L5 Prof Development Health and wellbeing of medical students (changed 5_3)

Overview

This lecture covers why physician and medical student wellbeing matters for both the individual and patient care, the specific risks to medical student mental health (including perfectionism and imposter syndrome), and the psychological frameworks and practical strategies for coping and building resilience, closing with the university support services available to Otago medical students.

Professional obligations and why wellbeing matters

• Student Code of Conduct (2021): as a medical student you must (10.1) attend to your own health and wellbeing, and (10.5) remain aware of the wellbeing of your colleagues and support them, to the extent you are able, to seek help when needed.
• University of Otago Medical Graduate Profile (1.10): an awareness of your own needs as a person, how health needs might impact on competence to practice, and an ability to access appropriate support or healthcare.
• Wellness (Shanafelt, 2003): goes beyond the mere absence of distress; it includes being challenged, thriving, and achieving success in both personal and professional life.
• Physician wellbeing and patient care model: four contributing factors combine to produce reduced quality of care.
  • Workplace issues: long hours, organisational requirements & hospital strain, demand:resource imbalance.
  • Contextual factors: workplace culture, conflict, vicarious trauma, managing uncertainty.
  • Emotional labour: birth, death, disease, trauma, high-stakes situations, adverse events, challenging patients & families, moral distress.
  • Personal characteristics: coping strategies, self-care, support, resilience, personal issues.
  • Together these drive reduced quality of care: compassion fatigue, burnout, negative attitudes, task-focused (rather than patient-focused) care, not listening, inappropriate referrals, over-investigation, and increased risk of errors and complaints.

Risks to medical student wellbeing

• Medical students tend to have better physical health than the general population, but systematic reviews show a higher prevalence of:
  • Psychological distress: depression, anxiety, burnout, suicidal ideation.
  • Disengagement and exhaustion.
  • Substance abuse.
• Related contributing factors: societal and educational trends; demanding workload and competitive learning environment; high perfectionism tendencies; intolerance of uncertainty.
• Student Affairs sees students for: physical illness, mental health, sleep issues, study problems, financial issues, leave of absence, temporary or permanent withdrawal, and concerns about colleagues & tutors.

Perfectionism and imposter syndrome

• Perfectionism
  • Adaptive: conscientiousness, achievement-driven, appropriate delayed gratification.
  • Maladaptive: always needing to be in charge, intolerant of uncertainty, critical of self and others, fear of failure, excessive concern about others’ perceptions -> leads to anxiety, depression and missed opportunities.
  • More realistic goals: aim to be the “good enough” doctor; know when to be meticulous (e.g. patient safety issues) versus when it matters less; address unrealistic expectations.
• Imposter Syndrome: doubting your accomplishments, despite external validation, with a persistent fear of being exposed as a fraud.
  • Common in high achievers, women, and under-represented minority groups.
  • Can cause psychological distress: anxiety, depression, substance abuse; may lead to self-sabotage.
  • Responding to it: know you’re not alone; talk about it with a friend or mentor; reframe your thinking (from “everyone here is brilliant, and I’m not” to “everyone here is brilliant - and so am I”); “bank” your achievements; let go of perfectionism and accept mistakes and failures as part of learning; be your own best friend.

Stress and coping

• Stress is a normal part of life, with good stress vs bad stress; it arises when demands exceed our perceived ability to cope, and it prompts us to address the challenges and threats in our lives. The aim is to increase our resources to manage health and wellbeing and build resilience.
• Bucket model of stress: stressors pour into a bucket like water; the water’s surface marks the “manageable stress level,” while healthy coping skills act as drainage holes near the bottom. If coping skills can’t drain stress fast enough, the level rises past what is manageable and the bucket overflows.
• Two categories of coping strategy (cross-referenced from the Psych Med Stress & Coping lecture):
  1. Problem-focused coping: focusing on the stressor itself, reducing its demands or expanding resources to deal with it.
  2. Emotion-focused coping: focusing on the response to the stressor, controlling one’s psychological and/or physiological response to it.

