Mental health is key contributor

Around one in five UK medical students consider dropping out of medical school, with mental health issues a key contributor to their intention to abandon medicine, suggest the results of an observational study published in the open access journal BMJ Open.

The shortage of doctors worldwide is a major cause for concern, say the researchers, with the current shortfall thought to be around 6.5 million.

These shortages not only affect the quality of patient care, but also doctors’ well-being as a result of increased workload and chronic stress, which further undermine recruitment and retention, creating a vicious circle, they add.

Given that medical student attrition might have a significant impact on an already overstretched health care workforce, the researchers wanted to explore the relationship between various aspects of mental health and academic outcomes in medical education and training, with a view to informing preventive strategies.

They therefore selected nine geographically spread medical schools from England, Scotland, Wales and Northern Ireland, all of which varied in size and type of curriculum offered.

Students from all study years were invited to fill in an online survey between November 2020 and February 2021, and those who responded were invited (February–May 2021) to complete the questionnaire again three months later.

Of the 1,113 medical students who agreed to take part in the study, 792 (71%) filled in the initial questionnaire and 407 (almost 51.5%) completed the follow-up survey.

Among other things, the survey included questions about medical students’ intention to drop out in the recent past and the extent and frequency of various aspects of their mental health.

These included: emotional exhaustion; insomnia; somatic symptoms (stomach or bowel); hazardous drinking; anxiety/depression; anorectic tendencies; obsessive compulsive disorder; paranoia; and bipolar disorder.

The prevalence of mental ill health among all the respondents was high: a substantial number of medical students met screening criteria for mental ill health.

Six in every 10 were drinking hazardously and over half reported symptoms of insomnia (54%). More than half (52%) reported a medium to very high number of somatic symptoms while 52% had symptoms of obsessive-compulsive disorder. Nearly half had anorectic tendencies (45%).

Around one in three were emotionally exhausted (36%) and nearly four out of 10 (38%) had symptoms of anxiety/depression. Nearly one in five (19.5%) had symptoms of paranoia and 3% had bipolar symptoms.

Around one in five medical students (19.5%; 79) said they had considered dropping out of medical school in the recent past (previous four weeks).

With the exception of hazardous drinking and bipolar disorder, all the other aspects of mental ill health were associated with an intention to abandon their studies.

Those students who were more emotionally exhausted and had any higher symptoms of anxiety/depression, insomnia, somatization, paranoia, or anorectic tendencies expressed significantly stronger intentions to drop out of medical school than those at the lower end of the scale.

This is an observational study, and as such, can’t establish cause and effect. And the researchers acknowledge that intention may not always translate into action.

But the percentage of those who said they were considering dropping out is higher than the actual estimated percentage of 5%, say the researchers.

“Students who complete medical school while doubting their career trajectory may be more inclined to drop out of postgraduate training,” they suggest, adding that “the number of doctors who pause their training after completing Foundation training has doubled from 34% in 2011/2012 to 70% in 2020/2021.”

“Dropping out of medical school can have significant personal, financial and psychological consequences for the individual. There is also the financial cost to the taxpayer, and the time and effort wasted by educators,” they add.

Plans to shorten the curriculum to four years may only make matters worse, they suggest.

“The findings of this study suggest that medical students’ mental health is an important contributor to students dropping out and reinforces the importance of supporting students at medical school,” they write.

“The various mental health symptoms that have been found to predict dropout are particularly difficult to recognize in medical students, due to the ‘toxic’ and competitive work culture of medical school normalizing the idea of individuals experiencing them,” they add.

Medical schools need to do more to improve the learning environment for students and encourage them to seek help to reduce the stigma of mental health symptoms, they say.

“This can be through educating students on warning signs of mental decline through workshops or courses, and signposting clearly where they can go for help. Medical schools should also actively clarify that seeking help will not jeopardize their careers, but rather improve their chances of completing their degree.

“There should be no discrimination against individuals with these diagnoses, as with appropriate interventions and more supportive learning environments many students can flourish,” they emphasize.

But they also point out that medical schools need to help prospective applicants better understand the demands of their chosen career.

“While medical schools can take action to improve their environment, it is important to acknowledge that medical school is not for everyone, and to provide resources for those medical students who are deciding whether to continue and those who choose to leave.

“It may be useful for medical schools to have systems in place that can help new applicants (and existing medical students) consider whether medical training is for them by setting realistic expectations of the demands of medical training,” they suggest.