The Challenge of At-Risk Students

By Steve Frandzel

Time and again, researchers have found that a significantly higher proportion of medical school students suffer depression and anxiety compared to their peers. Ample evidence also suggests that mental health issues worsen as students advance through their medical training.

At a panel discussion in April titled “Students at Risk,” several experts shared their views on some of these major concerns and explored how some of the data regarding medical students dovetails with other communities in the university at large. Panelists included experts on the question of student mental health from the Mayo Clinic College of Medicine, and respondents from Emory College and Emory School of Medicine.

The event was sponsored by the CFDE in partnership with the Medical Education Interest Group at the School of Medicine.

“There’s little doubt depression is prevalent [among medical students] and it seems to peak in the second year. We’re seeing a pretty staggering proportion of students who are struggling,” said Lotte Dyrbye, MD, an associate professor of medicine at the Mayo Clinic College of Medicine, and associate director of the Department of Medicine Program on Physician Well-Being.

Dyrbye categorized two types of distress: personal distress (anxiety and depression), and professional distress, or burnout (poor mental health caused by work-related stress). A good deal of data show that 30 to 60 percent of physicians experience burnout, and that medical students and residents are highly susceptible as well. One of Dyrbye’s studies found that 40 to 50 percent of medical students experienced symptoms of burnout. About half had very high levels of stress – stress as high as that reported by women with breast cancer undergoing chemotherapy.

“If you think about just one aspect of distress at a time, you’re seeing the tip of iceberg,” Dyrbye said. “Many students suffer multiple manifestations of distress.”

There’s also no certainty as to whether the high levels of distress result from the rigors of medical school, the nature of the people who attend medical school, or a combination of both. It may be, said Dyrbye, that the typical physician personality – a bit compulsive, higher than average levels of guilt and doubt, an exaggerated sense of responsibility, difficulty setting limits, a hard time relaxing, and a sense of not doing enough – predisposes them to unhealthy stress responses.

She also reported that a precarious learning environment (for example, low level of faculty support, inadequate supervision, repetitious nature of the work) was a strong predictor of burnout. Heavy workload, however, was not a predictor for students at risk. “They want to be out there on the ward and work hard, but in an environment that’s supportive and that values them,” Dyrbye said.

The worst-case scenario for all of this distress is suicide. For male physicians, the suicide rate is 40 percent greater than for the general population. For women, it’s 130 percent higher. Suicide data for students is limited.

What can be done? Some measures that make sense include making it easier for students to seek help, Dyrbye said. Many often don’t because of the stigma and concerns about confidentiality and career impact. Some studies suggest that students are more likely to seek help if they can get it off campus.

Some other possibilities include:

  • Teaching students stress-reduction and positive coping skills
  • Debt reduction counseling
  • Counseling about healthy relationship skills
  • Fitness memberships to help them stay in shape
  • Mentoring systems
  • Career counseling
  • Increased support during periods of transition.

Emory has many, but not all, of these support systems in place for their medical school students. “We also need to make it really clear to students, faculty, and mentors what warning signs to look for,” Dyrbye said.

Unfortunately, medical students seek help most often because of career concerns, such as which specialty to go into, not because of burnout, depression, or anxiety, said Nadine Kaslow, professor and vice chair of faculty development, Emory University School of Medicine Department of Psychiatry and Behavioral Sciences, and chief psychologist, Grady Health System. “But underneath, many are depressed, anxious, suicidal, and substance abusers,” she said, adding that a broad culture change is needed to address the problem.

Issues of depression, burnout, and suicide risk are partly reflective of the organizational structure and system itself, said Kaslow. It’s not enough to tell a student to get help, and there are preventive measures that can be taken before treatment is needed.

Currently, Emory is training a team of faculty, student, and staff “gatekeepers” to recognize and reach out to at-risk students. The goal is to have 1,000 gatekeepers trained within three months. Emory will also begin screening all graduate students via a short 10-minute online survey. Students whose scores indicate high risk will receive an anonymous email from a trained mental health professional encouraging them to seek help. By the spring of 2011, the screening will roll out to all professional schools.

“Most of us just accept that we’ll feel burned out,” said Kaslow. “That’s not a good culture. We really need a culture of self care, not of burnout. We need a culture of mindfulness, , meditation, and exercise.”

The troubles plaguing medical and graduate students also apply to undergraduates, said Wendy Newby, associate dean of Emory College and director, Learning Programs, Division of the Office for Undergraduate Education.

Students coming to Emory typically had been at the top of their high school classes. Once here, many find they’re just part of the pack, Newby said. On top of that, they may feel tremendous pressure to succeed from parents. “There’s a huge level of competitive stress and students are also faced with academic overload,” said Newby. So they often struggle to find a balance between their academic lives and other aspects of college.

One change at Emory that might ease the pressure is the new undergraduate curriculum, which will allow students more freedom to choose courses outside of a narrow range and complete general education requirements in a variety of ways. In addition, a new faculty advising program specifies that undergraduate faculty advise only three or four students. Previously, larger advising groups were the norm. “This provides personal interaction of increased quality,” said Newby.

Also planned is a greater emphasis on bringing needed resources directly to the residence halls, so that students can more readily receive advice and support. Newby calls the plan “a resources on wheels approach.”

The challenges of students at risk is clearly a timely one. Response to this workshop was so positive and discussion on the topic so lively that CFDE will be planning a follow-up event in AY 2010-11 concerning students at risk and the Emory environment.