme based on a systematic approach to prevent medicine from turning "bad". In fact, in New South Wales, there is a Medical Board Program ⁽²⁾ which aims to identify the "impaired registrants", diagnose their ailments and deal with it in a non-disciplinary way while keeping the person concerned in his/her position of work.

Recent research on the subject in USA ⁽³⁾ found high rates of depression prevalent in the academic setting. It recommends formation of groups that will help to prevent depression in all and fight it in those who have it. Such measures are definitely needed if the future of all health professionals is to be secure.

References:

1. Sima A, Piko B, Simon T. Epidemiologic study of the psychological health and risk behaviors of medical students. Orv Hetil.2004 Jan 18; 145(3): 123-9
2. Wilhelm KA, Reid AM. Critical decision points in the management of impaired doctors: the New South Wales Medical Board program. Med Jaust.2004 Oct 4; 181(7): 372-5.
3. Stecker T. Well being in an academic environment. Med Educ.2004 May;38(5): 465-78

In the article 'Bad medicine'¹, it is stated that "the use of alcohol as a stress reliever starts at university" and that medical students cope with stress by drinking alcohol. Certainly medical students experience a lot of stress and indeed as the author states, "the student’s own psychological traits play an important role."

The use of alcohol sadly starts before medical school and is worsened by the drinking culture in university. It was found that the alcohol consumption of final year medical students was lower than pre-university levels², and in addition, final year students drank less than second year students. The final year is clearly the time when medicine is most stressful and therefore it does raise the question of to what extent the stress of medical training contributes to the drinking problem. Furthermore in the same study, about a third of students overestimated safe levels of drinking; perhaps ignorance may be an important cause. In another survey 32% of medical students and 30% of doctors did not know the correct safe drinking limits³.

Research on the cause of the drinking problem has also focused on inheritance⁴, and researchers are putting more weight on ‘nature and nurture’, suggesting that having alcoholic parents or childhood events, such as marital breakdowns, can increase the chance of excessive drinking by medical students.

Thus 'Bad medicine'¹ paints a very negative picture of the medical course as being disproportionately more stressful. However it is probable that the culture in medical school merely encourages as oppose to instigates the alcohol problem in medical students and in order to improve the situation a recognition of other important factors, such a student’s actual knowledge of alcohol and the psychological predispositions may be more effective. The former is being targeted successfully, for example medical schools such as Imperial College London, have a whole day dedicated to teaching the effects of alcohol, ‘Alcohol Misuse Day’, which assists in dealing with the lack of accurate knowledge on the effects of alcohol.

1. Dadi Y. Bad Medicine. studentBMJ 2005; 13: 29.
2. Jeremy E. A follow-up survey of alcohol consumption and knowledge in medical students. Alcohol and Alcoholism 2001; 36, No.6, 540-543.
3. Myszor M et al. Alcohol and health: do we know enough? Health Trends 1990; 22, 23-27.
4. Flaherty JA. Substance use and addiction among medical students, Residents and Physicians. Psychiatric Clinics of North America 1993; 16: 189-197.

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