The impact of the core clerkships on medical students with chronic health conditions and student wellness

Abstract

Background

The objective of this study is to determine if medical students with chronic health conditions adhere to personal health appointments during their core clerkship year, the Principal Clinical Experience (PCE), barriers to doing so, and the association between missed appointments and burnout.

Methods

An email survey was sent to current medical students who had completed their PCE at Harvard Medical School. The survey assessed chronic physical, mental, and dental health conditions; registration with the Office of Disability Services; healthcare utilization; number of appointments missed; perceived barriers to attending appointments; and burnout using the Maslach Burnout Inventory- Student Survey (MBI-SS).

Results

Of the 90 students that completed the survey ,75% had a diagnosed chronic health condition. 72% of students had at least one medical appointment scheduled during the PCE and 43% of those missed at least one appointment. Only 12% had registered with the Office of Disability Services to attend personal health appointments, notably due to lack of awareness that disability accommodations applied to them. Female respondents were significantly more likely to miss a medical appointment than male respondents (p = 0.044). The primary barrier to attending appointments was concern about negative clerkship evaluations. Burnout (MBI-SS) was significantly associated with missing appointments (p = 0.028).

Conclusions

Missed health appointments was linked to greater burnout. Difficulty disclosing medical appointments was independently associated with burnout, consistent with studies surveying residents. Future work is needed to improve student awareness of disability accommodations and support faculty in fostering communication about the importance of health appointments for medical students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09217-4.

Introduction

Chronic health conditions are broadly defined as any health condition that lasts one year or more and requires ongoing medical attention or limits activities of daily living or both [1]. The percentage of medical students with chronic health conditions has increased [2]. In 2016, 2.7% of medical students reported a health condition [3] which increased to 4.9% in 2019 [4], and 5.9% in 2021 [5]. For many students, managing a chronic health condition contributes to their decision making when choosing a medical specialty, in part, leading them to pursue career paths that accommodate their health needs [2]. In response, more medical schools offer broader accommodations for didactics, extended testing time, and excused absences for clinical appointments [4]. Despite having an assigned Primary Care Physician (PCP), 43% of medical students report informally consulting a friend or relative rather than attend a formal appointment [6]. Of medical students who have a PCP, only 33% saw their provider when they were sick [7].

Understanding the health of medical students with chronic health conditions is important as routines created during medical school often carry over into residency, influencing how trainees care for themselves and manage their wellbeing during a more demanding stage of training [8]. Previous literature describes the effects of compliance with appointments and managing health conditions among residents. In one study, only 50% of internal medicine (IM) residents had a PCP and almost 80% did not attend their yearly physical. In addition, the majority of IM residents (66%) missed their doctor appointments of any kind due to work obligations [9]. Another study found that the majority (57%) of residents had never attended a personal health appointment during scheduled clinical duties, and 34% thought it would be hard to disclose an appointment to a supervising physician [10]. Surgical residents report similar appointment rates [11]. A larger number of missed appointments or avoidance of care during residency is associated with poorer self-reported mental and physical health in surgical residents [12]. Interestingly, burnout is independently associated with the perception of the inability to disclose a health appointment during residency [10].

While there is considerable literature on residents, there is a lack of research focused on medical students’ ability to maintain their personal health appointments during their clinical years in medical school and how this impacts their chronic health conditions and perceived wellness. The objective of this study is to determine if medical students adhere to scheduled personal health appointments during their core clerkship year, Principal Clinical Experience (PCE), at one institution, the barriers to doing so, and the association between missed appointments and burnout. Addressing this knowledge gap is crucial for developing targeted interventions that promote both student well-being and long-term professional success for students with chronic health conditions.

Methods

All currently enrolled Harvard Medical School (HMS) medical students who had completed their Principal Clinical Experience (PCE) in the 2024–2025 academic year at the time of survey administration were eligible to participate in this study. Students were recruited via email invitation which was distributed to the entire eligible study body by the school listserv. Participation was anonymous and voluntary. Informed consent to participate was obtained from all participants; after reading the study information, completion and submission of the anonymous online survey were taken as evidence of informed consent.

