To de-stress or distress: making well-being a priority in med school

January 22, 2020 Jane Coutts

medical student well-being

Medical school should be challenging — even seriously difficult — but not soul crushing. Fortunately, how to improve the well-being of med students is a question getting increasing attention from researchers and university administrators.

In an article in Mayo Clinic Proceedings, Liselotte Dyrbye and colleagues say “well-being is distinct from the mere absence of distress and includes achieving a high [quality of life] in multiple domains (physical health, mental health, emotional health, spiritual health, etc.)”

So well-being is a holistic state where people feel all aspects of life are broadly positive. Many articles about student well-being, however, are based on studies of depression. That’s likely because depression is a good indication of a lack of well-being: in addition to their sadness, depressed people tend to have low energy, sleep too much or too little and lose interest in food and activities they normally enjoy.

Research varies on whether medical students are more likely to suffer from depression than their peers in other areas of study. A meta-analysis published in Medical Education in Review in 2016 looked at 77 studies covering a total of more than 62,000 medical students and 1,800 students in other disciplines. The authors found 28 per cent of medical students world wide reported depression, but that represented “…no significant difference in prevalence of depression between medical and non-medical students.”

Another systematic review and meta-analysis of 167 studies, published in JAMA put the overall prevalence of depression at 27 per cent among more than 129,000 med students in 195 studies, but the prevalence rates reported in the individual studies ranged enormously, from 1.4 to 73.5 per cent — leaving open the possibility that medical students are much less depressed than the general population, or far more.

Other researchers have looked at the finer details behind those numbers. A 2017 article, “Current directions in medical student well-being,” in the Columbia Medical Review mentions a survey of 2,246 medical students, 82 per cent of whom said they had “experienced some form of distress, including depression, suicidality…or thoughts of dropping out of medical school.”

A pilot survey of personal well-being in medical students by the Association of American Medical Colleges looked at how the impact of five factors that influence well-being varied among different groups of medical students.

Minority students were less likely than whites to report positive mental health. Women reported higher stress than men. Lesbian, gay and bisexual students reported higher stress and financial concerns, and lower social support than other students. Asian students had high stress and low social support, but fewer financial worries. “Underrepresented minorities” reported lower quality of life.

Apart from the toll depression and stress take on individuals, they’re bad for patients: the American Association of Medical Colleges paper says “The negative consequences of distress during medical training, such as reduced empathy, lower ethical  conduct, substance abuse and broken relationships, are problematic if they undermine the goal of graduating knowledgeable, effective and professional physicians.”

Liselotte Dyrbye, quoted above, is a professor at the Mayo Clinic School of Medicine, whose research focuses on well-being in physicians and medical students. In a commentary written with Tait Shanafelt, “Medical student distress: A call to action” she notes both Canada’s Royal College of Physicians and Surgeons and the U.K. General Medical Council make self-care a competency required of physicians, which the U.S.A. does not.

Dyrbye and Shanafelt go on to say “Medical schools’ responsibility to promote student wellness goes beyond teaching students self-care skills to promote resilience. Indeed, promulgating such activities without establishing an appropriate organizational culture and shaping the modifiable aspects of the learning environment that influence student wellbeing is likely to be viewed by students as setting a double standard, which will breed cynicism.”

They add that student cynicism is at least partly driven by organizational culture, where faculty and residents “model” cynicism, stigmatize mental illness “and convey the message that only the ‘weak’ struggle or need help.”

Despite the numerous studies into the prevalence psychological distress among med students, there is relatively little evidence-based information on how to deal with it. That hasn’t stopped schools and student groups from trying. Students who would once have been shamed for feeling depressed or overwhelmed are less likely to be told to “suck it up, buttercup,” and there’s a general consensus that schools need to do more for student well-being than just offer a few voluntary classes in stress management and mindfulness.

So what can be done to lessen distress and build a sense of well-being? “Student well-being can be enhanced by good educational practice, including well-constructed curricula, effective teaching and learning methods and appropriate assessment procedures, delivered by faculty and staff who are responsive, engaged and offer ongoing personal contact,” according to Diana Wood of the University of Cambridge, in an article in Medical Education.

One “appropriate assessment procedure” that is often recommended for medical schools is pass/fail grading, which is thought to reduce competition and therefore build camaraderie and support networks among students. Some studies on problem-based learning (where students learn by working in groups to solve problems, rather than by attending lectures) found those who worked together to learn reported less stress than those in traditional classrooms and apparently formed beneficial longer-term bonds.

Some schools have established support programs for students. A 2005 article in the Canadian Medical Association Journal described steps the University of Alberta medical school had taken to help students cope with both general life stressors and “…stressors specific to medical school, which include information and input overload, financial indebtedness, lack of leisure time and pressures of work, work relationships and career choices.”

The suicide of a dental student led the university to review the Student Affairs Office, which was responsible for much of the counselling and support programs available to students. In response, the university introduced mandatory one-on-one meetings between first year students and advisers, who had a script to follow designed to draw out concerns students were feeling.

“Making the meeting mandatory eliminated any stigma…At the year-end assessment, 13 per cent of students were identified as having significant stressors and as being unlikely to have sought help voluntarily.” Some students, the author says, “required addition counselling or referral for specific services. Issues were successfully resolved for 80 per cent of the students with significant stressors.”

A 2007 article in Teaching and Learning in Medicine described a student-led stress management program for first-year medicine students at Oklahoma State University. Over seven weeks, the program features student group leaders, drawn from upper years, and sessions on relaxation methods, reframing negative thoughts and conflict resolution, among other things. Surveys show its small-group format makes students feel supported and reassured their feelings are not unusual. 

In what might become a model for the rest of the world, Australia and New Zealand issued a consensus statement on medical student wellbeing in 2019. “Worldwide, medical schools have responsibilities to respond to concerns about student psychological, social and physical well-being, but guidance for medical schools is limited. To address this gap, this statement clarifies key concepts and issues related to well-being and provide recommendations for education program design to promote both learning and student well-being.” Those recommendations are:

  • Design curricula that promote peer support and progressive levels of challenge to students.
  • Employ strategies to promote positive outcomes from stress and to help others in need.
  • Design assessment tasks to foster well-being as well as learning.
  • Provide mental health promotion and suicide prevention initiatives.
  • Provide physical health promotion initiatives.
  • Ensure safe and health-promoting cultures for learning in on-campus and clinical settings.
  • Train staff on student well-being and how to manage well-being concerns.          

It will take time, of course, for the message of the consensus statement to be read and debated around the world, and longer for universities to respond. Nevertheless, its concepts — from designing curricula to promote peer support and communities of practice, to promoting exercise, to encouraging students to support each other, to ending bullying and discrimination — can give medical schools everywhere ideas of what to focus on to improve the well-being of students.

In the meantime, students looking to “be the change they want to see” can start small. Even a gesture like inviting someone who looks stressed to take a walk with you can make a difference. And you’ll both feel better for it.

 

If you are in distress or need someone to talk to, know that you are not alone. You have access to support and resources through your provincial physician health program, the Canadian Federation of Medical Students and your medical school.

If you are in a crisis and need immediate help, please contact your local distress centre.

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This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about physician-led innovation? Please connect with us at jouleinquiries@cma.ca.

About the author

Jane Coutts is an Ottawa-based writer and editor who specializes in healthcare issues. She worked as a journalist for 15 years, mainly at The Globe and Mail, where she was the health policy reporter for five years. Since she founded Coutts Communicates in 2002, Jane’s work has focused on making healthcare policy and research more readable and relevant. Jane also leads workshops plain-language writing.

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