http://informahealthcare.com/ada ISSN: 0095-2990 (print), 1097-9891 (electronic) Am J Drug Alcohol Abuse, 2014; 40(4): 336–341 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/00952990.2014.907302
ORIGINAL ARTICLE
Prevalence of binge drinking and associated co-factors among medical students in a US Jesuit University Michael Trostler, MS1, Ying Li, PhD, MS2, and Michael W. Plankey, PhD2 Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Otago on 04/22/15 For personal use only.
1
Office of Medical Education, Georgetown University School of Medicine, Washington, DC and 2Department of Medicine, Georgetown University Medical Center, Washington, DC, USA Abstract
Keywords
Background: Alcohol consumption is the third leading cause of preventable death in the US. Limited research has been conducted examining drinking habits of medical students. Objective: This study was designed to measure the prevalence and associated risk factors of binge drinking among a sample of medical students. Methods: A total of 485 medical students at a private, Jesuit medical school in the US participated in a confidential web-based survey in April 2011. Univariate and multivariate generalized linear regressions with robust error variance were performed for estimated prevalence ratio (PR) of binge drinking. Results: The prevalence of binge drinking was 58.1% among the sampled medical students with the majority being white (67.0%) and between 18 and 25 years old (60.0%). After adjusting for age, gender, race/ ethnicity, and year in medical school, there were statistically significant (p50.05) associations of drinking during an after-exam party (PR ¼ 2.82), protective behavioral strategy (PR ¼ 0.97 per 1-score increase), self-reported diagnosis of depression (PR ¼ 1.19), tobacco use (PR ¼ 1.21 for previous use, 1.39 for current use), and previous illicit drug use (PR ¼ 1.24) with binge drinking. In addition, the prevalence of binge drinking decreased among this sample of the medical students with older age (PR ¼ 0.80 for 26–28, 0.60 for 428, p50.01) compared to those of 18–25 years old. Conclusion: Binge drinking was highly prevalent among the sampled medical students, especially during an after-exam party. Identifying healthy coping strategies among medical students is warranted to reduce binge drinking.
Binge drinking, survey
Introduction Alcohol consumption is the third leading cause of preventable death in the US, costing $223.5 billion in loss in productivity, increased healthcare expenses, and causing 80 000 deaths annually (1,2). Research has shown 7–15% of healthcare professionals have a problem with drugs or alcohol during their career (3,4). Previous research has demonstrated the personality risk factors (achievement oriented, self-controlled, independence, less comfort asking for help) that predispose to addiction and abuse among physicians are shared by medical students (5,6). It has been shown that alcohol and drug use often begins early and is based on behaviors that are learned before and during medical school, and that early hazardous drinking patterns are the biggest predisposing factor for later
Address correspondence to Michael W. Plankey, PhD, Department of Medicine, Georgetown University Medical Center, 2115 Wisconsin Avenue, NW, Suite 130, Washington, DC 20007, USA. Tel: +1 202 7842607. Fax: +1 202 7840791. E-mail: [email protected]
History Received 15 November 2013 Revised 6 March 2014 Accepted 11 March 2014 Published online 7 May 2014
hazardous drinking (4–9). The consequences of hazardous drinking include: mental, emotional, spiritual, familial, and occupational disruption, depression, suicide, under diagnosis of a patient’s substance abuse, withdrawal symptoms, liver disease, malpractice lawsuits, loss of license, and many more (3,5,10–13). Limited research has been conducted examining drinking habits of medical students, with two recent studies showing excessive alcohol use with a third of students binge drinking at least once a month (3,14). Medical school offers students a new experience with more responsibilities, higher stress, and a change in their living habits; there are less social activities, with a greater proportion of them revolving around alcohol. While drinking habits often precede medical school, limited studies have found overall drinking decreases upon entering medical school with a measurable increase in alcohol intake over the course of the first year (15,16). The aim of this study was to determine the prevalence of binge drinking and to identify associated risk factors such as stress, protective behavioral strategy, depression, tobacco use, illicit drug use, non-prescribed prescription drug use, age, year in medical school, and race/ethnicity among the medical students attending a private, Jesuit university in the US.
Binge drinking among medical students
DOI: 10.3109/00952990.2014.907302
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Methods All of the current full-time medical students and medical graduate students at a private, Jesuit medical school in the US were invited to participate in an anonymous Web-based survey from March 2011 to April 2011. Students for each class year were contacted through an institutional e-mail list serve. Participation was completely voluntary without coercion and it was clearly specified that participation or non-participation would not impact their academic status. Participant could decide at any point not to submit the survey response. Each participant was assigned a random identification number that was not linked to IP address or other personal information. Data were collected from only those who consented to and completed the survey. After completing the survey students were invited to participate in a raffle drawing for prizes (i.e. iPad, gift card, or school apparel). All survey questions, related to alcohol, tobacco, and drug use, protective behavioral strategy, stress, depression, and demographics were chosen from the National College Health Assessment II (NCHA II) survey organized by American College Health Association (17). The Georgetown University Institutional Review Board approved this study and granted an exemption of documentation of signed informed consent to preserve anonymity. Participant’s drinking status was the outcome of interest. We used the definition of binge drinking by the Center for Disease Control and Prevention (CDC), that is, binge drinking has been defined to drinking five or more drinks for men or four or more for women during a single occasion (1). We considered the alcohol use in two kinds of situations: drinking during the last after-exam party and/or the last non-after-exam party. Participant’s drinking status was defined as non-binge drinking (including non-drinking) or binge drinking. Social demographics included participant’s age (18–25, 26–28, 428), gender (female, male), race/ethnicity (nonwhite, white [non-Hispanic]), and year in medical school (graduate/1st year, 2nd year, 3rd year, 4th year). Drinking during the last after-exam party, drinking during the last non-after-exam party, self-reported ever diagnosis of depression, non-prescribed prescription drug use in the last 12 months (antidepressants, erectile dysfunction drugs, pain killers, sedative, and/or stimulants) was categorized as yes/no. Stress was self-rated with the overall level of stress the student experienced within the last 12 months (18) and categorized as no stress, less than average, average, more than average, or tremendous stress. Tobacco use (i.e. using cigarettes, tobacco from a water pipe, cigars/little cigars/clove cigarettes, and/or smokeless tobacco) and illicit drug use (i.e. using marijuana [pot, weed, hashish, hash oil], cocaine [crack, rock, freebase], methamphetamine [crystal meth, ice, crank], other amphetamines [diet pills, benzedrine], sedatives [downers, quaaludes], hallucinogens [LSD, PCP], anabolic steroids [testosterone], opiates [heroin, smack], inhalants [glue, solvents, gas], MDMA [ecstasy], other club drugs [GHB, ketamine, rohypnol], and/or other illegal drugs) were categorized as never, previous, or current. Current use was defined as having used in the last 30 days, and previous use as having used but not in the last 30 days.
