Characteristics of ADHD in Struggling Residents and Fellows

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by inattention, impulsivity, and/or hyperactivity that leads to functional impairments.^1,2  The estimated worldwide prevalence of adult ADHD is 3.1%.³  While ADHD is well-described in K-12 education⁴  and, to a lesser degree, in medical school,^5-9  little is known about the graduate medical education (GME) population. Untreated ADHD may affect the well-being and clinical performance of medical trainees.

In the general population, ADHD is more common in males versus females (1.6:1).^1,10  Females and adults are more likely to present with predominately inattentive symptoms.^2,3,11  In a survey of 3199 adults with ADHD, 86% reported no notable symptoms during childhood.¹⁰  Most patients with ADHD have at least one concomitant mental health diagnosis.^2,10,11  The prevalence of ADHD in medical students ranges from 0.9 to 24%,^5-8  and most are not diagnosed until adulthood.^5,9  Medical students with any disability have lower United States Medical Licensing Examination scores and are less likely to graduate on time.¹²  Evidence-based treatments for ADHD include medication and/or behavior therapy.

Two surveys of emergency medicine residency program directors report the prevalence of ADHD among their residents as 0.06%¹³  and 4%.¹⁴  These studies, relying on learner self-report, may underestimate the true prevalence of ADHD in this population due to apprehension about reporting to regulatory agencies.¹⁵  One study of psychiatry residents suggests those with ADHD may struggle with clinical decision-making, accurate completion of daily work, task prioritization, and effective interpersonal communication.¹⁶ 

In comparison to those in grades K through 12 or medical school programs, residents and fellows are assessed primarily on their clinical performance, yet little is known about how ADHD influences clinical training. This represents a significant gap in our understanding of the ramifications of ADHD on residency and fellowship performance.

The purpose of this study was to identify the prevalence and performance characteristics of ADHD among residents and fellows referred to a centralized remediation program.

We conducted a retrospective analysis of data obtained from a centralized GME remediation program at the University of Virginia Health System (UVA) from 2017 to 2023. UVA trains approximately 850 residents and fellows in 100 programs.

At UVA, residents and fellows with performance concerns are referred to a centralized remediation program known as COACH (Committee on Achieving Competence through Help).¹⁷  Following written informed consent, a physician remediation specialist identifies performance deficits and creates an individualized remediation plan.^17-19  Performance deficits are characterized as medical knowledge/test-taking, clinical reasoning, organization/efficiency (O/E), professionalism, and technical skill. Professionalism concerns are further classified into 4 behavioral themes: failure to engage, dishonest behavior, disrespectful behavior, and poor self-awareness.²⁰  Trainees who self-report a history, or symptoms, of ADHD are referred for additional evaluation and/or treatment by a mental health professional.

We conducted a retrospective review to describe learner and performance characteristics for referrals with ADHD. Inclusion criteria were residents and fellows referred to COACH between 2017 and 2023 who disclosed a diagnosis of ADHD or were diagnosed with ADHD following referral. We report the frequencies of demographic variables and training performance characteristics. Using chi-square tests, we explored the association between performance characteristics of referred learners with and without ADHD.

The project was approved by the UVA Institutional Review Board.

During the study period, 173 residents and fellows were referred to COACH with performance concerns. Of these, 20% (35 of 173) disclosed a diagnosis of, or were diagnosed (clinical diagnosis by mental health professional or neuropsychological testing), with ADHD. Although ADHD was most commonly diagnosed in childhood (57%, 20 of 35), 26% (9 of 35) were diagnosed during or after medical school. The majority with ADHD were not on medication for ADHD symptoms and reported at least one concomitant mental health diagnosis—most commonly anxiety and/or depression—for which they were receiving treatment. Descriptions of the 35 residents and fellows with ADHD are found in the Table.

The most common performance deficits among residents and fellows with ADHD were professionalism (69%, 24 of 35) and O/E (63%, 22 of 35). Thirty-four percent (12 of 35) with ADHD struggled with repeated errors or inaccuracies in patient care. Approximately one-third (12 of 35, 34%) required formal remediation, and 20% (7 of 35) required extension of training. When compared to referrals without ADHD, residents and fellows with ADHD were more likely to struggle with O/E (63% vs 31%, P=.001) and repeated errors (34% vs 12%, P=.002). While the frequency of professionalism difficulties was similar in ADHD and non-ADHD referrals, the phenotype of unprofessional behaviors was different between these groups (Figure). The professionalism lapses demonstrated by most learners with ADHD were classified as failure to engage,²⁰  including missing deadlines, not taking ownership, and arriving late (63% vs 30% in the non-ADHD referrals, P<.001).

The prevalence of ADHD among residents and fellows referred to our program is considerably higher than that of the general adult population and higher than most studies reporting prevalence among medical learners. Residents and fellows with ADHD struggled across multiple competencies, most commonly professionalism.

To our knowledge, this is the first study to describe phenotypic characteristics of ADHD in struggling residents and fellows. Our study is consistent with evidence that medical learners are diagnosed later in life and that ADHD symptoms are often under-identified in individuals with high IQ and higher education.²¹  Most performance issues in our cohort reflect the inattentive symptoms of ADHD, which are known be the most important predictors of impairment in adults.²²  These differences provide evidence for the existence of a unique, previously undescribed phenotype of trainees with ADHD.

The relatively higher prevalence of ADHD in our cohort may be explained by the fact that our remediation program focuses specifically on areas of impairment directly impacted by the hallmark features of ADHD. These include self-management strategies, environmental modifications, organizational skills, and long-term planning. Further, we have created a program that allows participants to engage with minimal concern about confidentiality, which likely has increased participation and more accurate reporting of symptoms without fear of negative outcomes. In fact, 38% (65 of 173) of our cohort self-referred to COACH, which offers evidence that COACH is perceived positively. Although most self-referrals initially identified symptoms of other mental health disorders as their primary reason for seeking help, these learners ultimately disclosed either a previous diagnosis or symptoms of ADHD as significant and impairing their lives.

The current study is limited by small sample size and being conducted at a single center, which may limit generalizability. Given the reliance on self-report for the majority of learners identified with ADHD, it is likely that the prevalence of ADHD in our sample is an underestimate of the true prevalence of ADHD among struggling residents and fellows. In addition, our study could not account for trainees who may have ADHD with symptoms that are managed and not affecting performance.

Future studies should explore earlier diagnosis and treatment of ADHD in medical learners, as well as the most effective treatment strategies and subsequent performance outcomes for ADHD and concomitant mental health issues. Of particular interest are the effects of untreated symptoms of ADHD on professionalism, widely viewed as the most challenging competency to remediate.

ADHD is a form of neurodiversity that is likely underrecognized and undertreated in struggling residents and fellows and affects clinical performance. In this retrospective review of a population of residents and fellows referred for remediation, ADHD was more prevalent than in the adult population, newly diagnosed in one-fifth of those with ADHD, and associated with organization issues, errors, and failure to engage.

The authors would like to thank Diane Farineau, MS, Director of the Graduate Medical Education Office, University of Virginia Health, Charlottesville, Virginia, USA.

The online supplementary data contains a visual abstract.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This study was presented as a poster at the University of Virginia School of Medicine’s Excellence in Education Week Poster Session, March 1, 2024, Charlottesville, Virginia, USA, and the Association for Medical Education in Europe Annual Meeting, August 24-28, 2024, Basel, Switzerland.