Why medical students’ mental health is a taboo subject
Why stigma and misconceptions persist
Mental health problems such as eating disorders, anxiety, and depression are common and affect many medical students. However, while medical schools have a duty to provide support for students with these illnesses, a combination of stigma, fear, and misunderstanding often prevents students from coming forward to ask for help. We take a look at current attitudes towards mental health at medical school and some of the misconceptions that stop students from asking for help.
Although as many as one in four adults in the United Kingdom experiences mental ill health during any given year, mental illness has always carried a stigma that physical illness does not. In part, this comes from the invisible nature of the illness, which is less apparent to the observer than a broken leg or a respiratory infection.
Also, a degree of fear is attached to some types of mental illness, such as schizophrenia. With more common illnesses such as depression or anxiety, there is a tendency to blame people for being unable to manage everyday stresses. These attitudes seem to be changing, albeit slowly. An ongoing survey by the charity Time to Change, which began in 1994, shows that attitudes to people with mental illness have become more favourable and understanding of mental illness has improved. For example, 92% of people in the 2013 survey said they believed that “virtually anyone can become mentally ill.”
You might think that students choosing to study medicine would be less likely to attach stigma to mental illness than the general population. However, some people think that the stigma is even stronger among medical students.
Amy Boyle, a second year medical student at Queen’s University Belfast who had an episode of depression in her first year, said: “We’re supposed to treat the sick, not be sick ourselves. A lot of it comes from the profession itself—doctors are seen as infallible; they’re OK doing twelve or fourteen hour shifts.”
Damien Brown, a fourth year medical student at Barts and the London, said he found it hard to ask for help when he was diagnosed with depression. “If you know something is wrong, but it’s not like a physical trauma . . . it’s not as acceptable to get help for mental illness. We keep saying and we all know as medical students that it’s just as bad as a physical illness, but still there’s that stigma attached and we still feel it.”
So what is it about medical school that perpetuates the stigma of mental illness?
Medical school culture
Research into the wellbeing of medical students at schools in the United Kingdom by Debbie Cohen, senior medical research fellow at the University of Cardiff, found that the culture at medical school is dominated by what she called the “hidden curriculum.”
She said, “It’s the way doctors believe and expect students to believe that we’re invincible, we can’t get ill.” Her research showed that a change of culture would have the biggest impact on wellbeing of anything that medical schools could change (D Cohen, personal communication, 2012). “We’re not very forgiving of students who are ill,” she observed.
Some students believe that another fundamental problem may be the competitive and perfectionist nature of medical students themselves.
“A lot of people on the course have very high expectations of themselves, a perfectionist attitude. We want to do well, be the best, do well in exams. But when you have to take time out because you’re not well, that’s seen as weakness. It mars the hero image,” said Boyle.
Anyssa Zebda, a second year student at Manchester, said the competitive environment would be a barrier to many people. “Right away in the beginning of medical school you are made aware that the people surrounding you are not just your peers, but competitors and future colleagues. You’re building relationships that will matter later in your career.”
She added: “Medical students tend to have a perception of themselves to be indestructible. They expect a lot of themselves and can’t have any weaknesses. If a student does feel they are struggling, they are less likely to seek support because they don’t want to seem weak. They question themselves about whether they can cope with the course.”
It’s a culture that Twishaa Sheth, joint deputy chair of the Medical Students Committee of the BMA with responsibility for welfare and a third year student at Nottingham, is trying to change.
“We know it’s a problem. We’re trying to reduce the stigma and increase the support and awareness of the support,” she said. “Because of how competitive and difficult it is to get in, you’re surrounded by very confident and outgoing people and can feel everyone around you is coping fine. That’s a big reason people are not too keen on speaking out.”
There’s another major reason why student medics don’t seek help for mental health problems, however, and it stems from a common misunderstanding of the consequences of disclosing this type of illness.
Fitness to practise
In its document Supporting Students with Mental Health Conditions, the General Medical Council (GMC) states: “In almost every case, a mental health condition does not prevent a student from completing his or her course and continuing a career in medicine.” It goes on to say: “If you engage with your medical school and ask for support and follow the advice given, then there will be no need for a fitness to practise committee to be involved.”
So why do so many students fear that disclosing mental illness to their medical school will end their career? Sheth admitted it was “a huge issue” for many students. “It is important to realise that it’s only in rare or unusual situations that the GMC can get involved,” she said.
