What is the extent of the problem?

The prevalence of reported mental distress amongst university students is increasing. Does this apply to medical students too? They experience a fuller, more structured timetable and set career path than many other students, and thus have more contact time with academic staff and their peers and potentially greater levels of support. To date, though, few UK studies have reviewed levels of mental distress specifically in medical students.

However, a 2018 BMA survey of doctors and students revealed 40% of participants reported psychological conditions.¹ In the US a systematic review revealed 27% of medical students reporting depressive symptoms during their studies.² Given high levels of burnout and work stress in the medical workforce, it would be concerning to see levels of distress also increasing for students before they enter the workforce. The General Medical Council (GMC) and BMA have both made urgent calls to understand the particular issues affecting the wellbeing of medical students and doctors.

What are the stressors for medical students?

Like their counterparts in other subjects, medical students may face stresses due, for example, to making the transition from home to university, deadlines, exam pressure and relationships issues.

However, medical students also experience additional pressures, including:

• Heavy workload, increasing the risk of burnout and difficulties in work/life balance
• Higher incidence of personality traits potentially leading to distress: perfectionism, competitiveness, and high empathy
• Reluctance to report distress due to stigma i.e. what a doctor should be able to cope with; leading to presenteeism
• Frequent relocation, leading to disruption in supportive networks and the impact of adapting to different learning styles and environments
• Encountering ethical/distressing situations, including exposure to death and distress

Despite experiencing numerous known stressors and complex situations, medical students are also more likely to be disadvantaged by the structure of university services, which are often still based on a traditional 9-5 model. The BMA have called for university counselling services to operate an out of hours service and allow remote access for those away from campus on placement to at least ensure access to services is possible. However, the onus of reporting mental health issues still appears to be on the students themselves and encouraging engagement with support services even when more accessible may be challenging.

What can be done to support medical students better?

Although the factors contributing to mental distress amongst medical students are known, the picture is complex and to date few interventions have been conducted in the UK to target the increasing problem. Results of a 2013 survey of eight medical schools commissioned by the GMC suggested that the biggest gain in student mental health would be gleaned from tackling the “domain of culture” in medicine.³ However, achieving culture change will be challenging and take time.

Instead, interventions so far have favoured targeting interventions at the individual or programme level. One recent study found an eight-week mindfulness course significantly improved students’ well-being, coping reserve and professionalism on training placements.⁴ Mindfulness has been promoted by the GMC to help support students better. However, there is little direct UK evidence on the impact of such schemes, and more understanding is needed of the optimal way to deliver mindfulness training.

Intervention studies have started to inform guidelines in the US, New Zealand and Australia. An intervention run in St Louis, US, redesigned the medical education curriculum to integrate wellbeing at the heart of the medical curriculum not just as an added training opportunity.⁵ The programme included changes to grading, lengthening elective time, establishing a new learning community, reducing contact hours in pre-clinical years and running resilience and mindfulness courses within the curriculum. This multifactorial design showed significant improvements in the depression, anxiety and stress levels of students and also enhanced community cohesion – suggesting the value of integrating wellbeing initiatives.

Conclusions

Evidence is starting to emerge that there are steps university can take to better safeguard the wellbeing of medical students. Despite strong calls from UK medical bodies to urgently investigate the impact of medical student distress and address shortcomings in the higher education system, little action has been taken in the last 5 years.

Universities need to start identifying better ways to make quick wins in the wellbeing of medical students (recognizing the greater stressors they often face) to start the process of culture change and ensure students entering the workforce are better prepared to deliver a medical service and better equipped to tackle the stresses of working within the NHS. There is also a continued need for greater clarity on how the mechanisms increasing distress cause psychological issues for students and might better inform the design of any interventions.

Lesley Hulmes  December 2019

References

1. British Medical Association (2018) BMA surveys doctors’ mental health. https://www.bma.org.uk/news/2018/october/bma-surveys-doctors-mental-health

2. Rotenstein L.S., Ramos M.A. & Torre M. (2016) Prevalence of depression, depressive symptoms, and suicidal ideation among medical students. Journal of American Medical Association. https://jamanetwork.com/journals/jama/fullarticle/2589340

3. General Medical Council (2013) Factors that impact on medical student wellbeing https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/research-and-insight-archive/factors-that-impact-on-medical-student-wellbeing

4. Malpass, A., Binnie, K., & Robson, L. (2019). Medical students' experience of mindfulness training in the UK: wellbeing, coping reserve and professional development. Education Research International, https://doi.org/10.1155/2019/4021729.

5. Slavin, S.J., Schindler, D.L. & Chibnall, T. (2014) Medical student mental health 3.0: Improving student wellness through curricular changes. Academic Medicine. https://www.ncbi.nlm.nih.gov/pubmed/24556765