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POLICY DOCUMENT –
Mental Health and Wellbeing

BACKGROUND
The New South Wales Medical Students’ Council (NSWMSC) is the peak
representative body for medical students in New South Wales (NSW). One
of the four key goals of the NSWMSC is to promote the well-being for all
NSW medical students, which is intrinsically tied to mental health.

According to the World Health Organisation, mental health is “a state of


well-being in which every individual realizes his or her own potential, can
cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to her or his community” . That is, it is
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not just the absence of ill-health, but ability to live a full and flourishing life.

Mental disorders account for a large proportion of the disease burden in


young people in all societies. Most mental disorders begin during youth
(12–24 years of age), although they are often first detected later in life . 2

Thus, the highest prevalence (25%), is found in Australians aged 18-24


years old . In light of this, several studies suggest that medical students are
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particularly at risk .
 
4,5

Levels of distress in medical students

The demanding, time-consuming and competitive nature of medical school


may present a significant risk to the mental health of medical students. A
landmark 2013 report by beyondblue found levels of very high
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psychological distress among Australian medical students were almost three


times that of the general population, with 26% of female students and 18%
of male students experiencing very high levels of distress. These levels were
also more than double that reported by intern doctors, and occurred most
commonly in regional, pre-clinical and Indigenous students.

Furthermore, approximately 4% of medical students have attempted suicide,


while more than 20% of female and 17% of male students experienced
thoughts of suicide over a 12 month period. These rates are almost tenfold
higher than in the broader Australian population.

The most common psychological disorders experienced by medical students


in the beyondblue report included: depression, anxiety, attempted suicide
and suicidal ideation, substance abuse, and burnout . Rates of current and
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previous episodes of depression and anxiety are substantially higher in


medical students than in the general population, despite under-reporting of
clinically significant mental ill-health in the medical student population.
 
Burnout, which is characterised by exhaustion, inability to cope, and a
negative state of mind, has been associated with major depressive episodes , 6

and is extremely prevalent among medical students , with more than 57% of
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female and 44% of male students found to have high levels of emotional
exhaustion .  
5
 

Causes of mental ill-health among medical students

Mental ill-health and distress can be linked to individual attributes and


behaviours (such as social and emotional intelligence), social and economic
circumstances (such as a person’s socioeconomic status or their social and
work environment), and the wider sociocultural and geopolitical
environment . 3

Among university students, financial difficulties and personal injury have


both been associated with a 3-fold higher risk of the development of new-
onset depression, with depression and financial difficulties also linked to
exam performance . Of note, beyondblue found the majority of medical
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students also had a part-time job, with nearly half of those who worked
working approximately 12 hours per week, and one in ten working
approximately 36 hours per week . The majority of Australian medical
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students are concerned about their finances, with one in five being very
concerned . The high debt associated with medical education, and long
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contact hours that limit time for paid work may also contribute to financial
stress.

The risk factors identified in research examining workplace-related mental


distress may also be applicable to medical schools. Five evidence-based risk
and protective factors have been established:

1) The level of demand on an individual combined with their


ability to control their work;
2) The team environment and interpersonal relationships with
peers and leaders;
3) Organisational factors such as the level of organisational justice,
psychosocial safety climate, and reward;
4) The degree of conflict between home and work demands, and;
5) Individual factors such as resilience 10.

This summary is supported by a range of literature . In general, 11

psychologically demanding but uncontrollable daily work, which creates


what is known as “job strain”, has been linked to depression, with the
combination of high demand, low decision-making control and high effort
with low reward putting a person at significant risk . 12

The demands of medical education may create their own form of “job
strain”, with high mental load, little control and poor psychosocial safety in
some clinical environments.

