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It’s no secret that drinking is a noted pastime among college students. However, the problem seems to be exacerbated in the medical school community. In fact, a recent study by the Mayo Clinic found that about a third of medical students experience clinical alcohol abuse or dependency. That’s twice the rate found in US surgeons, physicians, and the general public.

Why does there seem to be such a problem in this community? Researchers didn’t have concrete answers, but suggested extreme burnout factors compared to those of their peers: emotional exhaustion, feelings of depersonalization and depression, and an overall poorer quality of life. On top of those stresses, there are the aspects of their jobs and training that can make things more difficult. Medical school comes with an exceptionally competitive environment and the requirement of learning to cope with human suffering and death. Empathy tends to decline as training goes on, which could create mixed emotions for students torn between the desire to do well and the fear of losing a piece of their humanity. There’s also a significant financial burden — physicians who graduated in 2014 faced an average of $180,000 in educational debt. When all of these stress factors come to a head, it’s no wonder that alcohol abuse is a growing problem for medical students.

This guide aims to help tackle the problem by providing 15 warning signs that indicate a medical student may be abusing alcohol, and offers advice that will be useful to loved ones who may be deciding when and how to intervene. Early diagnosis is usually the best route to recovery, but knowing what to look for to prevent a bigger problem is half the battle. Even if you fear your loved one is dealing with a serious addiction, there are still ways you can help her before things escalate further. 

Warning Signs of Alcohol Abuse and Addiction

Family history. Research has shown that genetics are responsible for about half of the risk of alcoholism. If your loved one’s parents have a history of substance abuse, it doesn’t necessarily mean she’s guaranteed to face the same situation, but it certainly puts her at greater risk. If you’re close enough with your loved one to discuss this history with her, do so with respect and caution. Don’t make any assumptions or accusations; instead, simply let her know you care about her and wouldn’t want something she has no control over, like genetics, getting in the way of her achieving her dreams.

Irritability and mood swings. This can be a tricky one to keep an eye out for in medical students. Your loved one is facing excessive amounts of stress with school alone, plus any other personal issues she may have on her mind. It may come down to noting exactly which topics make her irritable, especially if it happens when discussing her drinking habits or tendency to spend nights going out. This warning sign alone isn’t enough to immediately point to an alcohol abuse problem, but its presence along with other indicators is certainly significant.

Recurring arguments or fights with family and friends. The irritability and mood swings discussed above can often lead to regular fights with loved ones, even over seemingly inconsequential topics. This can often lead to general problems in her relationships. If you’ve noticed she seems to constantly be at odds with family, friends, roommates, classmates, professors, and anyone else close to her, there might be a bigger problem at play.

Blackouts and forgetfulness. Drinking so much that you can’t remember the entire occasion is a major sign of alcohol abuse. She might not remember how she got home from a party, how she got that scrape on her arm, or how her cell phone screen got shattered. Her forgetfulness may even come into play throughout the day — alcohol interferes with the brain’s ability to record memories, so she may have more difficulty retaining information in general. She might forget the due date of a paper, an upcoming exam, or an important appointment.

Acting secretive and engaging in suspicious behavior. Even if she hasn’t fully acknowledged that she has a problem, she may start to hide her activities from others. She may demand more privacy from her roommate who comes home unexpectedly or accuse parents of giving her the third degree when they ask what she did over the weekend. This is often overcompensation in attempting to hide her habit.

Further, people who have become physically dependent on alcohol may look for any opportunity to drink — in the mornings before class, in their rooms alone, even at work or school — and become paranoid that their habits will be found out. If you notice that she’s sneaking off to be by herself at strange times and isn’t willing to talk about what she’s doing, there may be cause for concern.

Tolerance. There are two types of alcohol tolerance: metabolic tolerance occurs when the liver increases its production of enzymes to break down consumed alcohol. In other words, your body adapts to the increased presence of alcohol by finding a way to eliminate it from your system more quickly. Function tolerance occurs when someone becomes less sensitive to alcohol’s effects as a result of chronic use.