The survey instrument included previously validated questions from research with resident physicians [10, 11]. The authors with experience as medical educator leaders generated additional questions based on review of literature through iterative review and discussion to assess student experiences accessing healthcare during the PCE. The final survey (Supplementary Appendix 1) consisted of 33 total items with adaptive routing so that only students who endorsed specific experiences (such as being diagnosed with a chronic health condition or missing appointments) received tailored follow-up questions. The survey addressed participants’ medical, dental, and mental health histories, healthcare utilization (such as insurance status, primary care access, and timing of last routine visits), and whether personal health experiences influenced their career choices. Further, items assessed awareness and use of disability support services, frequency and attendance of health-related appointments during the PCE year, and perceived support from supervisors. Students were asked about the difficulty in disclosing health needs, concerns about academic consequences of absences, and perceived health impacts of missed care. Burnout was assessed using an abbreviated Maslach Burnout Inventory- Student Survey (MBI-SS) [10, 13]. Burnout was assessed through 2 questions with one asking about burnout specifically and the other focusing on emotional exhaustion and cynicism generating a resulting callous score from 0 to 7. The callous score represents the extent to which respondents report feelings of emotional detachment, indifference, or a lack of empathy toward patients or others, as assessed by the depersonalization subscale of the MBI. Respondents were asked to rate their frequency of experiencing burnout and callousness via a 7- point Likert scale ranging from never to every day (Supplementary Appendix 1). Higher scores indicate greater levels of burnout or callousness. The full survey was administered electronically via Qualtrics. Participants remained anonymous, with no identifying information collected as part of the survey. Recruitment occurred over 60 days with reminder emails sent at weeks 1, 4, 6, and 8 to maximize response rates.

Descriptive statistics were reported. Pearson chi-squared test was used to assess associations between categorical variables and independent samples t-tests were calculated to test for differences in means between groups. ANOVA was performed to test differences in burnout scores between groups of more than two. A two-sample proportions test was used to test differences between responders and non-responders. Multivariable linear regression was used to test for independent associations with burnout scores. Qualitative responses were analyzed using ChatGPT4 AI language model [14] with the prompt to identify and summarize the broad themes ranked from most represented to least represented in the data for content analysis (Supplementary Appendix 2). Authors reviewed analysis for face validity. Statistical analyses were performed using Stata version 18.0. The study was approved by the Harvard Medical School Program in Medical Education’s Educational Scholarship Review and deemed exempt from Institutional Review Board review.

Results

Of the 392 eligible students, 107 (27%) started the survey and 90 (23%) completed it. The mean age of respondents was 26 years with 71% of respondents being female. The proportion of females that responded to this study was higher than the proportion of females eligible for the study (71% vs. 53%; p < 0.001).). Most (91%) respondents had a primary care provider (PCP) but 15% of respondents had not been to their PCP in over 2 years. Almost 30% of respondents had not seen a dentist in over a year (Table 1).

Table 1.

Students’ health history and adherence to health appointments

	N (%) N = 90
Health history
Last routine health maintenance
0–12 months	51 (57.3)
> 12 months	38 (42.7)
Last dental check up
< 12 months	63 (70.8)
12–24 months	26 (29.2)
Been diagnosed with physical health condition	56 (64.4)
Been diagnosed with dental condition	18 (20.7)
Been diagnosed with mental health condition	36 (41.4)
Been diagnosed with any condition (physical, dental, or mental)	68 (75.6)
Status of health condition
Previous – no longer exists	19 (28.4)
Requires continued follow-up	48 (71.6)
Condition motivated you to go to medical school	24 (36.4)
If yes, how much? (n = 24)
A lot	12 (50.0)
Moderate amount	8 (33.3)
Somewhat	3 (12.5)
Just a little	1 (4.2)
Not at all	0
Health appointments
Med appointments scheduled during PCE?
Yes	56 (71.9)
No	22 (28.2)
Attend all appointments? (n = 56)
Yes	32 (57.1)
No	24 (42.9)
Missed how many (n = 24)
1	2 (8.3)
2	10 (41.7)
3	4 (16.7)
> 3	8 (33.3)
Dental appointments scheduled during PCE?
Yes	24 (31.2)
No	53 (68.8)
Attend all appointments? (n = 24)
Yes	15 (62.5)
No	9 (37.5)
Missed how many (n = 9)
1	4 (44.4)
2	3 (33.3)
3	0
> 3	2 (22.2)
Mental health appointments scheduled during PCE?
Yes	25 (32.5)
No	52 (67.5)
Attend all appointments? (n = 25)
Yes	10 (40.0)
No	15 (60.0)
Missed how many (n = 15)
1	3 (20.0)
2	5 (33.3)
3	1 (6.7)
> 3	6 (40.0)
Appointments missed total
0	60 (66.7)
1–2	10 (11.1)
3–4	11 (12.2)
5+	9 (10.0)

Of all students, 64% reported being diagnosed with a chronic physical health condition, 41% with a chronic mental health condition and 21% with a chronic dental health condition (Table 1). Overall, 76% of respondents were diagnosed with a chronic health condition at some point in their lives. Out of those who had any health condition, 72% considered their condition active and requiring continued follow up during their clerkships. Out of those diagnosed with a chronic health condition, 36% of respondents reported that their condition had motivated them to attend medical school.

