Protecting students and promoting resilienceBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5266 (Published 02 September 2013) Cite this as: BMJ 2013;347:f5266
- 1Whittington Campus, University College London Medical School, London N19 5NF, UK
- 2Faculty of Medicine and Health Sciences, Nottingham University, Derbyshire Children’s Hospital, Derby DE22 3NE, UK
Overall the teaching session seemed to be going well. There is a gentle buzz of activity but one of the students seems distracted. Paul’s attendance on this attachment has been poor and your attempts at engaging him with gentle, simple questions have been stonewalled. You speak to him after the session and it’s evident that he has been struggling for some time. His mood is low; he appears to be holding back and is clearly worried about confiding in you and the university.
Our experience as educators would suggest that everyone involved in teaching will encounter a similar situation. Compared with non-medical teachers, healthcare professionals often feel an extra responsibility to students with health concerns. With mental health problems we can find ourselves caught in a maze of ethical and professional dilemmas. The reluctance of medical students to discuss mental health problems candidly is understandable. In the past, the response to students who are struggling has been variable. Attitudes of individual teachers and medical schools have differed considerably. The publication of the General Medical Council guidance on supporting medical students with mental health conditions is therefore particularly welcome.1
The document itself is just over 70 pages long and covers all aspects of mental health, from stress to more serious mental illnesses such as schizophrenia and bipolar disorder.1 It is accompanied by a longer report that contains a summary of the evidence base and details of current practice within medical schools in the United Kingdom.2
It is clear that the existing evidence base for both documents is relatively sparse. A systematic review of the literature by the guideline authors identified only 73 recent relevant studies, and all but one of these were related to prevention, identification, and referral. Little work has been conducted on how best to escalate concerns, facilitate treatment, and reintegrate students.
Although the evidence base identifies some interesting themes, it is the qualitative research undertaken by the authors themselves that adds breadth and depth to the document. They conducted an online survey and structured telephone interviews with medical schools. In addition, they talked to educators and students. Student focus groups identified some important themes. One of the most striking was the reluctance of students to seek help. When asked to choose available sources of support, just over half the students would prefer to seek help from a friend, a quarter would approach their family, and 10% would try to help themselves. Only 10% would choose to approach their GP, medical school, or university support services.
Although the narrative approach has its limitations, we believe that the shorter GMC report is essential reading for all those who come into contact with undergraduate medical students. There are three reasons for this conclusion. Firstly, it is clear that the document itself will be widely circulated and medical students will be encouraged to read it and refer to it. Therefore, students will reasonably expect to be treated in a manner consistent with the GMC advice.
Secondly, wide appreciation of the scale of the problem and application of a supportive, nurturing response to mental health problems should help de-stigmatise mental health problems in the wider community. Doctors and medical schools have an opportunity to lead in this area.
Finally, it offers some clarity on our professional responsibilities to students with mental health problems. This includes practical advice about how and when fitness to practise procedures should be considered and how to manage transition from medical school to foundation training.
Both reports highlight how dealing with mental health problems at an early stage of training can help to promote resilience and reduce burnout in the longer term. Involvement of students themselves with peer support programmes not only helps to provide a supportive and nurturing environment for those experiencing mental health difficulties, but training itself has a positive impact on the personal resilience of those undertaking it.3 Student engagement in peer support programmes ensures that students and doctors will be better informed to access help should they experience problems themselves.
So aside from identification and signposting, how can the current situation for students be improved? Alternative paradigms of teaching, such as the Longitudinal Integrated Clerkship model, which brings with it the support of dedicated faculty over an extended period, may be more beneficial for students than the traditional block structure of randomly rotating clinical firms.4 The evidence base suggests that careful attention to the learning environment, in particular the perceived attitude of teachers, can also help reduce the risk of stress and student burnout.5 Some suggestions—such as having only a pass/fail grade for examinations,6 keeping all student assessment information in one place (accessible by the student), and restricting medical school autonomy—may be met with resistance, but there are compelling arguments to suggest that each of these will improve the lot of students.
The stakes are high. The suicide rate in doctors as a group remains higher than that of the general population,7 8 and these problems seem to have their roots in medical school, with medical students reporting poorer mental health than age matched controls.9 10 11 12 The problems experienced by students like Paul are real and need to be dealt with. This should enhance resilience and reduce burnout throughout the medical community.
Cite this as: BMJ 2013;347:f5266
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.