Trends in medical students' health over 5 years

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https://doi.org/10.1177/00207640221133944 International Journal of Social Psychiatry 2023, Vol. 69(3) 675 –688

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sagepub.com/journals-permissions DOI: 10.1177/00207640221133944 journals.sagepub.com/home/isp E CAMDEN SCHIZOPH

Introduction

The health of physicians has important implications, both for quality of care (E. Frank et al., 2013) and patient safety (Fahrenkopf et al., 2008) as well as for the profession itself, with consequences like burnout and attrition (Hawken et al., 2012; Lewis et al., 1991). Doctors’ own health behavior is linked to their desire and ability to com- municate with and motivate patients about those health issues, as well as their frequency of actually counseling patients (E. Frank, Breyan, & Elon, 2000; E. Frank, Carrera, et al., 2007; Frank, Rothenberg, et al., 2000;

Oberg & Frank, 2009). Multiple prevention and health promotion areas, such as influenza vaccination, mammog- raphy screening (E. Frank et al., 2013), dietary fat intake, sunscreen use, physical activity, smoking, and alcohol use

all have strong personal–clinical correlations (E. Frank, 2004). For example, doctors who exercise more themselves, report having more conversations with patients

Trends in medical students’ health over 5 years: Does a wellbeing curriculum make a difference?

Fiona Moir

¹

, Bradley Patten

¹

, Jill Yielder

¹

,

Christopher SE Sohn

¹

, Brandon Maser

²

and Erica Frank

^3,4

Abstract

Background: Trends in New Zealand (NZ) medical students’ health and the influence of a wellbeing curricula are unknown.

Methods: The author’s collected self-report data from NZ medical students on ‘Graduation Day’ from 2014 to 2018, using a serial cross-sectional survey design with validated scales assessing psychological health, stigma, coping, and lifestyle.

Comparisons were made with NZ general population same-age peers. Analyses examined trends, differences between

‘cohorts’ of students receiving different exposures to a wellbeing curriculum, and correlations between students’ own lifestyle practices and their frequency of talking with patients about those topics.

Results: Of 1,062 students, 886 participated. The authors found statistically significant self-reported increases from 2014 to 2018 for negative psychological indices, including scores for distress and burnout, suicidal thoughts in the preceding year, and the likelihood of being diagnosed with an anxiety disorder. There was a significant increase in numbers of students reporting having their own doctor as well as increased healthy coping strategies and a significant decrease in stigma scores. Academic cohorts of students who had completed a wellbeing curriculum were more likely to report high distress levels, having been diagnosed with a mood disorder, and being non-drinkers than students without wellbeing training. When compared to NZ peers, medical students smoked less, exercised more, and were less likely to have diagnosed mood and anxiety disorders, but reported more distress. The authors found a significant correlation between the amount of exercise students undertook and their likelihood to discuss exercise with patients.

Conclusions: NZ medical students have better physical health than general population peers and are more likely to discuss exercise with patients if exercising themselves. However, cohorts of graduating students report increasing distress despite the implementation of a wellbeing curriculum. Research is needed into mechanisms between students’

self-awareness, willingness to report distress, stigma, mind-set, coping, and psychological outcomes, to inform curriculum developers.

Keywords

Medical students, wellbeing, curriculum, general population, New Zealand, mental health

1 Medical Programme Directorate, University of Auckland, New Zealand

2 Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada

3 Faculty of Medicine, University of British Columbia, Vancouver, Canada

4Annenberg Physician Training Program in Addiction Medicine, Bethel, MI, USA

Corresponding author:

Fiona Moir, Medical Programme Directorate, University of Auckland, Building 507, Level 2, 22-30 Park Avenue, Grafton, Auckland 1023, New Zealand.

Email: [email protected]

Original Article

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about exercise (E. Frank et al., 2003) and non-smoking doctors will more frequently advise patients not to smoke (E. Frank, 2004; E. Frank, Rothenberg, et al., 2000; Oberg

& Frank, 2009). There is also a correlation between the intention and interest of practitioners in improving their own health, with frequency of health promotion counseling, and patient receptivity (E. Frank, Rothenberg, et al., 2000; Rogers et al., 2006).

These personal-clinical associations have relevance for the medical education environment, as encouraging students to be healthy themselves increases their rate of health promotion counseling (E. Frank, Carrera, et al., 2007).

Aside from patient interactions, medical students health is important because distress and burnout during training has been linked to poor academic performance (Stewart et al., 1999), increased thoughts of dropping out of medical school (Dyrbye, Thomas, et al., 2010), lower levels of pro- fessionalism (Dyrbye, Massie, et al., 2010), decreased empathy (Thomas et al., 2007), and increased substance abuse (Jackson et al., 2016). Additionally, it has been known for over two decades that psychological vulnerabil- ity and suicidal ideation as a student are known predictors of suicidal ideation after graduation, which further strengthens the argument for interventions during medical school (Tyssen et al., 2001).

