Zaya's Creations

By Zaya Altangerel & Katy Chamoun 

*Last names were excluded from this story in order to give partial anonymity to some of our first-hand sources.

Peppered with small moments of “quiet and controlled panic attacks in lectures, toilet cubicles, and [her] room, managed with impersonal and ineffective online counselling”, Grace’s first year in medical school was “messy and difficult”.

Like many of her peers, along the long road to becoming a medical doctor, Grace was forced to tackle the arduous issue of a decline in mental health. A hard thing for anyone to do, especially a licensed doctor to-be.

It’s a complex problem that can have disastrous consequences.

A 2013 Beyond Blue survey study showed that 33.5% of female and 23.2% of male health practitioners may develop a minor psychiatric disorder, sometime during their career. A grim prediction that’s rarely addressed by an industry whose primary goal is to preserve and protect the wellbeing of individuals.

Those who practice medicine face incredibly confronting situations every day. As a result, many of us place doctors on a pedestal, presuming they are unfazed by such an intense work environment. In reality, nothing could be further from the truth.

The pecking order

As suggested by our interview subjects, the stigma around mental illness is fostered in the early years of medical school. It seems that Australian doctors to-be are forced to hide their mental health struggles, long before they enter the workforce.

Upon entering medical school, a highly competitive cohort brimming with over-achievers and high expectations, students immediately feel the pressure to be stoic.

“Everyone in med seems like they’re with it. ” said Cerys, a current medical undergraduate at one of Australia’s leading universities.

“You can feel very isolated if you yourself feel like you don’t know what’s happening, and feel very inadequate compared to your peers.”

Like the other medical students we interviewed, Cerys was hypersensitive to the possible consequences of talking about the pressures of being a medical student, and was hesitant to voice her opinions.

Over the years, to nobody’s surprise, a pecking order has been established amongst medical students. Like in most academic cohorts, medical students are encouraged to participate in voluntary, student organised, vertical study groups. In these study groups, senior students help those below them with revision for upcoming exams and give advice on what to expect from hospital placements.

Most of the time, these groups are helpful and build strong relationships between students of different levels. However, the casual nature of these study sessions can lead to rare cases of intimidation and belittling.

“The older students do it to help us, but they can get quite egotistical. So they can start to put you down if you don’t know the answer and they can put you on the spot in front of all your peers.” said Cerys.

One such incident occurred mid last year, when a respected fifth year student delivered a revision lecture to a group of 100 younger medical students, ahead of a major exam.

“He was incredibly abusive…picking on students’ physical appearances, putting people on the spot and making fun of them when they got questions wrong.” said Grace.

The senior student allegedly made fun of students’ accents and even mocked the social status of some of the attendants.

According to Grace, the incident was “flagged straight away…and many people were allowed to voice their concerns in response to it”.

When doctors need help

“Mental health is something positive, but mental health and mental illness are on a continuum and everyone is somewhere along that continuum even during the course of one day, and certainly over a person’s lifespan as well.” said Nataly Bovopoulos, Acting CEO of Mental Health First Aid Australia.

According to Beyond Blue, around 40% of licensed doctors feel that those with a history of mental illness were less competent than those with no history of mental illness. Furthermore, up to 59% of doctors felt embarrassed by the idea of being a patient.

“It comes back to the idea that you’re a health professional treating other people’s illnesses, so you can’t be ill yourself.” said Ms Bovopoulos.

This attitude is also prevalent in medical school.

Daisy, a current medical undergraduate at a leading Australian university, empathises with this perspective.

“You don’t want your doctor to look like…they’re struggling themselves.” said Daisy.

According to the Beyond Blue report, over 41% of medical students believed that a history of mental health issues decreased your employability as a doctor.

When health professionals, including medical students, start experiencing symptoms of mental illness, they are legally obliged to file a report to the Australian Health Practitioner Regulation Agency (AHPRA).

“The reason why that mandatory reporting is around, is to protect the patient from doctors who might be experiencing symptoms of a mental health problem that’s interfering with the ability to actually practise medicine. ” said Ms Bovopoulos.

It’s there to help address “the severe end of mental health problems”.

However, according to Ms Bovopoulos, health professionals and medical students avoid reporting to the AHPRA, in fear of losing their medical licence. And this even applies to minor cases like the early stages of an anxiety disorder which is unlikely to impact their professional life.

High exepectations

One thing that was surprisingly universal amongst our sources, was the idea that those who venture into the world of practical medicine, have a distinct type of personality.

“They’re high achievers. They do really well in school and then they come into medical school where everyone is bright.” said Dr Anjali Dhulia, Director of Medical Services at Monash Health.

“It’s about them expecting the best from themselves and nothing but the best.”

