Medical students in distress: The impact of gender, race, debt, and disability.

BACKGROUND: In 2012, over half of US medical students experienced burnout and depression. Since that time, there have been many changes to student demographics, school resources and awareness of burnout in the medical field altogether. New tools are also available to screen for student distress, a condition that correlates with low mental quality-of-life, suicidal ideation and serious thoughts of dropping out. Despite increased attention on wellbeing and improved screening methods, no large-scale studies have evaluated student distress in the modern era of medical education. The objective of this study was to determine the current prevalence of medical student distress and contributing risk factors.
METHODS: Student wellbeing from a national cohort of US medical students was measured with an electronic survey in a prospective, observational survey study from 2019-2020. Medical student distress was defined as a Medical Student Wellbeing Index (MS-WBI) of ≥4. Demographic details including age, race, gender, marital status, disability, desired specialty, and debt burden were evaluated in a multivariate logistic regression model to determine possible risk factors for the development of distress.
RESULTS: A total of 3,162 students responded to the survey, representing 110 unique medical schools. Of these respondents, 52.9% met criteria for distress and 22% had either taken or considered taking a leave of absence for personal wellbeing. Independent risk factors for distress included involvement in the clinical phase of medical school (OR 1.37); non-male gender (OR 1.6); debt burden >$20,000 (OR 1.37), >$100,000 (OR 1.81), and >$300,000 (OR 1.96); and disability status (OR 1.84).
CONCLUSIONS: Medical student wellbeing remains poor in the modern era of medical education despite increased attention to wellbeing and increased availability of wellbeing resources. Disability status is a novel risk factor for distress identified in this study. The persistence of previously identified risk factors such as non-male gender, debt burden and clinical phase of school suggest that efforts to curb medical student distress have been inadequate to date.

Introduction

Medical students experience alarmingly high rates of distress. Distress can manifest as depression, burnout, alcohol abuse, suicidal ideation or simply a desire to leave the field of medicine altogether [1-5]. It is estimated that medical students are 40% more likely to be burned out and 20% more likely to be depressed compared to age-matched controls [6], despite having higher mental and physical quality-of-life scores at matriculation [7].

In 2012, the prevalence of burnout, depression, and suicidal ideation amongst US medical students was 55.9%, 58.2% and 9.4%, respectively [8]. Since that time, medical education has undergone considerable change. Medical school matriculants are more diverse than ever before [9, 10]. Females now account for over half the current medical students in the country [10] and students who identify as having a disability have increased five-fold over the last five years [11]. African American, Hispanic and Asian American student enrollment has also increased sharply [9]. Current medical students are shaped by technology and utilize innovative methods to learn medical content [12]. They also face new challenges in school, such as catastrophic debt burden [13, 14], highly competitive residency positions [15] and the need to keep pace with an exponential increase in medical knowledge.

Medical schools are well aware of the negative consequences that medical education can have on student wellbeing. In an effort to curb medical student distress, some schools have begun offering pass/fail-grading systems [16] and novel curricula designed to shorten the preclinical phase [17]. Schools have also invested considerably in wellbeing resources [18, 19] as awareness and dialogue about burnout in the medical field has become inescapable [20, 21].

Lastly, the scientific and psychological understanding of personal wellbeing has grown tremendously [22]. Wellbeing is now considered along multiple domains (i.e., emotional, physical, social, financial, etc) [23]; providing a more holistic view of one’s state of being. The breadth of research about personal wellbeing has led to the development and validation of novel tools to study this subject. In 2010, Dyrbye et al. created the Medical Student Wellbeing Index (MS-WBI), a comprehensive and simple questionnaire to screen for student distress utilizing questions from the Maslach Burnout Index, the PRIME-MD depression test and the Short Form-8 mental and physical quality of life screening [24]. They found that an MS-WBI score ≥4 was associated with severe distress, correlating with low mental quality-of-life, recent suicidal ideation and/or serious thoughts of dropping out of school, with a sensitivity and specificity of 90% [25]. Using this definition, the prevalence of severe distress was 31.7% [26]. Since that time, the MS-WBI has been adapted to screen for distress in resident [27] and attending physicians [28].

Despite an increased understanding of the complexities of personal and professional wellbeing, a change in medical student demographics, and an increased awareness of burnout in medical schools, there have been no national studies in the last eight years measuring medical student wellbeing. Recent literature has focused on small sample sizes and single institutions. The purpose of this study was to quantify US medical student wellbeing in the modern era of medical education.

