Medical students keep quiet about depression because of fear of stigma

Not only are a considerable proportion of medical students depressed, those who are believe they’ll lose the respect of their peers and their tutors if they speak out, according to new research in published in Journal of the American Medical Association.

The study of 505 medical students in Michigan found that more than one in 10 (14.3%) of them were depressed, almost three times as many as in the general population of the United States (prevalence 5.4%).

More than half of those who were depressed felt that telling a counselor would be risky and that fellow medical students would respect their opinions less if they knew (53.3% and 56.0%, respectively), whereas far fewer of their non-depressed peers held these views (16.7% and 23.7%).

The authors of this research invited all 769 medical students enrolled at the University of Michigan Medical School in September-November 2009 to do an anonymous internet survey on depression and their attitudes to the disease.

Women were more likely than men to have moderate to severe depression (18.0% vs 9.0%), and students who were depressed were nearly eight times more likely to have considered leaving medical school than had those with minimal depression (43.1% vs 5.6%). As many as 68% of those with depression had seriously considered committing suicide, although the overall number of students with “suicidal ideation” was small (22/505 (4.4%)).

Medical school is mentally and academically demanding, so it’s not surprising that rates of depression, burnout, and suicide are higher in medical students than in the general population. Yet despite no doubt being familiar with mental health issues given their training, medical students with depression are notoriously bad at seeking treatment. In this study, for example, approximately 70-80% of students with moderate to severe depression had not received a diagnosis or treatment for depression.

As well as worrying about what their tutors and peers thought of them, medical students with moderate to severe depression were more likely than those not depressed to think that asking for help would mean their coping skills were inadequate (61.7% vs 33.5%). They also felt that others would consider them unable to handle their medical school responsibilities (83.1% vs 55.1%).

It wasn’t just the students who were depressed who believed stigmas associated with the disease: those without depression were more likely to think that depressed medical students would be a danger to patients (25.7% vs 13.6%).

The fact that so many medical students seem to hold negative views of depression is rather worrying, not least because one study found that 30% of first year and second year medical students with depression cited stigma as a barrier to seeking treatment. It does seem counter-intuitive that this group exposed to health messages pretty much non-stop thanks to their course of study seems to sign up to negative stigmas surrounding depression.

The authors suggest that rather than the emphasis on academic excellence and professionalism scaring medical students out of reporting depression, medical education programmes could be tweaked so that students perceive looking after the mental health of themselves and their peers as a key aspect of being an outstanding doctor.
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Schwenk T, Davis L, & Wimsatt L (2010) Depression, Stigma, and Suicidal Ideation in Medical Students. JAMA: The Journal of the American Medical Association 304 (11): 1181-1190. DOI: 10.1001/jama.2010.1300

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The pill could lower sex drive in young women

The pillThis month marks the 50th anniversary of the contraceptive pill, first approved by the FDA in 1960 and now the choice of contraception for more than 100 million women worldwide. By uncoupling sex from pregnancy, oral hormonal contraceptives finally allowed women to become agents of their own bodies.

Life isn’t all rosy on the pill though. The various different formulations have been associated with all sorts of side effects, the most issue being venous thromboembolism.

Now new research from female medical students in Germany has found that hormonal contraception such as the pill could also reduce sex drive.

Several previous studies have suggested that oral contraception might affect female sexual function, but overall the evidence as to whether they have a positive or negative effect is pretty mixed.

The researchers behind this study emailed female students at six medical schools in Germany and asked them to fill in an online questionnaire about their sexual function in the past four weeks and their usual means of contraception over the past six months.  A total of 1,086 women (15-20%) aged mostly under 25 years responded.

A total of 87.4% of women had used contraception in the previous 6 months, most of whom had used oral hormonal contraception (69.5%).

About a third (32.4%) of participants were considered at high risk of sexual dysfunction.  However, this figure actually isn’t too bad compared with a previous study of 78 female medical students in the US, which found that 63% were at high risk of sexual dysfunction.  Other larger studies put the rate at a more conservative 38% in Germany and 43% in the States.

When the sexual dysfunction data were analysed on the basis of single usual form of contraception (1,046 participants), women who used oral hormonal contraception or non-oral hormonal contraception were most at risk of having sexual dysfunction. Oral hormonal contraception was associated in particular with low desire and arousal compared with other forms of contraception and no contraception.

The authors suggest that the link between oral hormonal contraceptives and sexual dysfunction may be because oral contraceptives decrease the circulating levels of testosterone, “which is needed to (i) stimulate sexual desire and (ii) regulate genital blood flow and the structural and functional integrity of the genitals.”

Interestingly, smoking was associated with a lower risk of sexual dysfunction than not smoking, an effect the authors hilariously suggest might be down to the fact that “smokers might have greater ability to enjoy themselves.”