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Protective behavioral strategy was assessed with 11 questions: When at a party/socializing within the last 12 months: (1) how often alternated non-alcoholic with alcoholic beverages? (2) avoided drinking games? (3) chose not to drink alcohol? (4) determined in advance not to exceed a set number of drinks? (5) ate before and/or during drinking? (6) had a friend let you know when you have had enough? (7) kept track of the numbers of drinks? (8) paced the drinks to 1 or fewer per hour? (9) stayed with the same group of friends the entire time when drinking? (10) stuck with only one kinds of alcohol when drinking? and (11) used a designated driver? The responses to these questions were scored (never ¼ 0, rarely ¼ 1, sometimes ¼ 2, most of the times ¼ 3, always ¼ 4, don’t drink ¼ 5) and then summed to get a protective behavioral score. We analyzed the data using descriptive statistics and crosstabulations. After performing stepwise, forward and backward logistic regression modeling with p value 50.05 as entry level, we omitted drinking during non-after-exam party and non-prescribed prescription drug use from the final model. Univariate and multivariate analyses were performed using generalized linear regression with robust error variance (19,20) to explore potential associations between the covariates and participants’ drinking status and estimate the prevalence ratio (PR) for binge drinking. We defined statistical significance as a p value 50.05. All computations were done using SAS version 9.2 (SAS Institute Inc., US).
Results A total of 485 out of 988 students completed the survey. The distribution of gender and race of the sample was comparable to the entire medical student population. However, the majority of the sample was graduate/1st year students. The overall prevalence of binge drinking among the sampled students was 58.1% (n ¼ 282), with 64.2% among the males (n ¼ 158/246), and 51.9% among the females (n ¼ 124/239), respectively. As shown in Table 1, the majority of the sampled medical students were between 18 and 25 years old (n ¼ 291, 60.0%), white (n ¼ 325, 67.0%), drank during the last afterexam party (n ¼ 346, 71.3%), drank during the last nonafter-exam party (n ¼ 424, 87.4%), did not self-report the diagnosis of depression (n ¼ 427, 88.0%), rated their stress level above average (n ¼ 329, 67.8%), and were non-users of non-prescribed prescription drug (n ¼ 441, 90.9%). About half of the sampled students were female (n ¼ 239, 49.3%), medical graduate student or first-year student (n ¼ 238, 48.0%), rated their stress level as ‘‘more than average’’ (n ¼ 259, 53.4%), never used tobacco (n ¼ 233, 48.0%), and never used illicit drug (n ¼ 269, 55.4%). The median protective behavioral score among the binge drinking students was 10 points lower than that among the non-binge drinking students. The univariate and multivariate prevalence ratios (PR) for binge drinking are listed in Table 2. The univariate analysis
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Table 1. Demographics and other characteristics of the sampled medical students by drinking status.
Age 18–25 26–28 428 Gender Female Male Race/ethnicity Non-white White (non-Hispanic) Year in medical school Graduate/1st year 2nd year 3rd year 4th year Drinking during last after-exam party No Yes Drinking during last not-after-exam party No Yes Reported diagnosis of depression No Yes Self-rated stress level No stress Less than average Average More than average Tremendous stress Tobacco use Never Previous Current Illicit drug use Never Previous Current Non-prescribed prescription drug use No Yes Protective behavioral score median (IQR)
Non-binge drinking* students (n ¼ 203)
Binge drinking students (n ¼ 282)
Total (n ¼ 485)
111 (54.7%) 72 (35.5%) 20 (9.8%)
180 (63.8%) 91 (32.3%) 11 (3.9%)
291 (60.0%) 163 (3.6%) 31 (6.4%)
115 (56.7%) 88 (43.3%)
124 (44.0%) 158 (56.0%)
239 (49.3%) 246 (50.7%)
91 (44.8%) 112 (55.2%)
69 (24.5%) 213 (75.5%)
160 (33.0%) 325 (67.0%)
113 32 34 24
120 76 40 46
238 108 74 70
(55.7%) (15.8%) (16.7%) (11.8%)
(42.5%) (27.0%) (14.2%) (16.3%)
(48.0%) (22.3%) (15.3%) (14.4%)
118 (58.1%) 85 (41.9%)
21 (7.4%) 261 (92.6%)
139 (28.7%) 346 (71.3%)
58 (28.6%) 145 (71.4%)
3 (1.1%) 279 (98.9%)
61 (12.6%) 424 (87.4%)
186 (91.6%) 17 (8.4%)
241 (85.5%) 41 (14.5%)
427 (88.0%) 58 (12.0%)
2 12 54 112 23
4 15 69 147 47
6 27 123 259 70
(1.0%) (5.9%) (26.6%) (55.2%) (11.3%)
(1.4%) (5.3%) (24.5%) (52.1%) (16.7%)
(1.2%) (5.6%) (25.4%) (53.4%) (14.4%)
142 (70.0%) 50 (24.6%) 11 (5.4%)
91 (32.3%) 120 (42.5%) 71 (25.2%)
233 (48.0%) 170 (35.1%) 82 (16.9%)
157 (77.3%) 39 (19.2%) 7 (3.5%)
112 (39.7%) 117 (41.5%) 53 (18.8%)
269 (55.4%) 156 (32.2%) 60 (12.4%)
199 (98.0%) 4 (2.0%)
242 (85.8%) 40 (14.2%)
441 (90.9%) 44 (9.1%)
30 (25, 55)
20 (17, 25)
24 (19, 30)
*Non-binge drinking included non-drinking.
