Fourth Year Medicine (Graduate)
Monday, November 5th, 2012
Doctors continue to record significant rates of burn out, stress-related illness, substance abuse and suicide, despite greater awareness of these issues in the profession. [1,2] Whilst improved support services have been a positive move, there are underlying systemic issues that must be addressed within the profession.
Physician distress results from a complex interplay of several factors that include a challenging work environment, specific physician characteristics and other contextual factors such as stigma (Figure 1).  Specific physician characteristics that may make us prone to stress-related illness include the motivated and driven personality types that many of us possess; these are useful in meeting heavy workloads, but can be detrimental in times of distress. When combined with a great sense of professional obligation to patients, an “admirable but unhealthy tradition of self-sacrifice” can ensue. 
Stigma is also a contributing factor, with many doctors concerned about how they will be perceived by others. Common stigmatised attitudes include the fear of being considered weak, concern about registration status and career impact, and the need to appear healthy to patients.  These individuals are less likely to seek help for their illness or to take time off, which can be compounded by the pressure of ‘letting the team down’ when they do. Attitudes such as this develop early on as a medical student, and are often reinforced later in professional practice by colleagues and supervisors. [5,6]
These factors contribute to a culture within medicine of the frequent neglect of preventive health issues.  Commonly, there is a reliance on informal care from colleagues (‘corridor consultations’), and many doctors may self-diagnose and self-treat.  While this might suffice for minor illnesses, during times of serious distress or mental illness, this approach may lead to late or suboptimal treatment and a poor prognosis or to relapse. 
In the past, little effort has been made to promote prevention, wellbeing and appropriate self-care, particularly in the early stages of the profession such as during medical school. Current undergraduate medical curricula focus almost exclusively on the acquisition of clinical knowledge, with a clear deficit in the development of self-care skills and an understanding of the personal challenges of the profession.  This is increasingly evident in new graduates, with 38% of Australian junior doctors recently reporting that they were unprepared for life as a doctor and 17% who would not choose medicine as a career again, if given the choice. 
With a suicide rate up to two and a half times greater than the general population, a culture of self-care and wellbeing in the profession needs to be nurtured to ensure a more resilient medical workforce. [1,5]
So where do we stand?
The doctors’ wellbeing movement has had strong leadership through individual doctors and small groups such as Doctors’ Health Services.  In South Australia, ‘Doctors’ Health SA’ has developed into a fully independent, profession-controlled organisation that acts as a focal point for doctors’ health and provides clinical services in the central business district for doctors and medical students. The program offers comprehensive after-hours check-ups and easier access to a state-wide network of general practitioners and health professionals associated with the program. Similar programs are in development in other states. 
Medical student groups have also played important roles in health promotion and advocacy for student welfare needs. The Australian Medical Students’ Association has focussed heavily on medical student health and wellbeing in recent years, developing policy and resources to support student wellbeing.  Student-run wellbeing events are also now common place at most medical schools around Australia. It is essential that medical educators also play a role in promoting student wellbeing; Monash University has been a leader in this area, with the incorporation of a ‘Health Enhancement Program’ into its core medical curriculum, which aims to teach students about the relevance of mental and physical health in medicine. Further examples of initiatives aimed at students are listed in Table 1. 
Table 1. Summary of interventions to improve medical student wellbeing and health seeking behavior.
|Intervention / Setting||Aims||Intervention||Evaluation||Results|
|Health Enhancement Program
(Monash University School of Medicine)
Evidence level: III-1* 
|Foster behaviours, skills, attitudes and knowledge of self-care strategies for managing stress and maintaining healthy lifestyle, and understanding of the mind-body relationship.||Eight lectures on mental and physical health, mind-body medicine, behaviour change strategies, mindfulness therapies, and the ESSENCE lifestyle program, supported by six two-hour tutorials.||Depression, anxiety and hostility scales of the Symptom Checklist-90-R incorporating the Global Severity Index (GSI) and WHO Quality of Life (WHOQOL) questionnaire to measure effects on wellbeing.||Improved student well-being was noted for depression and hostility subscales but not the anxiety subscale.
