Methylphenidate use and misuse among medical residents in Israel ... - Human Resources for Health

Main results

In this cross-sectional study, we suggest that the prevalence of MPH use and misuse among Israeli medical residents was 51.5% and 35.1%, respectively. Half of all users in our study began to use MPH during their residencies, and 83.3% used MPH without an official ADHD diagnosis. The main reason for MPH use was preparing for residency examinations (87.5%). Hospital residents and those in the surgical professions (45.6%) were more likely to misuse MPH than family medicine residents (24%). Female pediatricians and internists were less likely to misuse MPH. Those born outside of Israel were more likely than native-born Israelis to misuse MPH.

Misusers and users were more liberal than non-users in their approach toward using and prescribing MPH. In addition, misusers did not perceive the act of misusing as affecting the equality or fairness of exams or as a crossing of boundaries.

Interpretation

In this study, we suggest that misuse of MPH among Israeli medical residents (35.1%) is extremely high compared to the known misuse rates among the general adult population (2%) [4], college students (17%), and medical students (8–17%) [7].

Twenty-four percent (24%) of respondents reported they began using MPH before residency. This rate is somewhat higher than the rates found in previous studies on medical students. Cohen et al. found a 17% usage rate among Israeli medical students [26].

Interestingly, almost half of all users (84/176, 47.7%) began using MPH during their residencies. The majority of these did not have a formal ADHD diagnosis (70/84, 83.3%) and could be labeled as misusers. The high rate of misuse during residency was associated in our study with preparing for exams (88% of misusers reported using MPH during exam preparation) and working night shifts (22% of misusers reported using MPH during night shifts). These findings are in line with those regarding medical students, among whom the main reasons for misuse of MPH were the desire to enhance academic performance and increase wakefulness [32].

Psychological factors associated with the misuse of MPH include procrastination, difficulty with time management [33], anxiety, and stress [8, 34, 35], all of which characterize the residency period [36,37,38,39,40], a stressful, overwhelming time during which residents work long hours and the lives of others depend on them [41].

The residency period is considered particularly demanding in terms of both tasks and working hours. A recent survey conducted by the Israeli residents' organization, Mirsham, revealed that most residents work over 280 h a month and many of them are on in-house duty for 26-h shifts six or more times a month [42].

The difference between specialties is the main finding of our study. An especially high rate of MPH misuse was found in residents working in the hospital, specifically in surgical fields. This finding can be explained by the significant variations in the number of hours and night shifts residents from different specialties are required to work. In addition, surgical residents experience more burnout than residents in non-surgical residencies [43].

Another explanation for high rates of misuse, which in many studies reached over 50% [44, 45], could be residents' tendency to self-prescribe and self-treat. In general, it was found that physicians are vulnerable to substance abuse/addiction due to their access to the substances of abuse. The majority of substance-abusing doctors prescribe drugs to themselves [46]. Self-prescription is an ethical issue that should be addressed by health policymakers, but there are currently no guidelines regarding it or laws against it in Israel, and it is very common [47].

We found that not being a native-born Israeli was associated with MPH misuse. This finding is in line with those of previous studies that revealed immigration as a risk factor for substance abuse [48,49,50]. It is not surprising to discover that the misusers' group had the most liberal approach toward prescribing and using stimulant drugs as cognitive enhancers. Two of the factors associated with increased MPH use among students are the perceived safety of the medication and the perception that MPH use is normative on campus (and perhaps during residency) [33, 35].

Strengths and limitations

One of the main strengths of this study is its nationwide coverage of residents from different medical specialties. To the best of our knowledge, until now, little has been known about the prevalence of MPH misuse among residents.

The main limitations of the study include the low response rate (26.4%), although this rate is not very low compared to other online questionnaire studies, and a possible selection bias. Due to the sampling methods (a convenience and snowball sampling), residents who were more interested than others in the survey subject because they used or misused stimulants may have been more likely to respond, resulting in an overestimation of the apparent involvement of users and misusers in the study. This results in a possible selection bias. The demographic characteristics of the residents who participated in the study are somewhat different from those of the general resident population, and the study included relatively high percentages of women (63.5%) and native-born Israelis (81.6%).