results showed that gender (p ¼ 0.007), race/ethnicity (p50.001), drinking during the last after-exam party (p50.001), self-reported depression (p ¼ 0.017), tobacco use (p50.001), and illicit drug use (p50.001) were all statistically significantly positively associated with binge drinking. Protective behavioral strategy was statistically significantly negatively (PR ¼ 0.94 per 1-score increase, p50.001) associated with binge drinking. Drinking during the last after-exam party, self-reported diagnosis of depression, tobacco use, and previous illicit drug use were all statistically significantly positively associated with the prevalence of binge drinking, after adjusting for age, gender, race/ethnicity, and year in medical school. When drinking during the last after-exam party was compared to no drinking there, the prevalence of binge drinking increased 182% (p50.001), 19% for the self-reported diagnosis of depression (p ¼ 0.037), 21% for previous tobacco use (p ¼ 0.037), 39% for current tobacco use (p50.001), and 24% for previous illicit drug use (p ¼ 0.011) compared to never
use. However, protective behavioral strategy was statistically significantly negatively associated with the prevalence of binge drinking after the adjustment. The prevalence of binge drinking decreased 3% per 1-score increase of protective behavioral strategy (p50.001). In addition, there were statistically significant associations of age and year in medical school with binge drinking. Binge drinking decreased 20% for ages 26–28 (p ¼ 0.004) and 40% for the age older than 28 (p ¼ 0.008), compared to age of 18–25; it increased 28% for the 4th year (p ¼ 0.022), compared to the graduate/ 1st year.
Discussion Our results showed that the prevalence of binge drinking was high among this sample of medical students. It was also found that drinking during the last after-exam party, use of less protective behavioral strategy, self-reported diagnosis of depression, tobacco use, and previous illicit drug use were
Binge drinking among medical students
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Table 2. Estimated prevalence ratios for binge drinking among GUSOM medical students calculated by univariate or multivariate logistic regression, in the school year of 2010–2011. Univariate model
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PR (95% CI) Age 18–25 26–28 428 Gender Female Male Race/ethnicity Non-white White Year at GUSOM Graduate/1st year 2nd year 3rd year 4th year Drinking during last after-exam party No Yes Protective behavioral score per 1-score increase Self-rated stress level No stress Less than average Average More than average Tremendous stress Reported diagnosis of depression No Yes Tobacco use Never Previous Current Illicit drug use Never Previous Current
Multivariate model p
PR (95% CI)
p
1 0.90 (0.77, 1.06) 0.57 (0.35, 0.93)
0.22 0.024
1 0.80 (0.68, 0.93) 0.60 (0.41, 0.88)
0.004 0.008
1 1.24 (1.06, 1.44)
0.007
1 1.01 (0.89, 1.16)
0.83
1 1.52 (1.25, 1.84)
50.001
1 1.10 (0.94, 1.28)
0.24
1 1.37 (1.15, 1.63) 1.05 (0.82, 1.34) 1.28 (1.03, 1.57)
50.001 0.70 0.023
1 1.14 (0.99, 1.31) 1.05 (0.84, 1.31) 1.28 (1.04, 1.58)
0.070 0.67 0.022
1 4.99 (3.35, 7.44)
50.001
1 2.82 (1.93, 4.12)
50.001
0.94 (0.93, 0.95)
50.001
0.97 (0.95, 0.98)
50.001
1 0.83 0.84 0.85 1.01
0.59 0.56 0.58 0.98
1 0.68 0.72 0.78 0.78
1 1.25 (1.04, 1.51)
0.017
1 1.19 (1.01, 1.40)
0.037
1 1.81 (1.50, 2.18) 2.22 (1.85, 2.66)
50.001 50.001
1 1.21 (1.01, 1.44) 1.39 (1.15, 1.69)
0.037 50.001
1 1.80 (1.52, 2.13) 2.12 (1.79, 2.51)
50.001 50.001
1 1.24 (1.05, 1.46) 1.17 (0.97, 1.40)
0.011 0.09
(0.43, (0.47, (0.48, (0.56,
1.61) 1.51) 1.51) 1.82)
(0.33, (0.37, (0.40, (0.40,
1.40) 1.40) 1.52) 1.53)
0.29 0.33 0.46 0.48
PR, prevalence ratio.
associated with increased binge drinking after adjusting for age, gender, race/ethnicity, and year in medical school. We observed that the prevalence of binge drinking among this sample of male medical students was much higher than among females. This finding was similar to several studies including two large studies of US medical students (3,14), a study among US first-year military medical students (21), and a study of German medical students (18). One of the largest studies of medical student drinking by Frank et al. surveyed 4847 students from 16 medical schools, that were relatively representative of the US average, for ‘‘excessive drinking’’ defined by the 5 drinks in a single episode or more than 2 drinks per day on average for males or more than 1 drink per day on average for females (3). Our study found many similarities including higher prevalence of binge drinking among males, white race, and tobacco users. In our sample, the prevalence of binge drinking was 58.1%, which was much higher than the prevalence of excessive drinking (34%) in the Frank’s study, which was probably due to the fact that our study defined the binge drinking based on the alcohol use [according to CDC (1), 5 for men and 4 for women] during an episode (i.e. last
after-exam party or last non-after exam party). Another reason to explain this difference might include sanctioned drinking on-campus where alcohol was provided after exams as a way to relax and socialize. Frank et al. found that a very strong religious identity was negatively associated with excessive drinking. While religious attitudes were not addressed in this study, the protective effect towards binge drinking at a medical school endorsing Jesuit values could only be conjectured. Shah et al. performed a web-based survey among 2710 medical students from 36 US medical schools and found that being of younger age, male, using illicit drugs, and smoking tobacco products were independent predictors for at-risk drinking among a national sample of medical students (14). The associations of age, tobacco use, and illicit drug use were present among our sampled medical students. We found that the prevalence of binge drinking was negatively associated with the increasing age, in agreement with Weisner et al.’s findings among 9051 US males (22) and Fillmore’s 12-year cohort study results among 1358 US males (23). The study among 901 Norwegian medical students showed that older students were less likely to drink to intoxication but more
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likely to use drinking to cope with tension (24). The National Survey on Drug Use and Health (NSDUH) 2009 Report demonstrated the increased likelihood of concurrent use of illicit drug and alcohol, especially when binge drinking (25). We observed a positive association of previous illicit drug use with binge drinking. Da Silveira et al. observed among 456 Brazilian medical students that female students switched from illegal to legal drugs (26), which might explain why no association of current illicit drug use was shown in our study. The positive association of tobacco use and binge drinking in this study has been shown in other studies including a casecontrol study in which 83% of alcoholics were smokers while only 34% of non-alcoholics smoked (27), and a statewide study among 70 516 of 7 12th-grade students in which the significant co-occurrence of smoking and alcohol use was observed and this concurrent use was associated with increased risk of personal and social problems and delinquency (28). Drobes summarized the mechanisms contributing the concurrent alcohol and tobacco dependence including genetic factors, neurobiological point of view, conditioning, and psychosocial factors (29). Keller et al. studied 252 German medical students and demonstrated that the most frequently reported occasions for binge drinking were social occasions like parties (30). Our study showed that drinking during the last after-exam party was highly positively associated with binge drinking among the medical students. Ball and Bax observed significant changes in health habits (such as increased alcohol consumption, decreased exercise, and decreased total socialization) among 54 first-year medical students and found that the increased work load did not allow them to relieve the tension as often as they did in their undergraduate education (15). Kuzel et al. suggested that increased work load might lead to more dysfunctional alcohol use among 119 medical students (16). Grotmol et al. followed 288 new doctors over 6 years and found a positive association between alcohol expectancy and hazardous drinking (8). We postulate that the increased alcohol expectancy that medical students need to relieve the immediate stress of exams might be positively associated with a higher prevalence of binge drinking during after-exam parties. Two studies demonstrated that depressed medical students were more likely to report at-risk drinking (14,31), which agrees with our results. Richman et al. found that the medical students who were the subject of any abuse were more likely to experience depressive symptoms and drink to escape (31). Some studies have also shown the association of risk taking with binge drinking. Goudriaan et al. found that ‘‘disadvantageous decision making’’ was positively associated with heavy drinking among 176 healthy college students (32). A study among 75 undergraduate students indicated that behavioral risk-taking and non-planning impulsivity predicted the increase of alcohol consumption (33). Quinn and Fromme studied 1136 college students and suggested that self-regulation would protect against heavy drinking and alcohol-related problems (34). Self-regulation might buffer the behaviors of those with high sensation seeking personalities, stopping the negative effects, but not overcoming them (30).