“This is a very important research investigation,” stated Dr Irwin Goldstein, Editor-in-Chief of Journal of Sexual Medicine, which published this study. “There are hundreds of millions of women, in particular young women at the beginning of their sexual lives, who regularly use hormonal contraception for many years. The irony is that these women are provided a medication that enables freedom from reproductive worries but these same women are not provided information that there are significant adverse sexual effects that may ensue.  Agents that interfere with the hormonal milieu of women may adversely affect their sexual lives.”

Don’t panic yet though, this study isn’t the final word and has various shortcomings, not least the possibly of participation bias – where women with perceived sexual problems might have felt more inclined to participate than women with no sexual problems – and reporting bias – where participants might have overestimated or underestimated the scale of their sexual difficulties.

Furthermore, the low response rate to the questionnaire (15-20%) means the study population probably isn’t a great reflection of all the female medical students at the eight schools studied, much less students worldwide, and, as the authors say, their stats suggest that “the factors considered can only explain a small fraction of the variability of total [female sexual function] scores.”

As it is, hormonal forms of contraception – both oral and non-oral – are the most successful forms around.  So I wouldn’t throw away your pills just yet.

  • Put off oral hormonal contraceptives? Nature Medicine has an article on the 50th anniversary of the pill that highlights some possible alternatives under development.

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Wallwiener C et al. (2010) Prevalence of Sexual Dysfunction and Impact of Contraception in Female German Medical Students. Journal of Sexual Medicine DOI: 10.1111/j.1743-6109.2010.01742.x

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Medical school entrance exam favours white public school boys

Exam hallNew research has found that the UK Clinical Aptitude Test (UKCAT), introduced to level the playing field in selection for medical and dental schools, favours male applicants, white people, and students from a higher socioeconomic class or who attended an independent or grammar school.

In the UK, students take advanced level (A level) exams aged 18, and it is the grades they get in these exams that primarily determine whether they can secure a place at university. A levels are affected by socioeconomic bias though – students who are academically able but whose education has been compromised by attending a bad school can end up performing badly and miss out on a place.

The UKCAT, however, doesn’t examine acquired knowledge and candidates can’t be “coached” to pass, so in theory it should provide a more fair assessment of aptitude than A level grades.

In addition, medical school selectors aren’t just interested in academic ability – they want to pick out students who have the personality attributes that will make them a good doctor, like excellent interpersonal skills and professional integrity.

The various components of the UKCAT – verbal reasoning, quantitative reasoning, abstract reasoning, and decision making – are supposed to be best measures to pick out such traits, so the test should also help determine the students who have the personality attributes to make a great doctor.

Unfortunately, the research by James et al, published in the BMJ, suggests that the UKCAT doesn’t really provide a more “equitable assessment of aptitude” than A levels.

The authors looked at data from applicants to 23 UK medical schools who took the UKCAT in 2006, the year it was first introduced. People who sat the test were asked to supply demographic and socioeconomic data such as their parents’ or carers’ occupation. The UKCAT data was then compared with A level results, the current “gold standard” in selection.

From the 18,582 individuals who took the UKCAT in 2006, the authors identified a subgroup of 9884 (53%) students who lived in the UK and for whom they had results data on at least three recent A levels. There was a modest correlation between A level grades and UKCAT scores, which indicates that the test could be used as an alternative to A level grades in the selection process

As far as bias in A level results went, sex didn’t have much of an effect on whether a student scored AAA or AAB – the minimum requirement for medical school admission. However, white students and those whose parents had a managerial or professional job were more likely to get top scores.

Startlingly, applicants who went to an independent or grammar school were more than twice as likely to get top A level grades than those who went to a comprehensive school, sixth form college, or some other sort of higher education institution.

The UKCAT was slightly less subject to socioeconomic bias than A level results. However, male applicants were more likely to get a high score (i.e. a score within the top 30% out of all applicants) than were females. White students were twice as likely to get a high score than students in other ethnic groups, and “professional or managerial background” and “independent or grammar schooling” were likewise independent predictors of a top score.

So although the test is less biased than A levels, the UKCAT still has “an inherent favourable bias to male applicants and those from a higher socioeconomic class or from independent or grammar schools,” conclude the authors.

One major limitation of the study is that about 30% of participants did not provide socioeconomic data when they sat the UKCAT, so a considerable proportion of applicants covered in the A levels calculations were excluded from the UKCAT analyses. Those who withheld socioeconomic status data were more likely to be male, non-white, and from non-selective schools, and were less likely to have top A levels grades and high UKCAT scores. “Arguably, this group contained those candidates who were more likely to benefit from widening participation,” say the authors.

In a rapid response to the research, Rachel Greatrix, chief operating officer of UKCAT, rather unexpectedly welcomes the findings. “It is reassuring that medical and dental schools can use the test as a reasonable proxy for A levels given the on-going debate regarding the speculative nature of predicted grades and discussions regarding post-qualification admissions,” she says. “However, the fact that UKCAT scores are less subject to bias than A level results alone, potentially indicates that if combined with A level achievement, they may offer a fairer tool for selection.”

