Physicians’ Mental Health: Is It Possible to Tackle the Problem throughout Academic Education?

Abstract

Changes over the years require adaptation to thrive in today’s academic and professional scenarios. Teachers of future healthcare professionals face new challenges daily, like artificial intelligence and its impact on learning, helping young students to keep focused, using the best available data and good teaching/learning resources, making evidence-based decisions. As new demands arise, some of the old ones are still present, challenging students, teachers, and professionals. When it comes to medical education, learning how to deal with professional’s mental health is still an issue. This chapter aims to discuss strategies to improve physicians and medical students ‘abilities to cope with stress and mental health issues, and its impacts on their life and on the lives of their patients and families.

1. Introduction

Science and technology develop fast, and it is possible to encounter something new almost every day. Perhaps one of the latest technological developments is the application of Artificial Intelligence to healthcare services [1]. Keeping up to date is no easy task, and time and energy consuming but fortunately as soon as something new is launched there are studies in the area applying and assessing its use and its impact [2]. A high-pressure working environment, long hours on the job, limited resources, restricted autonomy, and several other obstacles and dilemmas, may turn physicians more vulnerable to high levels of stress, burnout, and mental disorders [3, 4, 5].

Being a physician is considered a rewarded and sought-after profession. But there are stressors associated with medical education and the practice of medicine that raises concerns about medical students and physicians’ mental health. And those concerns increased after COVID-19 [5, 6, 7, 8, 9].

High levels of stress, burnout, suicidal ideation, and suicide have been frequently reported among medical students and physicians, leading organizations from different countries to issue “calls to action, demanding a greater focus on physician mental health within training programs, workplaces, and health service more broadly”. Beyond the concern about professionals’ mental health, several studies have shown its negative impact on patient care (e.g. medical incidents) [5].

Any mental disorder may affect medical students and physicians, but depression and anxiety are the most prevalent. A German study among first year medical students [10] identified a prevalence of 4.7% of major depression, 5.8% of depressive symptoms, 4.4% of anxiety symptoms, 1.9% of panic disorder, and 15.7% of psychosomatic complaints. Although these results were higher than those of the general population, medical students fared better when compared to those on advanced medical training (e.g. residency. The same study also identified that 10.7% of the first-year medical students used psychotropic substances regularly, 5.1% used medication for anxiety, 4.6 to improve sleep, 4.4% for depression and 3.1% to improve cognitive performance.

A systematic review and meta-analysis estimated a prevalence of 28.8% of depression or depressive symptoms among residents [4]. A study with Dutch physicians showed a prevalence of 42% of work-related fatigue, 29% of depression, 24% of anxiety, 15% of PTSD (Post-Traumatic Stress Disorder), 15% of stress complaints and 6% of burnout [11]. Those numbers are situated above the prevalence observed in the general population [12].

Anderson et al. [13] analyzed data from Dutch medical school applications to assess the association between becoming a physician and the use of prescription drugs and receiving mental health treatment. The authors concluded that “becoming a physician increases the use of antidepressants, anxiolytics, opioids, and sedatives” and that the use is larger among female physicians.

Since the prevalence of stress, burnout and mental disorders is high among medical students, residents, and physicians’, data from several studies and organization emphasize the need for prevention at the beginning and during medical school [3]. This shows that something must be done to tackle the problem [14].

Even though the burden of mental illness in medical students and professionals has been an issue for a long time, not enough has been done to improve the situation. This raises a few questions about the topic. Is this a problem inherent to the profession? Is it related to the work context, like long hours, high pressure on the job, life and death decision making, high responsibilities and little room for error? Is it possible to help medical students and physicians to better cope with the problems associated with the practice of medicine?

Mental health problems are not inherent to studying and practicing medicine but related to other variables as well. Studies about burnout among health care professionals show that many other variables have a significant role when it comes to this, and workplace is an example. Physicians working in hospitals (inpatient settings) are more vulnerable to mental health problems than their colleagues working in outpatient settings [15]. Also, when it comes to COVID-19, frontline workers showed higher prevalence of burnout when compared to second line workers [16]. Besides workplace, other variables were associated with high levels of burnout, like administrative tasks, harassment at work, sacrifice of personal time and regretting decisions regarding patients [17].

It is safe to say that seeking mental health is an issue when it comes to healthcare professionals. Braquehais and Vargas-Cáceres [18] pointed several reasons that preclude those professional from seeking mental health care. The most frequent ones are related to an increased sense of invulnerability, perfectionism, a proneness to trying to cope alone, insecurity and stigma related to mental distress and fear of licensure problems when facing a mental health condition. Although there are some difficulties, not seeking help could pose a higher threat to both professionals and patients.

Treating mental health problems is possible and should be done, but there is also need for prevention. Preventing these problems and teaching students and physicians how to deal with them could be a better solution on the long run. A recent study among Portuguese medical students found that adaptive coping, academic engagement, and social support were inversely correlated with the intention of dropping out of medical school. The study also concluded that burnout was associated with lack of social support, depression, anxiety, stress, and non-functional coping strategies [19]. This is very promising since it shows a few variables to look for and to try to develop throughout medical school.