Medical students have been found to have high rates of distress, burnout, suicidal ideation, anxiety, disorders, and depression (Compton et al., 2008; Dyrbye et al., 2006;

Hope & Henderson, 2014; Maser et al., 2019; Molodynski et al., 2021; Rotenstein et al., 2016). In some settings, these rates have been shown to be elevated beyond those seen in comparable populations (Dyrbye et al., 2014;

Maser et al., 2019). Potential contributing factors include aspects of the learning/work environment, feelings of

‘impostor syndrome’, and other major life stressors con- current with training (Dyrbye et al., 2006, 2011; E. Frank, Carrera, Stratton, et al., 2006; Slavin, 2016). Students’ personal resilience, coping strategies, help-seeking behaviors, and perceptions of stigma regarding mental health are also known contribute to this concerning picture (Compton et al., 2008; Kötter et al., 2016; Moir, Yielder, Sanson, &

Chen, 2018; Silva et al., 2017).

In terms of their physical health, there is abundant evidence that medical students and doctors typically have consistently healthier physical health practices than their peers (E. Frank, Carrera, Elon, et al., 2006; Frank et al., 2008; E. Frank et al., 2013; Frank, Galuska, et al., 2004;

Frank & Segura, 2009; Oberg & Frank, 2009). However, sleep, nutrition, exercise, and substance use may be adversely affected by the demands of medical training (Ahmed et al., 2017; Ayala et al., 2017; Terebessy et al., 2016). Furthermore, there may be a bi-directional relationship between students’ physical and mental health, with

better physical health practices in medical school being associated with better mental health outcomes (Dyrbye et al., 2017; Frank et al., 2008; Peleias et al., 2017). While the medical school environment has been previously iden- tified as an important determinant in students’ personal health and physical health behaviors, there are few studies that have explored the health of medical students longitu- dinally as they progress through medical training (Clark &

Zeldow, 1988; Compton et al., 2008; Quince et al., 2012).

There are even fewer studies that have evaluated the impacts of learning environment and curricular interventions (E. Frank, Elon, & ertzberg, et al., 2007 ; Hassed et al., 2009; Wasson et al., 2016).

Although there is limited data about the health of New Zealand medical students, a recent study suggested there were lower rates of mental illness in New Zealand’s medical students compared to other countries (E. Frank, Carrera, Elon, et al., 2006; Molodynski et al., 2021).

Nonetheless, a 2019 study found that 21% of Auckland students reported they were currently seeking professional help for their mental health (Farrell et al., 2019). Therefore, our study aimed to explore trends in the physical and psychological health of New Zealand medical students over a 5-year period, following the introduction of a wellbeing curriculum. Additionally, we aimed to investigate the relationships between students’ own health behaviors, their interactions with patients, and their perception of curriculum content. Lastly, we compared medical students’ health trends to those in same-age peers in the New Zealand general population to put the results in context. This study is important as it will provide much-needed information for educators regarding the design, content, and possible impacts of wellbeing curricula in medical school.

Methods

Survey design, setting, and participants

A serial cross-sectional survey design was used, and all graduating Year-6 students in the Medical Programme at The University of Auckland were eligible to participate, with no students excluded. An administrator invited each graduating class, from 2014 to 2018 inclusive, to complete an anonymous paper-based survey alongside the University of Auckland’s ‘Exit Survey’, during their final time in an undergraduate lecture theatre on the last day of medical school in November of each year.

The survey consisted of a set of validated questions and inventories taken verbatim from previously validated instruments and national surveys of Canadian, US, and Australian medical students and physicians (Supplemental Appendix A). The study was approved by the University of Auckland Human Participants Ethics Committee in 2014 (reference number 013433) with an extension in 2018.

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Curricular intervention

‘SAFE-DRS’ is a 4-year wellbeing curriculum with man- datory components (Moir, Yielder, Dixon, & Hawken, 2018) in the Auckland Medical Programme. The SAFE- DRS components are Self-Care Skills, Accessing Help, Focused Attention (Mindfulness), Emotional Intelligence, Doctor as Patient and Colleague, and Stress Resistance.

The Class of 2014 was not exposed to this curriculum (‘No SAFE-DRS’), the Classes of 2015 and 2016 each received 2-years of the SAFE-DRS curriculum (‘Half SAFE-DRS’

in Years 4 and 5), and the Classes of 2017 and 2018 each received 4 years (‘Full SAFE-DRS’ in Years 2–5). We conducted post-hoc ‘cohort’ analyses using these different exposure groups.