Materials and methods

Study overview

This was a prospective observational study to evaluate the prevalence of medical student distress and to determine contributing risk factors. Medical students were surveyed via an electronic questionnaire after institutional review board (IRB) approval was obtained from the University of California, San Francisco. Informed consent was obtained electronically prior to survey participation. The quantitative data in this study is part of a larger research project on medical student wellbeing.

Survey development

A novel instrument, the Medical Student Wellbeing Survey (MSWS), was developed to evaluate various aspects of medical student wellbeing. This 30-question survey assessed student demographics, specialty consideration, and stressors (S1 Appendix) and included a combination of validated and novel survey questions. The validated MS-WBI questionnaire was administered within the survey with permission from the authors. Novel questions were created based on foundations established from previously validated wellbeing survey methods [29-31]. Changes in students’ physical, emotional, and social domains of wellbeing since entering medical school were assessed on a five-point Likert scale. Students were asked to designate whether they identified as having a disability and/or chronic illness. Additionally, respondents were asked about their frequency of participation in activities known to be protective against distress and burnout, such as exercise, meditation/mindfulness practices, healthy eating, hobby participation, and connecting with a loved one [32-35]. Frequency of actual participation in protective activities was compared against students’ self-reported ideal participation frequency.

The survey was piloted with a cohort of 10 medical students from various institutions and demographics over two testing cycles prior to administration. During the first cycle, time to survey completion was recorded for each participant. After completing the survey, each participant was interviewed for question clarity and survey content and completeness. Feedback obtained from the first pilot cycle was incorporated, and the survey was readministered to the 10 participants. Upon completion of the second pilot cycle, all interview participants reported that the survey questions were easy to comprehend and adequately addressed the topic of medical student wellbeing.

Participant selection and recruitment

The MSWS was administered from September 2019 to February 2020. Participants were included if they were actively enrolled in an accredited US or Caribbean medical school during the survey administration time period. For survey distribution, we first contacted the Association of American Medical Colleges (AAMC). However, the AAMC administers a national survey that targets second-year and graduating medical students only, does not include the MS-WBI, and would not allow for individual response tracking. We also contacted several Medical School Deans who voiced concern that respondents were asked to identify their medical school. Ultimately, to obtain national survey distribution, we sent a recruitment email to a medical student liaison (MSL) at every medical school in the US and Caribbean, identified through the AAMC medical student representative listserv. In total, seventy-four MSLs responded to our request with interest to distribute the survey. MSLs were provided a copy of the study’s IRB approval and study materials (email recruitment letter and survey link). MSLs then redistributed the study materials to their own classmates. Access to the survey was also available through social media platforms on Twitter and Facebook. Participation in the survey was voluntary and all students were advised to take the survey once. The need to administer the survey through MSLs precluded the ability to determine the response rate.

Student characterization and geomapping

Respondents were asked to identify their phase in medical school. “Pre-clinical,” “Clinical,” and “Post-Clinical” were defined as time spent prior to, during, or having completed core clinical clerkships, respectively. “Gap” was defined as dedicated time away from clinical work for research, additional degrees and/or to take a leave of absence. Respondents identified their medical school, which was further categorized by state and region, as defined by US Census Bureau [36]. Severe distress rate per state was mapped using the online software DISPLAYR. States with <10 respondents were excluded from severe distress rate-mapping.

Specialty competition

Survey participants were asked to select their intended specialty choice and confidence in the stated specialty choice. Specialties were then categorized by competitiveness based on 2018 National Resident Match Program data. High and Low competition was defined as an average United States Medical Licensing Examination (USMLE) Step 1 score of >240 or <230, respectively or if >18% or <4% of applicants were unmatched, respectively. Moderate competition was defined as any specialty not meeting criteria for either High or Low competitiveness.

Medical student stressors

Survey respondents were asked about the effect of various factors on their stress level using a five-point Likert scale. Candidate variables were identified in the literature as contributing to student distress which included year in medical school, age, gender, marital status, debt burden, underrepresented minority (URM) status, disability status, specialty competitiveness, and confidence in specialty [5, 26, 37]. Mean values of scores were displayed and used to derive a stressor ranking list.