“I feel like the kind of people who get into med school, they’re generally pretty hard working, and pretty perfectionist. So it’s hard for you to admit when you’re feeling down.” said Cerys.

“People don’t openly talk about it, their own struggles. I think there definitely is some pressure to make sure you look okay.”

Entering the workplace

As they reach the end of their undergraduate degree, medical students are required to balance full time study with hospital placement – their first experience with the confronting reality of being a health practitioner.

In a hospital placement program, students are assigned to a small team with a hierarchal structure consisting of a third year student at the very bottom, a fifth year student, an intern, a resident and a registrar at the very top.

Sometimes, those near the bottom of this hierarchy can feel as if they’re being unfairly singled out by their mentors.

“People higher up can let their ego get in the way and forget how it feels to be a medical student who is learning. They can expect too much of you and ask you kind of vague ‘read my mind’ questions.” said Cerys.

However, students believe that this method of teaching is slowly being filtered out of the industry.

“I think in the past it has been quite common for consultants and teachers to teach by humiliation or intimidation. And then in turn, this culture filters down through medical schools, creating a hierarchy where it isn’t necessary or useful.” said Grace.

Grace is currently undergoing placement at a rural hospital. And so far, her experience has varied depending on which department she was placed in.

“I’ve been in a few groups. My first two, which were surgical, were surprisingly supportive. Surgery is known for fostering most hostile teaching styles, but my experience was wonderful.” said Grace.

However, things were different when she moved to the general ward. There, Grace had to interact with terminally ill patients for the first time, which she found to be emotionally challenging.

“My more senior doctors did not offer any help or support where it would have been very helpful.” she said.

According to Dr Dhulia, Grace’s discomfort with her initial exposure to heavy medical cases is not abnormal.

“You’re dealing with life and death … at a very young age … So it’s a very high stakes game that they get into and not everyone may be prepared for that.” said Dr Dhulia.

“They do prepare us for using stress management and being easy on ourselves when we face confronting situations. But nothing can really fully prepare you for those feelings.” said Grace.

“The most important support, in my opinion, is being able to debrief from confronting rotations or patients.” said Grace.

So what’s the solution?

In response to concerns raised by students, local hospitals like Monash Health have introduced peer mentorship programs focused on helping trainee doctors deal with the emotional hardships they may experience.

“We have a program where 60 junior doctors are trained. They get a three hour training which is basically about how to provide peer support.” said Dr Dhulia.

On top of this, Monash Health have created a ‘touch-in’ initiative for medical graduates who are just moving into the workplace.

“Every intern has been given a 15-minute slot and they will come and speak to one person … and just check in basically.” said Dr Dhulia.

During these 15-minute sessions, each intern is asked questions like ‘How are you going? Are there any problems?’. And if an intern raises a problem, they’re made aware of the support systems available for their use.

What about the stigma?

Currently in the first year of medical school, students are made aware of the prevalence of mental illness within their cohort.

“We have lectures called the ‘Health Enhancement Program’, and we get taught about mindfulness and how to look after our mental health.” said Cerys.

“They always throw statistics at us…we are made aware of it, but it’s still hard to express it because everyone seems like they have it together.”

“They’re doing a decent job but I think it’s mostly that we’re harsh on ourselves.” said Daisy.

“It’s like a cycle where you think ‘oh you shouldn’t be feeling this way because everyone else seems to have it together, I’m fine.’ But really you’re not fine.” said Cerys.

To combat this toxic cycle. Medical institutions are starting to offer free mental health first aid courses to their staff and students on campus.

“It’s essential to change those behaviours and encourage early help seeking so that people don’t hold back because they’re worried about saying something,” said Ms Bovopoulos, the Acting CEO of Mental Health First Aid.

In relation to the work environment within hospitals, our sources have suggested that it would be beneficial to increase health practitioners’ awareness and sensitivity to the different factors that contribute to mental health decline.

“We try to raise awareness about the fact that doctors are humans.” said Dr Dhulia.

“It’s about accepting that and creating an environment where they can actually come out and ask for help and treat it just like any other illness. If you have diabetes or a heart condition you just get on and get treated, whereas [with] mental health there’s a stigma around it. So, we’re trying to get rid of that stigma and that can only be done by talking about it.”

Although this sounds like a fairly insignificant method of addressing the problem, it’s better than doing nothing at all.

“Team morale swings very quickly in such a high-pressure environment. It’s so important for consultants to be aware of the impact of their actions.” said Grace.

“Medical students and junior doctors are under so much pressure and feel so much like fish out of water. They are so vulnerable to being affected by poor teaching methods and even ‘mild’ bullying.”

This investigative feature was created as part of my tertiary assessment.