There is no doubt that the practice of medicine has always been an extremely stressful profession, but of late, with the introduction of more complex investigations and interventions, it has become even more stressful. Furthermore, with changes in public expectations, health is now seen as a commodity and thus, additional pressures are placed on health practitioners. In addition, training and education in medicine also create a degree of pressure.
Over the past 50 years, although increasing attention has been paid to the mental health and well-being of doctors, it is only recently that the focus has shifted to the mental health and well-being of medical students.
A series of studies have shown that the rates of mental ill-health among doctors and medical students are exceptionally high and are getting worse. In studies across 12 countries with over 3600 responses, it was reported that rates of burnout among medical students vary between 65% and 95% across countries.
Medical students are the future workforce and are the key to patient care and the well-being of society in decades to come. It is well recognised that the majority of mental illnesses in adulthood start below the age of 24, which corresponds with the age of students in medical schools. Additionally, factors such as loneliness, isolation, the stress of medical education, financial pressures, and rapidly changing advances in medicine, are also likely to contribute to burnout and poor mental functioning.
Although there have been challenges to the use of the term burnout, it is defined as a pervasive and debilitating state due to a period of overwhelming stress. It has been classically defined as an experience of physical, emotional, and mental exhaustion. In addition to exhaustion (that is, the feeling of being emotionally overextended by one's work and its effect on functioning), burnout also has other components, which include depersonalisation (the feeling of being outside yourself and observing your actions, feelings, or thoughts as if from a distance), and feeling an absent sense of personal accomplishment.
Although burnout itself may show symptoms of anxiety, individuals experiencing burnout are likely to be in despair and depression.
It has been noted that medicine has always been a stressful job related to making life-and-death decisions, 24 hours a day, with pressures to not being able to form personal relationships with the team, or the patients and their carers. Additionally, increased bureaucracy and managerialism in the NHS, as well as other healthcare systems, further contribute to a sense of powerlessness. These factors are only further complicated by two factors: the changing face of medicine and the role of doctors, but also changing patient expectations which contribute to blame culture.
Burnout creates not only a detached attitude towards others but also a sense of disengagement. Thus, if individuals already feel they are not part of a team, such further isolation and alienation can be truly damaging.
Of the three stages of burnout, the first one is to do with stress arousal, poor concentration, memory lapses, irritability, and anxiety.
The second stage focuses on energy conservation and maladaptive strategies, such as avoidance, lateness, and social withdrawal when students do not attend their classes or wards.
The third stage is exhaustion, which is associated with anxiety, depression, apathy, and suicidal ideation. This can result in non-presence, low work rate, rage, and difficulties with examinations. Individuals may disappear, not respond to calls, or be on frequent sick leave. They may be physically present but mentally absent. Not surprisingly, future doctors may face problems related to career choice and promotion, as well as disillusionment with medicine.
Most doctors tend to work long hours and worry constantly about the welfare of their patients. Furthermore, a fear of things going wrong puts them under additional pressure. Medical students may observe this and further feel worried about potential pressures as blame culture, on the one hand, and obsessional personality characteristics on the other, contribute to stress.
Studies have shown variation in rates across countries as well as varying pressures which contribute to burnout. These factors are related to academic pressures, relationship difficulties, financial pressures, and housing problems.
Worryingly, across countries, students show increased usage of alcohol or cannabis to cope with burnout. The BMA survey mentioned earlier, showed that one-third of consultants were using alcohol and /or self-medication to cope.
What should be done?
There are things that need to be done at national policy level, at institutional (University or Hospital) level, and at individual level.
For example, at policy level resources must be allocated to provide confidential services to medical students. Institutions have a duty to provide services which are easily accessible, confidential and ensure privacy. Bullying and harassment can contribute to stress and burnout, so these must be eliminated with prompt action.
At an individual level, other strategies can be used. These include developing the ability to adapt to and manage stress by facing fear through coaching and mentoring. Additionally, developing cognitive and emotional flexibility and realistic optimism, learning how to get work-life balance, whilst asking for appropriate support and advice as needed.
Attaining and maintaining good mental health is critical to one’s functioning. This can be achieved through a number of actions, including exercise and other physical activity, yoga, meditation, mindfulness, amongst many more. These can help an individual to relax, and time must be made available to allow this to happen.
Receiving support from peers can be incredibly helpful as it is less stigmatising and more 'acceptable'. Safe spaces must be made available to take this forward. Systems should be in place to ensure that immediate access to support is available and that students are aware of this. For example, Balint groups can provide support in the context of clinical pressures. Balint groups are small group sessions involving case presentation and discussion, centred on the emotional component rather than the clinical content. As a final reccomendation, individuals, when on call or in hospital or university settings, must have access to places where they can rest and good quality healthy food.
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