Risk factor modeling

A multivariable logistic regression model was developed to determine risk factors for severe distress. The data was randomly split (7:3) into training and validation cohorts to allow for model building and testing, respectively. The cohorts were well matched for severe distress and all candidate variables with an absolute value of the standardized difference of <0.2. Missing data was present in <5% of all respondents in both the training and validation cohort.

Using least absolute shrinkage and selection operator (LASSO) and net elastic regression, a model was created to predict the presence of severe distress in medical students from candidate variables. The tuning parameter associated with the smallest cross-validated error was used. The multivariable regression model had an adequate fit with a Pearson chi-square goodness-of-fit test equal to 0.2. The model was then tested on the validation data cohort with similar receiver operating characteristic curves. Additionally, observed and predicted probability for severe distress from the validation cohort was closely matched.

All statistical tests were two-sided and p <0.05 was considered significant. Statistical analyses were performed using SAS version 9.4 and R version 3.6.1. The "glmnet" package in R was used to fit the elastic net and LASSO penalized regression models.

Results

Survey respondents

A total of 3,162 students responded to the survey. Respondents represented 110 unique medical schools throughout the US, Caribbean and US territories. Students from medical schools in the Caribbean and/or US territory represented <0.1% of all responses. There was an even distribution of respondents from medical school phases with 52.0% in the pre-clinical phase and 42.8% in the clinical/post-clinical phase (Table 1). A small proportion (5.2%) of respondents identified as being in a “gap” year. Most respondents were female (64.5%), between the ages of 22–27 (79.8%) and never married (87.2%). According to the definitions set forth by the AAMC, 11.4% of respondents were characterized as URM, including Black / African American, Hispanic / Latinx and Native American [38]. Nine percent of respondents identified as having a disability or chronic illness.

Table 1

Demographic characteristics of the study cohort.

	Pre-Clinical	Clinical	Post-Clinical	Other	Grand Total
N (%)	1644 (52)	643 (20)	710 (22)	165 (5)	3162
Age, N (%)
<21	46 (1)	1 (0)	0 (0)	0 (0)	47 (2)
22–27	1388 (45)	490 (16)	474 (15)	111 (4)	2463 (79)
≥28	179 (6)	135 (4)	220 (7)	42 (1)	576 (18)
Gender, N (%)
Male	533 (17)	233 (7)	223 (7)	54 (2)	1043 (33)
Non-Male*	1073 (34)	390 (13)	469 (15)	96 (3)	2028 (65)
Marital Status, N (%)
Never Married	1470 (47)	535 (17)	554 (18)	131 (4)	2690 (86)
Married	136 (4)	83 (3)	134 (4)	21 (1)	374 (12)
Divorced / Widowed	8 (0)	7 (0)	5 (0)	1 (0)	21 (1)
Debt Burden, N (%)
<20K	526 (17)	155 (5)	188 (6)	54 (2)	923 (30)
20-100K	681 (22)	121 (4)	111 (4)	27 (1)	940 (30)
100-300K	291 (9)	292 (9)	278 (9)	50 (2)	911 (29)
>300K	10 (0)	25 (1)	89 (3)	9 (0)	133 (4)
Not Sure	56 (2)	16 (1)	9 (0)	8 (0)	89 (3)
Race, N (%)
Asian	323 (10)	111 (4)	131 (4)	31 (1)	596 (19)
Black / African American	76 (2)	29 (1)	24 (1)	13 (0)	142 (5)
White	929 (30)	376 (12)	397 (13)	75 (2)	1777 (57)
Hispanic / Latino	78 (3)	35 (1)	60 (2)	13 (0)	186 (6)
Multiracial	161 (5)	53 (2)	48 (2)	12 (0)	274 (9)
Other	16 (0)	7 (0)	10 (0)	2 (0)	34 (1)
URM, N (%)
Yes	162 (5)	66 (2)	88 (3)	26 (1)	342 (11)
No	1421 (46)	545 (18)	581 (19)	120 (4)	2667 (86)
Disability, N (%)
Yes	156 (5)	49 (2)	49 (2)	23 (1)	277 (9)
No	1435 (46)	559 (18)	636 (20)	128 (4)	2758 (89)
Desired Specialty Competitiveness, N (%)
Low	695 (22)	309 (10)	387 (12)	73 (2)	1464 (47)
Moderate	600 (19)	214 (7)	219 (7)	44 (1)	1077 (35)
High	289 (9)	92 (3)	78 (3)	31 (1)	490 (16)
Confidence in Specialty, N (%)
Low	479 (15)	84 (3)	34 (1)	18 (1)	615 (20)
Moderate	474 (15)	159 (5)	34 (1)	24 (1)	691 (22)
High	660 (21)	382 (12)	625 (20)	110 (4)	1777 (57)

Abbreviations: URM = underrepresented minority

* Includes Female, Transgender, Other, Prefer Not to Say

Respondent geographic distribution

Respondents represented medical schools from 33 states with the largest percentage of respondents from New York (15.6%), Pennsylvania (15.3%) and California (12.7%). The average number of respondents per school was 28.5 (range 1–224).