Study measures

The survey instrument included self-reported demographics: age, gender, ethnicity, entry route, and mental/physical health. Measures used were the Kessler Psychological Distress Scale (Kessler et al., 2002), the Maslach Burnout Inventory (MBI) two item (Maslach & Leiter, 1996; West et al., 2009), the Connor-Davidson Resilience Scale two item (CD-RISC2; Vaishnavi et al., 2007), and the Interpersonal Reactivity Index (IRI; Davis, 1980). An item regarding past-12-months suicidal ideation was adapted from the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) 3.0 (Kessler & Üstün, 2004). Mood and anxiety disorder diagnoses were also queried by asking respondents to indicate ‘long-term conditions that are expected to last or have already lasted 6 months or more and that have been diagnosed by a health professional’ (Statistics Canada, 2013). Questions about stigma and coping strategies were taken from The National Mental Health Survey of Doctors and Medical Students (Wu et al., 2013). Additional items regarding self-perceived mental and physical health were taken from the 12-item Short Form Health Survey (SF 12; Huo et al., 2018; Ware et al., 1996) and the Behavioral Risk Factor Surveillance System, U.S. Centers for Disease Control and Prevention (CDC BRFSS; Centers for Disease Control and Prevention, 2019; Nelson et al., 2001).

Lifestyle assessment measures included items from the Godin-Shephard Leisure-Time Physical Activity Questionnaire (Godin, 2011; Godin & Shephard, 1985) and a 6-item dietary screening instrument previously validated in medical students (Spencer et al., 2005). To deter- mine alcohol use, we asked students how many days in the past month they had drunk any alcoholic beverages and how many days they binge drank (defined as five or more drinks on one occasion) (National Institutes of Health, 2019), using validated questions adapted from the CDC- BRFSS (Centers for Disease Control and Prevention, 2019; Nelson et al., 2001). We also adapted questions from

this questionnaire with regards to smoking. To explore the Auckland Medical Programme’s health promotion environment (Frank, Hedgecock, et al., 2004) we took questions regarding patient counseling practices and training verbatim from a prior instrument implemented in U.S.

medical students (E. Frank, Carrera, et al., 2007).

Where possible, we used New Zealand Health Survey (NZHS) data as the general population comparison (Ministry of Health, 2020). As a comparator for stigma and coping strategies, we used the Beyond Blue National Mental Health Survey of Doctors and Medical Students (Wu et al., 2013). We have provided details regarding individual study measures and data analysis, including sources of items/instruments and scoring, in Supplemental Appendix A.

Results

We have documented the demographic characteristics and response rates in Table 1. A total of 1,062 medical students were invited to participate in the five graduating cohorts from 2014 to 2018, with between 77% and 92% of each class taking part each year. The total number of participants was 886, giving a response rate of 83%. Across the entire 5-year period, the New Zealand medical students had a mean age of 25.2 years (SD = 2.8) and 50.9 % were female. Ethnicity was diverse with European (34.7%), Asian (35.9%), Pacific Islander (7.8%), Māori (11.4%), and others (11.4%). Data from 83% were available for analysis. We have reported the trends in a variety of health variables over the 5-year period for New Zealand medical students in Table 2. In Table 3, we have reported trends in the students’ coping mechanisms and stigma measures, and in Table 4 we have compared these data to similar data from Australian medical students.

When testing for a trend from 2014 to 2018, we found statistically significant results in the percentage of respondents experiencing at least 1 day of poor mental health in the past month, perceiving their health had worsened since starting medical school, reporting K10 scores indicating high or very high distress, reporting a formal diagnosis of an anxiety disorder, contemplating suicide in the last year, and/or experiencing burnout. We also found a significant increase in the percentage of respondents with their own regular doctor. We did not find any significant trends for resilience or empathy scores, perception of medical school support, alcohol consumption, smoking, fruit and vegetable intake, or exercise.

When comparing SAFE-DRS ‘cohorts’, we found that students who had completed 4 years of the wellbeing curriculum were more likely to report suicidal ideation and/or burnout, to indicate that they had worse mental health since starting medical school, and to have been diagnosed with an anxiety disorder when compared with those with no SAFE-DRS training. Cohorts with 2 or 4 years of

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SAFE-DRS training were more likely to report high levels of distress, more likely to have been diagnosed with a mood disorder and more likely not to drink any alcohol relative to the ‘No SAFE-DRS’ 2014 cohort.