The high workload, worries about future endurance and competence,


pedagogical shortcomings, and a lack of free time for relaxation and paid
work, as well as the clinical exposure and feedback that medical students
experience, all contribute to high levels of distress .13

Medical student distress has also been linked to endogenous factors


(personality traits and life events) and to medical students’ perception of the
medical learning environment . Medical studies attract students who may
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have personality traits such as perfectionism, which put them at high risk of
experiencing mental ill-health . Furthermore, it has been found that older
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students tend to experience higher levels of distress throughout their


medical degrees. Despite this, there is very little research into the mental
 

health of postgraduate medical school students, even though many


Australian medical schools offer such programs . 5

Distress caused by the clinical environment

It is known that symptoms of mental distress and dissatisfaction increase


between nonclinical and clinical years . 16–18

The cause of this distress is likely multifactorial, but may be related to the
clinical environment. Both under-exposure to clinical roles, and
unsupported exposure to challenging clinical environments can affect the
mental health of students, and a feeling of being “useless” is commonly
described by medical students in interviews about the transition to clinical
practice . 19–21

Another contributor is the culture within clinical environments, with


bullying, abuse and other forms of mistreatment commonly directed towards
medical students. Experiences of mistreatment can vary depending on the
specialty students are on rotation in, and also the gender and racial
background of the student .
22–24

Students who report frequent mistreatment having a far greater level of


burnout , and even experience symptoms of post-traumatic stress .
25 26

The “hidden curriculum” of medicine - the set of influences that function at


the level of organisational structure and culture including, for example,
implicit rules to survive the institution such as customs and rituals - may
teach students to accept rather than challenge problematic values and
behaviours directed at them . “Teaching by humiliation” has been
27,28

identified as one way in which acceptance of mistreatment and learned


inappropriate behaviours may become inculcated in junior doctors . 29,30

There have been calls to treat medical students as junior colleagues in order
to create a more “nurturing” learning environment, and to implement
policies to try to prevent undesirable behaviours such as bullying 22,31

However, the “hidden curriculum” may also counter positive programs to


prevent sexual harassment and mistreatment, due to ingrained cultures of
bullying, harassment and hierarchy . 22

Clinicians and educators should not assume that perceptions of mistreatment


relate to the sensitivity of individual medical students rather than systemic
problems, with research finding medical students with higher levels of
sensitivity are no more likely to perceive they have been mistreated . 32

For more on bullying and harassment, please refer to the NSW MSC
Policy .
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What creates a mentally healthy environment?

Interventions to improve medical student well-being can take two forms;


either attempting to counteract or balance out the stressful elements of
medical school through programs such as mindfulness training or access to
counselling, or taking a more directly preventative approach and attempting
to alter the source of the stress by changing the environment of the medical
school itself . 34
 

Interventions targeting students

Barriers to young people accessing help-seeking include stigma and


embarrassment, problems recognising symptoms (poor mental health
literacy), and a preference for self-reliance. Targeted, proactive programs to
improve mental health literacy and reduce stigma may later facilitate help-
seeking .
35

Of note, beyondblue found a high level of mental health stigma among


medical students, with more than half of students with a current diagnosis
feeling that doctors with a mental health history are less competent . More
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than 38% of students without a current diagnosis shared this belief, despite
the fact that experiencing personal illness has been found to help doctors
empathise and communicate more effectively with patients ; rather than
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reducing doctor competency .36

There is growing evidence that physically active people are at a reduced risk
of developing depression, and that exercise interventions are associated with
significant benefits for patients with mild to moderate forms of depression
as well as being implicated in reducing anxiety . Thus, there have been calls
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to introduce such physical activity programs for medical students .38

Furthermore, mindfulness based stress reduction techniques, which focus


only on the mental aspects of relaxation techniques, have been found to
reduce stress, and improve mood . As there is growing evidence to support
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these three main stress reducing techniques in the general population, they
are likely to be of benefit to medical students and doctors.