Severe distress in US medical students

The average MS-WBI score was 3.56 ± 1.95. A total of 1,646 respondents (52.9%) had an MS-WBI score ≥4, indicating severe distress (Fig 1A). Respondents reported a decline in physical (60.9%) emotional (66.3%) and social (56.9%) wellbeing since starting medical school (Fig 1B). They also reported a significant gap (>3 days) between their ideal and real participation in mindfulness practices (22%), hobbies (15%) and exercise (12%) (Fig 1C). A mild gap (1–3 days) between ideal and real participation was reported for hobbies (58%), exercise (58%) and healthy eating (57%). The percentage of respondents who reported taking a leave of absence from medical school for their personal wellbeing was 3.8% and 17.5% had considered a leave of absence (Fig 1D). Severe distress rates ranged from 39% (Massachusetts) to 72% (Wisconsin) (Fig 2). The average rate of severe distress by state was 53.8% ± 9.6%.

Fig 1

Medical Student Wellbeing Survey results by component.

Fig 2

Rate of severe distress amongst medical students by state & region.

Darker color corresponds to higher rates of Severe Distress as defined by MS-WBI.

Risk factors for severe distress

Results of the multivariable regression model are listed in Table 2. Controlling for all other variables in the model, severe distress was more likely for students in their clinical phase (OR 1.4, 95% CI 1.1–1.8, p = 0.02) and those in a gap year (OR 1.8, 95% CI 1.1–2.8, p = 0.01) compared to students in their pre-clinical coursework phase. Additional variables significantly associated with severe distress included non-male gender, disability, and higher debt burden. All other associations in the model were not significant.

Table 2

Predictors of severe distress in medical students from multivariable logistic regression model.

	Odds Ratio (95% CI)	P-value
MS Year (vs. Preclinical)
Clinical	1.37 (1.06–1.77)	.02*
Post-Clinical	0.80 (0.61–1.06)	.12
Other	1.78 (1.12–2.84)	.01*
Age (vs. 22–27)
<21	0.69 (0.32–1.45)	.33
≥28	0.99 (0.76–1.29)	.93
Gender (vs. Male)
Non-Male	1.60 (1.31–1.95)	< .001*
Marital Status (vs. Never Married)
Married	1.18 (0.88–1.59)	.28
Divorced / Widowed	1.04 (0.32–3.37)	.94
Debt Burden (vs. <$20K)
20-100K	1.37 (1.08–1.72)	.009*
100-300K	1.81 (1.42–2.31)	< .001*
>300K	1.96 (1.19–3.24)	.009*
Not Sure	1.22 (0.70–2.13)	.48
URM (vs. No)
Yes	1.11 (0.83–1.32)	.49
Disability (vs. No)
Yes	1.84 (1.32–2.57)	< .001*
Desired Specialty Competitiveness (vs. Low)
Moderate	1.19 (0.97–1.46)	.10
High	1.16 (0.89–1.51)	.28
Confidence in Specialty Choice (vs. Low)
Moderate	1.07 (0.84–1.36)	.59
High	0.82 (0.63–1.07)	.14

* Statistically significant at p < .05

Top stressors for all students were national board exams (1.55 ± 0.71), grades (1.33 ± 0.73), uncertainty about the future (1.22 ± 0.77), isolation from family and friends (1.16 ± 0.76) and lack of control over one’s schedule (1.07 ± 0.8) (Fig 3A). Stressor ranking did not vary substantially according to medical school year, gender, debt burden, race or disability status (Fig 3B).

Fig 3

Key stressors for medical students.

A: A 5-point Likert scale was used with positive scores corresponding increased stress due to specific stressor. B: Abbreviations: AA = African-American; Lx = Latinx.

