A scoping review of mental health status in Australian medical students and doctors-in-training (DiT)

doi:10.21203/rs.3.rs-3594198/v1

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A scoping review of mental health status in Australian medical students and doctors-in-training (DiT)

https://doi.org/10.21203/rs.3.rs-3594198/v1

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Background

The study and practice of medicine is known to contribute to burnout in medical students and junior doctors. There exists limited data on the degree of mental health burden for Australian medical students and doctors-in-training (DiT)

Objectives

The aim of this scoping review is to explore the impact of medical training on mental health of Australian medical students and DiT. Exploring the mental health landscape across different stages of training will help establish putative factors underlying psychiatric co-morbidities in this demographic.

Methods

The JBI framework for scoping review was utilized, involving the PCC criteria to identify the target population group and to develop the search strategy.(1) Peer-reviewed articles, published in English from 2012 to 2022 focusing on Australian medical students’ and doctors-in-training mental health were considered.

Results

Of the 177 articles identified, 24 studies were included in the review. Majority of the studies focused on DiT (n = 19) of which interns and residents were most well represented (n = 12) followed by surgical training (n = 5), with general practice (GP) (n = 2) and physician specialities (nil) being poorly represented. Most studies were quantitative (n = 18), with qualitative studies(n = 6) being under-represented. Common mental health themes identified were overall psychologic distress, burnout and depression/suicidal ideation with workplace harassment and discrimination being poorly represented.

Conclusions

Australian DiT are not equally represented in the literature with regards to the implication of the different specialty training pathways on their mental health landscape. Most studies were cross-sectional, preventing a detailed longitudinal assessment of burnout and work associated psychologic distress. The contributions of workforce factors versus speciality training factors contribution to overall mental health burden in DiT remain unclear and further research is required in this area.

Junior doctors’ mental health

physician burnout

medical students’ mental health

The study and practice of medicine have recently been identified as contributing to burnout in medical students and junior doctors given the nature and demands of their profession.(2, 3) This has been linked to impairments in mental well-being such as depression and suicide.(4) Mental well-being can be defined as a “state in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community”.(5) Compared to the general population, Australian doctors and medical students appear to have higher rates of general stress, with doctors specifically having poorer mental well-being and greater suicidal attempts.(6) The training required by Australian doctors is considered to be demanding with long working hours, stressful working environments, and overall challenges in preserving personal commitments. There is a paucity of literature identifying the impact of medical training on medical students' and doctors-in-training (DiT) mental well-being. As such, this scoping review aims to explore the degree of impact medical training and workplace factors have on mental health in medical students and DiT in Australia. This will allow us to firstly identify factors in medical training that can be addressed to improve the mental health of medical students, secondly prevent further psychiatric burden in the medical profession and ultimately support the development of evidence-based interventions for junior doctors.

The scoping review was conducted as per the JBI Protocol for Scoping Reviews framework described elsewhere.(1) The rationale for conducting a scoping review was to map the landscape of literature about Australian medical students and DiT given the different methodologies of qualitative and quantitative approaches, and the paucity of Australian-specific literature that would not allow for a robust systematic review.

Review Question

The review question was developed using the PCC framework. (1) Understanding that medical education in Australia involves medical students (via direct and graduate entry) and junior doctors in various specialty training pathways with variable impacts on mental health, “What is the impact of medical training throughout medical school and post-graduate training on the mental wellbeing of medical students and junior doctors?” was developed.

Eligibility Criteria

Peer-reviewed qualitative and quantitative studies including observational, quasi-experimental, and randomized control trials were considered. Medical students gaining entry directly after high school or graduate entry and DiT were included in this review. DiT for this review included doctors from internship to senior registrars before attainment of fellowship. Only studies including Australian medical students and/or DiT were included. Studies published after 2012 were included to reflect the contemporary practices in medical schools and training pathways for junior doctors.

Search Strategy

The research question was simplified to five domains including “medical school and training”, “stream of training”, “mental health effects”, “types of studies” and “country of publication” to derive search terms. Phrase searching, truncation, and wild card symbols with alternate word and spelling strategies were used to maximize the coverage of relevant literature. Exclusion criteria included studies published in languages other than English, before 2012 and outside the area of interest. Databases included in the search were Ovid MedLine, PsycINFO, Cochrane Library, Ovid Embase, and PubMed.

Data Collection and Extraction

Shortlisted articles from the relevant databases were imported into the Covidence data management tool, with duplicated studies being automatically removed. After excluding the duplicated search, 646 studies were screened based on the title and abstract, with 35 studies being short-listed for full-text review, of which 24 studies were included in the review. Both abstract screening and full-text reviews were conducted independently by the authors (A.G and P.S). A summary of the study selection process is detailed in Fig. 1.

