Intellectual doping: Stimulant abuse in medical students

No one can deny that medical students today face an increasingly competitive environment with a strong focus on board scores and class grades as strong requirements for entrance into competitive specialties. Mirroring the trends in both primary and secondary school, a standardized test has become the yardstick by which all physicians-in-training are compared.

The most recent survey reported by the National Resident Matching Program, showed that scores on Step 1 of the board licensure exam were the most highly cited factor that program directors used to determine which applicants to interview for their residency programs. While medical schools have expanded to accept more students, the number of residency positions available to finish the training of these newly minted physicians has remained stagnant.

The pressure for graduating physicians with $100,000 to $200,000 of student loan debt to obtain the necessary residency training in their chosen specialties is increasingly fierce. Medical students, already a competitive group of people by nature, are sometimes driven to extremes by their perceived need to outperform their peers.

Medical school requires countless hours of study, many of it necessarily spent alone with textbooks, flashcards, and lecture notes. When old fashioned study sessions are insufficient to make it to the top of the class, some students are turning to prescription stimulants to give them a competitive edge. At one medical university, it is common knowledge among the student body that struggling individuals are encouraged to see a physician about their “possible ADD,” or attention deficit disorder. It should be remembered that all of these individuals possessed the ability to successfully complete a baccalaureate degree, take the medical college admission test, and interview successfully in a competitive admission process to medical school. If these highly functional individuals have a disorder of attention, than perhaps the entire human population requires a prescription for stimulants.

In addition to the personal side effects of stimulant use — including high blood pressure, insomnia, and anxiety — the use of these medications by individuals who have never exhibited genuine symptoms of attention deficit prior to adulthood, is comparable to the use of anabolic steroids among athletes and should be discouraged. Test scores and class ranks are meaningless when they are derived through intellectual “doping” at the expense of the mental and physical health of the individuals involved.

Additionally, one has to wonder if the short term gains in concentration and study abilities really translates into a meaningful improvement in the future physician’s ability to diagnose disease and treat patients. The current environment of competition between medical students drives individuals to unhealthy extremes and is counter-productive when their future role as physicians will require collaboration with one another and other members of the healthcare team.

Changes to medical school curricula that reduce competition and enhance team-building abilities should be implemented to improve training and deter stimulant abuse.

Aimee Merino is a medical student. 

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  • John C. Key MD

    This is hardly a new problem. Things were competitive and scary when I was there 40 years ago, too. We “doped” also–No-Doz, coffee, Vivarin plus runs to the late night diner. Plus ca change, plus c’est la meme chose. Dumbing down curricula, standards, or advocating 21st century psychobabble like “team building” is a non-starter. Do the work and make the grades and it will all level out in the end.

    The first thing an upperclassman told me when I was stressing over grades was, “Do you know what they call the bottom guy in the class? They call him ‘doctor’”. It is a truism worth remembering. The grade chase is a fool’s errand. I guess this is enough cliches for one reply.

    • guest

      The difference today is that if you end up at the bottom of the class, you are consigned to a career as a primary care provider with the attendant risks for limited income and drastically reduced career satisfaction. Concern over this occurring with our bright and compassionate 20 year old who processes a bit more slowly than peers in his IQ cohort led us to inform him we would not support his aspirations to pursue a medical career.

      • John C. Key MD

        Again, this is nothing new. 40 years ago students with weaker grades were more likely to go unmatched, or not to get the preferred residency programs. It is not as if students today have a harder row to hoe–they do not. They just have a less financially rewarding career to look forward to.

        • guest

          As someone who teaches medical students and interviews applicants to our residency training program, it’s my impression that the bar has been raised considerably for medical students since we were in medical school, not the least of which is that there’s a tremendous amount more to know than when we were doing our training, whether we like to admit that or not.
          Also, on a somewhat related note, I would say that the “tough it out, suck it up, don’t feel sorry for the students” mentality that is so prevalent in medical culture is one of the factors that leads to our educational system producing physicians with low levels of empathy for their patients.

          • John C. Key MD

            It’s my impression that the “bar” is a lot lower, and the results are poorer too. All succeeding generations have had “a tremendous amount more to know” than the previous one. I think you are confirming and demonstrating what is wrong with the process and the attitudes. “and that is all I have to say about that” (with apologies to Forrest Gump.

          • guest

            Well I think it depends on what bar you are looking at…if you are looking at bars related to how independently the student functions, how extreme their work ethic is, and how much of a sense of entitlement they have, I agree that those bars appear to have fallen quite a bit in the last 20 years.

            On the other hand, I really don’t think anyone could dispute the fact that today’s students have to take a lot more tests, and the tests are harder than they used to be. There also appears to be some sort of requirement that students have these elaborate resumes, so that every applicant to our program arrives with a resume full of things I didn’t have to have on my cv thirty years ago when I was applying to programs. I really don’t think, again, that you can argue that these requirements have gotten stiffer, especially with respect to testing, and so it’s not too surprising to see students turning to stimulants as a way of gaining an edge.

