For privacy, aggregate participant characteristics and pseudonyms reflecting the background of the school cohorts are presented. Ten interviews were conducted; six of the ten students identified as female (Anika, Emily, Mariam, Nadine, Shakti, Tho) and four as male (Abdul, Colin, Nikhil, Sasha). Three groups of themes were found: Peer Support Experiences, Initiating and Providing Support, and Peer Support Roles. These are described in turn with illustrative quotes.
Peer Support Experiences
Participants described situations and encounters where there was an opportunity for peer support to be offered or was offered. Peer support was nearly always mediated by existing social interactions, whether through shared learning experiences or friendship.
Awareness of stress and distress
Participants described being increasingly aware of psychological stress and distress in their peers, noting signs such as being absent, appearing withdrawn or distressed and admitting to negative thoughts:
…he was not going to uni as much…he was sleeping more…he just seemed a bit - maybe his mood or the way he carried himself - seemed a bit down. Colin
Students did not view teaching or professional staff as sources of advice or assistance for mental wellbeing concerns; some expressed astonishment at this idea:
Even though the admin staff at the hospital are super lovely, I can’t imagine ever going to talk to them about a personal issue. Anika
Peers, in contrast, could be well-placed to identify and support other students in need, especially through existing social networks:
… it’s even better combated when students are on board as well, because we have direct connections to everyone. Colin
When peer support was offered, it was within the context of relationships based on spending time together in the course, or on existing friendship groups. Initiating contact through social media was described, but most encounters were in person, often through casual conversations:
We would get the train home together at the end of the day and she was often in tears so in the end I sent her a Facebook message that said, ‘Hey, if you ever want to talk about it, I’m here and I hope you’re doing okay, and if you want to hang out this weekend,’ and just that kind of casual friendly message. Yeah, and she just wrote back saying, ‘Thanks, that’s so nice’ Tho
…mostly just like commiserating…being like – brush it off and like, you know, tomorrow’s a new day and you don’t know, it might be way better tomorrow. Nikhil
These contacts signaled care and concern, and assisted decision making by exploring options. Occasionally students described more practical advice:
…we had a long chat as well, and we devised sort of like an action plan of how we would get his work done and also like what sort of help he should seek externally, to make sure he was like safe and in a good headspace. Abdul
Friendships developed easily within the small group learning environment of the early on-campus years. The value and meaning of these new relationships to medical studies and to becoming a doctor were not realised until later:
I went into medical school thinking I didn’t need to make any friends because I already had friends….but I made amazing friends for life, and I think that’s been the most important and the most beneficial thing for me, getting through this degree. Anika
Connections within friendship groups changed with course progression, with on-campus friendships becoming more distanced as students entered the clinical years and experienced the relative dislocation of clinical placements:
….it’s a bit isolating, I think, being put in – you know, one clinic for one day and then another clinic for another day. Sasha
Long hours in clinical settings, together with reduced opportunity for extracurricular social connections led to a new camaraderie, modelling the support medical professionals receive from colleagues, united by shared experiences and challenges.
But someone used the term, ‘prison friends’ as in you spend so much time with everyone here. Emily
However, not all students could easily access informal support from friends and peers. Three participants voiced concerns about socially isolated students:
I think the best thing is just to have a good group of friends around you, which I'm personally lucky to have, but not everyone does have that, which is a shame. Shakthi
Initiating and Providing Peer Support
Overall, more concerns were raised than expressions of interest in supporting peers. These concerns were interrelated, and interacted to express a general reluctance to offer peer support. They included: feeling ill-equipped to help, confidentiality and privacy, mental illness stigma and uncertain boundaries.
Lack of expertise
Participants felt for the distressed student and that they should help, but also that they lacked expertise because circumstances were beyond their level of comfort or expertise.
Like someone has told me that they’ve had suicidal intentions, and I thought that I was just not equipped… Nadine
…like I wanted to help but there was nothing I could do. It was beyond my expertise. Shakthi
Safeguarding confidentiality and privacy
Yet, despite recognising that more help was needed, participants repeatedly emphasised the importance of maintaining peer confidentiality.
That seems like the rules of a good friend is someone tells you something in confidence, they wouldn’t tell someone else. Anika
While a medical emergency justified breaching confidentiality, the choice of action was moderated by privacy concerns:
I’d probably try and call someone, like the mental health service kind of thing, rather than go to a hospital. Because I don’t know how I would feel if I was really struggling and then someone took me to the hospital that I was going to work at.” Sasha
Mental illness stigma
Pervasive stigma amongst peers about mental illness, and the desire to maintain face increased the need for confidentiality, driven by concerns about impact on future careers. Paradoxically, mental health education – especially when framed as disease – augmented this stigma, rather than legitimizing the symptoms:
…once we learn about mental illness, then, I think it would be a huge step for any one of my friends to say that they actually have one of those, like an actual diagnosis. Emily
Students described expectations to maintain face through a calm professional persona, knowing that public demonstrations to the contrary would be long remembered:
hopefully, we’re moving towards not having so much stigma around mental health but if someone’s only real recollection of you is you like sobbing uncontrollably in the emergency room… Sasha
However, peers could also reduce stigma, by normalizing the experience of stress and distress through self-disclosure:
…just knowing that someone else is struggling with the same thing, probably makes you feel better and it makes me feel better…people look around and they think that everyone else has just got it together and they don’t really. Sasha
To participants, the boundaries between offering and not offering peer support were indistinct. For some, reluctance to be involved in peer support was based on an assumption that counselling or knowledgeable advice was required. Others were able to describe limits, expressing more confidence in offering support:
…we don’t feel like we’re professionals and, maybe, our role or someone might see their role as general support and general friendliness. But if things are serious, then, continue to do that, but you need to escalate it to someone else. Emily
Another boundary was created by the absence of friendship or shared learning experiences on which to initiate contact. Most were yet to adopt professional behavioural norms about care for colleagues, so this boundary could become an additional barrier, especially if the struggling student was not attending classes or was withdrawn:
... some people don’t make friends as easily as others and then those people are isolated, and they don’t get the support that they need. Sasha
Peer Support Roles
While students valued peer support in the context of friendship groups, they raised concerns about formalised programs. These included the selection of “peer support officers”, perceptions of lack of authority, and the potential for breaches of confidentiality and of negative emotional impact on students in these roles.
I think it should be an informal role, I think it has to do with sort of, friendship and supporting your friends. Sasha
Despite the participants’ overall reluctance to be involved in peer support, there were some willing individuals, who suggested various curricular additions for promoting peer support (see Additional File 2: Curricular strategies suggested by participants to facilitate peer support).