Are we preparing our medical students to fail with a reactive not proactive approach to managing workplace stress, reducing burnout and addressing mental health problems?

Abstract

Stress, burnout and mental health problems are pervasive among medical students globally. Mental health difficulties during undergraduate training may persist throughout medical careers, yet current support remains predominantly reactive, addressing problems only after they emerge. This approach is problematic: harm has already occurred, students must self-identify difficulties despite documented help-seeking barriers, and psychological support resources remain insufficient. We argue for a paradigm shift towards proactive, preventative interventions that prepare students for the predictable stressors of clinical education and practice. Our preliminary research evaluating a cognitive-behavioural intervention demonstrated improvements in resilience, confidence and burnout indicators in medical students, and we are now building upon this with a randomised controlled trial of Thumos, an intervention based upon cognitive-behavioural principles. While acknowledging that individual-level interventions cannot address systemic causes of occupational stress, evidence-based proactive approaches should be prioritised alongside organisational change. International collaboration is essential to develop and implement effective preventative programmes.

‘A system breaking its people’ is how Sharon Nash described the NHS in a recent King's Fund report.¹ Over 40% of NHS staff feel unwell due to work-related stress and almost one-third report taking time off due to mental health issues.^2,3 Stress and burnout are degrading staff wellbeing, causing an international workforce crisis and detrimentally impacting the safety and quality of patient care.⁴

Stress, burnout and mental health issues have been significant problems within the global medical profession for decades, and the situation is worsening.5, 6, 7 One frequently overlooked feature of this crisis is that these problems begin prior to qualifying, with poor mental health in medical students a global concern.⁸ Burnout affects 50% of medical students,⁹ one-third experience depression and 10% report suicidal ideation.^10,11 Medical students have not only been shown to have worse mental health outcomes than qualified physicians,¹² but those that do have mental health problems at the undergraduate stage may be more likely to have mental health problems throughout their careers.^13,14

Many causative factors have been identified, including the learning environment,¹⁵ high academic workload,¹⁶ a tendency towards maladaptive perfectionism,^17,18 exposure to dying patients, involvement in medical errors,¹⁹ and unprofessional behaviour from colleagues.¹⁷ As many as one in five medical students are considering leaving the profession, citing stress and burnout as the most common reason.²⁰

At present, there is a lack of mental health support available for students and that which is provided is generally reactive.²¹ Reactive interventions relate to those that are employed once mental health issues have developed, as opposed to preventative interventions which might reduce the risk of them developing. There are three principal problems with a reactive approach. Firstly, waiting until students are unwell means that harm has occurred, therefore greater resources will be required in treatment or recovery. Secondly, a reactive approach relies heavily on the students themselves recognising the problem and seeking help, something which both students and qualified doctors can struggle to achieve.²² Thirdly, a reactive approach requires sufficient resources and access to psychological support for students, which is currently lacking.²¹ The British Medical Association created a wellbeing checklist in 2021, which contained guidance for medical schools as to how they might improve student wellbeing. This was followed up with a survey in 2024, finding that less than 50% of medical schools offered voluntary wellbeing sessions and easily accessible psychological support, and some universities had as little as one support officer for 400 students.²¹

As with health in general, prevention is considered better than cure. It is the opinion of the authors that we should proactively prepare students for the inevitable stress of work within healthcare. Whether stress comes from distressing patient encounters or understaffing, challenging professional relationships, or challenging training needs and exams, we should support students to develop effective and healthy ways in which to handle and process stress. With the predictably stressful nature of undergraduate medical education and subsequent practice, it could be argued that there is a moral imperative to design and deliver a supportive programme for students; failing to do so could be likened to sending soldiers into battle without armour.

Following previous pilot studies in multidisciplinary healthcare professionals, the authors published the results of a single-arm study evaluating a tailored intervention based on cognitive-behavioural principles in medical students.²³ The intervention, delivered by a trained psychological therapist, aims to prepare medical students for the stressors they’ll face on placement. Results suggested that it was associated with improvements in resilience, confidence, burnout and depression indicators and had good retention over 4 months (>70%).²³ The authors are now evaluating ‘Thumos’, an intervention based on cognitive-behavioural principles using a randomised controlled trial in medical students.²⁴ This work appears to be important to both the medical student community, with recruitment targets exceeded in the preliminary study, as well as funding bodies, with the BMA Foundation and MPS Foundation providing support.

It is the opinion of the authors that reactive approaches to stress exposure and subsequent mental health problems and burnout are insufficient and inefficient. The predictable and increasingly stressful nature of study and work in the clinical environment necessitate a proactive and prophylactic approach. Medical students are provided with the skills to care for others, but must also be supported to develop the skills to protect their own psychological wellbeing.

It is important to make clear that we are not suggesting that the issue of stress and burnout in doctors can simply be fixed by training more ‘resilient’ doctors.²⁵ Stress and burnout are well-documented occupational hazards in healthcare work,²⁶ which are likely to require a combination of approaches to address. Many factors that contribute to stress and burnout are beyond the control of individual students and doctors, relating for instance to the structure and delivery of training or assessments,27, 28, 29, 30 or time pressures and lack of resources.³¹ It is however likely that, even with a healthcare system perfectly designed to reduce external sources of stress, students and qualified doctors are going to be exposed to stress.

While a growing body of interventions show promise in effecting positive impacts on medical student mental health, it is clear that further high-quality research is needed to identify effective interventions and programmes.³² It is the opinion of the authors that priority should first be given to interventions based on theory and evidence, rather than popular zeitgeist. For example, cognitive-behavioural approaches are well evidenced for a range of mental health problems, and previous research in emergency healthcare professionals suggests that they are one of the most effective interventions.³³ There are also cognitive-behavioural strategies which target the development of self-esteem, mental flexibility and explanatory style, all key factors known to protect against psychologist distress.³⁴ We would recommend considering cognitive-behavioural and other evidence-based strategies before reaching for interventions which may have greater surface appeal, but a weaker support base in healthcare professionals and students.

Those responsible for training and wellbeing of doctors at undergraduate and postgraduate level need to prioritise the integration of evidenced-based proactive preventative interventions to reduce the impact of predictable stress. As this is a global problem, there are likely to be great benefits from international collaboration and learning.

CRediT authorship contribution statement

William Lea: Writing – review & editing, Writing – original draft, Conceptualization. Vijay Jayagopal: Writing – review & editing, Conceptualization. Lucy Pointon: Writing – review & editing, Conceptualization. Raoul Ovalekar: Writing – review & editing, Conceptualization. Rajjan Singh: Writing – review & editing, Conceptualization. Judith Johnson: Writing – review & editing, Writing – original draft, Conceptualization.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: William Lea reports financial support was provided by MPS Foundation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.