Resilience: locus of control and self-efficacy

• Resilience: the ability to persevere, recover and rebound despite adversity, discouragement and setbacks. “Resilience is how you recharge, not how you endure.” (Kabat-Zinn: “You can’t stop the waves, but you can learn how to surf.”)
• Characteristics of resilient people: internal locus of control; problem-solving skills; strong social connections; self-efficacy; emotional regulation (self-awareness, managing emotions, psychological support); self-compassion; physical health (sleep, diet, exercise).
• Locus of Control (Rotter, 1966): the extent to which we believe we have control over the outcome of events in our lives.
  • External: determined by external factors, e.g. authority figures, work conditions, other people, fate (what others do).
  • Internal: depends on internal resources, coping mechanisms, personal skills, sense of purpose and meaning (what we do).
  • Guidance: focus on what you can control and let go of what you can’t.
  • In my control: my boundaries, my thoughts & actions, the goals I set, what I give my energy to, how I speak to myself, how I handle challenges.
  • Out of my control: the past, the future, the actions of others, the opinions of others, what happens around me, what other people think of me, the outcome of my efforts, how others take care of themselves.
• Self-Efficacy (Bandura, 1977): a person’s belief in their ability to successfully achieve something.
  • High self-efficacy: develops deeper interest and commitment to learning; recovers quickly from setbacks and disappointment; views challenges as tasks to be mastered.
  • Low self-efficacy: avoids challenging activities; believes complex tasks are beyond their ability to cope; focuses on personal weaknesses.
  • Building self-efficacy: learn by observing competent others; identify good role models (colleagues & peers); embrace new opportunities; set SMART goals (specific, measurable, achievable, relevant, time-bound); reframe apparent failures as learning opportunities; plan how to overcome barriers and challenges; examine outcome expectancies (what messages you tell yourself); reflect on achievements and learn from setbacks.

Building resilience: the SAFE-DRS framework

• Self-care & skills: time management, nutrition, sleep, exercise, work-life balance, professional & personal boundaries.
• Accessing help: knowing when you need it, your circle of support, knowing what formal supports are available.
• Focused attention: increased focus, concentration & awareness, e.g. mindfulness, reflection, spiritual care.
• Emotional intelligence: awareness of your own and others’ feelings, and capacity to respond appropriately.
• Doctor as patient/peer/colleague: managing your own health, supporting peers in distress, working collaboratively.
• Stress resistance: awareness of personal, educational & workplace stressors; managing stress proactively to prevent burnout.

Support resources at Otago

• The Student Health and Well-being Moodle page offers resources for physical, mental/emotional, social and spiritual wellbeing at Otago.

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• ELM Student Supports (a hub of services around the medical student):
  • Whānau, friends & family.
  • OUMSA: provides social and academic supports (oumsa.org).
  • International Office: supports international students (03 479 8344, international.support@otago.ac.nz).
  • ELM Tutors: good initial sounding boards.
  • Pacific Islands Research & Student Support Unit (PIRSSU): support for Pacific students.
  • Student Affairs: supports students with health or personal issues (dsm.studentaffairs@otago.ac.nz).
  • Kōhatu Centre: support for hauora Māori students (03 479 7263).
  • Student Health team: Health and Counselling appointments (0800 479 821).
  • Te Huka Mātauraka (Māori Centre): supports students of Māori descent (03 479 8490).
  • Student Learning Development: a free and confidential service.

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• Reflection prompts: what are your default coping mechanisms, and are they helpful/healthy? Identify unhelpful patterns of thinking and behaviour. Identify one change you can make to improve your wellbeing, and make a plan.

Self-test

1. Under the Student Code of Conduct and the Otago Medical Graduate Profile, what is a medical student expected to do regarding their own health and wellbeing?
2. Describe how workplace issues, contextual factors, emotional labour and personal characteristics combine to produce reduced quality of care in the physician wellbeing model.
3. List three risks to medical student wellbeing that are more prevalent in medical students than in the general population, and two factors they are related to.
4. Distinguish adaptive perfectionism from maladaptive perfectionism.
5. Define imposter syndrome and describe two strategies for responding to it.
6. Using the bucket model, explain what happens to a person’s stress level when stressors increase but their healthy coping skills (drainage) are inadequate.
7. Distinguish problem-focused coping from emotion-focused coping.
8. Distinguish an internal locus of control from an external locus of control, giving one example of each.
9. Define self-efficacy and describe one difference in how people with high versus low self-efficacy respond to challenges.
10. List three strategies for building self-efficacy.
11. List the six elements of the SAFE-DRS framework, with one distinguishing feature of each.
12. A medical student is overwhelmed, unsure who to talk to at university about a personal health issue. Name two Otago support services relevant to this situation and what each provides.
13. Integrative: a medical student with maladaptive perfectionism is overwhelmed by a heavy clinical workload and has started making errors. Using the concepts of locus of control, self-efficacy and the SAFE-DRS framework, describe two strategies that could help this student build resilience.