Table 3 shows that in comparison to Australian data (Wu et al., 2013), NZ medical students’ scores for stigma were higher than those reported by Australian students in all years for both variables. However, the statistically significant longitudinal trends in Table 4 show that NZ medical students’ stigma scores reduce for each year group. In terms of coping strategies used ‘often’, a higher percentage of NZ students reported talking to others and seeking spiritual help, while a lower percentage of NZ students reported avoiding people, retreating to bed, and eating or drinking more than usual in comparison to Australian medical students, findings which were statistically significant. Looking at the trend for NZ students, there was a significant increase in the percentage of students who used mindfulness or another relaxation technique, with 18.4%

of the 2018 cohort reporting that they did this ‘often’, which was approximately double the percentage employ- ing this strategy in 2014 (9.8%).

We compared NZ medical student data with same-age general population peers from the NZHL survey (Figure 1). We conducted one additional comparison comparing fruit and vegetable intake between students and the general population in 2018, and found no statistically significant difference (p = .927) between the percentage of medical student respondents meeting the NZ guidelines (27.7%, N = 197) and the NZHS survey respondents (27.4%).

In comparison with same-age peers in the NZ general population, medical students were more likely to report their health as being excellent, very good, or good. They consistently reported having better physical health practices, being more likely to meet the WHO guidelines for exercise and less likely to have smoked 100 or more ciga- rettes in their lifetime throughout the 5-year period. In terms of mental health, although medical students consistently reported higher rates of distress than their general population peers, our results indicate they had lower rates of diagnosed mood and anxiety disorders throughout the entire period.

A significant but weak positive correlation was found between the amount of exercise students reported complet- ing in an average week and their reported likelihood to counsel patients about exercise (p = .031). We found no statistically significant associations between students’ own intake of fruit and vegetables and their frequency of talking with patients about patients’ weight (p = .286) or nutrition (p = .085), nor between students’ own (uncommon) smoking behaviors and counseling patients about smoking (p = .233).

Among drinkers, we found that students whose drinking had frequently interfered with their responsibilities were significantly more likely to report more alcohol consumption. This included more frequent drinking (p = .004,), consuming more drinks per session (p < .001), and more frequent binge drinking (p < .001). Among drinkers, respondents who drank more frequently were also more likely to report receiving training in the curriculum on Table 1. Demographics by year group.

Class 2014 2015 2016 2017 2018

Cohort No SAFE-DRS (control cohort) Half-SAFE-DRS Half-SAFE-DRS Full-SAFE-DRS Full-SAFE-DRS Response rate, % (n) 77 (148/192) 85 (165/194) 77 (168/217) 92 (198/216) 85 (207/243) Age, mean ± SD (n) 24.9 ± 2.5 (147) 25.2 ± 2.8 (161) 25.5 ± 3.3 (168) 25.3 ± 3.2 (197) 24.8 ± 2.2 (207) Gender, % (n)

Male 47.6 (70) 49.1 (81) 47.6 (80) 54.5 (108) 46.1 (95)

Female 52.4 (77) 50.9 (84) 52.4 (88) 45. (90) 53.9 (111)

Ethnicity, % (n)

European 38.1 (56) 40.2 (66) 38.1 (64) 36.4 (72) 31.4 (65)

Asian 37.4 (55) 32.9 (54) 35.1 (59) 35.9(71) 41.5 (86)

Pacific peoples 11.6 (17) 5.5 (9) 6.0 (10) 7.6 (15) 7.7 (16)

Maori 8.2 (12) 12.2 (20) 13.1 (22) 7.6 (15) 12.6 (26)

Other 4.8 (7) 9.1 (15) 7.7(13) 12.6 (25) 6.8 (14)

Entry route, % (n)

General 71.6 (106) 65.9 (108) 64.3 (108) 71.2 (141) 68.6 (142)

MAPAS 16.2 (24) 17.7 (29) 17.9 (30) 13.1 (26) 15.0 (31)

RRAS 8.8 (13) 9.1 (15) 12.5 (21) 12.6 (25) 10.6 (22)

International 3.4 (5) 7.3 (12) 5.4 (9) 3 (6) 5.8 (12)

Note. Gender information excludes data from two respondents who did not answer the question. Ethnicity excludes data from two respondents who did not answer the question. Entry routes to the Auckland Medical Programme include a Māori and Pacific Admission Scheme (MAPAS) and a Regional Rural Admissions Scheme (RRAS).