            What troubles me is that how well you do on a test, and how impressive your cv is, really says very little about how good a doctor you’ll be. But those are the benchmarks we’re paying the most attention to right now, so that’s what the students are trying to address through stimulant use.

      • brettmd

        You mention that the 20-year-old is both “bright” and “processes a bit more slowly.” Please elaborate. Thank you kindly.

        • guest

          It’s really not something I feel is appropriate to discuss further, but thanks for your interest.

          • brettmd

            Then perhaps you should stop making such claims if you can’t provide the data to back it up. Making claims about a trainees empathy levels without any observational information is comparable to gossip. I certainly know that I am a very empathetic person and this is affirmed by numerous persons in diverse settings.

          • brettmd

            Do you perceive that you can assess a persons empathy during a residency interview?

          • brettmd

            Have you ever validated your assessment skills by a third party from another department? Surely that is something that would provide objective information validating your claim that you are an empathetic assessor competent in the assessment of another person’s empathy.

  • Luke A Kane

    100k debt? Who has that little and who worried about a mere 100k? I’m racking up 80k/year at a private institution = 320k + for my medical education. It’s really time to stop posting about insignificant debt. PTs/nurses/other mid levels come out with debt in the 100k range and have no where near the earning potential as a physician.

  • Aimee Merino

    No-Doz and caffeine pills such as Vivarin are not even comparable to amphetamines such as Adderall. For one thing, these are prescription drugs that are meant to be prescribed for a specific disorder and possessing them without a prescription is a felony.

    Further, this is not an issue of “dumbing down curricula” or changing standards. An example is USMLE Step 1 scores, which have increased over time with the minimum passing score being raised this year. Obviously the objective measures for physician competence are important, but does a medical student with higher board scores or better didactic scores ultimately make a better physician? The issue is whether or not competition between students is productive and whether or not the use of stimulants that are meant to treat ADHD is an appropriate way to improve one’s performance.

    • brettmd

      If the person has ADHD, I would encourage them to see their physician. The medications for ADHD, namely amphetamines have been reviewed by an advisory board of the FDA, and they have been studied in clinical trials. Amphetamines have been noted to have abuse potential, and that is why they are schedule II medications and no longer over the counter.

      In reference to the USMLE Step 1 Scores Rising, I would encourage students with ADHD to see a doctor; and I would encourage all students to study, quiz each other, and work diligently.

    • guest

      I couldn’t agree more. One of the most significant weaknesses in our medical education system is its tendency to select trainees who are intensely competitive and excel at solitary pursuits such as studying. These types of trainees are much less likely to feel empathy towards their patients (no matter how well they learn to mask their lack of empathy) and are much less likely to “play well with others.” Both of these abilities are critical if our profession is to survive some of the pressures that it finds itself under.

      • brettmd

        Right, and someone competent to assess them is essential.

        • guest

          Happy to provide some evidence:

          Empathy decline and its reasons: a systematic review of studies with medical students and residents.

          Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, Haramati A, Scheffer C.

          Author information

          Abstract

          PURPOSE:

          Empathy is a key element of patient-physician communication; it is relevant to and positively influences patients’ health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency.

          METHOD:

          The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded.

          RESULTS:

          Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the "hidden," "formal," and "informal" curricula as main reasons for empathy decline.

          CONCLUSIONS:

          The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

      • brettmd

        If you assert someone lacks empathy, perhaps you might provide an example instead of permitting gossip in an evaluation.

      • brettmd

        If only one person asserts a trainee lacks empathy, and several different physicians disagree, then perhaps that assessor is not competent.

      • brettmd

        You might assert solitary pursuits, but perhaps the person simply doesn’t like being around you. Again, your assertions are devoid of details and based only on what you assert to be true and provide no objective documentation.

      • brettmd

        Many physicians might enjoy being around others and they have enough professionalism to publicly make their views known. This is in contrast to others who make accusations of
        “isolation” and “lack of empathy” based upon only prejudice.

      • brettmd

        This may help you make describe your assessments of “isolation” and “solitary pursuits” and “lack of empathy” and the malicious claim that someone would “fake it.” Why would you think people would fake empathy. Perhaps you would do so yourself. Surely you have details to support your very strong claim of a trainees character. You have yet to add anything from the left side of this photo.

  • brettmd

    I concur that Doping should not be condoned. Doping was defined above as taking stimulants by persons who do not meet the diagnostic criteria for ADHD yet somehow are being treated for ADHD. If this is the case, then I agree, they should not be treated for a condition which they do not have. This should not be misconstrued to state that persons with ADHD should not receive treatment while in medical school.

    Please remember, that you are not your classmate’s physician. If you think a co-medical student is abusing drugs you should contact an attending physician or school supervisor. In order for them to take appropriate action based on the given information, please try to document as much of the following as you can:

    1. Who you think is abusing drugs.

    2. Why you think that they are abusing drugs

    3. When they were abusing drugs

    4. What drugs they were abusing

    5. Whether they were engaged in other unprofessional conduct, why you think that, and when it occurred

    Try to provide sufficient documentation for another physician who reviews your note to understand what you think, why you think that, and what would be an appropriate course of action.

