Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

WMJ Vol. 118 No. 1: Letter to the Editor

The Illusion of Selection Bias in Matters of Students’ Mental Health

Jayshil J. Patel, MD; Kathlyn Fletcher, MD; Erica Chou, MD; MaryAnn Gilligan, MD; Kurt Pfeifer, MD; Martin Muntz, MD


Read the full article:
Download PDF



Dear Editor:

We read, with significant interest, the study by Van Remortel et al that described the state of mental health of Wisconsin medical students.¹ We applaud the authors for shining a bright light on a common, yet often overlooked, problem plaguing medical education. They humbly suggest, “Voluntary participation may have resulted in selection bias, as distressed medical students may have been more likely to complete the survey.” Here, we offer 2 scenarios that consider the implications of full survey participation and boldly suggest that, even if selection bias were present, the findings remain germane.

In the University of Wisconsin cohort, if the 455 nonrespondents had indicated “medical school did not have a negative impact on their mental health,” 20% still would have indicated that medical school had had a negative impact on their mental health.

Similarly, in the Medical College of Wisconsin cohort, if the 510 nonrespondents had not reported having a “mental health condition while in medical school,” 12% still would have reported that they did have a mental health condition while in medical school.

These calculations might be interpreted as best-case scenarios. Nevertheless, the numbers remain alarming, and we speculate the report underestimates the scope of the problem. Ironically, barriers to survey participation may mirror those identified for not pursuing mental health services (eg, lack of time and fear of stigma) or those encountered in reporting mistreatment (eg, fear of reprisal).²

Medical educators must be vigilant of the “hidden” mental health epidemic among our learners. As training progresses and rigor increases, concealed disturbances may go unnoticed, continually spiraling, and resulting in damaged relationships, injured patients, and self-harm. The authors have provided a starting point, and we should not allow limitations of a surveybased study blind us to the gravity of the findings. Instead, we should wholeheartedly congratulate them for naming (eg, depression) and calling out the impact of disrupted medical student mental health (eg, limited self-care), no matter how prevalent—a necessary first step in alleviating its burden.

To stem this epidemic, the Kern National Transformation Network at both Wisconsin medical schools is laying innovative groundwork to transform medical education by reimagining and resetting such best-case scenarios. We remain optimistic that transforming the clinical learning environment will prioritize character development, competency training, and caring. Otherwise, if we cannot optimize care to heal our learners and each other, how can we expect them to for our patients and communities?

Jayshil J. Patel, MD; Kathlyn Fletcher, MD; Erica Chou, MD; MaryAnn Gilligan, MD; Kurt Pfeifer, MD; Martin Muntz, MD

Author Affiliations: Medical College of Wisconsin, Milwaukee, Wis (Patel, Fletcher, Chou, Gilligan, Pfeifer, Muntz).

Corresponding Author: Jayshil J. Patel, MD, Associate Professor of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Road, HUB, 8th Floor, Milwaukee, WI 53226.


1. Van Remortel B, Dolan E, Cipriano D, McBride P. Medical student wellness in Wisconsin: Current trends and future directions. WMJ. 2018;117:211-213.
2. Chung MP, Thang CK, Vermillion M, Fried JM, Uijtdehaage S. Exploring medical students’ barriers to reporting mistreatment during clerkships: a qualitative study. Med Educ Online. 2018;23(1):1478170. doi:10.1080/10872981.2018.1478170.