Dealing with stress

It is not easy being a medical student. Medical students have a notoriously large quantity of work. They study and live on borrowed money for a longer time before earning compared with students on other courses. During a medical degree students are constantly evaluated by peers and superiors and must come to terms with death, disease, and complex ethical issues. Some students bottle up their problems so that they appear to be coping. And many have to take on extra jobs to make ends meet.

The burden of these stresses can be multiplied in the face of personal problems. In addition they are entering a profession that has higher rates of mental illness, drug and alcohol dependence, and suicide than the general population.^w1 Perhaps the most worrying aspect of all of these observations is the fact that doctors seem to acquire patterns of health behaviour at medical school.^{w2 w3}

Perhaps the strategies that students use to cope with stress at medical school are responsible for the greater prevalence of mental health problems later in their career. To improve the health of doctors, therefore, it might prove feasible to target the health of medical students.

Where do students seek help?

Improving the general health care of students is not simple. Research shows that students, especially of medicine, tend to seek help through unorthodox channels.^{w3 w4} They are more likely to seek informal advice from family and friends. In addition they have high rates of self diagnosis and self medication with psychotropic drugs. Many students are young and have recently left home and are experiencing new stresses in their lives.

The first step towards getting help is realising that there is a problem. Many things can represent a problem: difficulty understanding parts of the course; not getting work in on time; financial difficulty when it is time to pay a bill; relationship difficulties; family commitments; or constant low energy. It is all too easy to think that everyone has these problems and that they just cope with them. But how much do these problems really affect you? Everyone has their own coping strategies, and perhaps you have not tried a strategy that would help you. British medical students are fortunate to have a variety of sources of help available to them.

What do medical schools offer?

A first point of call at a UK medical school might be the student office. One senior member of medical staff is likely to be assigned to the welfare of students, and many medical schools assign a tutor to each student who is starting the course. These members of the department know the sources of help available, whether it is work related, financial, or psychological.

You might consider simply contacting the most approachable member of staff even if they are not formally associated with welfare. He or she was once a student too and will have access to similar resources as the staff member responsible for welfare.

Every medical school has a students’ union, which has a welfare contact who provides an alternative route for help. The union and medical school are in contact with the welfare and counselling services of the university, which is often the best placed to get practical advice. Many charities, hardship funds, and religious and social groups can help students, and the university’s services will know which ones are most appropriate. To find sources of help try typing the name of your medical school or university and “welfare” into an internet search engine.

National organisations can offer an alternative approach to gaining help. Many of these were mentioned in a recent article in the Student BMJ (box).^w5 Other rich countries have similar sources of help, which can be found using the internet. Resources available in poor countries are of mixed quality. In Nigeria, for example, there are reports of effective student counselling,^w6 whereas in Mozambique a study from 1998-9 makes no mention of support for student welfare despite “dismal” academic performance.^w7 Only the students in these countries know the true level of support, but it seems that many medical students in poorer countries do not have as much access to local and international help as in the UK.

Despite these services the mental health of future doctors still falls below that of the general population.^w1 Encouraging students to seek help rather than to rely on self help may improve the health of the medical population in all countries.

Extra support from peers

Several medical schools in the UK run informal peer support groups under a number of guises. A specific example is the “buddy system,” in which advanced students support new students. These groups provide an extra avenue for new students to seek help, but the students providing support are rarely given formal training, and the system often encourages social networking.

A more sophisticated peer support service involves either one student overseeing the whole medical school or one student in each year. They receive brief training from the university counselling service, which focuses on knowing what services are available within and outside the university, the quickest way to get support, and when professional help is needed in serious situations.

The student advisers are often a similar age to their peers and experience similar problems. The adviser may act as a direct source of information but most importantly they coordinate the needs of students who need help. They can promote the acceptance of seeking help from other people, especially other healthcare workers, and reinforce the need to recognise problems before they become serious stressors.

Reaching out

An important job for the peer adviser is to reach out to students who are most at risk of concealing their problems. One way is to run weekly open sessions, as many UK course tutors do, which offer a listening ear and perhaps even academic help with work. This identifies students who are struggling, which may be a signal for stresses in other areas of life.

In addition, the adviser can show the entire student body that it is possible for students to get time off the course or opportunities to resit exams, for example, without blemishing their record, which is available in some situations in UK medical schools. This might encourage students to seek help and find coping strategies as soon as possible, breaking the cycle of students coping alone in progressively increasing situations of stress.

Could you set up a scheme?

Only a few universities have this kind of peer support scheme, and it might take action by individual students to set up such a project. This type of scheme organised by students could work anywhere in the world, even in countries that lack structured support. Student advisers could investigate local and national sources of help and tailor their advice based on these and ethical and religious beliefs.

Interest in such a service was great in a recent cross sectional study of final year medical students at University College London, which currently has no such scheme (unpublished data). Some respondents claimed to have not sought help despite feeling stressed. A peer led service would hopefully emphasise that it is acceptable to seek help, even informally.

You are not alone

A simple and cost effective peer led service in all medical schools would complement the help already available. This might improve the mental health of medical students and, therefore, future doctors. The most important message to any medical student who feels any degree of problem is that they are not alone.

Without the help of several other medical students this work would not have been possible. We thank Neil Halliday, Anna Hourmouzios, Esther Hullah, Gila Milner, Laura Mindel, Sarah Mohamed, Victoria Mulcahy, Rebekah Nasta, and Marianna Turner.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

   

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