It has been long recognised that the practice of medicine is stressful and that doctors are prone to anxiety, depression, drug and alcohol problems, and even suicide.1,2 Similarly, the process of medical education is stressful and medical students, too, are at risk of psychological problems.3
In New South Wales, in 1997, after a report on doctors' mental health, the NSW Medical Board convened an independent Doctors' Mental Health Implementation Committee, with wide-ranging representation from the profession. This Committee produced the NSW Doctors' Mental Health Policy to provide a framework for the NSW Doctors' Mental Health Program.4 Separate policies were developed for rural practitioners, area health services, specialist medical colleges, and for medical schools.
The policies for medical schools included:
promoting the importance of mental health — by embedding it in the curriculum;
encouraging a caring culture within the medical school;
identifying suitable personnel to provide assistance to students with social and psychological problems; and
assisting students to obtain good medical and psychological care.
Many factors may contribute to stress and distress in medical students. These include not only the intrinsic stressors within medical education, but also significant changes and conflicts in lifestyle. For example, students in graduate programs, who are often older and married with young children, may have great financial pressures placed upon them.
The policies were implemented primarily in two ways:
by incorporating the theme "Personal and Professional Development and Ethics" in the curricula; and
by establishing a Student Welfare Committee.
Personal and Professional Development and Ethics is one of the four teaching themes in the graduate medical program, which are integrated both vertically and horizontally. The others are Basic and Clinical Sciences (pre-clinical sciences), Patient–Doctor (diagnostic and clinical skills) and Community–Doctor (epidemiology and social medicine). The Personal and Professional Development and Ethics theme is integrated into all aspects of the students' learning program, which is centred around "problem-based learning" in small groups meeting twice weekly. These groups focus each week on a specific clinical problem. The students are encouraged to develop good listening and communication skills and to be aware of the functioning of the group. In the context of these clinical problems, they are exposed both to the multiple roles of doctors — as clinicians, educators, supervisors, and patient advocates — and to the professional and ethical issues in the clinical case.
Larger lecture or seminar teaching sessions cover healthy lifestyle, stress and stress management, anxiety and depression, and substance misuse. Other sessions deal specifically with mental illness and stigma in mental health, and students are encouraged to understand the political, financial, legal, and ethical impacts of these disorders. In addition, they understand the duty of care in relation to mental health problems in their colleagues and their own mental health. The Personal and Professional Development and Ethics theme is assessed at several points during the medical course, in both a formative and summative manner. (A formative assessment does not involve a pass or fail, but, if unsatisfactory, may require some remediation. A summative assessment is a pass/fail assessment).
A Student Welfare Committee was established with basic principles of confidentiality regarding student information, a duty of care to students, and, in some instances, a duty of care to hospital staff and to patients.
The Committee comprises the coordinators for the first two, non-clinical years of the medical course and the Associate Deans of the teaching hospital clinical schools, with the chair being a psychiatrist on the university staff. If appropriate, a member of the Medical Board is invited to attend. Information about individual students discussed in the committee is de-identified. The importance of collecting detailed information about problems has been emphasised, particularly as the Medical Board requires detailed information to be able to make the most appropriate decisions if and when students are referred.
The Committee has established appropriate processes for referring students to appropriate clinicians — counsellors, psychologists and psychiatrists — outside the faculty. Other options available are referral to the Medical Board, for establishing and maintaining psychological care for the student, for placing specific requirements on the student for registration, or for deregistration. (In New South Wales, medical students are registered in a similar way to medical graduates.)
Students with problems tend to come to the Committee's attention in two ways. Firstly, students may self-present to the year coordinator or to the Associate Dean's office with either social or psychological problems. Initially, a supportive identified member of that office screens the problem. The matter can then be referred to the Associate Dean or the year coordinator and discussed at the Student Welfare Committee meeting. Appropriate documentation is kept. Secondly, students may be reported to the Associate Dean by other concerned students or staff, usually when they appear quite psychologically disturbed or have significant behavioural problems.
In the early days of this Committee, there were often differences of opinion, particularly in considering, firstly, duty of care to patients and other staff, and, secondly, confidentiality within the faculty. For example, should relevant university staff be notified of a student who was distressed or not coping so they could be of support and assistance in the student's next rotation? As the committee progressed, these issues were largely resolved. It was agreed that one key staff member in a rotation would be made aware of a student needing support.
The pressures placed on medical students during their education, which can lead to significant psychological problems, are increasingly being recognised. The consequences for the student — in distress caused, and in interruption to their education — are considerable. The problems may also adversely affect others. Medical faculties need to be aware of these problems and identify and deal with them as soon as possible. Structures should be in place to accomplish this.
- 1. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci 2001; 322: 31-36.
- 2. Verberne TJ. Suicide in doctors. J Epidemiol Community Health 2002; 56: 237.
- 3. Gaughran F, Dineen S, Dineen M, et al. Stress in medical students. Ir Med J 1997; 90: 184-185.
- 4. New South Wales Doctors' Mental Health Program. Available at: <http://www.mbansw.org.au/dmh.htm> (accessed August 2005 (updated)).
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