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Table 2. Trends in medical students’ perceptions and health behavior over 5 years. Variables20142015201620172018Analyses, OR [95% CI], p-Value No SAFE-DRSHalf SAFE-DRSHalf SAFE-DRSFull SAFE-DRSFull SAFE-DRSTrendHalf SAFE-DRSFull SAFE-DRS Self-perceived general health Excellent/very good/good current health, % (n)98.6 (148)97.6 (165)95.8 (168)93.9 (198)98.6 (207)––– Poor mental health on at least 1 day in past month, % (n)50.0 (126)44.3 (158)50.7 (160)54.2 (177)58.4 (197)1.03 [1.00–1.06] .020–– Poor physical health on at least 1 day in past month, % (n)58.9 (129)49.0 (157)48.8 (162)57.9 (183)50.8 (197)––– Perceived general health change from before medical school, % (n) Better25.0 (148)24.4 (164)28.2 (167)23.3 (198)26.8 (205)––– Worse14.2 (148)19.5 (164)16.8 (167)27.8 (198)22.4 (205)1.16 [1.03–1.31] .012–2.02 [1.23–3.46] .007 Perception of medical school support Encourages leading a healthy lifestyle, % (n)54.3 (140)53.2 (156)56.0 (159)48.2 (191)55.6 (205)––– Encourages healthy eating, % (n)17.9 (140)19.7 (157)19.4 (160)20.0 (190)18.0 (205)––– Encourages exercise, % (n)18.4 (141)26.1 (157)25.0 (160)22.0 (191)25.9 (205)––– Alcohol consumption, % (n) Non-drinkers12.1 (140)20.9 (153)20.5 (156)17.5 (183)22.3 (193)–1.89 [1.08–3.46] .0311.80 [1.05–3.27] .042 Low risk drinkers31.4 (140)30.1 (153)34 (156)27.9 (183)29.5 (193)––– Higher risk drinkers56.4 (140)49 (153)45.5 (156)54.6 (183)48.2 (193)––– Alcohol consumption among drinkers Days drinking in past month, M ± SD (n)7.18 ± 5.20 (123)7.03 ± 5.92 (121)6.56 ± 6.22 (124)6.75 ± 5.59 (151)6.45 ± 4.69 (150)––– Drinks each time, M ± SD (n)3.23 ± 2.83 (121)3.62 ± 4.03 (110)3.01 ± 2.31 (116)2.98 ± 2.36 (133)3.19 ± 2.40 (135)––– Binged at least once, % (n)63.4 (123)60.3 (121)57.3 (124)66.2 (151)62.0 (150)––– Among binge drinkers Binge sessions, M ± SD (n)3.10 ± 2.86 (78)3.77 ± 5.54 (74)3.11 ± 3.04 (72)2.76 ± 2.68 (102)3.14 ± 3.08 (97)––– Smoking Percentage who had ever smoked, % (n)5 (141)5.5 (163)11.6 (164)7.8 (193)7.8 (205)––– Nutrition Met NZ guidelines, % (n)34.6 (136)29.4 (153)29.1 (158)28.1 (178)27.7 (195)––– Exercise Met NZ/WHO guidelines, % (n)80 (140)77.8 (162)78.9 (166)79.9 (194)78.2 (206)––– Psychological distress (K10) High or very high, % (n)15.4 (136)26 (154)26.4 (159)25.3 (186)27.6 (203)1.13 [1.01–1.26] .0401.94 [1.16–3.37] .0141.97 [1.20–3.38] .010 Mental illness diagnosed Mood disorder, % (n)4.4 (137)10.1 (158)10.5 (162)10.9 (192)9.3 (204)–2.51 [1.10–6.78] .0442.45 [1.09–6.56] .046 Anxiety disorder, % (n)2.2 (137)2.5 (158)4.9 (162)9.9 (192)8.8 (204)1.49 [1.20–1.89] <.001–4.6 [1.63–19.29] .012 Suicidal ideation % (n)0.7 (139)2.5 (161)3.7 (162)8.3 (193)5.9 (204)1.49 [1.16–1.97] .003–10.47 [2.20–187.59] .022 Resilience CD-RISC2, M ±SD (n)6.24 ± 1.27 (139)6.12 ± 1.35 (161)6.12 ± 1.23 (161)6.04 ± 1.28 (193)6.16 ± 1.27 (205)––– (Continued)

