There is a growing body of evidence that medical students experience disproportionate levels of stress-related impairment. Before commencing medical school, their mental wellbeing is similar to that of the general student population.1-3 However, as they progress through their training, in an environment of multifactorial stressors, medical students exhibit lower psychological wellbeing than age-matched peers and the general population.4-9 Within the first year alone, there is a significant increase from baseline in the prevalence of stress, depression and burnout.10 These levels remain high throughout medical school,2,11 resulting in lower life satisfaction by the time students reach their final year.12

It has been reported that 24% of first-year and second-year medical students are depressed, of whom 26% have suicidal ideation, but only 22% have used mental health services.13 Identified barriers to accessing support include confidentiality concerns, stigma, poor service availability and difficulty in gaining access to care.13

Coping mechanisms learnt at medical school affect students’ long-term health and the quality of care they provide to patients.14-17 Stress and distress may also impair academic performance,18 and increase cynicism, academic dishonesty14 and the prevalence of suicidal ideation or suicide.19

Few studies have explored the teaching of wellbeing, and there is little consensus about what should be included in a wellbeing curriculum. This study aimed to identify students’ access to and awareness of support services, and their perceptions on the teaching of wellbeing and its relevance.

We developed a survey to investigate students’ experiences and perceptions of their wellbeing. It was reviewed by university academic staff and representatives of wellbeing awareness organisations. Response modes included yes/no options and five-point Likert scales (from 1 [strongly disagree] to 5 [strongly agree]). Identical hard-copy and online versions of the survey were used. The online version was hosted on the website of the relevant national medical students’ association. Both versions were completed anonymously.

Medical students enrolled at five universities in Australia and New Zealand were invited to complete the questionnaire in November 2007. Final-year students at one university completed the questionnaire during a lecture. All other students were informed of the online questionnaire via student email lists.

Of a total 5072 students, 1328 (26%) responded. Fifty-four per cent were clinical students and 64% were female. Fifteen per cent of respondents were international students, 26% were local graduates and 60% were local school-leaver students. The distribution by entry type, sex and stage of study was consistent with the study cohort at each university.

At the time of the survey, all medical schools involved offered support services, yet only 71% of students were aware of these services, and fewer than half of these thought they were adequately promoted. Clinical students, who are based off campus, were most likely to feel this way. These results highlight the need for greater promotion, awareness, and education about the services available, with a particular focus on the clinical years.

It was concerning that only 45% of international students had their own GP. International graduate students encounter cultural and language barriers, social isolation and financial hardship,20,21 and are known to have unsupported mental health requirements.22 We also found that international students are more likely to feel uncomfortable accessing help outside the university. This study indicates that international students need additional help to establish a relationship with a GP.

Our findings reinforce the importance of addressing stigma. Medical schools should actively counter the perception of stigma associated with mental health issues. Three methods of doing so have been identified — education, protest, and contact.23 Examples of these in the medical school setting include informing medical students about the reality of mental health issues within the profession; countering beliefs that bolster stigma, such as resultant academic jeopardy (the belief that seeking support will adversely affect academic standing and references);24 and facilitating medical students hearing of the experiences of senior colleagues who had undergone stress or had a mental health experience.

Only 56% of students believed that they had formal teaching on stress and distress, and only half of these students felt that the subject had sufficient time allocated and was approached appropriately. The Australian Medical Council (AMC), which accredits Australian and New Zealand medical schools, states: “The medical curriculum should specifically address issues of self-care, doctor health and the responsibility to identify and assist peers in distress”.25 Medical schools thus have an obligation to address these statistics by increasing or altering the way wellbeing is taught within their curricula. In doing so, they must prioritise its place within the curriculum and the development of its content.

There is no absolute consensus on what should be taught in wellbeing curricula. We found that student learning priorities were: helping others cope with stress and distress, identifying when others are experiencing stress or distress, and self-help techniques for coping with stress and distress. These align with AMC standards.25 Further research is required, in particular, to test the effectiveness of curriculum interventions.

We surveyed over a thousand students across five medical schools in two countries. A weakness of our study was the low response rate. There was possible selection bias. Sample bias was unlikely, as the demographic characteristics of the respondents reflected those of the student population.

The results of our survey reinforce the need for medical schools to ensure that student wellbeing receives appropriate attention. An integrated approach of curriculum inclusion and adequate support services provision is required to avoid the potential ill effects of low personal wellbeing.

2 Wellbeing teaching topics and teaching modes preferred by students

* For whether students feel they would benefit from learning about that aspect of stress and distress. † For whether students would attend or like to receive that mode of wellbeing teaching.