In general, developing a tolerance to alcohol means that it takes more to have the same effect. Although over the years our tolerance grows — it likely didn’t take you as much whiskey to become impaired on your 21st birthday as it does by the time you’re 30, for instance — the rate at which tolerance occurs is key. If you notice that your loved one would switch to water after four drinks in her first year of medical school and in her third year doesn’t slow down until around drink nine or ten, there’s an indication of a serious tolerance developing.

Changes in hygiene and appearance. A deterioration in the way someone takes care of herself can be another indicator of an alcohol abuse problem, but again this can be tricky when it comes to medical school. If she used to do her hair and makeup every morning but now usually puts her hair up and only washes her face, it’s more likely that the demands of school are causing her priorities to shift and she’s less focused on her appearance. However, there may be cause for concern if she begins to start showing a complete disregard for basic hygiene habits like regular showering, brushing her teeth, wearing clean clothes, and appearing generally disheveled every time you see her. This may be accompanied by strange smells on her breath, body, or clothing.

Neglecting other activities. Although medical school will certainly occupy a significant amount of her time and leave less opportunity for hobbies, it’s important to take note if she suddenly seems completely disinterested in participating in any activities she once loved. Maybe she used to go to yoga a few times a week but no longer practices at all, even at home. Her weekly Sunday lunch dates with her sister may have completely fallen to the wayside. It’s especially concerning if she’s the one constantly canceling and is unable to be coaxed into keeping plans.

Decline in school and/or work performance. Medical school is absolutely more difficult than any other level of education she’s encountered thus far, so it’s normal to see an adjustment period while she acclimates to the workload and demands. However, if she begins to show a sudden decline in her grades, rarely attends class, and underperforms in group projects, there’s likely a bigger problem. It may be especially obvious if you notice she’s going out on a regular basis, but keep in mind that sometimes alcohol-dependent people will hide their habits and choose to drink alone at home to avoid arousing suspicion.

Increased risk-taking behavior. Alcohol has the ability to lower our inhibitions and take the pressure off of social situations. This can be a good thing in moderation — it can ease you into a work party with your superiors, help you meet new people, and give celebrations an extra edge — but can be dangerous in some. Alcohol abusers tend to take it to the extreme. They may be more likely to engage in unprotected sex, drive under the influence, or commit petty crimes like vandalism and property damage.

Displaying physical signs. Depending on their level of abuse, alcohol abusers tend to display physical indications like flushed skin, broken capillaries on the face, bloodshot eyes, sudden weight gain or loss, impaired coordination, and shakes or tremors. She may also seem more fatigued and start changing her sleeping patterns or eating habits.

Constantly using alcohol as a way to cope. Alcohol can be an easy crutch in tough times, but in an environment filled with rigorous classes, detailed exams, and intense competition among your peers, it can be a dangerous way to blow off steam. She may begin to depend on alcohol to get her through the rough patches — a poor test score, relationship problems, a heavy school workload, or issues at the job she’s supporting herself with. She may even turn to alcohol first in the good times, whether as a way to celebrate a good grade or simply a way to unwind after a busy week. It’s one thing to have the occasional night of drinking, but if alcohol seems to be her number one choice for feeling “normal” or “better” no matter the situation, she’s displaying questionable judgment.

Loss of control. As things get worse, she may start to appear out of control, as if alcohol controls her life. She may fly into a sudden rage if she can’t acquire it or become desperate at finding someone to indulge with her. There may also be indications as she’s drinking — she might seem actually unable to stop drinking (even if she said she only wanted a couple) or stay out for much longer than originally planned. This is especially noticeable in a medical student, who needs plenty of rest and coherent study time in order to stay on top of her classes.

Displaying withdrawal symptoms. If she attempts to cut back on her drinking, she may exhibit symptoms of withdrawal including night sweats, nervousness, anxiousness, nausea, vomiting, increased blood pressure or heart rate, shaking, and twitching. Sometimes withdrawal can worsen into a condition called Delirium Tremens, which may cause hallucinations, fever, seizures, and confusion. If she displays these symptoms, she is in the midst of a medical emergency and should seek medical help immediately.

Continued use of alcohol despite negative consequences. If all or most of these warning signs are being displayed and her life seems to be in turmoil, yet she still shows no signs of cutting back on her drinking, this is the biggest warning sign of all. This could point to addiction, and she simply may not feel able to quit drinking.