Seventy-two percent of students had a scheduled medical appointment during the PCE work hours and 43% missed at least one appointment (Table 1). For dental appointments, 31% had a scheduled appointment during PCE with 38% missing at least one of those appointments (Table 1). Lastly, 67% of respondents had a scheduled mental health appointment during PCE with 60% missing at least one appointment and 33% missing more than 3 (Table 1). Female respondents were significantly more likely to miss a medical appointment compared with male respondents (52.5% vs. 21.4%; Table 2; p = 0.044). Qualitative analysis of the primary barrier to medical students to disclose the need to attend appointments highlighted several recurrent themes: (1) fear of negative evaluations (2) scheduling difficulties/administrative barriers (3) culture of medicine/self-neglect.

Table 2.

Students’ missed health appointments by gender

	Total n = 90	Males n = 24	Females n = 64	P value
	N (%)	N (%)	N (%)
Medical appointments scheduled during PCE?
Yes	56 (71.9)	14 (60.9)	40 (75.5)
No	22 (28.2)	9 (39.1)	13 (24.5)	0.197
Attend all appointments? (n = 56)
Yes	32 (57.1)	11 (78.6)	19 (47.5)
No	24 (42.9)	3 (21.4)	21 (52.5)	0.044

Fear of negative evaluations

“There were multiple occasions that I was delayed in getting labs done (which were required before I was able to refill a prescription) because of the difficulty in telling supervisors/fear of a detrimental effect on evaluations.”

Scheduling difficulties

“Work hours and absences are very strict requiring many canceled and/or rescheduled appointments.”

Culture of medicine/self-neglect

“I think the culture of medicine needs to change in that we should be able to prioritize taking care of ourselves without fear of retribution, especially in emergencies or in instances where the team is well staffed, we’ve wrapped up our individual tasks, and the team feels prepared to take over our responsibilities while we attend appointments.”

Slightly more than half of students reported supervising physicians during the PCE were very or somewhat supportive of medical students attending health appointments during clinical hours. Additionally, 17% of participants found it very difficult and 33% somewhat difficult to tell a supervising physician about a physical health appointment during work hours. Disclosing mental health and dental appointments was more difficult than physical health appointments with 36% and 32% of respondents reporting it very difficult to disclose, respectively. 21% of participants were extremely concerned that there would be potential consequences to their evaluations if they were unable to perform patient care responsibilities due to illness. 32% of respondents perceived no negative impact on their chronic health condition despite missing appointments and 28% believed there was a moderate negative impact. Qualitative analysis of the impact of PCE on their chronic health condition revealed several recurrent themes: (1) delayed or neglected healthcare (2) general wellness neglect (3) positive/neutral experiences.

Delayed or neglected healthcare

“My health suffered. I’d rather not be more detailed. I performed fine - my health did not.”

General wellness neglect

“Was less attentive to my overall health during PCE, not just abstaining from going to appointments but also neglecting to take care of my wellness in smaller ways.

Positive/neutral experiences

“I was ultimately able to attend most appointments. Some appointments I just never scheduled because I was too stressed about the logistics / thought it was more hassle than it was worth.”

A minority of medical students (12%) had registered with the Office of Disability Services to attend personal health appointments. Those who did not register cited lack of awareness that the Office of Disability Services applied to them as the greatest barrier.

The average burnout score (MBI-SS) for respondents was 3.9 (range 1–7; SD = 1.5) out of a 6-point scale with female respondents trending slightly higher compared to their male counterparts (4.1 versus 3.5, p = NS). The average callous score (Maslach Burnout Inventory) was 3.0 (range 1–7; SD = 1.8). Female subjects scored a 3.2 (SD = 1.8) versus males 2.6 (SD = 1.7, p = NS). While number of missed appointments was not associated with burnout scores (Table 3), it was significantly associated with higher callous scores (p = 0.028). Students’ difficulty telling a supervisor about a medical appointment of any kind was independently associated with higher burnout scores (Beta = 0.202, p = 0.030) after controlling for having reported any chronic health condition (Table 4).

Table 3.

Associations between burnout and missed appointments

	0 Missed	1–2 Missed	3–4 Missed	> 4 Missed	P value
Burnout score (mean, SD)	3.7 (1.5)	4.2 (1.6)	4.0 (1.6)	4.2 (1.4)	0.712
Callous score (mean, SD)	2.6 (1.6)	3.3 (1.9)	3.3 (2.0)	4.4 (1.8)	0.028

Table 4.

