Participants were from all years of the program, predominantly from the first clinical clerkship, or third year, and the subspecialty fourth year of the program [see Table 1]. Participants described medical student wellbeing as a positively experienced balance of different life factors, including health (including elements of mental, physical, and emotional health), academic performance, personal circumstances, attitudes to self, and ability to cope with stress. Satisfaction with undertaking a career in medicine was considered part of their wellbeing. Four major themes emerged as impacting on wellbeing and acceptability of wellbeing initiatives: aspects of program design including long contact hours; relationships and interactions with staff; relationships and interactions with peers; and trust and uptake of wellbeing initiatives such as WBD. These are described below with illustrative quotes indicating the year cohort of the participant.
Table 1: Year cohort of participants
Student year cohort
|
Number of responses
|
Proportion of total sample (%)
|
Year 1
|
4
|
6
|
Year 2
|
7
|
10
|
Year 3
|
21
|
31
|
Year 4
|
20
|
30
|
Year 5
|
9
|
13
|
Not disclosed
|
7
|
10
|
TOTAL
|
68
|
100
|
Long contact hours
Twenty participants, the majority from the clinical years, stated that contact hours affected their wellbeing. Concerns about full-time attendance requirement were strongly expressed; requirements were seen as overwhelming, and affecting their psychological wellbeing. Difficulty maintaining paid employment and resulting financial stress, incompatibility with activities of self-care were cited as factors. Terms such as “unsustainable”, “struggling”, “demanding” and “not dealing well” were used. Many described constraints on their personal time, with maintaining family and social relationships, physical health, pleasurable activities and hobbies, in addition to impact on paid work and home routines:
I need a part time or less time option. I'm not dealing well with spending 8 hours in the hospital, coming home, going to work, trying to do chores and study around it.
Participant 19, Third Year
The long contact hours, and late shifts led to ‘medicine’ being seen as all-consuming, with insufficient time during the week and scheduled vacations to rest and recover:
…more holidays, and the reason is that hospital can be quite isolating and gruelling. Yes, we have weekends, but no-one can be naive enough to think that after long hospital hours from Monday to Friday on top of assignments, study and extracurricular commitments, that there is sufficient time to be adequately balanced.
Participant 30, Third Year
The quality and culture of the clinical environment could greatly influence how the attendance requirements were experienced. A setting where the supervising clinical team was seen to be unsupportive and mistreating students catalysed negative experiences, whereas well-planned and supervised placements leading to positive learning experiences were seen as time spent well, despite the long hours.
Factors affecting student wellbeing can include high stress levels, bullying and harassment by academic and clinical personnel, being time poor and unable to engage in self-care.
Participant 61, Fifth year
...time spent on placement facilitates our learning, interacting with other students, having clear direction with expectations and goals for placement
Participant 15, Third Year
Relationships and interactions with staff
Relationships with staff and perceived attitudes toward students from staff were cited as significantly impacting on wellbeing by participants in all years. Academic and wellbeing support was reported as being sought from clinical tutors, university staff, placement supervisors, administrative staff and wellbeing support services. Interactions with academic staff (cited by 12 participants), placement supervisors (10 participants), and administrative staff (11 participants) were described as key to accessing support, but there were divergent views on this experience.
Some participants reported increased anxiety following negative experiences of help-seeking, further affecting their wellbeing. Staff responses were described as “intimidating”, perceiving a “threat of punishment”, “disciplinary” tones, and that “they don’t take notice”, with some first year participants feeling unheard by staff. Some participants reported this apparent lack of interest, and poor communication as causing greater stress and distress:
Admin staff at the university seem to almost enjoy keeping us in the dark… this is extremely stressful from an academic standpoint
Participant 14, Third Year
Negative perceptions were expressed about academic and administrative staff, with some participants only seeing academic staff as being responsible for disciplinary procedures, rather than to offer support. However, some preclinical students felt supported by administrative staff, and other clinical students highlighted positive interactions with clinicians:
Staff members have also been supportive and have provided opportunities to share
Participant 6, Second Year
Many junior doctors or doctors on placements have taken me aside and told me I could approach them if there was something I saw that was overwhelming
Participant 49, Fourth Year
Relationships and interactions with peers
Twenty-seven participants reported relationships with their peers as influential on wellbeing, particularly in the first clinical year. Students described bonding with peers as a way to develop a sense of community within the student body, and thus a sense of safety and belonging while adjusting to being in a healthcare environment. The student community functioned as an informal peer support network, a place where student concerns could be heard through student advocacy:
Because med school is so tough... we become very close to other med students
Participant 19, Third Year
I know medsoc runs events which promote wellbeing and socialising (which typically help your connection/belonging with other people).