When it comes to medical education there are a few struggles that need to be addressed. A qualitative exploratory study [20] highlighted emotions, academic and family related problems as the main themes that undergraduates were struggling with. Emotional problems, for example, were related to conflict with friends. Time management was associated with academic problems when living with the family (e.g. distractions, such as guests). Interesting enough, this study shows that, unlike previous ones, the increased workload and highly demanding nature of medical education were causing less stress among students than family related problems. This suggests that social skills development, emotional regulation and adapting to certain contexts may be more important than previously thought and highlights the importance of developing these skills to solve such problems.

2. How to improve medical students and physicians ‘mental health?

To help students cope with many problems faced throughout medical school and to prevent future mental health issues among physicians, there are a few programs that deserve attention.

2.1 Mentoring

Mentorship or mentoring programs in medical education date from the early 1990s. Their aim is to provide medical students with research opportunities, advice on career decisions, and to facilitate personal and professional development [21].

Mentoring aims to support, guide, and help students through a relationship with a mentor. A mentor is usually someone with more experience (e.g. a professor) that may help and guide the mentee (medical student) through different situations, such as: career development, interpersonal difficulties, personal and professional growth, and other issues [22, 23].

Although the term mentoring may be used in different contexts and with different meanings, its role during medical education may be better understood by Johnson’s definition [24]: “Mentoring is a personal and reciprocal relationship in which a more experienced (usually older) faculty member acts as a guide, role model, teacher, sponsor of a less experienced (usually younger) student or faculty member. A mentor provides the mentee with knowledge, advice, counsel, challenge, and support in the mentee’s pursuit of becoming a full member of a particular profession” (p. 23).

Using a qualitative approach, the strengths, and fragilities of a group mentoring program from a Brazilian medical school were assessed with mentors and mentees [23]. The strengths included: creating bonds between group members, the possibility to express feelings in a safe and welcoming environment, benefits for mentors (e.g. empathy for students) and mentees, and a space for integration. Fragilities were time management for group meetings, initial themes or triggers at the start of the meetings, and sometimes difficult integration between group members.

A systematic review on mentoring programs from a global perspective are presented on Table 1.

Main goals: Professional development. Emotional well-being. Psychosocial support. Exposure to specific fields of medicine.

Strategies for pairing mentors and mentees: Medical school faculty or physicians and students. Junior to more senior medical students. Combination of peers and faculty.

Type of meetings: One-on-one meetings. Group mentorship. And less frequently remote meeting.

Students/mentees perceived benefits: Social/personal support. Professional development. Advice on career. Advice/help on choosing a field. Increased relationship and technical skills. To better understand clinical culture. Opportunities for research. Enhanced self-confidence. Improved well-being. Possibility of scientific publications. Better grades. Improved skills to prepare for exams. Better satisfaction with rotations.

Mentors perceived benefits: Relationship with students and next generation of physicians. To be able to provide support. Opportunity to become a better teacher and to improve interpersonal skills. To stay up to date on the profession. To be able to support a career. To improve his/hers CV (Curriculum Vitae). To help students build confidence.

Table 1.

A global perspective on mentoring in medical school [21].

A mentoring program can be implemented in different ways and many aspects should be considered when doing so. How should the mentor and the mentee be matched? Should it be random or based on certain characteristics of the mentee, like personal interests, career goals and so on? Who should the mentor be (staff physicians, peers) and how should he/she be recruited (volunteer basis, invitation basis)? Should the mentor have special training? What are the program goals (career development, scholarly activities, provide psychosocial support, etc)? What is the mentee-mentor ratio? Taking all this into consideration might help jump start the program [23, 25].

Mentoring can be a way to develop skills and help students manage personal and emotional challenges related to work, uncertainty and changes. There are also other programs that help develop these skills such as coaching training [26]. According to the authors this model has been used at the Imperial College (London) and Harvard Medical School “to enhance self-directed learning approaches and person-centered conversations with patients” and “emphasizes the value of setting personalized goals, exploring the wider context such as barriers and enablers, identifying options and planning next steps” (p. 1308).

2.2 Emotional regulation

Emotional Regulation is the ability to respond to emotions in an adaptative way, and includes awareness, clarity and acceptance of emotions. It is defined as “the process by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” [27] (p. 275).

Medical students and physicians are frequently exposed to situations that arouse intense negative (e.g. death, patient suffering) and positive emotions (e.g. empathy). A study with medical students [28] explored emotions (e.g. shock, anger, stress) elicited by critical incidents (e.g. patient suffering, patient dying, interaction with doctors) and how students used emotion regulation strategies. Examples of emotion regulation strategies included inaction (doing and saying nothing), trying to comfort the patient, denial, focusing on a task to avoid the emotion, reappraisal, and distancing from the situation. Reports of negative incidents were more frequent (e.g. suboptimal patient care, mistreatment) as were negative emotions (e.g. shock when facing a patient in a serious condition). Suppressing emotions is a common yet maladaptive strategy. Although it may be “a pragmatic short-term survival strategy, the long-term consequences - for doctors, for patients, and for the wider healthcare system – are potentially grave” (p. 8).