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A study among 2710 US medical students showed that stress self-measured by the social readjustment rating scale was positively associated with at-risk drinking (14). Tyssen et al. found an association between use of alcohol to cope with tension and hazardous drinking after surveying 901 Norwegian medical students (24). Two other studies among 3777 and 274 medical students found that stress was negatively associated with drinking due to the responsibilities the medical students realized when they felt the stress (3,35). However, we did not find an association of stress with binge drinking. This is likely due to the use of a single self-reported variable, which was different from well-defined scales such as the Social Readjustment Rating Scale which assesses stress from many areas of life and give a global stress score. The high prevalence of binge drinking among medical students has many consequences including harming the patient, loss of license, marriage disruption, and loss of confidence in physicians. Baldisseri has demonstrated that physician substance abuse often begins during medical school and residency (4), while Ball and Bax suggested that the habits and coping strategies that students learned in medical school would impact their future careers as physicians (15). Ahmad et al. surveyed 135 physicians by mail and found 14% felt that social drinking while on call was acceptable, and that a high percentage of doctors were suspected to have used alcohol while on call (36). Although the questionnaire in this study has been nationwide used for the past 12 years, this study was limited by a number of factors. Asking students to recall alcohol, tobacco, and illicit drug use was likely to be underreported due to recall bias. Kaskutas and Graves found among 321 women that their typical drink size was 3–6 times larger than the standard drink size (12 oz of beer, 5 oz of wine, or 1 shot of liquor), and when given a sample of liquid they underestimated the volume by 70% (37). In a study of 6354 Danish citizens, Ekholm found the clear decline in recall of alcohol intake after 2–3 days (38). Furthermore, the time intervals of the questions varied and might have confused those when completing the questionnaire. For example, questions about drinking used the ‘‘last’’ after-exam or non-after exam party; for stress, protective behavioral strategy, and non-prescribed prescription drug use, it was within the last ‘‘12 months’’; for self-reported diagnosis of depression, ‘‘ever’’ was used; for tobacco and illicit drug use, it was separated by ‘‘never’’, not in the last ‘‘30 days’’, or within the last ‘‘30 days’’. In addition, this was a self-selected study and our findings might not be generalizable to all medical students. Although we found the prevalence of binge drinking was high among this sample of students, 41.9% of students did not drink or binge drink. A reservoir of healthy coping has been demonstrated among students with positive inputs (social support, mentorship, and social/healthy activities) maintaining the reservoir and negative inputs (stress, internal conflict, and demands on students’ time) draining the reservoir (39). Understanding how non-binge drinking medical students develop and maintain a coping reservoir can inform interventions for students who are vulnerable to binge drinking.
DOI: 10.3109/00952990.2014.907302
Acknowledgements The authors wish to thank Georgetown University School of Medicine, Office of the Dean for funding this study, the Dahlgren Memorial Library Staff for administering the survey.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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18. Oswalt SB, Wyatt TJ. Sexual orientation and differences in mental health, stress, and academic performance in a national sample of U.S. college students. J Homosex 2011;58:1255–1280. 19. Barros AJ, Hirakata VN. Alternatives for logistic regression in crosssectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21. 20. Petersen MR, Deddens JA. A comparison of two methods for estimating prevalence ratios. BMC Med Res Methodol 2008;8:9. 21. Lande RG, Marin BA, Chang AS, Mason S, Lande GR. A survey of alcohol consumption among first-year military medical students. Am J Drug Alcohol Abuse 2007;33:605–610. 22. Weisner C, Greenfield T, Room R. Trends in the treatment of alcohol problems in the US general population, 1979 through 1990. Am J Public Health 1995;85:55–60. 23. Fillmore KM. Prevalence, incidence and chronicity of drinking patterns and problems among men as a function of age: a longitudinal and cohort analysis. Br J Addict 1987;82:77–83. 24. Tyssen R, Vaglum P, Aasland OG, Gronvold NT, Ekeberg O. Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nationwide Norwegian samples of medical students. Addiction 1998;93: 1341–1349. 25. The NSDUH Report: Concurrent illicit drug and alcohol use. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, 19 March 2009; http://oas.samhsa.gov/2k9/alcDrugs/alcDrugs.pdf [last accessed 21 Apr 2014]. 26. Da Silveira DX, Rosa-Oliveira L, Di Pietro M, Niel M, Doering-Silveira E, Jorge MR. Evolutional pattern of drug use by medical students. Addict Behav 2008;33:490–495. 27. DiFranza JR, Guerrera MP. Alcoholism and smoking. J Stud Alcohol 1990;51:130–135. 28. Hoffman JH, Welte JW, Barnes GM. Co-occurrence of alcohol and cigarette use among adolescents. Addict Behav 2001;26:63–78. 29. Drobes DJ. Concurrent alcohol and tobacco dependence: mechanisms and treatment. Alcohol Res Health 2002;26:136–142. 30. Keller S, Maddock JE, Laforge RG, Velicer WF, Basler HD. Binge drinking and health behavior in medical students. Addict Behav 2007;32:505–515. 31. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA 1992;267:692–694. 32. Goudriaan AE, Grekin ER, Sher KJ. Decision making and response inhibition as predictors of heavy alcohol use: a prospective study. Alcohol Clin Exp Res 2011;35:1050–1057. 33. Fernie G, Cole JC, Goudie AJ, Field M. Risk-taking but not response inhibition or delay discounting predict alcohol consumption in social drinkers. Drug Alcohol Depend 2010;112:54–61. 34. Quinn PD, Fromme K. Self-regulation as a protective factor against risky drinking and sexual behavior. Psychol Addict Behav 2010;24: 376–385. 35. Newbury-Birch D, Lowry RJ, Kamali F. The changing patterns of drinking, illicit drug use, stress, anxiety and depression in dental students in a UK dental school: a longitudinal study. Br Dent J 2002;192:646–649. 36. Ahmad T, Wallace J, Peterman J, Desbiens NA. Doctors’ perceptions of drinking alcohol while on call: questionnaire survey. BMJ 2002;325:579–580. 37. Kaskutas LA, Graves K. An alternative to standard drinks as a measure of alcohol consumption. J Subst Abuse 2000;12:67–78. 38. Ekholm O. Influence of the recall period on self-reported alcohol intake. Eur J Clin Nutr 2004;58:60–63. 39. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry 2008;32:44–53.