Data from studies included after a full-text review was extracted using a Microsoft Excel template. Author details, study design, sample size, study location, and study findings were documented. The studies were categorized based on the stage of training, specialty of training, and whether they were qualitative or quantitative (Fig. 2).

Mental Health in Medical Students

Six studies assessed the impact of medical school on the students’ psychological state. Entrance into medical school in Australia can be directly after completion of high school or as a graduate entry candidate. DeWitt et al noted no overall difference in burnout between direct and graduate entry medical students.(7) Whilst graduate entry students were more well-prepared for training, they had increased maladaptive coping strategies with significantly higher alcohol consumption compared to direct entry students.(7) Despite no differences in burnout between graduate entry and direct entry cohorts, medical students had significantly higher levels of burnout compared to the general population.(8) Lyons et al noted that medical training during the COVID-19 pandemic resulted in high levels of psychological distress measured using the Kessler-10 (K10) score in graduate entry students.(9) First-year medical students were noted to have the highest mean K10 score compared to the rest of the cohort. In this study, the main concern raised by medical students across all years was the impact of COVID-19 on studies and social isolation secondary to the pandemic restrictions. Common coping strategies included connectedness using online social networking and practicing mindfulness, with less frequently documented strategies including support from mental health professional services. This may be due to the stigma associated with having mental health symptoms. Cryer et al demonstrated that medical students, irrespective of direct or graduate entry, were less likely to disclose depression and suicidal ideation to family and friends and even less so to colleagues.(10) This is supported by findings from Cheng et al who noted personal views of depression in medical students affected their perceived stigma towards it. Students who believed ‘I would feel ashamed if I had depression’ were statistically more likely to view depression as a measure of weakness, view individuals with depression as ‘unstable’, and are less likely to view it as a ‘real medical illness’.(11) History of anxiety, higher K10 scores, and year level of medical school training was noted to be independent predictors of mental health stigma in this cohort. Race was also an independent predictor with Caucasian students having a greater degree of perceived stigma compared to Asian, Middle Eastern, African, and Hispanic students. Practicing mindfulness has been noted by Lyons et al to improve psychological well-being. A quasi-experimental study by Kakoschke et al, and an observational cross-sectional study by Slonim et al noted that mindfulness in medical students attending Monash University in Victoria had a beneficial role in reducing stress and was associated with reduced psychological distress.(12)

Mental Health in Doctors in Training

The terrain of mental health research in DiT vastly differs for medical students, owing to a range of experience, different specialty program requirements and varied workplace environments. Overall, nineteen studies assessed the psychological burden of DiT spanning from internship to specialist training; eight studies involving interns and residents, seven involving registrars, and three studies that did not specify the stage of training or included DiT from different stages of training.

Mental health status of interns and residents

Parr et al noted the mental health burden in internship, measured using the Copenhagen Burnout Inventory score. This progressed throughout the year with personal and work-related burnout being significantly higher and peaking mid-way through the internship and patient-related burnout increasing linearly over the year.(13) In this single-centred study, interns and residents in 2014 had more favourable scores in psychometric questionnaires compared to 2009.(14) In comparison to the general population, the 2014 cohort had a statistically worse overall mental health state. A cross-sectional survey conducted by Pan et al assessing 1900 interns and residents’ mental health state using the K10 survey demonstrated that 50% of doctors were experiencing moderate or higher levels of psychological distress compared to a 30% prevalence noted in the general population.(15) Multivariate analysis in this group highlighted that workplace bullying, dissatisfaction, and poor relationships with other junior doctors were associated with higher rates of psychological burden.

The common themes identified as barriers to psychological well-being include the amount of workload, rostered hours, and bullying by patients and colleagues contributing to poor workplace culture.(16–18) To quantify the impact of workload on mental health outcomes, Petrie et al conducted a sub-group analysis of 2706 junior doctors surveyed as part of the broader Beyond Blue National Mental Health Survey of Doctors and Medical Students in 2013.(19) A strong positive correlation was noted between hours worked and psychological distress and suicidal ideation after adjusting for confounders including age, gender, training stage, specialty of practice, marital status, and history of overseas medical training. Junior doctors working greater than 55 hours per week have double the odds of experiencing common mental disorders and suicidal ideation, compared to the reference group working 40–44 hours per week. Hunter et al noted that the aforementioned variables were acutely worsened during the height of the COVID-19 pandemic, owing to staff furlough and rapid re-deployment of the junior medical workforce.(20)