Discussion

Medical student wellbeing remains poor in the modern era of medical education. Our study found that over half of the students we surveyed experienced severe distress, a rate 20% higher than that identified in a national cohort from 2007 [25]. Furthermore, we found that one in five students had either taken or considered taking time off from medical school specifically for their personal wellbeing. The high rate of medical student distress identified in this study suggests that current efforts to improve medical student wellbeing are inadequate.

Estimation of distress

To our knowledge, this is the first study to utilize the MS-WBI in a national sample of medical students since the tool was first validated. While we primarily evaluated MS-WBI as a binary index of severe distress, additional insight can be obtained through a more thorough evaluation of specific scores. Hansell et al. estimated burnout by measuring affirmative responses to the following MS-WBI questions: 1) Do you feel burned out from medical school? or 2) Do you worry medical school is hardening you emotionally? [5] Utilizing the same definition in our study population would have yielded a burnout rate of 76%. An affirmative answer to the PRIME-MD question within the MS-WBI (During the past month, have you often been bothered by feeling down, depressed, or hopeless?) would have resulted in a 49.3% rate of depression within our study population [24]. Furthermore, escalating MS-WBI scores are correlated with worsening wellbeing. Dyrbye et al. found that the likelihood ratio (and probability) for low mental quality-of-life, serious thoughts of dropping out, and suicidal ideation for students with an MS-WBI score of ≥6 were 12.1 (88.9%), 7.2 (44%) and 3.8 (29.6%), respectively [26]. These scores increased to 18.5 (92.5%), 11.0 (55%) and 14.3 (61.4%) when MS-WBI score was 7. In our study, 388 respondents (12.5%) had an MS-WBI score of 6 and 131 respondents (5.8%) had a score of 7. Importantly, one student with a score of 6 in our study population died by suicide during the study period.

Individual versus structural interventions

Current efforts to curb medical student distress have overwhelmingly focused on individuals rather than the underlying structure of medical education [37, 39, 40]. In our data, board exams, grades and uncertainty about the future were the most common student stressors regardless of individual characteristics. Programs such as resiliency training, mindfulness, and self-care education have all aimed to give students capacity to endure the challenges of medical school. Yet, little has been done to address increased competition for residency positions, expectation of mastery over expanding medical content or decreased autonomy and responsibility that medical students face on clinical rotations. Our data suggest that changes to the underlying structural components of medical education are likely to yield more substantial results to improve medical student wellbeing than continued focus on individuals.

Efforts to address risk factors known to contribute to poor medical student wellbeing have largely been ignored. The clinical phase of medical school as illustrated by our, and other studies is a particularly vulnerable time for medical students, yet most interventions to date focus on the preclinical phase [16, 41, 42]. Furthermore, our study and preceding studies found debt burden to significantly affect distress, yet schools have become more expensive with time. According to the National Center for Education Statistics, the total loan debt taken on by medical students at the time of graduation has more than doubled over the last decade from an average cost of $108,000 in 2003 to $223,000 in 2016 after adjusting for inflation [14]. Lastly, female or genders other than cisgender male are at a disproportionate risk of distress while also having higher representation in medical schools than ever before [10].

New risk factors

Our study identified disability status as a novel risk factor for the development of severe distress. We found that nearly 10% of survey respondents identified as having a disability and that disability status nearly doubled the risk of severe distress (OR 1.81). Self-reporting of disability in medical school has risen substantially over the last three years, specifically for psychological and chronic health issues. The prevalence of self-identified disability in our study is higher than previously cited (4.6%), which may indicate a higher willingness of students to disclose their disability if done with anonymity as in our study [43]. Little is currently known about the additional stressors faced by students with disability and to what degree accommodations from medical schools are being offered and utilized. Understanding this topic more thoroughly may prove pivotal for guiding medical schools in designing interventions to support this vulnerable group.

Study limitations

A major limitation to this study is the inability to determine a response rate of students. Our survey was conducted as part of a larger study on medical student wellbeing that required the ability to track individual responses and medical school identity. Survey distribution through national organizations or through selective school participation proved unable to fulfill this need. As such, we pursued an alternate survey distribution method for which calculating a response rate was not possible. Assuming the survey was distributed to every US allopathic medical student, the response rate would be 8.7% [44].