Boyle said that when she disclosed her depression to a close friend, he told her: “You can’t tell the university anything about this.” She said: “That was my worry, my fear. In the first year we heard so many horror stories of doctors in front of the GMC, doctors taken away from work because of illness. If you have very, very severe mental illness that makes sense, but something like anxiety or depression . . . that’s completely wrong.” She spent her first year saying nothing “because of fear of the GMC.”
Finally, her father found the GMC guidance online. She subsequently spoke to her tutor and was referred for support and guidance. She believes that the GMC guidance should be given directly to every medical student when they start their career and that medical schools have the responsibility to ensure students know about it.
Part of the confusion is that there is not always a clear demarcation between medical school staff with pastoral roles and those who rule on fitness to practise or disciplinary issues.
“Sometimes the people dealing with mental health concerns and disclosure are the same ones doing fitness to practise. That’s contrary to guidance and something we’re working on in terms of making sure it doesn’t happen,” said Sheth.
One medical student, who did not want to be named, said this had been a major disincentive in her case. “Often the support staff are also disciplinary staff and at the beginning I felt I couldn’t be open and honest about how much I was struggling. I held back quite a lot. It needs to be very distinct. I found it very hard to feel free to tell them my worries,” she said. However, once she had found the courage to speak up “they were all very, very supportive and understanding, and that did help.”
The GMC guidance is clear on the need to separate the functions. “It is important that those providing pastoral support are not in a position to make decisions on academic progression. This separation of function allows students to have a safe environment in which they can raise concerns without worrying that there will be any impact on their academic progression,” it says.
Medical school responsibilities
The guidance, which was published jointly by the GMC and the Medical Schools Council in 2013, does not just deal with pastoral care. It sets out a range of responsibilities for medical schools, among them the responsibility to create an environment where mental health is openly discussed, stigma is reduced, and good mental health is promoted.
The guidance says schools should explain that “mental health conditions are common in medical students” and should ensure people know that support is available and mental health conditions rarely prevent a student from becoming a doctor. The guidance also says medical school staff should maintain clear confidentiality guidelines and should encourage students to seek appropriate support.
All schools should be able to refer students to an occupational health service with experience of the specific pressures of medical study, it says. Occupational health physicians can advise students and medical schools about what supportive measures need to be in place to help students to recover from their illness and complete their studies. The medical school is legally required to provide reasonable adaptations for students with any long term disability that could have a significant impact on their career.
It seems that attempts to combat stigma and banish fears about seeking help have some way to go. However, once students have disclosed their illness, many schools have good support in place, although experiences are mixed.
Boyle said she had benefited from advice from the student guidance centre and disability services team at Queen’s. “They really helped me and offered me a lot of support. Sometimes you have to ask for help to be given help,” she said.
Specific adaptations included being able to sit exams in a smaller room with five or six other students, working in cubicles, rather than in a big, open examination hall. “That really took the anxiety away for me,” she said. “I haven’t needed to take time off, but that can be accommodated. They offered me time if I needed to take a year out and you can get out of class for counselling or medical appointments.”
However, she found just having disclosed her illness was a relief. “It was a help just knowing that someone actually knows what’s going on. That was reassuring,” she said.
Brown withdrew from Cambridge, his first medical school, because his depression had made it impossible for him to attend. He later reapplied and was accepted on to a course at Barts and the London. He disclosed his illness in his application and received regular support as a result. Consequently, he has been able to contrast the support given at the two institutions.
He said that one major difference was that he was discouraged from taking time off to recover from his illness at Cambridge, while Barts has a policy that students should take time off until they are better. “I wish I had been advised to take time out to get better, rather than being pushed forward. I think I could have got through a lot better, rather than having to withdraw myself. I would be qualified by now,” he said.
And Cohen says that medical students are sometimes faced with “mixed messages” when they do try to seek help, such as lecturers discouraging them from missing lectures for medical appointments or insisting they provide medical certificates. “There is a lack of clarity and transparency, no clear pathway for seeking help,” she said.
The GMC document gives a number of examples of ways that medical schools can be proactive about ensuring students know what help is available to them. These include:
- Offering peer support, where students are trained to provide help and advice about dealing with stress. Some students find it easier to talk to peers initially, rather than going straight to staff
- Lectures and courses early on in medical school to educate students about mental health and how to access support services when they need them
- Proper training of staff in pastoral care positions, so they know when and how to refer students with mental health problems, and how to recognise them
- Provision of counselling and psychological support services through the university or medical school, which can take self referred students or those who are referred by staff
- Monitoring of students’ performance, so that those whose academic performance gives cause for concern can be asked about potential problems with health or personal or family life.
