The following is a blog I wrote for PsychStart.
A 19 year old male presents with a two month history of anxiety, low mood and difficulty concentrating. He is finding it difficult to self-motivate and it is affecting his sleep, studies and appetite.
Your haven’t seen your friend on the wards or in teaching sessions. He’s probably being lazy and trying to cram for the placement exam.
Think about how you immediately responded to these scenarios; the first one probably sent you automatically down the “medical algorithm” pathway whilst the second sends you down a completely different thought process. But why? Think about this for a second, because it’s happening right now.
Mental health issues in medical students are a significant problem . There is no single cause and we need a multi-faceted, systemic approach to improve the situation. There are many driving factors (I have summarised some of the main ones below) but the message is simple: medical students need support.
However, I want to dive beneath the surface and look at something noteworthy- perhaps even, interesting? (There’s the desensitisation again). As medics we learn to recognise, treat and learn from diseases. But what unique insights and challenges do you get if you yourself are the patient? Let’s explore this.
Unique challenges: a mouse in a rat race
“We used to work two day shifts and we just had to get on with it…”
I remember this conversation well; supposedly a pastoral figure, initially framed around medical student burnout. However, I think it eloquently described a common thought in our healthcare environment, where if you aren’t able to stretch yourself beyond comfort, then you’re somehow letting the team down. The challenge is that if you have a mental health disorder, you are somehow weak and less “deserving” than your peers; you either carry on, or you’re not fit to be a doctor in today’s NHS.
Firstly, let’s just take a step back and remember that doctor burnout rates are increasing, burnout is occurring earlier and the common rhetoric is “I had to keep on going- until I couldn’t” . Secondly, mental health issues do not invalidate a student’s ability. As I explore later, it may even make you a better doctor.
“Fitness to practice issues? You will be reported to the GMC” tends not to marry well with “we will keep your personal health issues confidential.”
This is another unique challenge: having the looming threat of a governing body stamping your personal file with FLAWED- DO NOT HIRE on it. Medical students fear being flagged on the system and suffering subsequent career consequences. This is worsened by the tug-of-war which I can summarise as follows:
A medical student is in the unenviable position of being a young adult, told to function as a junior doctor, but also having sign-up sheets and strict timetables regardless of personal learning preferences. This doesn’t give any room to breathe- even if mental health issues are clamping down around you.
The barrier to sharing sensitive information has not been helped by historic data breaches, such as the data leak from the Cambridge Clinical School . If we’re to remove stigma, we need a system conducive to sharing and accessing help.
“How can I possibly complain when I saw two terminal patients today? I have nothing to complain about.”
Want to make mental health worse? Add in a hefty dose of guilt.
As medics we are taught to show empathy to every patient, regardless of circumstance or diagnosis. After all, every patient responds differently regardless of the “strength” of the hardship they face.
We are told to tell patients it’s not their fault, so why do we treat medical students differently? I have personal experience with a colleague’s resoundingly unhelpful stance on this: “take a step back and realise how lucky you are- think of the patients who have nothing!”
The truth is that you feel how you feel. In psychiatry, we learn about complex, multifactorial pathophysiology that explains how mental health disorders manifest. Your feelings are valid, they are real, and you are entitled to appropriate help and support. Part of the stigma is invalidation and medical students are unfortunately surrounded by peers who are desensitised to illness: think about the opening to this blog, and how differently we’re taught to think about the scenarios.
These unique challenges represent key targets as we work towards a more nurturing medical school environment. We need to openly challenge those who perpetuate unhelpful ideas and support medics who invariably succumb to mental health disorders.
Now for something even more interesting- finding opportunity in mental health illness.
The upsides: the expert patient?
The conversation usually stops here, and we think about the burdens on medical student shoulders and how improve it, but I want to explore some silver linings to add to those metaphorical shoulder pads.
“It’s like period pain, but worse and up here. Y’know?”
As a young male medic, I find it hard to empathise with certain patients, such as some gynaecology patients. I’m working hard on this and trying to learn as much as possible, but there is something to be said about lived experience.
There is a gaping chasm between what we are taught about psychiatric symptoms, pharmacology and treatments and the actual experiences. Some of the most emotionally charged or unpleasant sensations can arise from mental health problems, as well as some the most intangible feelings. The patient can benefit profoundly from the personal insight and experience, and isn’t that exactly what we want for them?
This is where the first major opportunity comes. Mental health disorders are all potential shared experiences with patients. As a result, they will encounter incredible empathy, understanding and a doctor who just gets it. This isn’t just limited to psychiatric patients: mental health issues can arise from virtually any core presentation, increasingly so with common issues such as chronic pain, diabetes and cancer.
“Junior doctors and students appear more inclined to engage with the subject of mental health in the workplace. This presents an opportunity for the future…”
This extract from the BMA 2019 report demonstrates another unique opportunity. We want to develop a nurturing healthcare environment that supports its members; the more comfortable we are with mental health treatment, services and support, the quicker we will get there.
In addition, stress does not end with finals and graduation- far from it. Hence, if you’ve experienced mental health issues then chances are you’ve done a great deal of introspection, have identified key personal triggers and have developed healthier habits and coping mechanisms for stress. This could be as simple as identifying and challenging cognitive distortions or may be a complete overhaul of your daily routine. However, going through the incredibly difficult process now, during medical school, gives you time to build these systems that may well help you significantly as a practising doctor.
Think of it as a dress rehearsal for future stress. Or like a vaccine, which seems more appropriate. Now you’ve built up your “memory” (in the form of cognitive techniques, stress management and experience) you’ll be able to respond quicker and better the next time the stimulus (e.g., stress) arises.
I firmly believe that we should be teaching these thought techniques in the medical school curriculum, as well as encouraging introspection and reflection as much as possible (although I’m aware not every medical student is keen on this idea).
Of course, it goes without saying that systemic changes are essential, as an individual approach can only take us so far. However, if we welcome an entire generation of doctors who have engaged with mental health services, it may be those very same doctors that become the decision makers to drive positive change. The BMA report also described an increasing uptake and awareness of talking therapies in junior doctors: the transition may already be happening.
I’ve touched on several aspects (and honestly could write an entire book on this topic), but I hope you can appreciate the unique challenges facing medical students with mental health issues, as well the opportunities they may paradoxically present.
I truly hope that we can open up the conversation and eliminate the stigma, especially that driven by current medics. Much like my struggles with gynaecology, it might be difficult for medical students without mental health afflictions to fully understand what their peers are going through. However, more discussion, greater awareness and improved medical school systems could bring forth a truly nurturing environment.
After all, medical students are all uniquely wonderful humans, but we are just that- human.
 Billingsley, Matthew. ‘More than 80% of Medical Students with Mental Health Issues Feel Under-Supported, Says Student BMJ Survey’. BMJ 351 (1 September 2015). https://doi.org/10.1136/sbmj.h4521.
 Lancet, The. ‘Physician Burnout: A Global Crisis’. The Lancet 394, no. 10193 (13 July 2019): 93. https://doi.org/10.1016/S0140-6736(19)31573-9.
 ‘“Extremely Unfortunate Data Breach” at Cambridge University Clinical School Affects over 300 Students | Varsity’. Accessed 9 September 2020. https://www.varsity.co.uk/news/19486.
 ‘Bma-Mental-Health-and-Wellbeing-Medical-Profession-Research-Summary-Oct-2019.Pdf’. Accessed 9 September 2020. https://www.bma.org.uk/media/1361/bma-mental-health-and-wellbeing-medical-profession-research-summary-oct-2019.pdf.