A second limitation is the potential for response bias in our study. Respondents may not accurately reflect the greater medical student cohort and there was a disproportion of female survey respondents, which may result in lower than expected rates of wellbeing. Shanafelt et al. investigated the topic of response bias amongst US physicians who participated in a survey on burnout and wellbeing. They compared initial survey respondents to respondents who required intensive follow-up and solicitation to participate. There was a higher proportion of females in the initial survey respondent group but no difference in respondent characteristics, burnout prevalence or wellbeing scores between the groups [45].

Conclusion

Current medical students are facing poor personal wellbeing at record levels. The proportion of students experiencing adverse effects from medical school including distress, burnout, and depression is rising despite increased attention to and discussion on the subject over the last decade. While some components of poor wellbeing may be individual, this alarming trend points to more systemic problems within medical education. If the medical education field is unable to create meaningful change toward improving medical student wellbeing, we risk an increasing number of talented students abandoning or never pursuing a career in medicine, a growing epidemic of distressed medical students, or worse, further irreplaceable loss of life from death by suicide.

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3 Sep 2020

PONE-D-20-23258

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

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Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper, I found the approach and results quite interesting.

I commend the authors on their novel investigation and aim of identifying risk factors for distress. Validation of their survey, the MSWS (portions not included in the MS-WBI) was not addressed. No information about the piloting of these questions was given. A copy of the survey was not available. These are critical to understanding the validity of the assessment, which is central to the validity of the findings.

Self-selection bias is a major limitation of this study and the approach using a liaison was poorly defined, for example, how many liaisons agreed to distribute the survey?Finally, variables added to the regression model are noted in the introduction, with the exception of disability, which is not discussed until the methods and results. Having a solid framework for choosing all variables is important. I would add this reasoning to the background/introduction alongside the others.

Reviewer #2: Despite the limitations you recognize (eg. response rate), this study offers significant contributions to conversations about medical schooling conditions that deserves wide dissemination in the public sphere as well as to the medical community. Foremost, this study identifies a need for "course correction" in the ways that medical schools & the profession address student well-being. As you state: "Our data suggest that changes to the underlying structural components of medical education are likely to yield more substantial results to improve medical student well being than continued focus on individuals." This recommendation to attend to structure is critical. Further, this study reveals that debt is a significant factor in students distress. Again, this is something, as the authors' indicate, that needs to be addressed at the structural level. For future studies and/or in disseminating and explaining the significance of these findings (op-eds, medical school leadership, undergrad institutions), I would encourage the authors to look at studies addressing the effects of student debt in education (outside of medical context) (eg Hormel & McAlistair) and those that show that small amounts of debt - as little as $5,000 are an effective deterrent for students of color and under-represented students in the pursuit of graduate or first professional school (Millet). Since this study does have demographic information, I wonder if there are additional findings around what the authors point to as "demographic changes" and their findings about stress that could be highlighted. The authors do state that their data show more work is needed to understand the links between disability and documented increased stress levels that were indicated by their data. As medical schools seek to diversify, they will need to address not only recruitment and cost, but retention and completion - taking into account the importance of well-being in that equation. The "fixes," as this study suggests, cannot just be individual, but must be structural. A different kind of conversation needs to take place and this study is a very important step in that direction - to think about the increased stress and its unequal distribution (and I am guessing the unequal distribution of other causal factors like debt) on people with disabilities, women, and students of color.

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Reviewer #1: No

Reviewer #2: Yes: Jeanne Scheper

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19 Sep 2020

We thank you for your time and insightful critiques about our manuscript. We appreciate the overall positive feedback and we hope to strengthen our manuscript by addressing your concerns.

1. Survey validation. In developing our survey instruments, we scoured the literature for previously validated questions that contribute to medical student wellbeing and burnout. Unfortunately, no single survey questionnaire contained what we were searching for and many wellbeing surveys were designed for either older populations, where chronic health conditions and dependence are more prevalent, or corporations, where productivity and distractions are of higher concern. As such, we opted to create a novel instrument centered primarily around the MS-WBI. Additional questions added to our survey were designed under the guidance of previously validated surveys, utilizing Likert scales and topics previously known to contribute to burnout and stress. These foundational surveys have been included as references in our manuscript in addition to a clarifying statement.

2. Survey piloting. We appreciate the reviewer addressing our oversight in not describing the piloting of the survey. The survey was piloted by 10 medical students from various institutions to ensure the survey was of adequate length, easy to comprehend and comprehensive. After an initial round of feedback regarding the survey, we made several edits and then underwent a second round of piloting, at which point there was universal acceptance of the survey for all participants. A description of this process has been included in the manuscript. A copy of the survey has been provided as supplemental material for the manuscript.

