Supporting Students with Mental Health Problems:

The GMC Perspective

David CottrellSchool of Medicine, University of Leeds

GMC Guidance

• But also a research report:

• Identifying good practice among medical schools in the support of students with mental health concerns.

• Grant et al

Part 1: The Research

What do we mean by Mental Health Conditions?

• Stress– Common, part of normal experience, may still merit help and

support • Mild to Moderate MH Conditions

– Common, 10-15% of general population– Depression, generalised anxiety disorder, panic disorder, social

anxiety disorder, OCD, PTSD• Severe Mental Illness

– Rare, but debilitating and time consuming. Schizophrenia, bipolar disorder, severe depression

• Eating disorders and Substance misuse may fall in mild to moderate or severe categories

Read the reports!!

• Lots of good practice examples

• Myth busters

Research Methods

• Systematic review 2000 - 2012• Mapping exercise of current practice• e-survey • Structured telephone interviews • Focus groups • Biographical narrative interviews with

students with experience of usually serious MH problems

The Staged Model

Prevention (Self) Identification Referral

EscalationTreatmentReintegration

Literature: Overview

• Medical students are more prone to MH problems than other students

• They are less likely to access help - stigma is a significant factor in this

• For intervention, most of the literature refers to prevention and identification

Literature: Prevention

• Signposting of support services• Stress reduction tools – mindfulness the most common

– may improve well-being but less evidence of later reduction in MH problems

• Peer support/discussion strategies – tend to focus on adjusting to medical school life and stress

reduction

• An interesting small literature on replacing grades with pass/ fail to reduce competitiveness

Literature: Identification

• Monitoring of performance by school • Screening questionnaires• Self-identification – on-line self-assessment

tools • Identification of past history on admission

Interviews: Staff

• Medical Education is different:– Duration– Intensity– Subject matter– Placements – more like work, travel, stress– Regulation– Tradition and Location (away from main campus)– Staffing – students exposed to staff beyond school

control

Interviews: Staff II

• Medical Staff stress how medical students are different form other students

• University staff acknowledge some of the course structure differences but argue that medical students are not that different

• Accepting this latter view potentially opens up access to a far larger range of supports than is often the case for many medical students

Summary of staff views  University Medical School

Model Social model of disadvantage

Medical model of incapacity

Services Integrated, triage to specialists, holistic

Restricted to performance and pastoral

Resources Large, breadth, depth Small, focused

Transparency Advertised widely, menu/portfolio

Formal system transparent, informal hidden

Confidentiality Absolute except when danger to self or others

Conditional on circumstances

Options Anything the student thinks is a good outcome

Course completion/becoming a doctor

Expectations Flexibility Compliance

Interviews: Students

• Tend to agree with medical school staff and in addition:

• early and largely irrevocable commitment• high expectations of self and others – fear of

failure• privilege and reward• constant transition• social bonding in school – pros and cons

Interviews: Students II

• A marked preference for not sharing things with the school either before admission or during the course

• Real concerns about stigma and confidentiality – when will it become FtP?

• Most likely to seek help from friends and family not the school

• A strong and widely held view that the systems supposedly there to help them are not to be trusted

Research Summary• Medical students will, if they can, conceal any illness from their medical

school because they think this will be perceived as weakness or result in the end of their career in medicine

• Medical students who have a health problem choose to consult friends and family first and medical school much later if not last

• Fears for their future career is currently stopping medical students from getting timely help for mental health disorders

• Some medical students have mental health problems, some of these severe, when they are admitted to medical school. Most do not disclose their illness because they fear that this will result in them not being admitted

• Medical students are wary of disclosing mental illness to their GP and to generic university support services because of concerns about [lack of] confidentiality.

Part 2: Good Practice

Prevention: General• Normalise mental health issues through the use of role models and everyday

dialogue, and integration of services • Explain:

– That MH problems are a normal part of life– That students are not immune to such problems– That support is available– Why it is important to be open about health issues

• Reinforce this at all stages of the student career – including pre-admission where it needs to be clear that interview panels will not know about declared conditions

• Web site messages are critical

• Consider screening with formal questionnaires for MH problems

Prevention: Promote well-being

• Group learning exercises focusing on how to deal with stress• Online resources on keeping healthy, including advice on

healthy lifestyles• Sessions on techniques such as mindfulness and meditation,• Opportunities for physical exercise and yoga• Highlight the importance of the work-life balance and

promote opportunities for involvement with extra-curricular activities.

• Must allow time for students to take part in extra-curricular activities and ensure this time is protected.

Prevention: Promote well-being II

• Have or promote access to services to help students deal with stress, for example:– Peer support or near peer support – but those

providing must be trained and supported– Mentoring or buddying schemes – Leaflets, CD and bibliotherapy, podcasts, signs to

external agencies, tutors, counselling and chaplaincy services in University

– Specific learning support – courses to help students identify their learning style

Prevention: Transparency • Confidentiality/ Record keeping policy which clearly states:

– what information is kept– who will receive that information– how the information will be used– where it will be stored and who will have access to it– instances where confidentiality may be breached

• Publish the name of the staff member responsible for this policy

• Have a process for students to complain if their confidentiality has been breached

• Students should be asked to agree to this policy when they access support services

• Publish examples of reasonable adjustments the University has made for students with mental health conditions

• Extend these principles to the TOI process at FY1 transfer

Identification• Processes to identify students who are struggling with the course and might need

support eg performance monitoring and follow up • Pastoral support tutors must:

– not make academic progress decision– have had the right training– be aware of the boundaries of their role – not treat the student themselves or insist that they share detailed or sensitive personal

information, unless the student asks to do so

• Academic tutors and support staff need training in:– recognising common signs and symptoms of mental health conditions– awareness of other support services available

• Encourage students to register with a GP local to the school or the student health

service

Referral

• Ensure access to an OH service independent from, the university and medical school.

• Ensure the OH service has the right knowledge to treat medical students and a good understanding of the medical school environment

• Make self-referral easy

Management / Treatment• Medical schools must not treat students themselves • Consider the case management model of support with a named person

responsible for coordinating the support that the student receives, and eth communication between different agencies. This person does not need to be a clinician

• Ensure students are aware that they may be entitled to Disabled Students’ Allowances to help pay towards the reasonable adjustments.

• Ensure flexibility to facilitate time off for appointments and catch up on teaching missed

• Allow students on temporary leave from the course to keep in touch with the school, their personal tutor or other member of staff who provides pastoral care, and the OH service.

• Mental health concerns should only be heard by formal fitness to practice procedures when the mental health condition significantly affects ability to study and practice.

Reintegration• Have a reintegration plan for each student who leaves the course

temporarily. The development of this plan should start early – well before the student is due to return or even at the point they leave the course.

• Consider whether some students could complete the course on a part-time basis

• Give students who leave the course an appropriate qualification

• Encourage students to declare conditions to the GMC, but emphasise that having a mental health condition – even a serious one – should not prevent them from being registered

The End

Thank you!