ORIGINAL ARTICLE
Prevalence of binge drinking and associated co-factors among medical students in a US Jesuit University Michael Trostler, MS1, Ying Li, PhD, MS2, and Michael W. Plankey, PhD2 Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Otago on 04/22/15 For personal use only.
1
Office of Medical Education, Georgetown University School of Medicine, Washington, DC and 2Department of Medicine, Georgetown University Medical Center, Washington, DC, USA Abstract
Keywords
Background: Alcohol consumption is the third leading cause of preventable death in the US. Limited research has been conducted examining drinking habits of medical students. Objective: This study was designed to measure the prevalence and associated risk factors of binge drinking among a sample of medical students. Methods: A total of 485 medical students at a private, Jesuit medical school in the US participated in a confidential web-based survey in April 2011. Univariate and multivariate generalized linear regressions with robust error variance were performed for estimated prevalence ratio (PR) of binge drinking. Results: The prevalence of binge drinking was 58.1% among the sampled medical students with the majority being white (67.0%) and between 18 and 25 years old (60.0%). After adjusting for age, gender, race/ ethnicity, and year in medical school, there were statistically significant (p50.05) associations of drinking during an after-exam party (PR ¼ 2.82), protective behavioral strategy (PR ¼ 0.97 per 1-score increase), self-reported diagnosis of depression (PR ¼ 1.19), tobacco use (PR ¼ 1.21 for previous use, 1.39 for current use), and previous illicit drug use (PR ¼ 1.24) with binge drinking. In addition, the prevalence of binge drinking decreased among this sample of the medical students with older age (PR ¼ 0.80 for 26–28, 0.60 for 428, p50.01) compared to those of 18–25 years old. Conclusion: Binge drinking was highly prevalent among the sampled medical students, especially during an after-exam party. Identifying healthy coping strategies among medical students is warranted to reduce binge drinking.
Binge drinking, survey
Introduction Alcohol consumption is the third leading cause of preventable death in the US, costing $223.5 billion in loss in productivity, increased healthcare expenses, and causing 80 000 deaths annually (1,2). Research has shown 7–15% of healthcare professionals have a problem with drugs or alcohol during their career (3,4). Previous research has demonstrated the personality risk factors (achievement oriented, self-controlled, independence, less comfort asking for help) that predispose to addiction and abuse among physicians are shared by medical students (5,6). It has been shown that alcohol and drug use often begins early and is based on behaviors that are learned before and during medical school, and that early hazardous drinking patterns are the biggest predisposing factor for later
Address correspondence to Michael W. Plankey, PhD, Department of Medicine, Georgetown University Medical Center, 2115 Wisconsin Avenue, NW, Suite 130, Washington, DC 20007, USA. Tel: +1 202 7842607. Fax: +1 202 7840791. E-mail: [email protected]
History Received 15 November 2013 Revised 6 March 2014 Accepted 11 March 2014 Published online 7 May 2014
hazardous drinking (4–9). The consequences of hazardous drinking include: mental, emotional, spiritual, familial, and occupational disruption, depression, suicide, under diagnosis of a patient’s substance abuse, withdrawal symptoms, liver disease, malpractice lawsuits, loss of license, and many more (3,5,10–13). Limited research has been conducted examining drinking habits of medical students, with two recent studies showing excessive alcohol use with a third of students binge drinking at least once a month (3,14). Medical school offers students a new experience with more responsibilities, higher stress, and a change in their living habits; there are less social activities, with a greater proportion of them revolving around alcohol. While drinking habits often precede medical school, limited studies have found overall drinking decreases upon entering medical school with a measurable increase in alcohol intake over the course of the first year (15,16). The aim of this study was to determine the prevalence of binge drinking and to identify associated risk factors such as stress, protective behavioral strategy, depression, tobacco use, illicit drug use, non-prescribed prescription drug use, age, year in medical school, and race/ethnicity among the medical students attending a private, Jesuit university in the US.
