Introduction – this newsletter covers student achievements – and some useful reading for us to help us cope with patients with problems we struggle to understand.
In this newsletter:
- Student and Staff Achievements
- Conferences and Events
- Staff Departures
- A personal insight into mental health
- Professors riding bicycles for charity
A state of mind many medical students may identify with especially close to exams – see the piece at the end of the newsletter
Clinical Psychology: Science and Practice. 2001;8(1):98-116.
Student Achievements
Why do we put these in the newsletter? To encourage you all to add to all this!
Treating cancer, keeping fertility:
Claire Grace Scrivener along with clinical colleagues in Cheltenham, Robert Gornall and Philip Rolland, wrote a paper, published in BMJ Case Reports, on an unusual way of treating cervical cancer to preserve someone’s fertility.
http://casereports.bmj.com/content/2016/bcr-2016-214627.full?keytype=ref&ijkey=J7DBtD08lnPqFLX
Well done to her: all should note that University staff and students can now submit papers to this journal free of charge.
Mental health in Doctors
Anna Taylor and others have written a very useful addition to the literature which covers the issues of mental health issues in doctors, especially in GPs.
It addresses aspects of the work in Exploring the barriers and facilitators to help-seeking by GPs: improving access to support. Please see a separate and extended paper later in this newsletter.
Conferences and Events
The annual meeting of ASME took place in Belfast in early in July. As well as many delegates, Bristol medical school yet again showed their strength by this year taking first prize for the best poster (work from Swindon). Work from Gloucester Academy won it last year – excellent work – Chantal Cox-George, an about to graduate year 5 student was a co-presenter. Well done!
Central team – Change of staff
Mr Nigel Rawlinson, previously a consultant in A&E in the BRI and for the past 6 years, Director of Student Affairs, steps down from his role this summer. Nigel will be remembered for a few memorable sayings (landing lights being one of them, see this year’s Clinical revue for all the others). I will be sorry to see him go, and while we look forward to his replacement, for the present, Nigel will still be here as the Lead for the ePortfolio.
How we can all become victims of mental health problems?
Introduction
An incident occurred to a medical student last year. This was quite dramatic and disturbing, and almost life threatening. This short paper describes the impact of this, the student’s attempt and then failure to cope with the effect of it, and their experience of being a patient in a psychiatric ward. The student has given me permission to publish this in the Newsletter to help us all understand the impact of something like this and provide us with some insight into such an episode.
This paper describes the journey from those first 5 seconds of silence after the incident, to why a medical student might then suffer in silence, and a possibly unique description of the experience of a private psychiatric hospital from a medical student’s perspective as a patient. The literature on these themes will be explored, so that medical schools and physicians taking care of medical students may learn from my experience.
Main Body
As medical students and doctors we are expected to be pillars of society – strong, resilient, caring, infallible – and yet statistically we are the most vulnerable to mental health issues. These include depression, anxiety disorders (including generalised anxiety disorder, post-traumatic stress disorder and Obsessive Compulsive Disorder), aswell as substance misuse (including alcohol) and eating disorders. Indeed prevalence of medical student psychological morbidity has been found to be close to 27%, of whom only around a quarter sought help, and 80% surveyed felt that the level of support was either poor or only moderately adequate4.
This high prevalence may be attributed to a number of factors. The first is (and perhaps most relevant) – the possession of the self-selected traits of a caring professional.
The second factor – the widely acknowledged stresses of the medical course, and finally – lack of appropriate help-seeking because of fear of stigmatisation. Indeed, many hold back from presenting because of the perceived fear of being declared unfit to practice by the GMC, simply because of the presence of a mental health issue.
When the fuse does eventually blow – where do we turn? Most of us will have to rely on a heavily overburdened NHS mental health service – waiting between 6 to 18 weeks for psychotherapy – while a few (like me) are lucky enough to have private health insurance. For most, by the time they start therapy, the student concerned may be in a significantly worse state, as well as behind in their studies.
