Dr. Sciolla is an associate professor at the Department of Psychiatry and Behavioral Sciences, University of California, Davis, co-director of the Doctoring 2 course at the University of California, Davis, School of Medicine, and medical director of a community mental health clinic, the Northgate Point Regional Support Team, in Sacramento, California. He graduated from the University of Chile School of Medicine and is a board-certified psychiatrist.
When it comes to psychological distress, individuals who aspire to a career in medicine are a queer lot. At matriculation, the average medical student has lower rates of burnout and depression symptoms and higher quality-of-life scores than the average age-matched college graduate.1 As medical education progresses, however, this initial advantage is gradually lost and depression and burnout rates increase significantly above those in the general population.2
What happens to the nonaverage medical students, to students who start medical school at a psychosocial disadvantage? Przedworski and her colleagues have identified one group of students deserving a close follow-up: the 5% of medical students in their sample who identified as bisexual, homosexual, or other (sexual orientation). Using data from the Medical Student Cognitive Habits and Growth Evaluation (CHANGE) Study, the authors found substantially elevated rates of depressive and anxiety symptoms and decreased levels of self-rated health. The difference between heterosexual and sexual minority medical students in these measures persisted after accounting for multiple explanatory factors. The results from allopathic medical schools are congruent with those from osteopathic medical schools, as reported recently.3
Przedworski and her group measured experiences of discrimination and loneliness, two determinants of this health disparity. When they controlled statistically for those social stressors, the association between minority sexual identity and mental and self-reported health persisted, albeit diminished.
In a twist that will disappoint lumpers and delight splitters, the sexual minority group did not behave as, well, a group. First, male sexual minority students, but not female sexual minority students, were significantly more likely to report depressive symptoms than their heterosexual counterparts. Second, female sexual minority students, but not male students, were significantly more likely to report low self-rated health than their heterosexual counterparts. The researchers speculate sensibly as to the reasons of these perplexing findings. As an individual with intersecting identities, I look forward to studies that are appropriately powered to uncover additional health disparities in students with either ethnic and sexual minority identities or disadvantaged status (e.g., the first generation to attend college4).
We can only speculate at this point what will happen over the next few years to the psychological well-being and self-rated health of the sexual minority students in the CHANGE Study. While it is possible that these students will be more resilient than expected, it is likely that their psychological distress will worsen during medical school and residency training—especially in those who train within noninclusive institutional climates. Although hopeful changes are on the horizon of medical education,5 they may not occur soon enough for these students.
That some future healers begin their training already wounded and that their peers6 and training environments7,8 perpetuate those harms is bad, but unsurprising, news. Przedworski and colleagues’ findings replicate what numerous studies inspired by the so-called minority stress model9 have found in this and other stigmatized groups. What is now needed is to move the field from documentation to intervention. We have the evidence and knowledge of the mechanism behind stigma-based health disparities. Individual physicians and organized medicine have long been leaders in the quest to eliminate health disparities elsewhere. Let’s focus now on our own.
- Brazeau CM, Shanafelt T, Durning SJ, et al. Distress among matriculating medical students relative to the general population. Acad Med. 2014;89:1520–1525.
- Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451.
- Lapinski J, Sexton P. Still in the closet: The invisible minority in medical education. BMC Med Educ. 2014;14:171.
- Association of American Medical Colleges. Personal well-being among medical students: Findings from an AAMC pilot survey. Analysis In Brief. 2014;14:1–2.
- Association of American Medical Colleges. AAMC Releases Medical Education Guidelines to Improve Health Care for People Who Are LGBT, Gender Nonconforming, or Born with Differences of Sex Development. https://www.aamc.org/newsroom/newsreleases/414490/11182014.html. Accessed March 5, 2015.
- Burke SE, Dovidio JF, Przedworski JM, et al. Do contact and empathy mitigate bias against gay and lesbian people among heterosexual first-year medical students? A report from the medical student CHANGE study. Acad Med. [in press].
- Lapinski J, Sexton P, Baker L. Acceptance of lesbian, gay, bisexual, and transgender patients, attitudes about their treatment, and related medical knowledge among osteopathic medical students. J Am Osteopath Assoc. 2014;114:788–796.
- Mansh M, White W, Gee-Tong L, et al. Sexual and gender minority identity disclosure during undergraduate medical education: “In the closet” in medical school. Acad Med. [in press].
- Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull. 2003;129:674–697.