Supporting students with mental health conditions

Prevention

  1. This section explains what medical schools can do to create a supportive environment for their students. Medicine is an intensive course and some stress is inevitable. But medical schools should try to reduce the pressure put on their students and help them to strike a balance between being committed and being overworked.
  2. When explaining that mental health conditions are a normal part of life, medical schools should be open about the fact that some students will struggle with university life. They should highlight the support services available to students.
  3. Mental health conditions are normal, in the sense that they are:
    • common - in fact they are more prevalent among medical students than among the general population
    • expected to happen
    • planned for with flexibilities in education and training.
  1. This message needs to be given and reinforced at every stage of a medical student's career - particularly during high-pressure assessments and when moving to the next stage of their education and training.

Entry to medical school

  1. From the first contact with a student, medical schools should explain that mental health conditions are common. Schools should make it clear that they do get applications from potential students who have mental health conditions and that this is normal and expected.
  2. The start of a student's medical course is an important point at which to provide support. There will be students who have had mental health conditions in the past. It is important that the medical school's occupational health or disability support service can check whether these students will need extra support while they are at medical school.
  3. Medical schools should clearly explain why it is important for students to tell the occupational health service about any health condition they have at the point of entry to the course. Students should do so for three key reasons.
    • Medical schools have a duty to support their students, but students have to help the school to do this by being open and honest about their health.
    • Being open and trustworthy is an important part of being a doctor - patients and the GMC expect this of practising doctors. Failure by a doctor on the medical register to disclose a health matter that could potentially impact on patient safety is a breach of this duty.*
    • A student should understand that their health condition could put their ability to study at risk. Where a student has this understanding - and shows this by getting help and support - their health condition rarely prevents them from completing the course. One way to demonstrate understanding from the start is for a student to declare whether they will need additional support when they begin their course.
  1. Medical schools should emphasise the importance of students being honest and open about their health, and make clear that support is available, in the information they give to their students. Schools should also raise the need to declare conditions in person with potential students, such as at interviews or open days.
  2. Medical schools should make it clear to applicants that declaring a mental health condition will not be held against them in the application process. Issues relating to an applicant's health are dealt with separately from the formal admissions process, and decision-making bodies, such as interview panels, will not know that the applicant has declared a health condition.**
  3. Medical schools may want to give the applicant access to an occupational health service to talk about their condition when they apply. They will be able to advise the applicant on what types of adjustment might be available to them should their application be successful.
  4. Once the decision has been made to offer a student a place, they can be referred to the occupational health service if appropriate. The occupational health service can give the medical school advice on whether the applicant will be able to meet the outcomes set out in Outcomes for graduates and the adjustments they might need during their course. They can also advise on the applicant's suitability for a career in medicine.

* General Medical Council (2013) Good medical practice para 75

** Medical Schools Council (2010) Guiding principles for the admission of medical students

Promoting wellbeing

  1. As well as supporting students who have mental health conditions, medical schools should also promote wellbeing among all of their students.
  2. Some of the ways that medical schools can do this include:
    • delivering group learning exercises focusing on how to deal with stress
    • providing and promoting online resources on keeping healthy, including advice on healthy lifestyles
    • providing sessions on techniques such as mindfulness and meditation, and providing opportunities for physical exercise and yoga, which some people find useful to help them manage their stress levels.

Some of these services may be provided by the medical school's parent university. Where this is the case, the medical school should let its students know this.

Promoting good mental health and wellbeing at Birmingham Medical School

Promoting good mental health and wellbeing at Birmingham Medical School

The Feel Bright campaign was set up in 2010-11 as a joint initiative between student representatives and senior welfare staff to promote good mental health and wellbeing, reduce the stigma associated with mental health conditions, and raise awareness that medical students:

  • can develop mental health conditions
  • can recover from mental health conditions
  • can continue with their medical degree, and practise medicine, despite declaring that they have a mental health condition
  • will be supported by the medical school.

The MBChB student welfare representative is responsible for coordinating the campaign.

Feel Bright's message is spread in three key ways.