Another variable impacting the mental health of residents is the specialty of practice. O’Sullivan et al noted that those interested in non-GP training pathways have increased difficulty in gaining entry owing to challenging application processes, with the idea of recurrent failure causing reduced morale and resilience.(21) Of the eight studies on interns and residents, two focused on interventions to improve the mental health of this group. Chanchlani et al explored the effect of peer-led mentoring of interns by conducting a randomized control study, with the outcomes captured qualitatively via semi-structured interviews followed by inductive thematic analysis. Peer-led mentoring resulted in improved navigation of the hospital system due to improved clinical skills, provision of rotation-specific advice, and greater connectedness amongst junior doctors. This was in part due to increased debriefing opportunities and an improved sense of overall support in all aspects of being a junior doctor.(22) However, debriefing alone was not associated with any meaningful reduction in overall burnout in interns. This was demonstrated in a randomized control study involving 31 interns by Gunasingnam et al, noting that regular formal debriefing sessions over two months did not result in a significant difference in the Maslach Burnout Inventory score.

Mental health status of registrars

Of the seven studies focusing on registrars, two focused on GP trainees. Hoffman et al identified through thematic analysis that the main determinants of psychological distress in GP registrars stem from imbalances in maintaining self-expectations and poor self-care with burnout occurring when the above domains crossover.(23) A novel strategy by Koppe et al to mitigate work-related stress in GP registrars, was the use of an online Balint Group. It was noted that work-related stress significantly declined in the Balint group compared to the control arm.(24)

Of the five studies focusing on hospital registrars, trainees from surgical backgrounds were included exclusively. A cross-sectional analysis by Kevric et al demonstrated that surgical registrars have significantly poorer scores in vitality, social functioning, and role emotion domains compared to the general population.(25) Variables that were associated with poor mental health included the amount of overtime worked, including unpaid overtime, poor work satisfaction, and perceived lack of support. Similarly, job security and perception of meaningful work were associated with improved mental health scores. Notably, no significant difference was present between male and female surgical registrars. This is contrary to the findings of Kavoor et al, noting that female registrars were more likely to have a poorer mental health state compared to their male colleagues. Other factors significantly associated with stress included being from a minority ethnic background and the degree of exposure to COVID-19 patients in the workplace. Junior registrars had increased amounts of stress, however seniority within registrars was positively correlated with depression. Arora et al conducted a similar study assessing burnout rates in orthopaedic trainees. Similar to previous studies, the main determinants of burnout were poor satisfaction with work and sub-optimal work-life balance.(26) This study demonstrated that greater than half of the trainees had experienced burnout measured by high scores in the emotional exhaustion or depersonalization domains of the Maslach Burnout Inventory Questionnaire. In contrast to the study by Kavoor et al, no difference was noted in burnout after adjusting for the gender and seniority of the orthopaedic registrars. The prevalence of burnout was significantly higher in otolaryngology, head and neck surgical registrars with approximately three-quarters of trainees meeting the burnout criteria on the Maslach Burnout Inventory Questionnaire.(27) In this cohort, trainees in New South Wales had a significantly higher rate of burnout compared to other states. Other notable factors linked with burnout included poor work-life balance and geographic isolation, particularly the duration of rural rotations away from support networks. Registrars experiencing burnout felt less comfortable approaching their professional mentors compared to those not experiencing burnout.

In obstetric and gynaecology registrars, the rate of burnout was comparable to the orthopaedic trainees, with 55% of trainees self-reporting burnout with similar rates of personal and workplace-associated stress.(28) Trainees who had considered leaving the program had lower mean resilience scores measured using the 14-item Resilience Scale and a higher rate of self-reported depression compared to registrars who did not consider leaving the training program. The level of trainee support received from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) was noted to be low or very low; a third of trainees reported low to very low support from their direct supervisor. Of self-reported burnout and personal and workplace stress, there appears to be a significant bivariate correlation among these factors, with burnout and workplace stress having the strongest correlation.

Our review of the current data on mental health in medical students and doctors in training (DiT) demonstrates that most of the studies are cross-sectional analyses (56%) with qualitative studies using thematic analyses being less well represented (24%). Quasi-experimental (8%), randomized control studies (8%) and cohort studies (4%) were not common. There were five themes identified in the literature about the mental health of medical students and DiT as represented in Fig. 3.