Participant 8, Second Year
Conversely, a lack of peer bonding diminished participants’ sense of wellbeing. Clinical learning could be accompanied by social isolation when allocated alone to unfamiliar clinical departments:
...lack of closeness with fellow students due to the constant rotations, multiple hospital locations and lack of tutorials with students in the same group.
Participant 58, Fifth Year
Further, competitiveness was sensed amongst peers, impacting negatively on wellbeing and worsening the sense of isolation:
Spending 40hrs a week sometimes in a hospital surrounded by high achievers makes me feel inadequate and as though I need to work harder. This constant comparison to others, the high stress environment…
Participant 21, Third Year
Trust and uptake of wellbeing initiatives
All participants were aware of the recently introduced Wellbeing Days (WBD), more so than other supports and initiatives. More than half (n = 37) participants identified the WBD concept as “good in theory”, providing an option to “regenerate and recharge” that could reduce stigma about mental health and thus self-care.
I think it is wonderful. Long before Wellbeing Days were officially recognised, students had been taking days off for mental health but being forced to come up with other supposedly more 'legitimate' sounding excuses. Often this meant feeling guilty for letting down our peers and faculty, and being made to feel lazy or just not cut-out for the work load.
Participant 38, Fourth year
I think it is incredibly symbolic and could really change peoples’ attitudes to what it means to succeed in medicine (i.e. not just working yourself to death at the expense of all other things in your life)
Participant 59, Fifth year
However, many also highlighted barriers to their uptake, expressed fear of repercussions, a lack of awareness of how WBD were monitored, or “policed”, and related accounts of students being “called up” and of measures that were perceived as “punitive”. Some felt dissuaded from using WBD for these reasons, and expressed disappointment at the perceived mistrust from staff members:
"I know of a particular student in 3rd year who had 2 days off over the span…and was called in for a meeting because this was deemed as too many and caused concerns. [The student] was really angry about being questioned unnecessarily about their mental health and did not feel it was in a comforting, supporting way"
Participant 24, Third Year
The underlying concern was the attendance policy, which had become a focus of official staff-student interactions, such as regular reminders about compulsory sessions. It appeared that applying the policy affected wellbeing, implying that WBD and other wellbeing initiatives might not be needed if this was not the case:
I think the attendance requirements in this medical degree are reasonable, but the policing of the attendance requirements is not. This is a degree to prepare us for a job that requires a great deal of responsibility. I do not understand why we need to be policed as though we are still school children if we have undertaken this responsibility
Participant 61, Fifth Year
Monitoring of attendance through WBD featured in anecdotal stories of students who had used WBD. Participants felt discouraged by such instances, feeling that they perpetuated mental illness stigma and signaled distrust of medical students:
“I know that people who have been followed up have felt like tabs are being kept on them to a) make sure they aren't just not turning up and using it as an excuse and b) to mark them as having "mental health issues"
Participant 31, Third Year
Some participants expressed a general lack of trust of students in faculty members and as an extension, wellbeing initiatives endorsed by the school.
...to take a day that is supposed to be, and I quote, '-a personal day off with no questions asked' and then to renege without warning and start punitive action against students taking ‘too many’ wellbeing days….completely defeats the purpose of the policy and in fact only further severs the trust and amenability between students and the administration
Participant 26, Third Year
Misuse by other students was also a factor which could erode staff trusting students to utilise WBD responsibly. Participants felt frustrated if they perceived that the consequences for unprofessional behaviour were inadequate. Using WBD for spurious reasons by peers for non-attendance was reported, with some perceiving that their misuse could lead to individual gain.
A sense of injustice - when some students are very lax with attendance but then get better marks than someone who has been present and involved in the rotation
Participant 22, Third Year
However, others expressed greater trust in school processes and staff intentions, suggesting that attendance monitoring was necessary to avoid abuse of WBDs, and that mutual trust between students and staff was necessary for initiatives to work well:
It requires honesty from students (nil abuse of 'days off') and understanding and compassion from the Medical School
Participant 33, Fourth year