In a study by Slavin, Schindler and Chibnall (2014), the implementation of


resilience/mindfulness techniques within a medical degree were associated
with significantly lower levels of depression and anxiety symptoms, and
stress, and significantly higher levels of community cohesion, in medical
students who participated in a wellness program, compared with those who
preceded its implementation . Such findings are also supported by other
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studies, including one which included the mindfulness program run by


Monash University, Australia. Additional benefits such as increased scores
on overall empathy levels, and improved quality of life were also
seen when mindfulness programs were implemented in medical schools . 39,40

However, a major consideration with such well-being activities is the


scheduling of the sessions. Where possible, they should be timetabled so
that attendance does not intrude on what could otherwise be used as a full
day of self-directed study or a break from medical education altogether . 34

Helping students cultivate the skills to sustain their well-being throughout


their careers has important payoffs for promotion of physician resilience and
personal fulfillment, and enhancement of professionalism and patient care . 41

Since stress predictably will increase in the residency and practice years,
students should be exposed to stress management techniques to help prevent
the known consequences of stress, such as substance abuse and suicide,
among practicing physicians 42.
 

Targeting the medical school environment

One of the most strongly supported, evidence-based interventions is


changing assessment processes from letter grades to pass/fail in the first two
years of medical school. It has been repeatedly found to confer distinct
advantages, including improved psychological well-being and satisfaction,
and increased group cohesion, without any reduction in performance or
ability to obtain highly sought after postgraduate training programs . 43–46

Pass/fail grading also created more time for extracurricular interests and
personal activities, and fostered intrinsic motivation, which is key to self-
regulated, lifelong learning . It has also been argued that acceptance into
44

internship programs should not rely solely on academic grades, in order to


promote well-rounded, mentally healthy graduates . 47

Decreasing contact hours and promoting flexibility of schedules so that


34

students have more control and predictability over their work days are also
likely to have benefits for mental health, while workplace mental health
literature indicates that training leaders and teachers, providing clearly
available assistance programs, partial sickness leave and formal return-to-
study programs, and mental health first-aid training are all evidence-based
interventions . 10

POSITION STATEMENT

The NSWMSC believes that:

1. All students are entitled to study in an environment which is not


detrimental to their mental health.
2. The current medical school environment, both at the university and
clinical level, has characteristics that may detrimentally affect
student mental health. Universities, hospitals and other workplaces
involved in medical student training should take steps to ensure their
environments, structures and processes do not negatively impact
student mental health.
3. Students should be equipped with the skills needed to actively
manage and support their own mental health.
 

POLICY

NSWMSC calls upon:

1. NSW medical students to:


1. Find a trusted general practitioner, particularly if they have
been accepted into an interstate medical school.
2. Assess their own mental health status regularly, take time
away from medical school to engage in activities beneficial
for their mental health, and seek help if need be.
3. Look out for peers that may be struggling, and encourage
them to seek appropriate help if necessary.
4. Be considerate and supportive of one another, and work to
create a collaborative learning environment.

2. NSW Medical Schools to:


1. Consider adopting pass/fail grading for non-clinical years.
2. Create free time in university schedules to allow students to
pursue work, exercise or other activities.
3. Ensuring time-table flexibility and predictability.
4. Ensure that students on placement (particularly in rural and
regional areas) have clear pathways for support that are
independent of their direct supervisors (for example, by
providing a mental health and debriefing hotline 24 hours a
day, 7 days a week).
5. Encourage students to undertake activities outside of the
medical curriculum, that promote a healthy and balanced
lifestyle.
6. Provide clear “return to study” pathways and special
consideration processes specifically for students with mental
illness.
7. Provide mental health first aid training to all students and
staff.
8. Have a dedicated mental health professional to advise staff
who are unsure of how to handle the needs of a student who
reports mental ill-health.
9. Consider providing regular mindfulness or other similar
resilience training as well as physical activity sessions for
students.
10. Adopt the recommendations of the NSWMSC 2016 Policy
on Bullying and Harassment.

3. NSWMSC Executive to:


1. Advocate for further research into the mental health of
medical students, and more specifically those in postgraduate
medical courses.
2. Continue to develop, and implement appropriate and
uptodate resources and policies that support medical
students’ mental health and wellbeing.
 