First impressions
After finding it especially difficult to access care in a timely manner, the decision was taken to address my PTSD and resulting depression with concentrated inpatient therapy at a private psychiatric hospital, or ‘wellbeing centre’. This pseudonym was apt since it had much the appearance of a leafy Wiltshire country retreat.
On admission, as I sat awkwardly at the end of the bed as a nurse searched through my personal effects – I contemplated the satire of the situation that might have seemed impossible, almost laughable, a year ago. This procedure was protocol for all patients, however it didn’t make having your knickers searched for knives and paracetamol any less dignified.
The first few days were uncomfortable, and I struggled to adjust to the role of patient. This sentiment was in no way lessened by the fact that to get medication- from citalopram for depression to paracetamol for a headache, one had to line up 3 times a day to a dispensary window complete with paper cups, very similar to that in the book and film ‘One Flew Over A Cuckoo’s Nest’. I understand and accept the reasoning underlying this mode of dispensation, however it does not make the removal of autonomy any less biting.
Furthermore, on the first night, despite prior warning, the 3am observation round was a shock as on hearing the door click open, I observed in my hypnopompic state a dark shadow approach from the corridor to stand over me, dementor-like (the nurse presumably listening for breath sounds). Indeed further on in the week. I was also greatly bemused when a confused, (and unashamedly nude) patient entered and sat on my bed at 1am – however this visit was neither procedural nor invited.
Treatment therapies
Upon settling in, I got to know and interact with the other patients – an extraordinary cross-section of society and of hidden illness and addiction. They included a fellow medical student, stockbrokers, CEOs, housewives, and ex-intelligence agents. I cannot recommend psychodynamic group therapy enough – not only because it has stood up to thorough scientific scrutiny, but through my own personal experience. It is through exploring our own issues – and others offering their own different perspective on our ‘problems’, that we may gain insight, as well as find a great deal of comfort and the impetus for change. By encountering another’s issues that we might perceive not to be a ‘problem’, we may recognise it to be a symptom of a pathology, and thus recognise that our own are also simply a symptom.
Admittedly, at first I found myself surreptitiously privately diagnosing the other residents, whilst following the different stages of alcohol withdrawal in others. Once trained, it is difficult not to notice the first signs of delirium tremens, or the dyskinesia suggesting long-term use of antipsychotics. I developed wonderful relationships with many of them – with such a wealth of life and experience to offer, and the great depth of wisdom and non-judgement that comes with having encountered great personal suffering.
Personally, I had previously encountered CBT in the community and had found NICE-recommended bibliotherapy/computerised self-help therapies disengaging because I always felt I had more pressing study work to do whilst at my desk. In essence I felt ‘guilty’ spending time doing CBT, and in short, I never got round to it. I then found one-to-one delivery patronizing – I did not engage with it because I found it hard to accept that a rational scientific mind could be so vulnerable to self-sabotage. It was only within group delivery, where the focus of the therapist’s attention was shared that I felt more comfortable. This was because I was able to normalise the core concept, by witnessing the manifestation of my peer’s negative automatic thoughts.
One thing this high-achieving cross-section of patients seemed to have in common is the lack of an ability to ‘switch off’- to truly relax and take time for themselves. brings to mind a sentiment expressed by poet William Henry Davies:
“A poor life this if, full of care,
We have no time to stand and stare”
‘Mindfulness’ is a treatment based on Buddhist meditation – by tuning into the ‘moment’. It has a robust evidence base for the prevention of depressive relapse.
Arguably medical students may benefit highly from the acquisition of this ability to tune into what their body and mind is feeling at that current moment. For example, on experiencing feelings of panic or angst about the future when revising for exams, the student may recognise that these are ‘fleeting events in the mind and body that they can choose to engage with – or not’.
The doctor treating the ‘doctor-patient’:
The psychiatrist treating the medical student is a unique relationship, because the student may feel better understood. Indeed the therapist who has experienced medical school may utilise countertransference to yield insight into the student patient’s experience and thus promote empathy. There is minimal literature written about this subject pertaining specifically to medical students, however several authors have encountered several disadvantages. These include excessive intellectualisation by the medical students, fears over confidentiality, over-identification and idealisation both by therapist and student, as well as internal conflict over reporting the student when substance abuse issues are raised.