The most common themes noted in studies focusing on medical students were psychological distress, the presence of burnout, depression, and suicidal ideation. Whilst emphasis is certainly placed on the higher rates of poor mental health, there is a paucity of longitudinal assessments to determine the evolving nature of psychological distress, or the development of common mental health disorders as medical students progress from their first to the final year of medical training. Factors contributing to psychological distress and burnout in medical students were not assessed, owing to the lack of qualitative studies in this demographic. Common factors described elsewhere include high workload often resulting in a perceived lack of control, self-imposed expectations of academic performance, poor time management skills, and poor management of work-life balance.(29, 30) Common coping mechanisms identified were support from social networks and practice of mindfulness. Seeking help from mental healthcare professionals was uncommon owing to the stigma associated with mental health diseases which could predispose them to further mental health issues during the next phase of their careers as junior doctors.

In doctors, common mental health themes included psychological distress and burnout, with a good distribution of qualitative and quantitative analysis. In pre-vocational DiT (interns and residents), workplace factors were contributing to poor mental health, including workplace bullying and harassment, work dissatisfaction, and poor relationships with colleagues. In contrast, the putative factors for poor mental health in registrars varied based on community or hospital placements. GP registrars identified burnout due to poor management of self-expectations and self-care. Hospital-based registrars shared common workplace factors as interns and residents in addition to a lack of support from senior staff members, a lack of unpaid overtime work, and geographic isolation from support networks during their vocational training. It remains a challenge to quantify the exact contributions of workplace and specialty training factors towards the mental health burden in DiT as these factors have an inextricable association. In addition to the aforementioned determinants of poor mental health, individual factors can further alter the risk of experiencing psychological distress with female gender, belonging to a minority ethnic group and poor self-care strategies being identified as independent risk factors. (Fig. 4). The degree to which these major determinants impact DiT is further compounded by a poor representation of the different vocational training pathways.

GP registrars were poorly represented with no representation from specialties including paediatric and adult medicine physician trainees. This is further demonstrated in the 2022 Medical Training Survey; an annual national survey aiming to assess the working conditions of all DiT. Adult physician specialties comprised only 16% of all the participants with paediatrics constituting 7%.(31) Given there exists multiple adult and paediatric physician sub-specialties with varying training requirements, studies should aim to capture the impact of training for each sub-specialty instead of distilling the trainees into an adult and paediatric group for the sake of simplicity.

Our review has several limitations as it only included peer-reviewed studies and excluded grey literature on this topic. Reports such as the 2016 AMA Safe Hours Audit and the annual Medical Training Survey data were therefore excluded. It may well be possible that these sources contain information about DiT that was not represented in the literature included in this review. Secondly, the review restricted studies from countries such as New Zealand and the United Kingdom that share many similarities to the Australian medical education curriculum. This was to ensure that the variance in work culture and environment did not negatively impact the findings of the scoping review for Australian medical students and DiT. Thirdly, due to the paucity of a large body of evidence, the scoping review did not grade the studies based on the robustness of the methodologies and included both qualitative and quantitative analyses.

This scoping review explores the current state of literature focusing on the mental health of medical students and DiT. It demonstrates that the increased psychological burden commences in medical school, which is further exacerbated during the training phase as junior doctors. The key determinants of a poor mental health state include a complex interaction of workplace and training specific factors. This review highlights some of the key gaps in Australian DiT mental health, specifically the unequal representation of different specialties, and identifies key putative factors that require upstream-level interventions to remedy the issue of exaggerated psychological distress on our medical students and DiT.

Ethics Approval and consent to participate

No ethics requirement or consent was required for this scoping review.

Consent for Publication

Not applicable

Availability of data and materials

The dataset used for the scoping review is available from the corresponding author on request.

Competing Interests

The authors declare that there are no competing interests.

Funding

None

Acknowledgement

AG and PS were both involved in the conception of this review, development of the search strategy and conducting data extraction for the shortlisted studies. AG conducted thematic analyses of common mental health themes identified in the studies and drafted the manuscript. All authors were involved in reviewing and approving the manuscript prior to submission

Acknowledgements

Not applicable

Author Details

^a Department of Cardiology, Ballarat Health Services, Grampians Health, 1 Drummond Street North Ballarat, VIC, Australia

^b Department of Mental Health, Drugs & Alcohol Services, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, VIC, Australia

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No competing interests reported.

SearchStrategyMentalHealthinJuniorDoctorsRevised.docx

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Journal Publication

published 01 Jun, 2024

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A scoping review of mental health status in Australian medical students and doctors-in-training (DiT)

Status:

Journal Publication

Version 1

Abstract

Background

Objectives

Methods

Results

Conclusions

Figures

Background

Methods

Findings

Discussion

Conclusion

Declarations

Ethics Approval and consent to participate

Consent for Publication

Availability of data and materials

Competing Interests

Funding

Acknowledgement

Acknowledgements

Author Details

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1