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Variables20142015201620172018Analyses, OR [95% CI], p-Value No SAFE-DRSHalf SAFE-DRSHalf SAFE-DRSFull SAFE-DRSFull SAFE-DRSTrendHalf SAFE-DRSFull SAFE-DRS Burnout Emotional exhaustion, % (n)30.7 (140)29.2 (161)36.8 (163)39.4 (193)40.8 (206)1.14 [1.03–1.26] .009–1.51 [1.01–2.29] .049 Depersonalisation, % (n)20.3 (138)18.8 (160)27.2 (162)34.4 (192)32.0 (206)1.22 [11.10–1.37] <.001–1.95 [1.24–3.15] .005 Overall, % (n)39.3 (140)32.9 (161)47.2 (163)51.3 (193)50.5 (206)1.18 [1.07–1.30] <.001–1.60 [1.08–2.38] .019 Empathy Touched, % (n)92.8 (139)95.0 (161)88.8 (161)91.1 (192)88.9 (207)––– Misfortunes, % (n)56.8 (139)49.7 (161)59.4 (160)59.8 (189)56.0 (207)––– Other Has regular doctor, % (n)81.0 (147)79.4 (165)84.3 (166)85.5 (193)87.8 (205)1.16 [1.02–1.32] .022–– Note. No linear regressions returned statistically significant results. Where logistic regression analyses returned significant results, odds ratios have been provided, along with confidence intervals and p- values. A – indicates that the component of the relevant analysis returned a non-significant result (p > .05).

Table 2. (Continued)

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counseling patients about alcohol (p = .004). Our analysis showed no other statistically significant correlations between students’ personal health practices regarding exercise, nutrition and smoking, and their perceptions of curricular content on similar topics.

Discussion

This study is unique in that it reports differences between cohorts of students with varied amounts of wellbeing training, whilst examining health trends over 5 years. As data collection finished just prior to the start of the COVID-19 outbreak, the trends were not influenced by the pandemic.

Our findings show that in comparison to same-age peers in the general population, a higher percentage of final year NZ medical students perceived that their own health was

‘excellent, very good, or good’ for all 5 years of the survey.

Students reported having adopted healthier habits than their general population peers in terms of exercise, alcohol, and smoking with their physical health behaviors showing little change between the different cohorts over 5 years.

Our study found that self-reported psychological distress has become increasingly prevalent in final year NZ medical students, with a similarly increasing trend to that shown by same-age peers in the NZ general population.

Medical students had higher scores of experiencing distress, but lower rates of reporting diagnosis of a mood or anxiety disorder. One explanation for this could be non- disclosure due to fears of lack of confidentiality or stigma and perceived impact on their future careers (Roberts et al., 2001). It is known that the perfectionist nature of

medical culture is a key contributor to feelings of shame and perceived weakness of psychological distress (Bynum

& Sukhera, 2021; Bynum, Varpio, & Teunissen, 2021).

Looking internationally at student populations, data from US national student mental health also indicates similar trends (Centre for Collegiate Mental Health, 2020).

However, it is unclear whether the worsening of psychological distress signifies a true increase in prevalence or whether it reflects changes in students’ awareness of, or desire to report ill-health due to environmental influences.

It is possible that the SAFE-DRS curriculum itself might have influenced students’ perceptions of psychological norms with negative psychological consequences, and/or negative reporting biases. In terms of reporting, the wellbeing curriculum is likely to have raised students’ awareness of psychological health, allowing more willingness to report. This hypothesis is supported by our findings of a statistically significant reduction in stigmatized mental health attitudes in our respondents over cohorts. Heightened awareness of stressors may lead students to ‘scan’ for those aspects highlighted in the curriculum, also increasing their level of self-reporting (Barker et al., 2015). Furthermore, we need to consider the potential for this awareness to make them more likely to actually experience an effect, similar to the nocebo effect that can occur with medical interventions (Petrie & Rief, 2019). Negative expecta- tions, symptom misattribution, and prior learning are all factors known to influence the nocebo effect, any of which may apply to our medical student population. However, we are mindful that not raising awareness of these issues carries with it possible harms, including somatization through suppressed thoughts and emotions and reduced Table 3. Comparison of New Zealand and Australian medical students’ coping strategies and stigma scores.

Survey item SAFE-DRS all years Beyond Blue comparator Chi square

% (n) % (n) p-Value

Stigma

Doctors think less of doctors who have

experienced depression or an anxiety disorder 58.7 (857) 37.6 (1,807) <.001

Being a patient causes embarrassment 64.1 (857) 56.7 (1,798) <.001

Coping strategies

Talk to other 58.5 (835) 36 (1,450) <.001

Avoid being with people 15.6 (834) 26.2 (1,449) <.001

Retreat to bed 13.1 (835) 21.4 (1,448) <.001

Eat more than usual 12.3 (832) 24.5 (1,448) <.001

Drink more than usual 3.9 (831) 4.9 (1,449) .289

Take non-prescribed medication 0.8 (826) 0.6 (1,448) .720

Exercise 41.2 (833) 35.8 (1,449) .012

Seek spiritual help 13.4 (834) 6.4 (1,449) <.001

Mindfulness/relaxtion technique 12.7 (832) 11.5 (1,448) .431

Note. Beyond Blue comparator data is from medical students and was collected in 2013. Results for the stigma items was obtained from the Beyond Blue dataset and relates to all respondents. Results related to coping strategies is taken from the public report and only contains responses from students indicating that they had ever felt anxious or depressed.