It is often said that ‘doctors make the worst patients’. BMA guidance states that ‘such patients should be offered the same explanations of what is involved in the investigation and management of their condition. They may be much better informed than most other patients and their special knowledge should be recognised, without assumptions being made about the amount of informational and detail they want’.
My personal experience has been that having somebody non-judgementally fill in the specific gaps (that the wide-ranging medical school curriculum can leave) was a great tool on the road to insight in one’s own experience of a condition. This, combined with being given the room for greater autonomy within the shared-decision making progress produces an efficacious care plan.
Protection of Autonomy
In medical school, students are taught about the Mental Health Act – this outlines citizens’ rights concerning consent, treatment and ultimately detention.
It is there to protect patients from the days where they could be admitted on the grounds of ‘masturbation’, ‘laziness’ or even ‘moral insanity’ simply for wanting a divorce. As part of a curriculum, it is an almost abstract concept – however when you are suddenly on the other side of the gate, it is sharply evident just how important this legislation is.
I noticed a strange dynamic at the weekly community meeting in which patient feedback is given. Never did I think I’d witness the patient (an executive in a multinational company) cowed so quickly by a hospital administrator. The administrator claimed that having a (requested) gym ‘would be too expensive in terms of supervision’ (despite the hospital rate of £800/night). Later, I asked the patients why they had allowed themselves to be silenced so easily, to which they expressed the fear that by rocking the boat, they might compromise their care or even be ‘sectioned’. Despite many of them being highly educated, their lack of familiarity with application of the Mental Health Act law led to unawareness of the actual checks and balances on staff ‘powers’. And naturally, they were unable to cite NICE guidelines advising exercise for depression, nor the awareness that many NHS psychiatric hospitals across the country do indeed have gym and exercise programmes. Unintentional or not, the imbalance of knowledge resulted in potentially poorer care, and an atmosphere of patient deference.
Discussion
Sophocles wrote ‘I have no desire to suffer twice, in reality and then in retrospect’. However, upon looking back I do not feel regret or indeed suffering when I think of that time. I take heart that by sharing at least part of my journey in mental health, I might inspire some encouragement for progress.
At a time of great change for the NHS, when the medical profession is battling against ‘efficiency savings’ being raided from the extension of ‘normal working hours’, might we also stress the potentially negating cost of considerably higher burnout rates and thus sick days? Stressed students are more likely to become stressed doctors who make more mistakes, and have less empathy than their counterparts.
We must bolster preventative measures, and equip students with the tools for resilience to mental health problems. Medical student ‘burnout’ is a state of emotional exhaustion, cynicism and low academic efficacy, which may then lead to sleep disorders. It results from excessive and prolonged stress in the learning environment. Risk factors to ‘depleting the reserve’ (see figure 7) include transition into medical training (first year), beginning of the clinical phase (third year), lack of family support, and bereavement. This predisposes to many mental health conditions including anxiety disorder, alcoholism, depression and/or suicidal ideation.
Stress management programmes have produced promising results in medical schools worldwide, and are advocated by NICE. These promote sleep hygiene and positive coping mechanisms, as well as discouraging maladaptive strategies such as denial and sleeping less to allow for more study time. Mindfulness and teaching ways to reduce self-criticism through CBT has also shown to help ‘top-up the coping reserve’.
Medical students must also be provided with appropriate support when they do develop mental health problems. The capacity for insight is key to keeping safe both the patients they come into contact with, and for their own long-term recovery. Denial is more likely to take precedence over insight, if fear of stigmatization or discipline is present. It is important to equip medical students with the reassurance that the GMC ‘is only concerned when patients are being put at risk; most doctors with mental health conditions are not in this bracket, and as long as the doctor has insight into their condition and seeks help, then the GMC are satisfied. Furthermore, pastoral support should be offered throughout the course, and that ‘those providing pastoral support are not in a position to make decisions on academic progression’. Thus, students are provided with a ‘safe’ point of access to services, and thereafter effective links with external mental health providers.