Teaching or training emotional regulation is a well-known practice to help enhance students and professionals’ motivation and well-being [29]. There are several programs to improve emotional regulation, such as the Adaptive Coping with Emotions (ACE) Model, the Affect Regulation Training (ART) [30] and the DRT Skills Training Manual [31].

One strategy to help dealing with difficult emotions is TIP (Temperature, Intense exercise, and Paced breathing). One way of using temperature when dealing with difficult emotions is submerging the face in a bowl of ice-cold water to help calming down fast. Dispending high levels of energy in an intense bout of exercise has the same effect. Paced Breathing is another important mechanism to calm down and could be done almost everywhere: breathing deep into the belly and then slowly exhaling can have a calming effect (important to remember to exhale slower than inhale) [31].

Training emotional regulation is something that may be done in academic contexts with reported benefits [32]. A Social and Emotional Learning program with adolescents showed improvements in communication, decision making, problem-solving skills, emotional regulation, and resilience [33]. Emotional regulation was also studied with nurses. Donoso [29] concluded that nurses with higher emotional regulation had higher motivation to work and reported higher well-being at home when facing high emotional demands. Another study with physicians and residents showed that higher levels of self-regulating abilities are associated with higher levels of psychological well-being, suggesting that nurturing self-regulation skills could be a way to help residents and physicians to deal with the demands of their medical profession [34].

Emotional regulation is necessary during medical education, since it impacts clinical reasoning: “positive emotions in medical students are associated with a reduction in cognitive biases and more precise approaches to clinical reasoning. In contrast, anxiety and stress are associated with impaired working memory and immediate recall, subtle changes in clinical reasoning, and impaired technical and clinical functioning” [35] (p. 6).

Although emotional regulation training is a necessary and promising area, more research in academic contexts, like medical schools, are necessary.

2.3 Communication skills

Effective communication skills should be a core component for all healthcare professionals training. Several organizations, like the World Health Organization [36] emphasize good communication as a fundamental skill in order to offer good quality healthcare. Physicians should be able to stablish good quality relationship with patients and families to effectively gather relevant information (e.g. to aid diagnosis), to provide information concerning treatment option and adherence, and general interactional skills, like empathy, professional etiquette, and time management [37, 38, 39]. They also need to provide team-based work, advocated by healthcare systems in several countries [40, 41, 42].

Sanson-Fisher et al. [39] reviewed studies about the quality of teaching communication skills to undergraduate medical students. Although they included 243 publications considered relevant, 63% of the studies were descriptive, followed by measurement studies (22%). Only 15% were intervention studies, the kind most needed “to ensure communication skills training can effectively improve interactions between clinicians and patients” (p. 1).

Examples of protocols available for different situations in clinical practice are available on Table 2.

The C-L-A-S-S Protocol includes five core components for the medical interview: Context (setting), Listening skills, Acknowledge (validate, explore and address emotions and concerns), Strategy (propose a plan that the patient understands), and Summary (provide a summary and clarify the conversation to make sure the patient really understood) The S-P-I-K-E-S Protocol for breaking bad news includes: S (setting up the conversation in a quiet and private area), P (perception of the patients understanding of the situation), I (invitation to discuss the problem according to what the patient wants to know about the situation), K (knowledge means explaining the facts in a way that the patient will understand), E (emotions, that include to be empathic and supportive and to deal with the emotions as they arise), S (strategy and summary, that means to decide and clarify the best treatment plan, and to summarize the whole conversation, being prepared to answer tough questions). The C-O-N-E-S Protocol may be used to disclose a medical error, a sudden deterioration in the patient’s condition and when talking to a family about a sudden death. C (context), O (opening shot, to alert the patient or the family about the importance of what is about to be discussed), N (narrative approach explaining the chronological sequence of events, E (emotions, using empathy to address strong emotions), S (strategy and summary, making plans to follow-up). The E-V-E Protocol includes three elements to be used when strong emotions occur: E (explore and identify the emotion), V (validate the emotion), and E (empathic response).

Table 2.

Examples of protocols used in medical practice [43, 44].

3. Conclusion

A physician must be prepared to communicate well with patients, including children, adolescents, and families, people from different cultural backgrounds, and healthcare teams. Gathering and sharing information, discussing sensitive topics, breaking bad news, discussing errors, and making shared decisions are tasks inherent to the practice of medicine and must be trained during medical education. Besides technical competence, the practice of medicine also requires learning to take good care of oneself, physically and mentally. Even attending a medical school that teaches beyond cognitive and technical skills, offering good role models, emphasizing the teaching/learning of communication skills, some students will need extra help (e.g. time management, study skills), that must include mental health services for those in need.