The results of our studies are in line with recent literature on mental health problems of medical students and physicians (7, 38–42). In contrast to most studies on medical students which focus on symptoms such as suicidal tendencies or disorders like depression, we examined our collective of future physicians for parameters of mental health using a salutogenetic approach. The factors examined, SOC (27, 28) and resilience (29, 30), are strongly correlated with symptoms of mental disorders such as depression and anxiety disorders. Our data indicate an impairment of those protective factors for mental health after a little more than the first semester of study. We found a significant percentage of medical students with low to moderate resilience and significantly reduced SOC at that stage which clearly exceeds the proportion in the general population. As previously shown in other studies, this circumstance correlates to an increased vulnerability to mental illnesses. This could in turn account for the increased prevalence of mental disorders over the course of medical studies (18, 43, 44). Deducing from the parameters we chose, we also assume this development is probably caused by an insufficient adaptation to psychological stress and a lack of coping mechanisms. In an earlier study, we already found lower SOC values in female students (18, 45), and our recent data indicates that the factor resilience follows an even more gender-imbalanced pattern. Although our survey was administered to a relatively small-sized sample group, we were able to find a significant difference between the gender groups with regards to their resilience. Thus, female students not only appear to be at higher risk for psychiatric disorders (46, 47) but also disproportionally lack protective features (32). This is very relevant for medical students and future physicians for several reasons, since almost two thirds (64.2% in the winter semester 2019/2020) of medical students in Germany are female (48). A similar trend towards a female majority in the student body can be seen in the US, as reported in 2017 by the Association of American Medical Colleges (31, 41). Extrapolating our results, we would have to assume that the majority of medical students find themselves at risk with regards to their relative lack of psychologically protective factors. Physicians have an increased suicide rate compared to all other professions, including the paradoxical finding of female physicians having much higher suicide rates than their male equivalents (49). We therefore consider gender-specific prevention courses to be all the more important.
Based on our analysis, we conclude that SOC and resilience have a mutual impact on each other. The connection between the two parameters has already been discussed in some studies (50, 51). We assume that this circumstance in turn can influence the development of mental disorders: In case of successful coping with a crisis, the awareness of the problem rises through a higher comprehensibility. A better manageability is perceived and retrospectively a value is recognized in the experienced event, which allows a crisis to be considered meaningful. The more often an individual experience occurs - regaining the original state of mind after a crisis - and the more understandable the situation gets, the more psychologically stable the individual gets. Therefore, it seems plausible that a stronger SOC is connected to a higher resilience – up to a certain extent both factors might be influenced and changed.
Back in 2008, Emma Warnecke wrote: "[...] students are taught about managing the health of others, there is an imperative to provide them with effective, evidence-based ways to manage their own stress." (52). We consider it mandatory for medical education and our future physicians to learn evidence-based ways to compensate for their own stress and keep their own mental health intact in a structured manner. Consequently, and in accordance with our approach, medical curricula should be didactically and content-wise orientated towards creating opportunities that allow the participants to grow in line with their challenges. We believe it far more likely for medical students to remain mentally healthy if the course program included resilience-skills as a central learning goal and was adapted to gender-specific needs (2, 18). Established programmes to improve resilience already exist. For example, "The Road to Resilience" was developed by the American Psychological Association (APA) and "10 ways to build resilience" offers concrete instructions for learning and implementing resilient behaviour (26, 53). These or similar programs could be adapted for medical students and be integrated as obligatory content at medical schools.
From our own experience and projects at other faculties (23, 25, 54–57), we consider relaxation and mind-body techniques to be feasible and promising options. A firm curricular anchoring of teaching and training these techniques could be achieved by implementing recurring and ultimately self-applied exercises in the curriculum. These measures might result in a higher sensitivity for the future physicians own stress tolerance and the habit of self-administered mental health maintenance (1, 18, 58). Moreover, to reinforce mental stability, we would recommend e.g. applying the construct of resilience on the didactic blueprint of teaching units. The concept of learning in the context of manageable critical situations could be applied to more than just to emergency medicine, where it is already partly being done. There, for example, training is carried out in a team on a simulation patient. Even if mistakes are being made, in the end the patient survives, the student gets a comprehensible and constructive feedback and repeats the training as long as it is necessary in order to be able to handle the situation sufficiently. With this approach the student has experienced manageability and comprehensibility of the scenario despite an extremely stressful situation (22, 59, 60), dosing the feeling of loss of control and frustration to a manageable level. We recommend to anchor stress management and promotion of resilience as crucial learning objectives in medical education.