Binge drinking among medical students
DOI: 10.3109/00952990.2014.907302
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Methods All of the current full-time medical students and medical graduate students at a private, Jesuit medical school in the US were invited to participate in an anonymous Web-based survey from March 2011 to April 2011. Students for each class year were contacted through an institutional e-mail list serve. Participation was completely voluntary without coercion and it was clearly specified that participation or non-participation would not impact their academic status. Participant could decide at any point not to submit the survey response. Each participant was assigned a random identification number that was not linked to IP address or other personal information. Data were collected from only those who consented to and completed the survey. After completing the survey students were invited to participate in a raffle drawing for prizes (i.e. iPad, gift card, or school apparel). All survey questions, related to alcohol, tobacco, and drug use, protective behavioral strategy, stress, depression, and demographics were chosen from the National College Health Assessment II (NCHA II) survey organized by American College Health Association (17). The Georgetown University Institutional Review Board approved this study and granted an exemption of documentation of signed informed consent to preserve anonymity. Participant’s drinking status was the outcome of interest. We used the definition of binge drinking by the Center for Disease Control and Prevention (CDC), that is, binge drinking has been defined to drinking five or more drinks for men or four or more for women during a single occasion (1). We considered the alcohol use in two kinds of situations: drinking during the last after-exam party and/or the last non-after-exam party. Participant’s drinking status was defined as non-binge drinking (including non-drinking) or binge drinking. Social demographics included participant’s age (18–25, 26–28, 428), gender (female, male), race/ethnicity (nonwhite, white [non-Hispanic]), and year in medical school (graduate/1st year, 2nd year, 3rd year, 4th year). Drinking during the last after-exam party, drinking during the last non-after-exam party, self-reported ever diagnosis of depression, non-prescribed prescription drug use in the last 12 months (antidepressants, erectile dysfunction drugs, pain killers, sedative, and/or stimulants) was categorized as yes/no. Stress was self-rated with the overall level of stress the student experienced within the last 12 months (18) and categorized as no stress, less than average, average, more than average, or tremendous stress. Tobacco use (i.e. using cigarettes, tobacco from a water pipe, cigars/little cigars/clove cigarettes, and/or smokeless tobacco) and illicit drug use (i.e. using marijuana [pot, weed, hashish, hash oil], cocaine [crack, rock, freebase], methamphetamine [crystal meth, ice, crank], other amphetamines [diet pills, benzedrine], sedatives [downers, quaaludes], hallucinogens [LSD, PCP], anabolic steroids [testosterone], opiates [heroin, smack], inhalants [glue, solvents, gas], MDMA [ecstasy], other club drugs [GHB, ketamine, rohypnol], and/or other illegal drugs) were categorized as never, previous, or current. Current use was defined as having used in the last 30 days, and previous use as having used but not in the last 30 days.
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Protective behavioral strategy was assessed with 11 questions: When at a party/socializing within the last 12 months: (1) how often alternated non-alcoholic with alcoholic beverages? (2) avoided drinking games? (3) chose not to drink alcohol? (4) determined in advance not to exceed a set number of drinks? (5) ate before and/or during drinking? (6) had a friend let you know when you have had enough? (7) kept track of the numbers of drinks? (8) paced the drinks to 1 or fewer per hour? (9) stayed with the same group of friends the entire time when drinking? (10) stuck with only one kinds of alcohol when drinking? and (11) used a designated driver? The responses to these questions were scored (never ¼ 0, rarely ¼ 1, sometimes ¼ 2, most of the times ¼ 3, always ¼ 4, don’t drink ¼ 5) and then summed to get a protective behavioral score. We analyzed the data using descriptive statistics and crosstabulations. After performing stepwise, forward and backward logistic regression modeling with p value 50.05 as entry level, we omitted drinking during non-after-exam party and non-prescribed prescription drug use from the final model. Univariate and multivariate analyses were performed using generalized linear regression with robust error variance (19,20) to explore potential associations between the covariates and participants’ drinking status and estimate the prevalence ratio (PR) for binge drinking. We defined statistical significance as a p value 50.05. All computations were done using SAS version 9.2 (SAS Institute Inc., US).
Results A total of 485 out of 988 students completed the survey. The distribution of gender and race of the sample was comparable to the entire medical student population. However, the majority of the sample was graduate/1st year students. The overall prevalence of binge drinking among the sampled students was 58.1% (n ¼ 282), with 64.2% among the males (n ¼ 158/246), and 51.9% among the females (n ¼ 124/239), respectively. As shown in Table 1, the majority of the sampled medical students were between 18 and 25 years old (n ¼ 291, 60.0%), white (n ¼ 325, 67.0%), drank during the last afterexam party (n ¼ 346, 71.3%), drank during the last nonafter-exam party (n ¼ 424, 87.4%), did not self-report the diagnosis of depression (n ¼ 427, 88.0%), rated their stress level above average (n ¼ 329, 67.8%), and were non-users of non-prescribed prescription drug (n ¼ 441, 90.9%). About half of the sampled students were female (n ¼ 239, 49.3%), medical graduate student or first-year student (n ¼ 238, 48.0%), rated their stress level as ‘‘more than average’’ (n ¼ 259, 53.4%), never used tobacco (n ¼ 233, 48.0%), and never used illicit drug (n ¼ 269, 55.4%). The median protective behavioral score among the binge drinking students was 10 points lower than that among the non-binge drinking students. The univariate and multivariate prevalence ratios (PR) for binge drinking are listed in Table 2. The univariate analysis
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Table 1. Demographics and other characteristics of the sampled medical students by drinking status.
Age 18–25 26–28 428 Gender Female Male Race/ethnicity Non-white White (non-Hispanic) Year in medical school Graduate/1st year 2nd year 3rd year 4th year Drinking during last after-exam party No Yes Drinking during last not-after-exam party No Yes Reported diagnosis of depression No Yes Self-rated stress level No stress Less than average Average More than average Tremendous stress Tobacco use Never Previous Current Illicit drug use Never Previous Current Non-prescribed prescription drug use No Yes Protective behavioral score median (IQR)
Non-binge drinking* students (n ¼ 203)
Binge drinking students (n ¼ 282)
Total (n ¼ 485)
111 (54.7%) 72 (35.5%) 20 (9.8%)
180 (63.8%) 91 (32.3%) 11 (3.9%)
291 (60.0%) 163 (3.6%) 31 (6.4%)
115 (56.7%) 88 (43.3%)
124 (44.0%) 158 (56.0%)
239 (49.3%) 246 (50.7%)
91 (44.8%) 112 (55.2%)
69 (24.5%) 213 (75.5%)
160 (33.0%) 325 (67.0%)
113 32 34 24
120 76 40 46
238 108 74 70
(55.7%) (15.8%) (16.7%) (11.8%)
(42.5%) (27.0%) (14.2%) (16.3%)
(48.0%) (22.3%) (15.3%) (14.4%)
118 (58.1%) 85 (41.9%)
21 (7.4%) 261 (92.6%)
139 (28.7%) 346 (71.3%)
58 (28.6%) 145 (71.4%)
3 (1.1%) 279 (98.9%)
61 (12.6%) 424 (87.4%)
186 (91.6%) 17 (8.4%)
241 (85.5%) 41 (14.5%)
427 (88.0%) 58 (12.0%)
2 12 54 112 23
4 15 69 147 47
6 27 123 259 70
(1.0%) (5.9%) (26.6%) (55.2%) (11.3%)
(1.4%) (5.3%) (24.5%) (52.1%) (16.7%)
(1.2%) (5.6%) (25.4%) (53.4%) (14.4%)
142 (70.0%) 50 (24.6%) 11 (5.4%)
91 (32.3%) 120 (42.5%) 71 (25.2%)
233 (48.0%) 170 (35.1%) 82 (16.9%)
157 (77.3%) 39 (19.2%) 7 (3.5%)
112 (39.7%) 117 (41.5%) 53 (18.8%)
269 (55.4%) 156 (32.2%) 60 (12.4%)
199 (98.0%) 4 (2.0%)
242 (85.8%) 40 (14.2%)
441 (90.9%) 44 (9.1%)
30 (25, 55)
20 (17, 25)
24 (19, 30)
*Non-binge drinking included non-drinking.