4. State government to:


1. Ensure staff who work with or are involved in the training of
medical students are adequately trained in teaching, and
using pedagogically proven methods, to ensure a supportive
and productive learning environment.
2. Ensure that students on placement are given appropriate and
clearly defined roles and activities.
3. Adopt the recommendations of the NSWMSC 2016 Policy
on Bullying and Harassment
4. Advocate for random allocation of medical internships in all
Australian states.
 

REFERENCES:

1. World Health Organisation. Mental Health: A State of Well-Being.


World Health Organization; 2014.
2. Patel V, Flisher AJ, Hetrick S, Mcgorry P. Adolescent Health 3
Mental health of young people: a global public-health
challenge.The Lancet.
3. Australian Institute of Health and Welfare. Australia’s Health
2014  : The 14th Biennial Welfare Report of the Australian Institute
of Health and Welfare.; 2014. http://www.aihw.gov.au/publication-
detail/?id=60129547205. Accessed August 9, 2017.
4. Samaranayake CB, Fernando AT. Satisfaction with life and
depression among medical students in Auckland, New Zealand. N
Z Med J. 2011;124(1341):12-17.
5. Beyond Blue. National Mental Health Survey of Doctors.; 2013.
6. Ahola K, Honkonen T, Isometsä E, et al. The relationship between
job-related burnout and depressive disorders—results from the
Finnish Health 2000 Study. J Affect Disord. 2005;88:55-62.
7. IsHak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein
C. Burnout in medical students: a systematic review. Clin Teach.
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8. Andrews B, Wilding JM. The relation of depression and anxiety to
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9. Bore M, Kelly B, Nair B. Potential predictors of psychological
distress and well-being in medical students: a cross-sectional pilot
study. Adv Med Educ Pract. 2016;7:125-135.
10. Harvey SB, Joyce S, Tan L, et al. Developing a Mentally Healthy
Workplace: A Review of the Literature.; 2014.
https://www.headsup.org.au/docs/default-
source/resources/developing-a-mentally-healthy-workplace_final-
november-2014.pdf?sfvrsn=8. Accessed August 9, 2017.
11. Nieuwenhuijsen K, Bruinvels D, Frings-Dresen M. Psychosocial
work environment and stress-related disorders, a systematic review.
Occup Med (Chic Ill). 2010;60(June):277-286.
12. Theorell T, Hammarström A, Gustafsson PE, Magnusson Hanson
L, Janlert U, Westerlund H. Job strain and depressive symptoms in
men and women: a prospective study of the working population in
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13. Dahlin M, Joneborg N, Runeson B. Stress and depression among
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14. Benbassat J. Changes in wellbeing and professional values among
medical undergraduate students: a narrative review of the literature.
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15. Henning K, Ey S, Shaw D. Perfectionism, the impostor
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16. Schwenk TL, Davis L, Wimsatt LA. Depression, Stigma, and
Suicidal Ideation in Medical Students. JAMA. 2010;304(11):1181.
17. Rosal MC, Ockene IS, Ockene JK, Barrett S V, Ma Y, Hebert JR.
A longitudinal study of studentsʼ depression at one medical school.
Acad Med. 1997;72(6):542-546.
 