Answers

Reveal answers

1. Attend to their own health and wellbeing (10.1), and remain aware of colleagues’ wellbeing, supporting them to seek help when needed (10.5); the Graduate Profile (1.10) additionally requires awareness of one’s own needs as a person, how health needs might affect competence to practice, and the ability to access appropriate support or healthcare.
2. Workplace issues (long hours, organisational demands, demand:resource imbalance), contextual factors (culture, conflict, vicarious trauma, uncertainty), emotional labour (trauma, high-stakes situations, moral distress) and personal characteristics (coping, self-care, support, resilience) combine to cause compassion fatigue, burnout, negative attitudes and lack of care, which in turn produces reduced quality of care (e.g. inappropriate referrals, over-investigation, more errors and complaints).
3. Any three of: psychological distress (depression, anxiety, burnout, suicidal ideation), disengagement & exhaustion, substance abuse. Related to any two of: societal/educational trends, demanding workload/competitive learning environment, high perfectionism tendencies, intolerance of uncertainty.
4. Adaptive perfectionism is conscientious and achievement-driven, with appropriate delayed gratification. Maladaptive perfectionism involves needing to be in charge, intolerance of uncertainty, criticism of self and others, fear of failure and excessive concern about others’ perceptions, and leads to anxiety, depression and missed opportunities.
5. Imposter syndrome is doubting your accomplishments despite external validation, with a persistent fear of being exposed as a fraud. Strategies (any two): know you’re not alone; talk about it with a friend or mentor; reframe your thinking; bank your achievements; let go of perfectionism and accept mistakes as part of learning.
6. Stress accumulates like water filling a bucket, with the “manageable stress level” marking the waterline. Healthy coping skills act as drainage holes that let stress escape; if coping skills are inadequate, the water rises past the manageable level and the bucket overflows.
7. Problem-focused coping targets the stressor itself, reducing its demands or expanding resources to deal with it. Emotion-focused coping targets one’s response to the stressor, controlling the psychological and/or physiological reaction to it.
8. Internal locus of control is believing outcomes depend on your own internal resources, coping mechanisms and personal skills, e.g. how you handle challenges. External locus of control is believing outcomes are determined by external factors, e.g. authority figures or fate.
9. Self-efficacy is a person’s belief in their ability to successfully achieve something. People with high self-efficacy recover quickly from setbacks and view challenges as tasks to master; people with low self-efficacy avoid challenging activities and focus on personal weaknesses.
10. Any three of: learn by observing competent others; identify good role models; embrace new opportunities; set SMART goals; reframe apparent failures as learning opportunities; plan how to overcome barriers and challenges; reflect on achievements and learn from setbacks.
11. Self-care & skills (time management, nutrition, sleep, exercise, boundaries); accessing help (knowing when you need it and what formal supports exist); focused attention (mindfulness, reflection, spiritual care); emotional intelligence (awareness of own and others’ feelings); doctor as patient/peer/colleague (managing your own health, supporting peers); stress resistance (awareness of stressors, proactive management to prevent burnout).
12. Any two of: OUMSA (social and academic support), Student Affairs (support for health or personal issues), the Student Health team (health and counselling appointments), the Kōhatu Centre (support for hauora Māori students), Te Huka Mātauraka (support for students of Māori descent), PIRSSU (support for Pacific students), the International Office (support for international students).
13. For example: reframe maladaptive perfectionism toward the “good enough doctor” standard, distinguishing when meticulousness truly matters (patient safety) from when it does not; shift toward an internal locus of control by focusing on what is within their control (their boundaries, how they handle challenges) rather than external pressures; and draw on SAFE-DRS elements such as self-care & skills (time management, sleep) and accessing help (formal supports, circle of support) to rebuild their capacity to cope.