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James D, Yates J, & Nicholson S (2010) Comparison of A level and UKCAT performance in students applying to UK medical and dental schools in 2006: cohort study. BMJ 340 (feb16 1). DOI: 10.1136/bmj.c478

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Multiple choice medical school exams favour male students

ExamUrgh, exams. The epic ‘true-false-no idea’ multiple choicers of my undergraduate days are not a distant enough memory for me. The whole ‘get it right, get 1 point’, ‘get it wrong, lose 1 point’ approach always seemed horrendously unfair, regardless of the statistical basis for the strategy (i.e. examiners don’t want to reward people that guess true or false on every question, as in theory they’ll get the right answer 50% of the time).

According to researchers at University of Nottingham, my personal MCQ fear is well founded. Shona Kelly and Reg Dennick have found that male medical students are much more likely to do well on an exam with some ‘true-false-abstain’ questions than are female students.

The authors of this study looked at seven years worth of results from medical school course assessments – which included course work, essays, in-class assessments, lab studies, Objective Structured Clinical Examinations (OSCEs), short answer tests, single phrase tests, spotter quizzes, single word answer exams, true-false-abstain questions, and Vivas.

Among the 359 course assessments, there was a statistically significant difference in the marks between the genders in a third of the courses in any given year. Univariate analyses indicated that women did better in assessments that included some in-class assessment and some short answer questions, but struggled with exams that included true-false-abstain questions. Men did better on assessments with some true-false-abstain questions and were at a disadvantage in those that included some short answer questions.

The female advantage seen with in-class assessment disappeared in multivariate analyses that took into account the subject area/content of the assessment and calendar year, however, and the advantage that females seemed to have in exams with short answer questions was very small (odds ratio 1.03).

On the other hand, the association between true-false-abstain and male advantage wasn’t affected in multivariate analyses. In fact, males were 16.7 times more likely to score higher than females if at least some true-false-abstain questions were in the assessment. This difference could be down to the fact that women were more likely to pick the ‘abstain’ option in this format exam.

So there’s the answer. My difficulty with university exams clearly had nothing to do with my preparation and was obviously down to the inherent gender bias in the format used for biomedical exams.  Cough.

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Kelly S & Dennick R (2009) Evidence of gender bias in True-False-Abstain medical examinations. BMC Medical Education 9(1). DOI: 10.1186/1472-6920-9-32

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Squeamish? Don’t worry, medical students are too

surgeryBMC Medical Education has just published an interesting study that examined the incidence of fainting among medical students observing surgery.  Apparently, more than 1 in 10 medical students almost or completely pass out in the operating theatre.

The authors of this study surveyed 630 clinical medical students in their fourth or fifth (final) year of study at the University of Nottingham medical school in northern England.  A total of  77 (12%) students reported at least one episode of near or actual operating-theatre-related loss of consciousness, also known as syncope.

The authors looked pretty closely at factors affecting whether a student was likely to faint in the theatre.  Those who did lose consciousness were on average 23 years old (range 20–45 years), were more likely to be an undergraduate student than a graduate student (60 undergrads versus 17 graduates) and were significantly more likely to be female than male (68 females versus 9 males).  Gynaecological operations were most likely to cause syncope among the fainters (29% of cases), followed by colorectal surgery (16%) and vascular surgery (16%).

The majority of students who passed out put their episode(s) down to the hot temperature of the theatre or the length of time spent standing.  None of the fainters identified needle or blood phobias as a cause of their fainting.  The authors do note, however, that 16% of episodes occurred during laparoscopic, or keyhole, surgery.  Given that keyhole surgery doesn’t involve much gore and blood, this finding suggests that the operation itself remains a strong contributory factor to fainting in the operating theatre.

Interestingly, more than 50% of the students who reported surgery-related fainting were still keen to pursue a career in surgery, although 16% said that their fainting episode(s) put them off that particular career path.

As well as affecting the clinical education and career choices of medical students, such operating-theatre-related syncope also has implications for patients.  In 9% of cases, the operation was affected by the medical student passing out, the most common issue being delays to surgery while the a new assisting student was brought in.

Student BMJ has some practical tips for squeamish medical students. Jessica Whitworth experienced episodes of syncope well into her penultimate year of medical school and eventually got some help from her university’s psychologist, who suggested distraction, dissociation and rationalisation techniques to overcome her problem.

I also have an illustrious history of passing out in medical circumstances. As well as several dramatic fainting episodes during work experience placements at local hospitals, I also spent a considerable proportion of my undergraduate human dissection classes with my head between my legs. In fact, a particularly gruesome lecture even made me pass out once. I find it quite reassuring to know that seasoned medical students also have this problem!

(h/t to Dr RW who pointed out this research on his blog Notes from Dr R.W.)

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Jamjoom A et al. (2009) Operating theatre related syncope in medical students: a cross sectional study BMC Medical Education 9 (1) DOI: 10.1186/1472-6920-9-14

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