With the reduction in the stigma of mental health comes increased rates of presentation. Whilst this is a positive thing, it raises the question – surely service providers should be able to recognise and adapt to medical students’ needs? Can the profession (and the system) learn how to look after their protégés in a more specialist or streamlined manner? A high index of suspicion for personality traits such as excessive self-criticism and a tendency to focus on other’s needs before one’s own may aid diagnosis and therapy selection for medical students (especially with regards to group therapy).
Is there a need for specialist training in addressing the unique challenges a medical student or trainee doctor consultation might bring to a psychiatrist. This would encompass the ability to discern ‘burnout’ and monitor for conversion to other morbidity, as well as acknowledge the difficulty of adjustment to the role of patient (particularly in hospital). Indeed the psychiatrist needs to protect him or herself from countertransference and over-identification, and be ‘ethically prepared’ with the clear guidance on reporting of substance abuse in medical students (whilst having warned the medical student at the beginning of the consultation of this exception to non-disclosure).
In order to facilitate this move towards taking better care of our colleagues, the dearth of up-to-date high quality literature concerning the mental health of both medical students’ and doctors’ has to be addressed. Trends in presentation, personality traits, concurrence, preferred consultation style, effective therapies and medical school wellness programmes need considerably more research and planning. Medical students and doctors alike should also be encouraged to write about their own encounters with mental health services.
Conclusion
Through exploring why I stayed silent from the first 5 seconds through to 4 months of suffering with a mental health problem, I have come to recognize that whilst society might no longer brand me ‘mental’, I am apprehensive about how my colleagues might view me in a different light should I publish under my own name.
Medical students are more at risk of mental health problems than other university students due to the stresses and length of the medical course, fear of stigma, and the self-selected personality traits of the caring profession. Inter-professional de-stigmatisation is the crux on which we must build the preventative and interventional strategies in caring for our colleagues. Ultimately, ‘medical students with better psychological and physical health can better handle the problems they face in academic learning’, and so more up-to-date, high-quality research must be done into how we can facilitate this most effectively.
Reflection
Writing this piece leaves me with a sense that things have come full-circle. By this I mean that by admitting that there is a high incidence of mental health issues in our supposedly infallible profession, we may provide a talking point – oiling the wheels of a new machine for normalisation and change.
After suffering in silence for 4 months previously I had learnt that it is stronger to ask for help – and ultimately get better, than to depreciate on one’s own. Through therapy, learning the skills to control this new fear and anxiety, and initially recognising it as ‘other’ rather than ‘self’ and ingrained in the personality, took a long time, however ultimately I have found more peace because of it.
Ultimately, I have learnt to be kinder and more forgiving…. to myself. We hold ourselves up to be ‘the best’: clever, respected, caring, strong, fit, miracle-working, life-saving, infallible, honest, trustworthy, pillars of society. Would you ask a friend to do all of this and then reject him when he failed to meet this standard? No? Then why do you do this to yourself? As one brave F1 doctor wrote – ‘It is often said that you should treat others as you would like to be treated yourself. So why do we doctors treat ourselves differently from those we treat? Perhaps it’s time we took our own advice’.
I wholeheartedly recognise that my experience, is very much a qualitative experience, and its representativeness is limited by the one-person sample that is me. Thus, others may well have had very different experience, however I hope that you will be reassured when I say I have tried to be honest – and express not necessarily what I feel I should say, but what is honest, and therein lies the value.
Finally
Prof David Cahill who fell off his bike 3 months ago and broke his elbow, managed to overcome that and other infirmities by cycling around the Ring of Kerry in Ireland – 180 Km in 10 hours – in support of a Bristol charity, Network Counselling and Training – and you can still sponsor him at
http://uk.virginmoneygiving.com/DavidCahill-KerryCycle
Do you have something to share? Send it to susan.pettinger-moores@bristol.ac.uk