3. Medical student liaisons. We have added the total number of medical student liaisons to our manuscript.

4. Rationale for disability in the regression model. We included disability in our regression model for severe distress as disability amongst medical students has risen substantially over the last decade and the effects of disability on wellbeing was previously unknown. Our study demonstrates that identifying as having a disability is a risk factors for having severe distress. We believe that this finding contributes significantly to the literature and we hope that publishing our results will better inform medical schools and help design interventions to mitigate this risk. We have included additional information about disability amongst medical students in our introduction.

Submitted filename: PLOS_Response to Reviewers_v2.docx

Click here for additional data file.

12 Oct 2020

PONE-D-20-23258R1

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

PLOS ONE

Dear Dr. Nikhil Rajapuram,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

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Yuka Kotozaki

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done a commendable job addressing the feedback. I would suggest accepting with minor revisions.

A few notes:

While the authors are correct that their findings are novel and add to the literature, they fail to mention the disability finding in the conclusion portion of the abstract.

Consider adding more updated citations for student depression/suicidal ideation.

Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta‐analysis. Medical education. 2016 Apr;50(4):456-68.

Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. Jama. 2016 Dec 6;316(21):2214-36.

The authors should add disability status to this paragraph under novel questions:

The validated MS-WBI questionnaire was administered within the survey with permission from the authors. Novel questions were created based on foundations established from previously validated wellbeing survey methods [27-29]. Changes in students’ physical, emotional, and social domains of wellbeing since entering medical school were assessed on a five-point Likert scale. Additionally, respondents were asked about their frequency of participation in activities known to be protective against distress and burnout, such as exercise, meditation/mindfulness practices, healthy eating, hobby participation, and connecting with a loved one [30-33]. Frequency of actual participation in protective activities was compared against students’ self-reported ideal participation frequency.

I’m not sure this needs to be included (could be removed for word count)

We first contacted the Association of American Medical Colleges (AAMC). However, the AAMC administers a national survey that targets second-year and graduating medical students only, does not include the MS-WBI and would not allow for individual response tracking. We also contacted several Medical School Deans who voiced concern that respondents were asked to identify their medical school.

In this paragraph I would mention that these numbers are higher than the latest findings (the implication being that students may not feel protected/well supported in disclosing to their schools.

We found that nearly 10% of survey respondents identified as having a disability and that

disability status nearly doubled the risk of severe distress (OR 1.81). Self-reporting of disability

in medical school has risen substantially over the last three years, specifically for psychological

and chronic health issues [41]. Little is currently known about the additional stressors faced by

students with disability and to what degree accommodations from medical schools are being

offered and utilized. Understanding this topic more thoroughly may prove pivotal for guiding

314 medical schools in designing interventions to support this vulnerable group.

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

1 Nov 2020

We thank you for your time and insightful critiques about our manuscript. We appreciate the overall positive feedback and we hope to strengthen our manuscript by addressing your concerns.

1. Abstract Correction. We appreciate the reviewer addressing our oversight in not including disability in the conclusion of the abstract. We have added disability status as a novel risk factor to the abstract conclusion.

2. Updated Citations. We have included updated citations on student depression/suicidal ideation as indicated.

3. Disability/Chronic Illness Status. We have added the fact that one of our novel questions was asking about disability/chronic illness status. We also included that a higher number of students self-identified as having a disability than has been found in prior literature possibly due to student discomfort.

Submitted filename: PLOS_Response to Reviewers_Round2.docx

Click here for additional data file.

18 Nov 2020

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

PONE-D-20-23258R2

Dear Dr. Nikhil Rajapuram,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yuka Kotozaki

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The revisions to this article strengthen the authors presentation and sufficiently address the prior feedback. The authors should be commended for this work and the novel addition of disability status to the discussion of wellbeing.

Reviewer #2: Author's had previously addressed my concerns and recent revisions were to address the concerns of other readers. While the study has limitations (not a large or perfect sample), it still has sufficient data to highlight an important and neglected area. This research will stimulate further work, hopefully, to map and address these concerns.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

25 Nov 2020

PONE-D-20-23258R2

Medical students in distress:The impact of gender, race, debt, and disability

Dear Dr. Rajapuram:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Yuka Kotozaki

Academic Editor

PLOS ONE