Multivariable linear regression associations with burnout scores (n = 75)

	Coefficient (Beta)	P value*	95% Confidence Interval
Difficulty telling supervisor about physical health appointment	0.202	0.028	0.022–0.381
Difficulty telling supervisor about mental health appointment	0.138	0.037	0.008–0.267
Difficulty telling supervisor about dental health appointment	0.184	0.004	0.062–0.305

^*Models control for reporting any medical (physical, mental, or dental) condition

Discussion

This study aimed to determine if medical students adhere to scheduled personal health appointments during their core clinical rotations (PCE) at our institution, the barriers to doing so, and the association between missed appointments and burnout. In our sample, 76% of respondents reported having at least one chronic health condition of any kind (including mental, dental and physical health conditions), which is much higher than the 5.9% reported in previous studies [2–4]. We do not have data on the prevalence of chronic conditions in students at our institution prior to this study. We are unable to explain why the rate of chronic conditions in our sample is higher than previously reported. For example, if there are higher rates of chronic anxiety in our sample compared to other institutions, we are unable to draw these comparisons as we did not collect data on which specific conditions respondents had, in order to preserve their anonymity. Notably, the last study investigating the rates of chronic health conditions in medical students was conducted in 2021. Since then, rates of depression and anxiety have increased substantially following the COVID-19 pandemic [15], which could help explain the higher rates of chronic conditions observed in our sample. Institutional factors specific to our school (such as a culture of self-disclosure or local mental health resources) may have contributed to higher self-reported chronic condition rates; however, we do not have sufficient data to evaluate this.

Our work demonstrated that almost three quarters of medical students missed necessary health appointments of any kind during the PCE. Additionally, female respondents were significantly more likely to miss an appointment of any kind (p = 0.044) compared to their male counterparts. On average within the general workforce, 19% of adult patients miss their primary care appointments [16]. While there are no studies focused specifically on the rates of missed health appointments within the general population that are age matched to the average age of medical students, our study suggests that appointment non-attendance among medical students may exceed rates observed in their young professional counterparts.

We found that difficulty disclosing medical appointments to supervisors, such as attendings and residents, was independently associated with burnout, consistent with studies surveying residents [10]. We demonstrated that medical students are not disclosing or adhering to their necessary personal health appointments during clinical rotations due to fears of a negative evaluation. Because a minority of attending physicians were perceived as very supportive of students attending health appointments, our study suggests that additional faculty development is necessary to support faculty in fostering open communication about the importance of health appointments for medical students. This is crucial during medical school as it has been established that routines created early on in training help learners adjust to more demanding residency schedules [8]. Given that many supervising physicians trained during a time when mental health and chronic illness were less openly discussed, some may inadvertently reinforce the perception that personal health should be deprioritized. Faculty development could include explicit guidance on how to respond when students request time for appointments, scripts for normalizing personal health care, and clear messaging that performance evaluations will not be negatively affected by appropriate use of disability accommodations or excused absences. In this way, supervising physicians can partner with students to create an environment that fosters and supports overall wellness and avoids burnout.

The Office of Disability Services at HMS offers accommodations to students who need to attend multiple health appointments during clerkships due to chronic health conditions. However, only 12% of students with chronic health conditions had registered for accommodations citing a lack of awareness as the largest barrier to utilizing the resource. As the rate of medical students with chronic health conditions increases [3–5] the importance of ensuring access to care and students’ ability to do so will continue to grow. Our results suggest that students are not aware of the support services that the Office of Disability Services can provide for students with chronic health conditions. Students must register with the Havard Office of Disability Services to have accommodations that allow them to be excused from clinical duties for health appointments. Harvard employs a full‑time Director of Disability Services who supports medical, dental, and other graduate students at the Harvard Medical and Dental Schools. Students are first informed about the Office of Disability Services when they receive an electronic orientation package upon acceptance to Harvard Medical School. Once students arrive to campus, the Director of Disability Services presents information about the services offered at a resource fair and again during an orientation class during the first few weeks of medical school. To receive accommodations, students must have a documented condition that affects major life activities (e.g., learning, digestion, sleep) and must provide appropriate documentation. The Office of Disability Services ensures compliance under the Americans with Disabilities Act (ADA), state regulations, institutional policies and clerkship educational objectives. The Director of Disability Services helps students navigate balancing their accommodations necessitating time away from their clerkship duties with ensuring adequate time in clerkship activities to show proficiency and meet educational objectives to pass each clerkship. Prior to each clerkship, the Director of Disability Services informs the Clerkship Director about each student registered with the Office of Disability Services and outlines the approved accommodations. The student must then communicate with each Clerkship Director how the accommodations will be operationalized during the clerkship while ensuring educational objectives are met.

