Protecting students and promoting resilienceThe GMC’s report is essential reading for all those who come into contact with medical students

Caroline Fertleman site sub-dean 1, Will Carroll honorary associate clinical professor 2

1Whittington Campus, University College London Medical School, London N19 5NF, UK; 2Faculty of Medicine and Health Sciences, NottinghamUniversity, Derbyshire Children’s Hospital, Derby DE22 3NE, UK

Overall the teaching session seemed to be going well. There isa gentle buzz of activity but one of the students seems distracted.Paul’s attendance on this attachment has been poor and yourattempts at engaging him with gentle, simple questions havebeen stonewalled. You speak to him after the session and it’sevident that he has been struggling for some time. His mood islow; he appears to be holding back and is clearly worried aboutconfiding in you and the university.Our experience as educators would suggest that everyoneinvolved in teaching will encounter a similar situation.Compared with non-medical teachers, healthcare professionalsoften feel an extra responsibility to students with healthconcerns. With mental health problems we can find ourselvescaught in a maze of ethical and professional dilemmas. Thereluctance of medical students to discuss mental health problemscandidly is understandable. In the past, the response to studentswho are struggling has been variable. Attitudes of individualteachers and medical schools have differed considerably. Thepublication of the General Medical Council guidance onsupporting medical students with mental health conditions istherefore particularly welcome.1

The document itself is just over 70 pages long and covers allaspects of mental health, from stress to more serious mentalillnesses such as schizophrenia and bipolar disorder.1 It isaccompanied by a longer report that contains a summary of theevidence base and details of current practice within medicalschools in the United Kingdom.2

It is clear that the existing evidence base for both documents isrelatively sparse. A systematic review of the literature by theguideline authors identified only 73 recent relevant studies, andall but one of these were related to prevention, identification,and referral. Little work has been conducted on how best toescalate concerns, facilitate treatment, and reintegrate students.Although the evidence base identifies some interesting themes,it is the qualitative research undertaken by the authorsthemselves that adds breadth and depth to the document. Theyconducted an online survey and structured telephone interviewswith medical schools. In addition, they talked to educators andstudents. Student focus groups identified some important themes.

One of the most striking was the reluctance of students to seekhelp. When asked to choose available sources of support, justover half the students would prefer to seek help from a friend,a quarter would approach their family, and 10% would try tohelp themselves. Only 10%would choose to approach their GP,medical school, or university support services.Although the narrative approach has its limitations, we believethat the shorter GMC report is essential reading for all thosewho come into contact with undergraduate medical students.There are three reasons for this conclusion. Firstly, it is clearthat the document itself will be widely circulated and medicalstudents will be encouraged to read it and refer to it. Therefore,students will reasonably expect to be treated in a mannerconsistent with the GMC advice.Secondly, wide appreciation of the scale of the problem andapplication of a supportive, nurturing response to mental healthproblems should help de-stigmatise mental health problems inthe wider community. Doctors and medical schools have anopportunity to lead in this area.Finally, it offers some clarity on our professional responsibilitiesto students with mental health problems. This includes practicaladvice about how andwhen fitness to practise procedures shouldbe considered and how tomanage transition frommedical schoolto foundation training.Both reports highlight how dealing with mental health problemsat an early stage of training can help to promote resilience andreduce burnout in the longer term. Involvement of studentsthemselves with peer support programmes not only helps toprovide a supportive and nurturing environment for thoseexperiencing mental health difficulties, but training itself has apositive impact on the personal resilience of those undertakingit.3 Student engagement in peer support programmes ensuresthat students and doctors will be better informed to access helpshould they experience problems themselves.So aside from identification and signposting, how can the currentsituation for students be improved? Alternative paradigms ofteaching, such as the Longitudinal Integrated Clerkship model,which brings with it the support of dedicated faculty over anextended period, may be more beneficial for students than the

will.carroll@nhs.net

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BMJ 2013;347:f5266 doi: 10.1136/bmj.f5266 (Published 2 September 2013) Page 1 of 2

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EDITORIALS

traditional block structure of randomly rotating clinical firms.4The evidence base suggests that careful attention to the learningenvironment, in particular the perceived attitude of teachers,can also help reduce the risk of stress and student burnout.5Some suggestions—such as having only a pass/fail grade forexaminations,6 keeping all student assessment information inone place (accessible by the student), and restricting medicalschool autonomy—may be met with resistance, but there arecompelling arguments to suggest that each of these will improvethe lot of students.The stakes are high. The suicide rate in doctors as a groupremains higher than that of the general population,7 8 and theseproblems seem to have their roots in medical school, withmedical students reporting poorer mental health than agematched controls.9-12 The problems experienced by students likePaul are real and need to be dealt with. This should enhanceresilience and reduce burnout throughout the medicalcommunity.

Competing interests: We have read and understood the BMJ Grouppolicy on declaration of interests and declare the following interests:None.Provenance and peer review: Commissioned; not externally peerreviewed.

1 General Medical Council. Supporting medical students with mental health conditions.2013. www.gmc-uk.org/education/undergraduate/23289.asp.

2 General Medical Council. Identifying good practice among medical schools in the supportof students with mental health concerns. 2013. www.gmc-uk.org/about/research/23295.asp.

3 Hillis J, Morrison S, Alberici F, Reinholz F, Shun M, Jenkins K. “Care factor”: engagingmedical students with their well-being. Med Educ 2012;46:509-10.

4 Hirsh D, Gaufberg E, Ogur B, Cohen P, Krupat E, Cox M, et al. Educational outcomes ofthe Harvard Medical School-Cambridge integrated clerkship: a way forward for medicaleducation. Acad Med 2012;87:643-50.

5 Dyrbye LN, Thomsa MR, Harper W, Massie FS, Power DV, Eacker A, et al. The learningenvironment andmedical student burnout: a multicentre study.Med Educ 2009 ;43:274-82.

6 Spring L, Robillard D, Gehlbach L, Moore Simas TA. Impact of pass/fail grading onmedicalstudents’ well-being and academic outcomes. Med Educ 2011;45:867-77.

7 Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and genderassessment (meta-analysis). Am J Psychiatry2004 ;161:2295-303.

8 Meltzer H, Griffiths C, Brock A, Rooney C, Jenkins R. Patterns of suicide by occupationin England and Wales. Br J Psychiatry 2008;193:73-6.

9 Dyrbye LN, Tomas MR, Shanafelt TD. Systematic review of depression, anxiety, andother indicators of psychological distress among US and Canadian medical students.Acad Med 2006;81:354-73.

10 Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: across-sectional study. Med Educ 2005;39:594-604.

11 Dahlin ME, Runeson B. Burnout and psychiatric morbidity amongmedical students enteringclinical training: a three year prospective questionnaire and interview-based study. BMCMed Educ 2007;7:6.

12 Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medicalstudents. JAMA 2010;304:1181-90.

Cite this as: BMJ 2013;347:f5266© BMJ Publishing Group Ltd 2013

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