18. Kjeldstadli K, Tyssen R, Finset A, et al. Life satisfaction and


resilience in medical school – a six-year longitudinal, nationwide
and comparative study. BMC Med Educ. 2006;6(1):48.
19. Radcliffe C, Lester H. Perceived stress during undergraduate
medical training: a qualitative study. Med Educ. 2003;37(1):32-38.
20. OʼBrien B, Cooke M, Irby DM. Perceptions and Attributions of
Third-Year Student Struggles in Clerkships: Do Students and
Clerkship Directors Agree? Acad Med. 2007;82(10):970-978.
21. Cohen D, Winstanley S, Palmer P, Allen J, Howells S, Greene G.
Factors That Impact on Medical Student Wellbeing - Perspectives
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22. Fried JM, Vermillion M, Parker NH, Uijtdehaage S. Eradicating
Medical Student Mistreatment. Acad Med. 2012;87(9):1191-1198.
23. Babaria P, Abedin S, Berg D, Nunez-Smith M. “I’m too used to it”:
A longitudinal qualitative study of third year female medical
students’ experiences of gendered encounters in medical education.
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24. Richardson DA, Becker M, Frank RR, Sokol RJ. Assessing
medical students’ perceptions of mistreatment in their second and
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25. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The
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27. Hafferty FW, Franks R. The hidden curriculum, ethics teaching,
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28. Lempp H, Seale C. The hidden curriculum in undergraduate
medical education: qualitative study of medical students’
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29. Seabrook M. Doctor hierarchy makes it hard to fight sexist or
inappropriate behaviour. Studies in Higher Education.
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to-fight-sexist-or-inappropriate-behaviour-20150407-1mfocs.html.
Published 2004. Accessed August 9, 2017.
30. Seabrook M. Intimidation in medical education: students’ and
teachers’ perspectives. Stud High Educ. 2004;29(1):59-74.
31. Benbassat J. Undesirable features of the medical learning
environment: a narrative review of the literature. Advanced Health
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32. Bursch B, Fried JM, Wimmers PF, et al. Relationship between
medical student perceptions of mistreatment and mistreatment
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33. NSWMSC. Policy - Bullying and Harassment.; 2016.
http://www.nswmsc.org.au/policy.html. Accessed August 9, 2017.
34. Slavin SJ, Schindler DL, Chibnall JT. Medical Student Mental
Health 3.0. Acad Med. 2014;89(4):573-577.
35. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and
facilitators to mental health help-seeking in young people: a
systematic review. BMC Psychiatry. 2010;10(1):113.
36. Woolf K, Cave J, McManus IC, Dacre JE. “It gives you an
understanding you can’t get from any book.’ The relationship
 

between medical students’ and doctors’ personal illness


experiences and their performance: a qualitative and quantitative
study. BMC Med Educ. 2007;7(1):50.
37. Martinsen EW. Physical activity in the prevention and treatment of
anxiety and depression. Nord J Psychiatry. 2008;62:25-29.
38. Bitonte RA, DeSanto DJ. Mandatory physical exercise for the
prevention of mental illness in medical students. Ment Illn.
2014;6(2):43-44.
39. Shapiro S. Effects of Mindfulness-Based Stress Reduction on
Medical and Premedical Students. J Behav Med . 1999.
40. Dobkin PL, Hutchinson TA. Teaching mindfulness in medical
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41. Dunn LB, Iglewicz A, Moutier C. A Conceptual Model of Medical
Student Well-Being: Promoting Resilience and Preventing
Burnout. Acad Psychiatry. 2008;32(1):44-53.
42. Linn BS, Zeppa R. Stress in junior medical students: relationship to
personality. Journal of Medical Education.
43. Vosti, KL, Jacobs CD. Outcome measurement in postgraduate year
one of graduates. Acad Med. 1999.
44. White CB, Fantone JC, White CB, Fantone JC. Pass–fail grading:
laying the foundation for self-regulated learning. Adv Heal Sci
Educ. 2010;15:469-477.
45. Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker
PA. The Benefits of Pass-Fail Grading on Stress, Mood, and Group
Cohesion in Medical Students. Mayo Clin Proc. 2006;81(11):1443-
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46. Bloodgood R, Short J, Jackson J, Martindale A. A Change to
Pass/Fail Grading in the First Two Years at One Medical School
Results in Improved Psychological Well-Being. J Assoc Am Med
Coll. 2009.
 

 
 

This policy was ratified at the NSWMSC Council 3 meeting on October 15th
2017.
_____________________________________________________________
Authored by:
 

Amy Corderoy Audrey Grech


The University of Notre Dame The University of Notre Dame
Sydney Sydney
   

Under the supervision of:

Liam Mason
NSWMSC Advocacy Officer 2017
_____________________________________________________________
Media Contacts:

Liam Mason Ashna Basu


Advocacy Officer 2017 President 2017
NSWMSC NSWMSC
M: +61 432 949 086 M: +61 452 568 694
E: advocacy@nswmsc.org.au E: president@nswmsc.org.au
 

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