Despite this well-established, clear process at our institution, future work is needed to improve student awareness of institutional disability policies and accommodations. Although students are introduced to the Office of Disability Services at the start of medical school, they may benefit from an additional review prior to beginning their core clerkship year. The clinical phase may present new challenges for students with chronic health conditions, as it marks their first experience with full‑time clinical responsibilities. Prior to starting the PCE, students often have enough flexibility to schedule health appointments around required classes. The PCE is a new experience in which students have loss of control in their schedule due to increased clinical responsibilities. Students may also be unaware that certain chronic conditions qualify as disabilities. For example, while learning disabilities requiring extended test time may be familiar to students as constituting a disability, chronic anxiety requiring ongoing therapy during clinical rotations may not be. Additionally, students may have a misconception about what accommodations are available as their definition of accommodations has been heavily influenced by their experience prior to matriculation to medical school in educational spaces where the focus is on learning disabilities and test taking accommodations. Other barriers to students attending health appointments during clinical hours may also include that students’ reluctance to disclose their chronic health condition to clinical supervisors who are evaluating students and writing letters of recommendations. Thus, students may attempt to manage their appointments independently. For instance, during a four‑week clerkship, a student with biweekly appointments might use a sick day for one visit and skip the other entirely to avoid disclosure. Overall, the primary barrier to attending to students’ health care needs may not be the registration process with the Office of Disability Services, but students’ fear of potential negative downstream effects of having formal accommodations—particularly concerns about clinical evaluations and perceptions of proficiency. This fear may prevent students from disclosing their diagnosis to consistently attend necessary health appointments.

Conclusions

This study is the first analysis of medical student adherence to personal health appointments during their clinical rotations and how it correlates to burnout scores. Limitations of this study include a low survey response rate. While no information about specific conditions was collected and respondents were anonymous, fear of disclosing a chronic health condition may have impacted the response rate. However, the survey was deployed by a fellow student to avoid information bias associated with data collection by a faculty member rather than a peer. Additionally, this study is limited by its focus on a single institution. Future research could deploy this survey on a national scale to assess whether medical students with chronic health conditions experience higher rates of burnout during their core clerkship rotations across institutions. In response to high rates of resident nonadherence to medical appointments, residency programs have started initiatives to support residents such as opt-out mental health appointments [17], scheduling primary care appointments into resident orientation [18] and flexible days off to attend personal health appointments [19]. These programs were highly utilized by residents and received satisfactory reviews. To date, there are no published studies evaluating the effectiveness of these programs in medical students. While these interventions have been well-received by residents, it remains uncertain whether they would have the same positive impact among medical students, whose schedules and evaluation structures differ. Pilot testing and formal evaluation of adapted interventions in the medical school context are needed. Medical School leaders could consider adopting initiatives that have been successfully vetted for medical students to foster medical student wellness and decrease burnout.

Abbreviations

PCE

Principal Clinical Experience

MBI

SS–Maslach Burnout Inventory–Student Survey

MBI

Maslach Burnout Inventory

PCP

Primary Care Physician / Primary Care Provider

IM

Internal Medicine

HMS

Harvard Medical School

ADA

Americans with Disabilities Act

AI

Artificial Intelligence

SD

Standard Deviation

CI

Confidence Interval

NS

Not Significant

ANOVA

Analysis of Variance

Authors’ contributions

SL conceived the research idea and overall study design, obtained IRB exemption, and developed the survey instrument with critical revisions from AP, NJ, and BD. SL coordinated survey distribution and data collection. AP conducted the data analysis. SL drafted the manuscript, and AP, NJ, and BD provided substantive editorial feedback and revisions. All authors reviewed and approved the final version of the manuscript.

Funding

No funding sources to declare.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study involved human participants and was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study protocol was reviewed and approved by the Harvard Medical School Program in Medical Education’s Educational Scholarship Review and was deemed exempt from Institutional Review Board (IRB) review. Participation was voluntary and anonymous. An information sheet describing the purpose of the study, the voluntary nature of participation, and data confidentiality was provided in the introductory email and on the first page of the online survey. Informed consent to participate was obtained from all participants; completion and submission of the anonymous survey after reading the study information were taken as evidence of informed consent.

Consent for publication

Not applicable as no identifiable data was collected.

Competing interests

The authors declare no competing interests.