Interactive sessions

First-year students take part in an interactive lecture, which focuses on understanding stress, anxiety and depression. The student welfare representative, senior welfare tutors and a local consultant psychiatrist speak about:

  • common causes of stress in medical students
  • how students can recognise the difference between stress and depression or anxiety
  • the prevalence of depression or anxiety in medical students and doctors
  • sources of help and treatments available.

Throughout the lecture, students are invited to use anonymous audience response clickers to answer questions. Answers to the questions are then discussed to bust common myths, for example 'If I tell the medical school I am depressed, they will throw me out', and 'I can't be a good doctor if I have a mental health condition'.

Medical student volunteers from years three to five lead an interactive discussion session with small groups of second-year students. The session focuses on promoting good mental health - for example, students are encouraged to ask questions and discuss concerns about starting hospital placements. Each group is asked to come up with the top-ten tips for managing stress and anxiety, and the group with the best tips is awarded a prize. The best tips are then circulated to students in years one and two via email.

Website

The medical school website has a dedicated area for Feel Bright, which gives:

  • a brief overview of the campaign
  • a wealth of resources about mental health conditions
  • information on how students can access mental health advice and support services both within and outside the medical school.

The website hosts key documents, such as a poignant reflection written by an ex-medical student who developed depression at medical school and is now successfully working as a doctor. The Feel Bright booklet, which was written by two students, contains condensed user-friendly information about mental health conditions, and tips for managing stress and anxiety, especially at revision time, and clearly describes how to access help and support.

Email

The student welfare representative sends regular emails to students in all years of the MBChB course to:

  • remind students of the resources available on the Feel Bright website
  • inform students about special events taking part on campus - for example, World Mental Health Day sessions run by the wider university.
  1. Medical schools should also have supportive programmes, or access to equivalent university programmes, in place to help students deal with stress. There is a range of support services that schools could offer.
    • Peer support - students are trained and supported by the medical school to support their peers in dealing with stress. Near peer support, where a student or doctor who has already been through the course gives the support, can also be effective.
    • Group sessions on stress management - students are given the chance to discuss their problems with their peers and are given strategies to cope with stress.
    • Mentoring or buddying schemes - students are paired with senior colleagues or junior doctors to find ways to reduce stress.
    • Specific learning support - courses to help students identify their own learning style and develop skills for studying can help them to work more effectively and reduce stress.
  1. Medical schools should highlight the importance of the work-life balance and should promote opportunities for students to get involved with extra-curricular activities. Medical schools must allow time for students to take part in extra-curricular activities and should make sure that this time is protected.
What medical students say about work-life balance

'The only bad thing about med school so far in phase 1 is that it does take up a lot of your time. I can still fit in activities, but then I will be tired during lectures and unable to concentrate. I feel I have to sacrifice one or the other each week. People don't realise it is not necessarily the time but the exhaustion from concentrating and working hard that stops you from doing leisure activities and keeping in touch with non-medics.'

'My medical school allows time for leisure activities, but generally you don't have the energy both to enjoy leisure activities in time off and to keep up to date with work, as the work and lectures are intellectually challenging.'

'I am too tired to do anything at the end of the day - you commit yourself to the course. Before exams, we revise up to ten hours a day. I feel too tired and guilty to do anything else.'

Openness and transparency

  1. It is important to create an atmosphere that is open about mental health and wellbeing. Medical schools should reduce the stigma around mental health by discussing it as part of learning about mental health within the curriculum.
  2. As part of this policy of openness, medical schools must tell their students about their record-keeping policies. Schools should tell students what information they keep about their health and performance, where they keep it and who has access to these records. Students should also be told the name of the staff member responsible for information security and compliance with the Data Protection Act.
  3. Early training in communication skills can also benefit students by helping them to develop their skills in talking about their own health.
  4. It is important for medical schools to teach students about being both a doctor and a patient. They should consider teaching students about the Health for Health Professionals initiative (a joint initiative run by the Faculty of Occupational Medicine, the Royal College of General Practitioners and the Royal College of Psychiatrists). Students should know that they need to get the right help for their own health condition and should not self-treat, self-refer or have corridor conversations about their own health conditions or the health conditions of others. Addressing this issue early on can be of great benefit for future doctors.
  5. Medical schools must explain how they offer support to their students. This should form an important part of the induction to the course and should be repeated throughout the time they are at medical school.

