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Table of Contents
PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 3  |  Issue : 3  |  Page : 154-159

Medical Learners' Wellness: Systemic Perspective


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Submission22-Nov-2021
Date of Acceptance22-Nov-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Prof. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wsp.wsp_65_21

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  Abstract 


Health and well-being of medical learners' is important in itself and is a necessary precondition to good patient care. Medical learners suffer from high levels of mental illhealth due to challenging demands and pressurized learning/ work environments. These factors are aggravated by learners' tendency to avoid seeking help and support when unwell or under pressure and by a perceived stigma among them about mental illness. Many pressures that threaten learners' well-being as well as the health and effectiveness of the organisations in which they learn are systemic. While certain initiatives have been implemented to improve the ability of medical learners' to withstand pressure, fundamentally many of the modifiable risk factors for poor mental health and wellbeing have not been addressed. It is becoming increasingly clear that successful interventions to tackle learners' mental ill-health would have to be multidimensional, aimed at multiple levels and involve multiple stakeholders. Leaders of organizations designing interventions must improve learning/ work cultures to emphasize the importance of looking after one's own health, to normalize discussions of struggle in the context of educational/ work challenges, and to understand how and when to seek help. Finally, it may be mentioned that the evidence base for individual and systemic interventions to improve medical learners' well-being and mental health is very limited, hence there is need for much research to help develop new approaches to medical learners' mental health and wellbeing.

Keywords: Medical students, system, wellness


How to cite this article:
Sharan P, Shakya P. Medical Learners' Wellness: Systemic Perspective. World Soc Psychiatry 2021;3:154-9

How to cite this URL:
Sharan P, Shakya P. Medical Learners' Wellness: Systemic Perspective. World Soc Psychiatry [serial online] 2021 [cited 2022 Jan 23];3:154-9. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/3/154/333429



The World Medical Association's Declaration of Geneva (2017)[1] calls upon doctors to pledge to “attend to (their) own health, well-being, and abilities in order to provide care of the highest standard.”


  Introduction Top


Medical careers are stressful.[2],[3] A nationwide survey of doctors and medical students in Australia reported that doctors have greater levels of very high psychological distress (3.4%) compared to the general population (2.6%).[4] Medical students and females reported higher rates of psychological distress and mental health problems than older doctors and males.[5] The most common stressors among medical learners were studies and examinations (58.4%), workload (50.4%), conflict between personal/family responsibilities and studies (35.2%), staying up to date with knowledge (34.2%), and fear of making mistakes (34%).[4]

Studies all over the world have reported that the prevalence of mental health problems among medical learners is higher than age matched peers.[3] A meta-analysis of 183 studies conducted in 43 countries showed that the prevalence of depression was 27.2% and of reported suicidal ideation was 11.1%.[6] Depressive symptoms were 2.2–5.2 times higher among medical students than individuals of similar age in the general population. The median absolute increase in depressive symptoms before and during medical school was 13.5%.[6] Other studies show that the rates of anxiety (25.7%), stress (31.2%), and burnout (49.6%) are also very high in this population.[6],[7],[8]

Transitions in careers (student to doctor, resident to registrar, registrar to consultant) are particularly stressful.[9] Psychological distress regarding availability of specialist training places has intensified, so medical students incur significant financial and time costs on additional courses to increase their chances of qualifying for such programs. Junior doctors are concerned about career progression.[4] Examinations during specialist training, are particularly stressful for residents, when they need access to leave and a supportive workplace. More than 70% of residents at the start of their career express concerns about their physical or mental health.[10]

Burnout comprises emotional exhaustion, depersonalization, and reduced personal accomplishment.[11] Clinician burnout has a prevalence of 25%–75% and the rates may be increasing. It affects doctors at all stages in their career.[12] Residents often have long working hours, unpredictable rosters, and on-call/night shifts. These can be barriers to maintaining physical and mental health and wellbeing.[13],[14] A linear relationship between hours of work and higher rates of anxiety, depression, and distress has been noted.[12] Insufficient sleep and lack of time for nutrition/exercise lead to significant work-life balance conflict and increased risk of burnout and fatigue. Fatigue can act as a risk factor for sedatives use, road traffic accidents, needle stick injuries, and medical errors.[12]

There is an expectation that medical learners will take responsibility for their own physical/psychological health and will seek appropriate consultation from a professional when unwell. The beyondblue survey showed that while medical students were more likely to seek treatment for depression and anxiety than doctors, the rates were not high.[4] The meta-analysis by Rotenstein et al.[6] reported that the percentage of medical students screening positive for depression who sought psychiatric treatment was 15.7%. Only about half of depressed medical learners who contemplate suicide had sought help for the same.[15]

The beyondblue survey suggested that the barriers to medical learners seeking help included embarrassment (50.3%), fear of lack of privacy/confidentiality (49.9%), reticence to ask for help from others/self-reliance (47.7%), lack of time (40.6%), and concerns about career development and progression (37%).[4] Other important factors are systemic or access related issues (lack of independent services, timing, location, lack of personnel), stigma and concerns regarding mandatory notification of impairment.[16] Inappropriate practices on the part of medical learners contribute to the intervention gap and can include inadequate preventative care (e.g., screening tests/vaccines), self-diagnosis, self-treatment, corridor consultation, delays in obtaining independent medical advice.[16],[17] In part, this is because medical students and residents often fail to identify early warning signs of mental illness and burnout.