    Accusations of abusing medication are very serious and you should proceed only when there is reasonable cause to think that there is such conduct. These observation, interviewing, examining, and documenting are basic, common-sense clinical skills that are assessed by the USMLE Step 2 CS. You will most certainly learn many of these by your second year of school. For example, you see an attending physician shaking his cup of coffee as he sits in front of the computer typing his note at 7:30 am after having been awake most of the night. He is doping, and the catecholamine excess is the likely cause of his tremors. To help you address and document your concern, I wanted to share with you a useful photo that I saw posted by various Healthcare Leaders who understand the importance of documentation and presentation.

    If you think there is stimulant abuse, then you need to not complain about it through social media, but meticulously document and provide that information to a supervisor at your school.

    As a physician you may also want to be familiar with the stimulant that you suspect is being abused. Since amphetamine is used in the treatment of ADHD, then it may be reasonable to assert that you suspect that your classmates are abusing amphetamine
    If they claim they have ADHD, and you assert that they do not, then you may want to be familiar with the latest clinical practice guidelines and recommendations for both the diagnosis and treatment of ADHD. In addition, since you are asserting that there is ongoing wrongdoing, be familiar with the pharmacology, the safety data, and document frequently. The following link may be useful.

    http://www.nejm.org/doi/full/10.1056/NEJMoa1110212

    Next, you assert that your classmates do not have ADHD, that they are abusing medication (doping), and that this medication is going to lead to “expense of the mental and physical health of the individuals involved.” With many assumptions, and assertions of expense, you may want to familiarize yourself with the anticipated outcomes from treatment and nontreatment of ADHD (or alleged ADHD).

    http://www.nejm.org/doi/full/10.1056/NEJMcp1212625

    Competition probably is probably not a problem for medical schools. Consider the anology of a race. It may be considered that a person runs a race faster when there are other racers. Likewise,other students studying may compel a student to excel to a higher level than they might otherswise. Many years ago when I was a medical student, competition was present, but the other students and myself worked collaboratively to learn. We pushed each other, quizzed each other, and shared notes. We bonded through the hard times, and the challenge of medical school ultimately molded us into a group of skilled physicians.

    In summary, I support your efforts to address the alleged wrongdoing of others. With excellent documentation I think you will succeed with your aim.

    Best wishes.

  • Dave

    As happens so often in medicine, the law of unintended consequences is again at play. You write of doing something to decrease competition and enhance team building, but that is exactly what most schools did over the last 10-15 years as they all abolished grades and went strictly pass/fail. Sounded like a good idea, but residency programs were forced to look elsewhere for markers of high achievement and all they had was an exam designed to test minimum competency for licensure.

    My observation about stimulant use in med students is that they are usually abused by the average to below-average student looking for an edge or simply to stay afloat. One of the harder adjustments in early medical education is that, by definition, one half of a class of high-performing overachievers will suddenly be below average. Stimulants may buy someone a few rungs on the ladder by way of a few extra hours study time, but they won’t take you to the top. No, the truly gifted are able to study less and use their extra drug-free hours to do research, network, volunteer, found student and community organizations, and enjoy a rich family life. It is these other things in the context of top grades and scores that one finds in applicants for the most competitive fields, and fortunately/unfortunately stimulants just aren’t that powerful.

  • PrimaryCareDoc

    I agree. I also see this trend in college students. I often groan when I see a chief complaint of “Possible ADD” on my schedule. I will see a bright 19 year old who is doing well in school, graduated HS with no problem, but complains of not being able to concentrate and getting distracted. I’ll ask them where they study- invariable the answer is in their dorm room (surrounded by distractions). I ask them if they have Facebook or IM windows open on their computer- the answer is always yes.

    They don’t have ADD. The problem is that the online “questionnaires” put out by Pharma are so vague as to make just about everyone think they have ADD. They see multiple friends taking stimulants. There’s a healthily black market for sales of these drugs, also, so most of them have already tried Adderall, and low and behold, they were able to stay up all night and study.

    I’m beginning to think that all universities need to have some sort of mandatory study skills course taught at the beginning of freshman year.

    As for what I do with these patients- it takes a lot of time and patients to explain to them that they don’t have ADD. I don’t prescribe meds. I prescribe a visit to their school’s learning services for help.

    Sadly, many of them leave angry and resentful, and I’m sure seek out a doctor with a more lenient prescription pad.

  • brettmd

    Hardly easier than ever before. Amphetamines used to be over the counter. It may certainly be easier than it was ten years ago. Physicians should be critical thinkers, and not prescribe medications to persons who have a better diagnosis than ADHD. This is very basic medical practice, and it may be practiced less frequently than necessary for the provision of excellent health care.

  • MannyHMo

    The nursing staff really knows who are the truly compassionate physicians are. Get their opinion if you are really sick with a serious illness. Board certification is just that – he or she passed the boards but is he going to apply that knowledge ? Or is that which he was tested on truly applicable ?

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