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Table 4. Trends in New Zealand medical students’ coping strategies and stigma scores. Survey item2014 % (n)2015 % (n)2016 % (n)2017 % (n)2018 % (n)Analyses, OR [95% CI] p Value No SAFE-DRSHalf SAFE-DRSHalf SAFE-DRSFull SAFE-DRSFull SAFE-DRSTrendHalf SAFE-DRSFull SAFE-DRS Stigma Drs think less of Drs with depression/anxiety68.1 (141)63.9 (158)49.7 (160)61.0 (192)53.4 (206)0.88 [0.80–0.97] .0090.62 [0.41–0.94] .0250.62 [0.41–0.92] .020 Being a patient causes embarrassment69.5 (141)65.2 (158)63.5 (160)67.7 (192)56.8 (206)0.90 [0.81–0.99] .037–– Coping strategies Talk to other52.6 (135)56.1 (155)56.0 (159)63.6 (186)62 (200)1.12 [1.01–1.23] .027–1.54 [1.04–2.29] .031 Avoid being with people12.7 (134)12.9 (155)14.7 (156)16.1 (186)19.7 (203)1.15 [1.00–1.32] .045–– Retreat to bed9 (134)12.3 (154)8.9 (159)16.8 (185)16.3 (203)1.19 [1.03–1.38] .021–2.01 [1.08–4.03] .036 Eat more than usual12 (133)12.3 (154)8.9 (158)14.5 (186)12.9 (201)––– Drink more than usual4.5 (133)4.5 (154)4.5 (157)4.3 (185)2 (202)––– Take non-prescribed medication0.8 (132)1.3 (151)0.6 (157)1.1 (185)0.5 (201)––– Exercise40.3 (134)38.6 (153)41.5 (159)38.5 (187)46 (200)––– Seek spiritual help11.1 (135)18.8 (154)17.6 (159)9.7 (185)10.9 (201)––– Mindfulness/relaxation technique9.8 (133)11 (154)12.6 (159)10.8 (185)18.4 (201)1.17 [1.01–1.36] .041–– Note. A – indicates that the p-value was >.05 for the odds ratio in these cases.

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opportunities for learning coping strategies (Pennebaker, 2000). Therefore teaching students about these topics does not appear to be straightforward. It is perhaps a nuanced balance between tackling stigma (Bynum & Sukhera, 2021) and normalizing psychological distress by enabling students to acknowledge and discuss issues, whilst recog- nizing that some ‘threats to wellness’ are an inherent part of medical practice (Bynum, Varpio, & Teunissen, 2021).

An increased desire to report ill-health could also be due to other causes aside from curricular influence. Prior research is unclear regarding the association between

certain survey methodological factors, such as privacy, topic salience, incentives, social desirability, and other response biases (Murdoch et al., 2014; Ong & Weiss, 2000). However, as this study was an anonymized, paper- based survey, not involving face-to-face conversations during data collection, this may have somewhat reduced the potential for social desirability bias.

If our findings reflect a true increase in the prevalence of distress, it is possible that the medical school environment has become increasingly stressful over time. A recent survey of Canadian and US wellbeing programs indicates Figure 1. New Zealand medical students in comparison to the New Zealand general population.

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that preventative, reactive, structural, and cultural aspects of programs need be considered (Schutt et al., 2020). Our results could show the influence of structural and cultural aspects of the program such as the effects of assessment strategies or of hierarchy in training environments.

Structural drivers of student distress were found by Schutt et al. to be the area most in need of the development of wellbeing initiatives (Schutt et al., 2020). Slavin’s recent work supports this, in highlighting that it is the experience of their program that most affects students’ wellbeing, as opposed to the adoption of healthy practices encouraged within it (Slavin, 2020). It is worth considering how medical schools might empower students to consider what gives them meaning, purpose, and value in their training, and discover how they might connect with this and not lose sight of it during a lengthy training program (Ferguson

& Ark, 2021). Perhaps medical schools could also consider ways to show students that although they are junior, they are valued members of a health workforce. We suggest it is possible that having a positive experience of feel- ing valued and purposeful, and learning in an inclusive, respectful environment whilst at medical school, (Bynum, Teunissen, & Varpio, 2021) may develop future leaders who in turn treat their own clinical teams with respect and compassion, alongside their patients.