results showed that gender (p ¼ 0.007), race/ethnicity (p50.001), drinking during the last after-exam party (p50.001), self-reported depression (p ¼ 0.017), tobacco use (p50.001), and illicit drug use (p50.001) were all statistically significantly positively associated with binge drinking. Protective behavioral strategy was statistically significantly negatively (PR ¼ 0.94 per 1-score increase, p50.001) associated with binge drinking. Drinking during the last after-exam party, self-reported diagnosis of depression, tobacco use, and previous illicit drug use were all statistically significantly positively associated with the prevalence of binge drinking, after adjusting for age, gender, race/ethnicity, and year in medical school. When drinking during the last after-exam party was compared to no drinking there, the prevalence of binge drinking increased 182% (p50.001), 19% for the self-reported diagnosis of depression (p ¼ 0.037), 21% for previous tobacco use (p ¼ 0.037), 39% for current tobacco use (p50.001), and 24% for previous illicit drug use (p ¼ 0.011) compared to never
use. However, protective behavioral strategy was statistically significantly negatively associated with the prevalence of binge drinking after the adjustment. The prevalence of binge drinking decreased 3% per 1-score increase of protective behavioral strategy (p50.001). In addition, there were statistically significant associations of age and year in medical school with binge drinking. Binge drinking decreased 20% for ages 26–28 (p ¼ 0.004) and 40% for the age older than 28 (p ¼ 0.008), compared to age of 18–25; it increased 28% for the 4th year (p ¼ 0.022), compared to the graduate/ 1st year.
Discussion Our results showed that the prevalence of binge drinking was high among this sample of medical students. It was also found that drinking during the last after-exam party, use of less protective behavioral strategy, self-reported diagnosis of depression, tobacco use, and previous illicit drug use were
Binge drinking among medical students
DOI: 10.3109/00952990.2014.907302
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Table 2. Estimated prevalence ratios for binge drinking among GUSOM medical students calculated by univariate or multivariate logistic regression, in the school year of 2010–2011. Univariate model
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PR (95% CI) Age 18–25 26–28 428 Gender Female Male Race/ethnicity Non-white White Year at GUSOM Graduate/1st year 2nd year 3rd year 4th year Drinking during last after-exam party No Yes Protective behavioral score per 1-score increase Self-rated stress level No stress Less than average Average More than average Tremendous stress Reported diagnosis of depression No Yes Tobacco use Never Previous Current Illicit drug use Never Previous Current
Multivariate model p
PR (95% CI)
p
1 0.90 (0.77, 1.06) 0.57 (0.35, 0.93)
0.22 0.024
1 0.80 (0.68, 0.93) 0.60 (0.41, 0.88)
0.004 0.008
1 1.24 (1.06, 1.44)
0.007
1 1.01 (0.89, 1.16)
0.83
1 1.52 (1.25, 1.84)
50.001
1 1.10 (0.94, 1.28)
0.24
1 1.37 (1.15, 1.63) 1.05 (0.82, 1.34) 1.28 (1.03, 1.57)
50.001 0.70 0.023
1 1.14 (0.99, 1.31) 1.05 (0.84, 1.31) 1.28 (1.04, 1.58)
0.070 0.67 0.022
1 4.99 (3.35, 7.44)
50.001
1 2.82 (1.93, 4.12)
50.001
0.94 (0.93, 0.95)
50.001
0.97 (0.95, 0.98)
50.001
1 0.83 0.84 0.85 1.01
0.59 0.56 0.58 0.98
1 0.68 0.72 0.78 0.78
1 1.25 (1.04, 1.51)
0.017
1 1.19 (1.01, 1.40)
0.037
1 1.81 (1.50, 2.18) 2.22 (1.85, 2.66)
50.001 50.001
1 1.21 (1.01, 1.44) 1.39 (1.15, 1.69)
0.037 50.001
1 1.80 (1.52, 2.13) 2.12 (1.79, 2.51)
50.001 50.001
1 1.24 (1.05, 1.46) 1.17 (0.97, 1.40)
0.011 0.09
(0.43, (0.47, (0.48, (0.56,
1.61) 1.51) 1.51) 1.82)
(0.33, (0.37, (0.40, (0.40,
1.40) 1.40) 1.52) 1.53)
0.29 0.33 0.46 0.48
PR, prevalence ratio.