  Interventions at the Level of Individuals Top


Establishing a relationship with an independent practitioner/counsellor is crucial since it promotes appropriate help seeking, discourages self-prescription, ensures preventative health, and addresses concerns about confidentiality/privacy.[18] Doctors/counsellors who treat medical learners need training in occupational health, so that they remain aware of confidentiality and stigma related issues. Independent counsellors should explore alternative mechanisms for providing confidential support, e.g., telehealth, or ensuring access to non-campus mental health specialists, if needed.[16] Provision of such a contact helps the learner in discussing concerns and obtaining advice in a nonjudgmental, confidential manner.

At an individual level many evidence-based strategies are available, e.g., mindfulness-based stress reduction.[19],[20] Such strategies help reduce stress, anxiety, distress, self-doubt, and burnout; and are supportive of self-awareness, empathy, and positive affect. Self-care activities like nourishment, hygiene, sleep, intellectual/creative health, physical activity, spiritual care, balance and relaxation, time for loved ones, big picture goals, and personalized leisure activities and hobbies are useful.[21],[22] So is attention to financial health.[16]

Some of the strategies that individuals use require resources that can be made available at the institutional level, e.g., gyms, Schwartz rounds/Balint groups. Medical colleges can also seek to enhance the capacity of medical students for health and wellbeing by including evidence-based strategies in the core curriculum.[16]


  Interventions at the Level of Institutions Top


Many individual level strategies have been implemented to improve the ability of medical learners to withstand study/work pressure; however, many modifiable risk factors for poor wellbeing cannot be addressed at the individual level. For example, burnout and dissatisfaction that can lead to staff depletion, patient dissatisfaction, medico-legal risk and financial costs; are increasingly recognized as a consequence of poor organizational culture.[23] Evidence for resilience training in preventing burnout is inconclusive.[24]

Positive workplace cultures are associated with positive patient and practitioner outcomes.[25] Negative team culture based on the attitude of neglecting self-care and intergenerational expectations and cynicism about value of work among young doctors, can contribute to psychological distress and burnout, often through harassment and discrimination [Box 1].



Cultural change requires action at the organizational level and strong leadership.[27],[31] To curtail negative workplace cultures, there is a need to formulate, review and implement policies and processes that eliminate discrimination and harassment; create safe spaces for complainants to raise issues (free of shame, stigma, or repercussions); and provide for training for staff on how to deal with situations of discrimination and harassment. In addition, institutions should demonstrate organizational awareness of microaggressions, communicate intent to address these issues, and develop relevant interventions for both victims and witnesses.[16],[29]

In addition to elimination of negative practices, there is a need to create a positive workplace culture.[27],[31] It is known that sometimes a sense of collegiality (conversely) can increase pressure on learners to neglect their health. Learners socialized into team cultures are unable to take sick leave or holiday so as not to let their colleagues down or because of the expectation of reporting to duty even when sick.[32] Institutions should support initiatives that promote a positive professional culture, e.g., encouraging residents and medical students to support their colleagues in maintaining their wellbeing and seek help when unwell. This could be done through groups that promote wellbeing by providing resources (e.g., how to guides), organize events (e.g., wellness week), and conduct pilot interventions.[16],[33]

At the institutional level, having a nodal person for students' wellness helps. The nodal person should serve as a change agent in driving system-level transformation to a culture of well-being.[16] The nodal person should be responsible for the strategic vision for creating a culture of change, monitoring outcomes, and engagement with mental health leaders. The person should engage all stakeholders including the senior leadership of the organization, and maintain impartiality with reference to stakeholders (e.g., separation from training progression).[16],[31]

Technological advances have a complex impact on learners' wellness. It can be extremely useful as was seen during the COVID-19 pandemic;[33] but can also be disruptive. Sudden extensive changes in educational/work practices and workflow (e.g., implementation of user-unfriendly electronic health record) can adversely affect health and wellbeing.[34] Counterintuitively, rechnology can also increase the risk of isolation by reducing face-to-face contact. When implementing new technologies, institutions should consider their effect on staff wellbeing and conduct relevant research to ensure optimal use.[34]


  Interventions at the Level of Organizations/Systems Top


From a health care systems perspective, ensuring medical learners' wellness should be seen as furthering competency, promoting quality in the health-care system, and improving health system cost-effectiveness.