In terms of coping strategies, our study showed an increasing trend for NZ medical students to be registered with a doctor and to employ healthy coping strategies over the 5-year period. The SAFE-DRS curriculum emphasizes learning to ‘be a patient’ as well as a doctor. Students experiment with techniques to ‘calm the nervous system’, learn mindfulness as a core curriculum component and create a ‘stress action plan’ as part of a self-care diary.

With this curriculum content, it is likely that our results reflect some influence of the curriculum on coping strategies; however, given the cross-sectional nature of this study, a causal relationship cannot be inferred.

Despite an increase in healthy coping strategies, our results showed there is still a trend of deteriorating psychological health over cohorts. One possible reason for this is raised in recent research on ‘mindset’, which demonstrates that this is a distinct variable influencing the stress response, separate to coping strategies (Crum et al., 2013).

In our view, a continuing focus on coping strategies and mindset will be valuable during medical school and beyond, to manage the highly complex and demanding clinical situations students will face upon graduation. Prior studies have shown that active coping strategies, as opposed to avoidant coping strategies, are associated with a decreased risk of burnout and depression in medical students (Thompson et al., 2016). Knowledge and direct experience of these strategies is also intended as a resource for students to use for educating patients in the future, with the assumption that strategies that students have actually tried themselves will be easier for them to suggest and explain to others.

Our findings highlight an important personal-clinical correlation for exercise, having shown an association between students’ own exercise habits and their patient counseling practices. In 2017, the Auckland Medical Programme added enquiring about patients’ exercise habits to their clinical skills handbook, which might have influenced the frequency with which students asked about exercise. However, this does not negate the study findings, that students who exercised more were more likely to talk with patients about exercise, a finding which has been previously shown internationally for both doctors (E. Frank, Galuska, et al., 2004; E. Frank et al., 2003, 2013; Oberg &

Frank, 2009), and medical students (E. Frank, Elon, &

Hertzberg, 2007; McFadden et al., 2019; Yu et al., 2015).

Where appropriate, students could be encouraged to dis- close their own healthy exercise habits to patients, as this has been shown to make doctors more credible and moti- vating (E. Frank, Breyan, et al., 2000). Furthermore, medical schools should encourage students to be healthy, as students are then more likely to counsel their future patients about their lifestyles (E. Frank, Carrera, et al., 2007; E. Frank et al., 2003), and influence patients’ behavior (Kreuter et al., 2000; Rogers et al., 2006).

There were several important strengths of this study, including its’ longitudinal design, the high response rate, and the use of validated scales and relevant comparators where possible. The limitations of this study should be noted alongside these strengths, including the use of self- reported measures and the serial cross-sectional design, which limits the ability to exclude cohort or other con- founding effects on the results seen.

In an era where wellbeing curricula in medical schools are becoming more widespread, future research is urgently needed to explore if normalizing distress increases the frequency with which students experience distress, and any consequences of this. Intervention studies could investigate outcomes of students participating in different types of wellbeing curricula, although study designs may be limited by the requirements to deliver a consistent curriculum within a program, and require multi-institutional involve- ment. Future correlational research could investigate the nature of relationships between medical students’ self- awareness, desire, or willingness to report psychological distress, stigma scores, coping strategies, and mental health outcomes including feelings of shame (Bynum, Teunissen, & Varpio, 2021), and the extent to which differences in one variable are related to differences in others.

The findings of such research could inform medical educators about the design of wellbeing curricula and extra-curricular anti-stigma initiatives.

Furthermore, as our findings add to the evidence that medical students’ own health behavior influences their patient interactions, wellbeing educators may choose to include more learning outcomes focused on self-care, and healthy lifestyles in their medical curricula. There is international agreement about the importance of this issue, with

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the inclusion of this principle in the Hippocratic Oath, the World Medical Association’s (2017) statement on Physician Wellbeing, the Medical Council of New Zealand’s Curriculum Framework for doctors (Moir, Yielder, Dixon, & Hawken, 2018), and the Canadian (J. R.

Frank et al., 2015) and U.S. (Englander et al., 2013; NEJM Knowledge + Team, 2017) competency-based medical education frameworks. There is a requirement for doctors to maintain their own health and medical school is a win- dow of opportunity where the necessary skills, knowledge, and attitudes can be cultivated.

Author note

The manuscript has not been previously published and is not under consideration in the same or substantially similar form in any other journal. All those listed as authors are qualified for authorship. All those who are qualified to be authors are listed as authors.

Acknowledgements

The authors would like to acknowledge the Canada Research Chair program and the Annenberg Physician Training Program in Addiction Medicine

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Fiona Moir https://orcid.org/0000-0001-6585-4136

Supplemental material

Supplemental material for this article is available online.

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