In addition to her academic role, Cohen is director of the Medic Support Programme at Cardiff University School of Medicine, which is cited as an example of best practice by the GMC. The programme allows students to self refer if they are having problems or to be referred by staff. She said numbers had “more than doubled” in the past couple of years, and they had seen 70 students in the period September 2014 to February 2015.
Students are seen by trained case managers who can liaise with external agencies on their behalf and help them access the medical care they need, as well as act as intermediaries with the university. All medical students are given a wallet card at the start of each year with contact details for the service and also for a mentor support service which can help with less serious problems.
However, she said, the service cannot operate in isolation if the medical school is not supportive. “We train all the staff and tell them that if they see somebody struggling, the first thing you do is suggest they get help.” The school has also separated academic support roles from personal support, so that staff who provide one type of support cannot provide the other.
As Boyle put it, “Having a mental illness and being a doctor is OK.” The message is that students who come forward and ask for help with mental health should expect to receive support and help, not censure.
“It’s natural to feel stress. It’s common and expected. It’s not a weakness to ask for help.” Medical school is there to support you,” said Sheth. “It can sometimes feel like they are there looking for ways to penalize or that they are ‘out to get you.’ But they have a duty to support you and produce a doctor out of you.”
It’s a message that medical schools need to ensure their students hear, to prevent much unnecessary suffering and anxiety.
Mental health myth busting
“If I have a mental health condition, it will damage my career prospects.”
Mental health conditions are common in the general population and commonly occur in doctors. Legally, employers can’t discriminate against you if you have a mental health condition.
“If I tell my medical school that I have a mental health condition, the GMC will automatically put me in their fitness to practise procedures.”
This should not be the case. If you engage with your medical school and ask for support and follow the advice given, then there will be no need for a fitness to practise committee to be involved.
“Once I’m a doctor, if I have a mental health condition the GMC will automatically put me in their fitness to practise procedures.”
The GMC is only interested when a doctor’s mental illness puts patients at risk. The vast majority of doctors with mental health conditions are not a risk to patients. If a doctor understands their condition and seeks appropriate support, the GMC does not get involved. The GMC never removes doctors from the register solely because they have a mental health condition.
“Seeking help is seen as a sign of weakness.”
Seeking help is the strong thing to do. It is also the right thing to do. Your medical school has systems in place to support you and they want you to do well.
“I can never take time out from my studies.”
Medical students can and do take time out from their studies. If you are concerned, you should ask your medical school for advice.
Extracted from GMC: Supporting Students with Mental Health Conditions, 2013.
Sources of help
- The Doctors Support Network is a charity set up by doctors with experience of mental health problems to support others in the same situation. It has an online support forum for student members and points to some useful resources—www.dsn.org.uk.
- The BMA Counselling Service is a 24 hour confidential support line for doctors and medical students with immediate access to trained counsellors —tel 08459 200169.
- Money4MedStudents, run by the Royal Medical Benevolent Fund, provides practical advice on finances for medical students—www.money4medstudents.org/.
- University Nightline is a student run listening, support, and information service, covering many universities—see nightline.ac.uk to see if your university is a member.
- Your general practitioner: all students should be registered with a general practitioner and this should be your first port of call if you are worried about your mental health. They can start treatment and refer you to other services if required.
- University or medical school personal or pastoral tutors: all students should have access to a tutor who can provide personal support. The GMC says this should be clearly separated from staff with academic support responsibilities.
- The Samaritans offer a 24 hour service to anyone who wants to talk through their difficulties in confidence. You don’t have to feel suicidal to get help—www.samaritans.org/ or call 08457 90 90 90.
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Mental Health Foundation. Mental health statistics. 2001. www.mentalhealth.org.uk/help-information/mental-health-statistics/UK-worldwide/.
- Time to Change. Attitudes to mental illness. 2013 research report. 2014. www.time-to-change.org.uk/sites/default/files/121168_Attitudes_to_mental_illness_2013_report.pdf.
- General Medical Council and Medical Schools Council. Supporting medical students with mental health conditions. 2013. www.gmc-uk.org/Supporting_students_with_mental_health_conditions_1114.pdf_53047904.pdf.
- British Medical Association. Reasonable adjustments for disabled students and doctors in training. http://bma.org.uk/practical-support-at-work/doctors-well-being/reasonable-adjustments .
Cite this as: Student BMJ 2015;23:h722