|Mental Health in Medicine Seminar
(Flinders University Medical Students Society)
Evidence level: III-3*
|Foster behaviours, skills, attitudes and knowledge of self-care strategies or managing stress and maintaining healthy lifestyle, and understanding of the mind-body relationship.||Half-day didactic seminar discussing epidemiology, stigmatising attitudes, causes, risk factors, signs and symptoms of depression, stress management, and support avenues as a student and physician.||Pre/post intervention survey to assess changes in mental health literacy (knowledge/attitudes towards depression and helpseeking behaviour). Based on International Depression Literacy Survey.||Results pending at time of publication.|
|Student Well-Being Program (SWBP)
(West Virginia Uni. School of Medicine)
Evidence level: III-3* 
|Prevention and treatment of medical student impairment||Voluntary lunch hour lectures (six lectures over six month period) for first and second year students addressing various aspects of wellbeing.||Post-intervention questionairre distributed to 94 students assessing erceptions of depression, academic difficulties, substance abuse, health-seeking behaviour.||Participants who had one or more symptoms of impairment were more likely to feel a need for counselling and to seek help|
|Physician Life-style Management Elective
(Wright State Uni. School of Medicine)
Evidence level: III-3* 
|Enhance the quality of medical student life-planning as a future physician and prevent physician disability.||Voluntary two week elective (lectures) for first year students focusing on physician health, practice management, relationships, and physician disability.||Ratings of each didactic session were collected from seventeen first year medical students.||Students rated sessions on the residency experience highest followed by assertiveness training, then by emotional health management.|
(Case Western Reserve University School of Medicine)
Evidence level: III-3* 
|Provide students with information on wellness, stress reduction, and coping strategies.
|Series of six, weekly lectures from medical and allied health professionals on wellness, coping strategies and stress reduction.||Evaluated via essay review and a questionnaire administered after the elective concluded.||Participants reported that the elective helped them realise the importance of personal wellbeing, self-care, and provided a variety of coping strategies.|
(Indiana University School of Medicine)
Evidence level: III-3* 
|Promote positive health habits and emotional adjustment during students’ first semester via selfawareness and self-care interventions.||Lecture, written information, and group discussions on emotional adjustments, sleep hygiene, substance use and recognition/ management of depression and anxiety.||Survey assessing patterns of sleep, alcohol consumption, depression, exercise, caffeine use, satisfaction with teaching, social life, physical health, emotional health, finances, time management.||Promising effects on patterns of alcohol consumption, exercise and socialisation.
Influenced some sleep and exercise behaviours, but not overall emotional or academic adjustment.
*National Health and Medical Research Council levels of evidence. I: Systematic review of randomised controlled trials. II: One properly designed randomised controlled trial. III-1: One well designed pseudo-randomised controlled trial. III-2: Non-randomised trials, case–control and cohort studies. III-3: Studies with historical controls, single-arm studies, or interrupted time series. IV: Case-series evidence
Sadly, the doctors’ health agenda is still lacking within our hospitals, particularly for junior medical staff. Hospitals remain challenging places to work for interns and residents, with variable levels of support from the institutions. Administrative or support staff such as medical education officers may be asked to consider doctors’ health issues, but usually as an add-on to their daily roles, rather than as a core component of it. This has led to a sporadic approach towards junior doctor health, with the level of support dependent on individual clinical training staff. The Queen Elizabeth Hospital (SA) has a unique support program for interns, which incorporates five wellbeing sessions throughout the year as part of the weekly education schedule; however, this remains the exception rather than the rule.
For doctors’ health to move forward, it needs to become a mainstream workforce issue within medical education, training and practice. Leadership across each of these areas is important so that we can begin to implement systemic initiatives to facilitate resilience in doctors. One key area of focus should be greater mentoring and peer support, particularly within hospitals. [10,11] Whilst junior medical staff currently work fewer hours than in the past, this has also resulted in less ‘living in’, and reduced opportunities for peer support. Doctors’ common spaces, once typical places for medical staff to debrief with colleagues, are also the first areas to be expended within hospitals looking for more administrative space.
Health promotion also needs to occur across the learning and professional continuum of medical practice. It is essential that medical students and junior doctors are targeted, as this seems to be the time when an acceptance of self-treatment and stigmatised attitudes become entrenched. With a greater awareness of these issues amongst the next generation of doctors, we can gradually shift the culture within the profession. Whilst this is difficult and many of us are set in our ways, it is incumbent upon all of us to have a vision of a medical profession that is strong, vibrant and resilient.
Tips for those who are struggling
Don’t be afraid to tell someone; struggling in medicine is more common than you think.
Don’t rely on alcohol or other drugs to cope. This can have a brief mood-lifting effect but can later cause feelings of depression or anxiety.
Try to eat a healthy diet and stay active.
Keep connected with other people, including a support network outside of medicine.
Seek help early from a friend, teacher, doctor, or counsellor. All states and territories now have specific health services for doctors and medical students.
Conflict of interest
M Nguyen: firstname.lastname@example.org