There’s a problem: When do I step in and how?

First, it should be noted that if you are noticing problems in her health, education, relationships, and personal and professional life, you shouldn’t feel as if you are overreacting. We often wish to give our loved ones the benefit of the doubt and write off our concerns as superfluous. We tell ourselves that we’ll be approached if our help is needed. When it comes to alcohol abuse, however, it’s better to be overly-cautious. Many who are struggling may not want to admit there’s a problem, and this can be especially true in medical students who may worry they’ll be ridiculed if they seek help. She may not realize that not only is avoiding the issue putting her health at risk, she’s also risking her professional career.

If you suspect there may be a problem, make it a point to observe her behavior over a few days or weeks to better understand what leads you to that concern. It’s also important to have specific behavior to refer to if you decide to consult a professional or if you decide to speak directly to her. Consult trusted friends or family in confidence to see if they’ve noticed similar behavior and feel a similar need for concern. If you agree there’s a problem, decide who among you should approach her for a conversation. You may also want to contact a professional — be it a physician, a drug abuse counselor, or a mental health professional — to express your shared concerns and seek advice on whether there truly seems to be a problem and how to proceed.

It’s normal to worry that this conversation will lead her to react harshly, but approach it as an opportunity to be productive. She may not realize how her behavior has changed or that it’s causing problems, nor that continuing on her current path could lead to severe problems. Don’t let yourself worry it will be perceived as an attack — if you view it as an act of love and concern, it will be easier to convey to her that it truly is.

Ask her to set aside some time in the next few days where you can speak to her about something that’s been on your mind. Make sure you’ll be able to have more than a few minutes alone and she won’t have class or an appointment within a few hours following your talk. Neither of you should be under the influence so as to keep clear heads and prevent her likelihood of becoming impatient, dismissive, angry, or blaming. It also reduces the chances that she’ll give in to her weakened impulse control and become violent or storm out.

Start by telling her that you care a lot about her, and that your concern for her well-being and future has led you to this conversation. Calmly list the behaviors you’ve observed over time, and tell her you’re worried about the effect drinking has on her life now as well as implications for the future. It’s vital to create a two-way dialogue, so ask open-ended questions in an effort to hear her side. Don’t be accusatory, speculative, or judgmental. Let her know you understand that she is under an immense deal of pressure and stress, and that anyone in her situation would look for ways to lessen the burden. It’s important to show her compassion and understanding so that she feels safe enough to open up.

Keep in mind that the goal of this conversation isn’t to convince her she has a problem, but simply to let her know that you believe there is one based on observable behaviors. If she states that there is no problem, ask to speak again at a later time. Don’t expect to see a dramatic shift in her thinking or behavior immediately — again, this conversation may be the first time she’s ever considered there could be an issue.

Revisit the conversation in a few more weeks and ask if she’s thought about what you said. Again, give her the opportunity to share her side without jumping to judgment. She may still insist there’s no problem, so offer a chance to prove you wrong: ask her to see a professional for an evaluation. Although she might be resistant, tell her that an impartial third party professional might be the only way to settle the dispute. Approach the subject gently and offer to go with her to the consultation.

If she does become receptive to the idea that there might be a problem, tell her you’re there to help her in any way you can. Tell her specifically how you can help, whether it’s going to speak to a counselor together or offering to help her study so she doesn’t fall behind in classes. Help her explore her options for recovery and figure out what might be a good fit for her needs.

If, however, she refuses to acknowledge a problem no matter what you or a professional tells her, don’t give up. Maintain one clear message: “I care about you and want you to get help.” It may be advantageous to have someone else speak to her about her problem, or in extreme cases to have an intervention. An intervention will allow family and friends to present her with the opportunity to accept her problem and seek help before things get significantly worse. This option is often effective in helping a person understand how her choices affect not only her life but the lives of others. It can also help someone who may be feeling scared and alone see how many people love her and want to offer their support.

It’s a sad thought that preparing for such a noble occupation often leads students to such self-destructive behavior, but it’s never too late to help. If you have a loved one in medical school that may be facing alcohol abuse, don’t be afraid to let her know your concern. The journey to recovery is long and tumultuous, but with the right support by her side, she can continue following her dream of becoming a doctor in a healthy way.

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