Governance

Acknowledgment of the potential for unsafe educational and work environments to impact wellbeing, care quality, safety and access is a must for policy development. The policy should commit to making of safe spaces for education and.[27],[35]

Accrediting bodies should require inclusion of doctor health and wellbeing as part of the curriculum and ensure regular evaluation of health and wellness programs and initiatives.[16] Medical colleges should ensure that the training programs place the wellbeing and health of the learner as a core principle (e.g., in curricula, training requirements, and performance management). Colleges must implement flexible training structures to facilitate healthy work-life balance while ensuring training quality. They should engage residents in decisions that affect them because reduced physician autonomy, organizational bureaucracy and administrative burden, make time at work frustrating and unrewarding and contribute to burnout and unwellness.[36] Studies modelling causes of work stress evidence that jobs are stressful when there is a high demand but no power to alter the situation.

Individuals in leadership/supervisory roles have little training or support for these roles. Poor performance management can impact health and wellbeing, professional confidence, career progression and satisfaction;[30] hence management and leadership training is necessary to ensure performance management, constructive feedback, communication about difficult issues, and complaint management. Skills in leadership, mentoring and management could also be incorporated in the curriculum for medical students and residents and continuing professional development courses for senior doctors.[16]

Preventing fatigue and burnout

Health organizations have a major role in preventing and correcting burnout.[37] Optimal policies for burnout management should consider rates of burnout in workforce planning (staffing levels). The measures to prevent burnout should include promotion of a respectful workplace culture; provision of flexible work arrangements (rigid organizational structures and inflexible work hours are a leading cause of mental ill health); sustainable rosters with innovative shift work solutions and flexible rostering (institutions should adhere to working hour requirements and minimize unsafe rostering practices, e.g., long runs of night/on-call shifts); provision of good health and wellbeing initiatives and adequate facilities (common rooms, sleeping facilities for shift/on call work); and recognition of importance of physical health in wellbeing through provision of access to healthy food options (meal breaks, cafeteria opening times, choice of heathy foods) and exercise facilities.[16],[22]

Organizational culture can be a barrier to safe working conditions due to overarching expectations for residents to finish late, not take sick leave and not utilize meal breaks.[14] Organizations should ensure that medical learners have access to sick, personal and other forms of leave, both planned and unplanned. Examinations are other occasions that can be exceptionally stressful, and organizations should prioritize support and access to quarantined study leave when such leave is needed.[38]

Having to be away from work due to ill-health can be a major challenge to self-worth and sense of self and return to work is stressful. Long health-related leaves are a problem because delays are seen as gaps in curriculum vitae. Organizations should develop policies and services to support access to treatment and facilitate both return to work and continuance of training (while protecting confidentiality) through customized return-to-work plans.[39]

Other organizational (structural and cultural) solutions could be oriented to making workload manageable and work satisfying, e.g., through minimizing paperwork or streamlining technologies based on user experience.[39],[40] As mentioned earlier, such interventions should be undertaken by engaging residents in a meaningful level.[41] Removing sources of frustration and inefficiency leads to improved productivity and reduced burnout.[16]

Mandatory reporting and stigma

Mandatory notification is based on legal/ethical requirement for doctors to report impaired health professionals (e.g., due to intoxication, sexual misconduct, departure from professional standards) who place the public at substantial risk of harm. Professionals with mental health issues can be occasionally dysfunctional. However, it is emphasized that an overwhelming majority of medical professionals who experience mental ill-health and suicidal behavior can provide quality patient care. Therefore, the threshold for mandatory reporting of professionals with mental health issues should be high because the silent threat of mandatory reporting can act as a barrier for seeking help when unwell; besides having a detrimental impact on the confidentiality of the doctor-patient relationship.[42] Institutions should educate clinicians about mandatory reporting thresholds, ensure transparency in processes, and ensure access to support during the regulatory process.

Stigma regarding mental health in the medical profession prevents help seeking.[42] Research suggest that improving education, correcting attitudes, and improving communication help in reducing stigma.[43] Organizations should promote initiatives aimed at reducing stigma around doctors' health issues (including mental health) amongst the medical profession.


  Conclusions Top


Medical learners' health and well-being is important-in-itself and is a necessary precondition to good patient care. But medical learners suffer from high levels of mental ill-health due to very challenging demands and pressurized learning/work environments. These factors are aggravated by learners' tendency to avoid seeking help and support when unwell or under pressure and by a perceived stigma among them around mental illness.

Successful interventions to tackle learners' mental ill-health are likely to be multidimensional and multilevel and to involve multiple stakeholders. There is a need to improve learning/work cultures to emphasize the importance of looking after one's own health, to normalize discussions of struggle in the context of educational/work challenges, and to understand how and when to seek help.

The National Academy of Sciences, Engineering and Medicine, USA has made 10 recommendations for improving the wellbeing and mental health of students in institutions of higher learning.[44] These have been summarized in [Box 2].



Finally, there is need for research to help develop new approaches to medical learners' mental health and wellbeing. Till date, most studies have focused on the effectiveness of individual level interventions (e.g., resilience training and mindfulness). Much research is required on institutional/organizational level and system-wide interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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