Confidentiality

  1. For medical students to feel comfortable about asking for help if they have a mental health condition, they must understand the extent to which the services they are accessing are confidential.
  2. Every support service in every medical school should have a confidentiality policy. This policy should clearly state:
    • who will receive the information provided by the student
    • how the student's information will be used
    • instances where confidentiality may be breached.

Students should be asked to agree to this policy when they access support services.

  1. It is also important to make students aware that, in some circumstances, they can decide they do not want to share information about their health that they have previously agreed to share. Medical schools should have a process for students to complain if their confidentiality has been breached by medical school staff.
  2. Where people providing support feel that it might be necessary to breach confidentiality, they should discuss this with the student before taking any action. A student's right to confidentiality should be breached only in very rare circumstances.
The referral pathway at the University of Liverpool

The referral pathway at the University of Liverpool

The Psychological Support Service for Student Practitioners (PSSSP) began in 1996. Two clinical psychologists give psychological support to medics, dentists and health science students. After an internal review in 2006, PSSSP implemented several changes to make the service more visible, more integrated with other student support services within the university, and more proactive in researching and promoting wellbeing activities. For example, PSSSP developed a website to give students information about the service.

PSSSP set up the referral pathway several years ago without any other models available for guidance. A student is referred to PSSSP by a designated tutor in the medical, dental or health science school. This means that the school is aware of the referral and that the student has a mental health condition, but the nature of the student's condition is confidential to PSSSP. The school needs to know only that the student's needs are being met and whether the student needs any adjustments.

School tutors and students have become increasingly aware that there is support for students and that there is a confidential referral pathway to readily access this support.

  1. A student's confidentiality should be breached only to protect the individual student or others from risk of serious harm.
  2. Medical schools may also want to have an overarching confidentiality policy that sets out which staff members will have access to information about a student's health and what they will use it for.
  3. The use of an occupational health service can help medical schools with issues around confidentiality. Occupational health practitioners can give a medical school advice about any necessary adjustments, without the medical school needing to know the details of the clinical condition of the student. The occupational health practitioner will give the medical school an outline of the condition and the suggested adjustments to support the student's study. The medical school can then support the student without breaching confidentiality and maintain appropriate boundaries.
  4. Other services within medical schools and universities will also be able to provide a similar confidential service to occupational health. Whether a student needs to see occupational health or not will depend on the seriousness of their health condition. More complex health conditions should be assessed by an occupational health practitioner.
The GMC's guidance on confidentiality

The GMC’s guidance on confidentiality

The GMC's guidance on confidentiality should form the starting point for medical schools when considering confidentiality . The relevant paragraphs are set out below.

Confidentiality (2017)

  1. Trust is an essential part of the doctor-patient relationship and confidentiality is central to this. Patients may avoid seeking medical help, or may under-report symptoms, if they think their personal information will be disclosed by doctors without consent, or without the chance to have some control over the timing or amount of information shared.
  2. Doctors are under both ethical and legal duties to protect patients' personal information from improper disclosure. But appropriate information sharing is an essential part of the provision of safe and effective care. Patients may be put at risk if those who are providing their care do not have access to relevant, accurate and up-to-date information about them.

Principles

8

  1. Use the minimum necessary personal information. Use anonymised information if it is practicable to do so and if it will serve the purpose.
  2. Manage and protect information. Make sure any personal information you hold or control is effectively protected at all times against improper access, disclosure or loss.
  3. Be aware of your responsibilities. Develop and maintain an understanding of information governance that is appropriate to your role.
  4. Comply with the law. Be satisfied that you are handling personal information lawfully.
  5. Share relevant information for direct care in line with the principles in this guidance unless the patient has objected.
  6. Ask for explicit consent to disclose identifiable information about patients for purposes other than their care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest.
  7. Tell patients about disclosures of personal information you make that they would not reasonably expect, or check they have received information about such disclosures, unless that is not practicable or would undermine the purpose of the disclosure. Keep a record of your decisions to disclose, or not to disclose, information.
  8. Support patients to access their information. Respect, and help patients exercise, their legal rights to be informed about how their information will be used and to have access to, or copies of, their health records.