associated with increased binge drinking after adjusting for age, gender, race/ethnicity, and year in medical school. We observed that the prevalence of binge drinking among this sample of male medical students was much higher than among females. This finding was similar to several studies including two large studies of US medical students (3,14), a study among US first-year military medical students (21), and a study of German medical students (18). One of the largest studies of medical student drinking by Frank et al. surveyed 4847 students from 16 medical schools, that were relatively representative of the US average, for ‘‘excessive drinking’’ defined by the 5 drinks in a single episode or more than 2 drinks per day on average for males or more than 1 drink per day on average for females (3). Our study found many similarities including higher prevalence of binge drinking among males, white race, and tobacco users. In our sample, the prevalence of binge drinking was 58.1%, which was much higher than the prevalence of excessive drinking (34%) in the Frank’s study, which was probably due to the fact that our study defined the binge drinking based on the alcohol use [according to CDC (1), 5 for men and 4 for women] during an episode (i.e. last
after-exam party or last non-after exam party). Another reason to explain this difference might include sanctioned drinking on-campus where alcohol was provided after exams as a way to relax and socialize. Frank et al. found that a very strong religious identity was negatively associated with excessive drinking. While religious attitudes were not addressed in this study, the protective effect towards binge drinking at a medical school endorsing Jesuit values could only be conjectured. Shah et al. performed a web-based survey among 2710 medical students from 36 US medical schools and found that being of younger age, male, using illicit drugs, and smoking tobacco products were independent predictors for at-risk drinking among a national sample of medical students (14). The associations of age, tobacco use, and illicit drug use were present among our sampled medical students. We found that the prevalence of binge drinking was negatively associated with the increasing age, in agreement with Weisner et al.’s findings among 9051 US males (22) and Fillmore’s 12-year cohort study results among 1358 US males (23). The study among 901 Norwegian medical students showed that older students were less likely to drink to intoxication but more
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likely to use drinking to cope with tension (24). The National Survey on Drug Use and Health (NSDUH) 2009 Report demonstrated the increased likelihood of concurrent use of illicit drug and alcohol, especially when binge drinking (25). We observed a positive association of previous illicit drug use with binge drinking. Da Silveira et al. observed among 456 Brazilian medical students that female students switched from illegal to legal drugs (26), which might explain why no association of current illicit drug use was shown in our study. The positive association of tobacco use and binge drinking in this study has been shown in other studies including a casecontrol study in which 83% of alcoholics were smokers while only 34% of non-alcoholics smoked (27), and a statewide study among 70 516 of 7 12th-grade students in which the significant co-occurrence of smoking and alcohol use was observed and this concurrent use was associated with increased risk of personal and social problems and delinquency (28). Drobes summarized the mechanisms contributing the concurrent alcohol and tobacco dependence including genetic factors, neurobiological point of view, conditioning, and psychosocial factors (29). Keller et al. studied 252 German medical students and demonstrated that the most frequently reported occasions for binge drinking were social occasions like parties (30). Our study showed that drinking during the last after-exam party was highly positively associated with binge drinking among the medical students. Ball and Bax observed significant changes in health habits (such as increased alcohol consumption, decreased exercise, and decreased total socialization) among 54 first-year medical students and found that the increased work load did not allow them to relieve the tension as often as they did in their undergraduate education (15). Kuzel et al. suggested that increased work load might lead to more dysfunctional alcohol use among 119 medical students (16). Grotmol et al. followed 288 new doctors over 6 years and found a positive association between alcohol expectancy and hazardous drinking (8). We postulate that the increased alcohol expectancy that medical students need to relieve the immediate stress of exams might be positively associated with a higher prevalence of binge drinking during after-exam parties. Two studies demonstrated that depressed medical students were more likely to report at-risk drinking (14,31), which agrees with our results. Richman et al. found that the medical students who were the subject of any abuse were more likely to experience depressive symptoms and drink to escape (31). Some studies have also shown the association of risk taking with binge drinking. Goudriaan et al. found that ‘‘disadvantageous decision making’’ was positively associated with heavy drinking among 176 healthy college students (32). A study among 75 undergraduate students indicated that behavioral risk-taking and non-planning impulsivity predicted the increase of alcohol consumption (33). Quinn and Fromme studied 1136 college students and suggested that self-regulation would protect against heavy drinking and alcohol-related problems (34). Self-regulation might buffer the behaviors of those with high sensation seeking personalities, stopping the negative effects, but not overcoming them (30).
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A study among 2710 US medical students showed that stress self-measured by the social readjustment rating scale was positively associated with at-risk drinking (14). Tyssen et al. found an association between use of alcohol to cope with tension and hazardous drinking after surveying 901 Norwegian medical students (24). Two other studies among 3777 and 274 medical students found that stress was negatively associated with drinking due to the responsibilities the medical students realized when they felt the stress (3,35). However, we did not find an association of stress with binge drinking. This is likely due to the use of a single self-reported variable, which was different from well-defined scales such as the Social Readjustment Rating Scale which assesses stress from many areas of life and give a global stress score. The high prevalence of binge drinking among medical students has many consequences including harming the patient, loss of license, marriage disruption, and loss of confidence in physicians. Baldisseri has demonstrated that physician substance abuse often begins during medical school and residency (4), while Ball and Bax suggested that the habits and coping strategies that students learned in medical school would impact their future careers as physicians (15). Ahmad et al. surveyed 135 physicians by mail and found 14% felt that social drinking while on call was acceptable, and that a high percentage of doctors were suspected to have used alcohol while on call (36). Although the questionnaire in this study has been nationwide used for the past 12 years, this study was limited by a number of factors. Asking students to recall alcohol, tobacco, and illicit drug use was likely to be underreported due to recall bias. Kaskutas and Graves found among 321 women that their typical drink size was 3–6 times larger than the standard drink size (12 oz of beer, 5 oz of wine, or 1 shot of liquor), and when given a sample of liquid they underestimated the volume by 70% (37). In a study of 6354 Danish citizens, Ekholm found the clear decline in recall of alcohol intake after 2–3 days (38). Furthermore, the time intervals of the questions varied and might have confused those when completing the questionnaire. For example, questions about drinking used the ‘‘last’’ after-exam or non-after exam party; for stress, protective behavioral strategy, and non-prescribed prescription drug use, it was within the last ‘‘12 months’’; for self-reported diagnosis of depression, ‘‘ever’’ was used; for tobacco and illicit drug use, it was separated by ‘‘never’’, not in the last ‘‘30 days’’, or within the last ‘‘30 days’’. In addition, this was a self-selected study and our findings might not be generalizable to all medical students. Although we found the prevalence of binge drinking was high among this sample of students, 41.9% of students did not drink or binge drink. A reservoir of healthy coping has been demonstrated among students with positive inputs (social support, mentorship, and social/healthy activities) maintaining the reservoir and negative inputs (stress, internal conflict, and demands on students’ time) draining the reservoir (39). Understanding how non-binge drinking medical students develop and maintain a coping reservoir can inform interventions for students who are vulnerable to binge drinking.
DOI: 10.3109/00952990.2014.907302
Acknowledgements The authors wish to thank Georgetown University School of Medicine, Office of the Dean for funding this study, the Dahlgren Memorial Library Staff for administering the survey.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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