By the time we are finished our medical training, it’s too late. We have already absorbed or been infused with years of culture, tradition, attitude, and approaches to mental health. These attitudes are towards ourselves, our colleagues, and our patients. If we are to change the culture around physician mental health, we need to start with the doctors of tomorrow. Medical schools have a key role in tackling medical student mental health. And they should start yesterday.
Across the country, medical students are being trained to screen for signs of depression in their patients. What we may not realize, however, is that the mental health and well-being of these future healers is of equal importance. By normalizing physician mental health as an essential part of being a healthy healer, medical culture will change for the better. Rather than shamefully hiding perceived “weakness” we could accept it as a normal part of being human, and in particular of being a doctor. This article explores how we could normalize medical student mental health to the benefit of all.
“Improving mental health and wellbeing starts with the self, extends to physician peers, and must involve major changes in the medical workplace.” (Slat et al, 2021)
As doctors and medical students, we find it easy to talk about physical and mental pathology with colleagues and friends – when it doesn’t apply to us. We, as a profession, do not like to discuss our own vulnerabilities. Yet, being human, vulnerable we are.
Roughly 1 in 3 medical students report symptoms of depression, and 1 in 9 experiences suicidal ideation. We do not know how many US medical students die from suicide each year. Med students have double the proportion of psychiatric disorders, psychological distress, and burnout as junior doctors, and over 20% of students report harmful levels of alcohol use. Medical students during training develop higher rates of suicidality compared to their age-matched peers.
We think that mental health awareness, discussion, openness and safety need to be integrated into medical training from day 1 (or ideally at school but that’s another blog!).
The ideal is for every young doctor to start their careers with awareness of their own strengths and weaknesses, has a strategy for self-care, knows that it’s safe to reach out for mental help, and has easy access to that help without stigma or fear.
This is where medical schools around the world can and must play their part. Having taught at two medical schools in two countries, I have sympathy for educators who must squeeze an increasingly complex and vast knowledgebase into a fixed training time, all the while trying to keep up with the evidence in each field, improve educational quality, and reduce costs.
So we do not make this recommendation lightly. But space must be found to normalize mental health so that our physicians both survive and thrive throughout their careers. Happy, healthy doctors mean healthier patients (and lower costs, if that’s your thing).
So, what playbooks can educators use?
Multiple studies have demonstrated the efficacy of mindfulness-based or stress reduction interventions in various forms for reducing stress, anxiety, burnout scores, and increasing quality of life and happiness. Many of these have been summarized in the Collaborative for Healing and Renewal in Medicine (CHARM) Best Practices Subgroup paper on Evidence-Based Interventions for Medical Student, Trainee, and Practising Physician Wellbeing.
In addition to these broad approaches, we present below to success stories where organizations have taken the lead in normalizing medical student mental wellbeing. Of course, as with all interventions, the earlier the better, so why wait?
Medical culture can make trainees feel like there is neither room for mistakes, nor space for personal shortcomings in the makeup of physicians. A dearth of role models who can exemplify that it is acceptable to need support compounds barriers to help-seeking once students struggle.
A recent study used synchronized videoconferencing, in an intervention consisting of 3 physicians who shared personal histories of vulnerability (e.g. failure on high-stakes exams; immigration and acculturation stress; and personal psychopathology, including treatment and recovery), followed by facilitated, small-group discussions.
The researchers found that sharing histories of personal vulnerability by senior physicians can lessen stigmatized views of mental health and normalize help-seeking among medical students. Synchronous videoconferencing proved to be an effective delivery mechanism for the intervention in a ‘virtual wellness’ format. Candid sharing by physicians has the potential to enhance students’ ability to recognize, address, and seek help for their own mental health needs.
UNM SOM recognized that the student population was vulnerable and believed that a multi-faceted program was the best approach to address student mental illness and help-seeking behaviors. UNM SOM uses the Stanford model, which emphasizes that professional well-being is based on a culture of wellness, efficiency of practice, and personal resiliency, and that knowledge and skills need to be learned in each of these domains.
The goal was to show new students from the start that it is important and reasonable to seek help for stress, substance use, and mental health concerns. To encourage this supportive culture, the UNM SOM Director of Physician and Student Wellness, Wellness faculty, student mentors, and other medical educators developed a series of programs to normalize conversations about mental health and to make it culturally acceptable and convenient for students and physicians to access care.
Starting at the ‘white coat ceremony’ and orientation and throughout their education, UNM SOM proactively engages students on the topic of individual wellness and its importance in their future success:
Students are introduced to health and wellness resources during medical student orientation. Most notably, upper level students who have accessed these resources in the past share personal stories about using some of these resources, including why they needed a particular resource, why they found it helpful, and whether there were any repercussions to seeking help.
As the year progresses, students are also provided with a formal wellness check-in. The Wellness Dean meets for 45 minutes with each Learning Community House of 6 to 8 students by October of the first year of medical school to:
Topics covered included imposter syndrome, growth and fixed mindsets, sleep, nutrition, life-work integration, depression, and anxiety. The group always discusses available support services and how to access these resources.
The panelists’ presentations are followed by a question and answer session for more intimate dialogue. Each year, students ask about what the panelists wish their classmates had said to them to be supportive. They ask about the signs and symptoms of substance abuse, and how the panelists were able to stop using. They also asked about repercussions for their career. Because the panelists are practicing physicians, some of whom are UNM faculty members, the students learn that physicians can practice successfully after treatment for substance use. The students also identified physicians with whom they can speak if they themselves have concerns about substance use and several have reached out as a result.
In this article, we have explored two successful approaches to integrating medical student mental health within physician undergraduate training, and for a relatively low upfront investment.
While they are yet to demonstrate protective effects against future mental disorders and burnout, these interventions crucially normalize the area of mental wellbeing , making it easier for medics to talk about it and, we hope, get help when needed.