Inglés (pdf)
Articulo en XML
Referencias del artículo
Curriculum ScienTI
Traducción automática
Permalink
Introduction
The medical education process has been scientifically shown to be an environment prone to vulnerability of medical students in relation to mental health with significant proportions that affect the well-being of these students. Therefore, motivated by alarming numbers of medical students community mental illness and suicides, mental health and the need for a new perspective of care has come to light 1,2,3,4,5. They also have a lower quality of life than age-matched population 6. Mental health issues among medical students represent a challenge that medical schools need to address.
The medical school environment has an impact on student’s health and quality of life because it requires adaptation and lifestyle changes 2,6. A previous study evaluated emotional aspects in 117 medical students and found that 46% of participants suffered from symptoms such as insomnia, unexplained fatigue, headache, indigestion, fear, worry and loss of initiative. Many of these students were expected to suffer emotionally both in their personal lives and in their future professional careers 7.
Studies have shown that the proximity of the teacher to the student in order to understand their questions that go beyond classroom teaching are beneficial to the learning process in medical education 8,9. In fact, it has been argued that the social and cognitive compatibility that characterize the student-teacher relationship creates psychological safe learning spaces, mutual understanding of difficulties and customized models for explaining the learning content. Furthermore, it is argued that this proximity alleviates pressure on the medical student 10. Thus, the importance of observing the medical faculty's perspective regarding medical education and the impacts that this construct can generate on the mental health and training of these future doctors is reinforced.
Medical students are less likely than the general population to receive appropriate treatment, despite seemingly better access to care. They may engage in potentially harmful methods of coping, such as self-sabotage of feelings, excessive alcohol consumption or self-prescription of medications 6,10. Therefore, the role of teaching staff is fundamental to identify and adequately manage these harmful coping methods arising from medical education.
Understanding that various aspects of medical education, including human aspects, influence students’ mental health it is therefore necessary for professors responsible for the training process to express their concerns. Even more so when there is a lack of studies in the area in Latin America, which reinforces the importance of this discussion. Thus, the aim of this qualitative study was to explore the perspectives of Brazilian medical professors on the mental health of medical students through a focus group.
Methods
This qualitative study with focus groups was part of a longitudinal research on mental health involving medical students and professors from Brazil. In this country, a medical degree is obtained in a six-year undergraduate program, which is traditionally divided into three periods - basic cycle (1st and 2nd years), clinical cycle (3rd and 4th years) and clerkships (5th and 6th years). This medical school is a public university in Sao Paulo/Brazil with 120 students per year and was chosen to represent a traditional curriculum of medical education in Brazil. We chose a qualitative design so we could develop a better understanding of our participants’ perspectives regarding factors influencing the medical students’ mental health. The study was conducted according to Critical Appraisal Skills Program (CASP) parameters to evaluate the quality of evidence in this study 11. The protocol was reviewed and approved by the Research Ethics Committee, Brazil (Protocol#4,099,787 on June 19, 2020).
The authors recruited only professors to participate in the focus group process in this new stage of the study. All professors enrolled in this medical school were invited to participate in the study by e-mail. No calculations of sample size were performed, since a convenience sample was used. There was no compensation of incentives of any kind for the volunteers. The inclusion criteria were those professors enrolled in the medical school and those not enrolled as the exclusion criteria.
In October 2023, three of trained facilitators conducted the focus group (n = 1) to ensure uniformity. The primary facilitator led from the moderator guide to explore the perspectives of the participants, while the other facilitators observed, followed up on participants’ responses, and sought clarification and elaboration when necessary. The research team developed the moderator guide with the following topics:
(1) perceptions of mental health for medical students,
(2) factors that decrease medical students’ mental health,
(3) factors that increase students’ mental health,
(4) the impact of the professional practice of medical professors on student mental health, and
(5) proposals to improve mental health for future medical students.
At the beginning of each discussion, the primary facilitator welcomed participants, provided information about the objectives and methodology of focus groups, and warranted confidentiality. The facilitator also promoted participation and concluded the meeting by giving feedback on the discussed themes and by guaranteeing access to study results.
Groups were heterogeneous regarding gender and year of medical professors. A total of six professors participated in one group lasting approximately 80 minutes. Of the participating professors, four were female (66.6%) and 52.5 years old (SD: 9.1). All respondents considered themselves white. Two participants worked on a contract basis in the psychiatry department. The participants were - (P1: female, tenured professor, and pediatrician; P2: female, tenured professor, and preventive medicine; P3: male, tenured professor, and surgeon; P4: female, tenured professor, and pediatrician; P5: male, teacher assistant, and psychiatrist; P6: female, physician and preceptor, and psychiatrist). These professors were those who agreed to participate in the study. All discussions were digitally recorded. A professional transcriptionist transcribed the audio-recorded focus group data, removing all names and participant identifiers.
Two investigators with experience in qualitative analysis reviewed the transcripts. Using techniques of qualitative content analysis 11,12,13, each member of the research team independently read all of the transcripts and identified statements of interest, according to the phenomenological method of analysis. They then met to generate a list of themes based on the statements of interest from the medical professors focus group. Next, they used this initial set of themes in an iterative process to develop categorization of emerging themes and derived issues independently. The investigators reconciled differences through discussion, identified emerging themes, and highlighted illustrative or exemplar quotations. They analyzed the transcripts iteratively until they achieved saturation 12,13,14.
Results
In terms of defining the concept of mental health, the professors discussed different aspects of quality of life. Most of them (n = 4) associated mental heath with emotional aspect, which they defined as feeling good about yourself and being able to lead your own life. Participants remembered that aspects considered as problems, such as anxiety, are not always harmful to human beings.
Resoluteness in life and multiple social functions are also aspects that are part of mental health, since the student needs to prepare and plan for the different facets of life such as being a student, son, brother and father, for example (Table 1).
Table 1 Mental health concepts according to participants.
| Category | Issues | Examples |
| Quality of life | Emotional aspect | “Some aspects are not considered mental health problems, for example, anxiety. We need to have a minimum of it to get out of bed and go to work. Knowing that it is possible to accept suffering."(P2) |
| “The ability to lead your own life, according to your affection.” (P3) | ||
| Resoluteness in life | "Quality that individual has to solve problems that appear in everyday life. Autonomy combined with a power in carrying out, preparing and planning life."(P1) | |
| “Feel competent to plan and make decisions about your own life.”(P2) | ||
| "Mental health involves everything. If you do not sleep right, do not eat right and do not have a daily routine, your mental health is compromised."(P5) | ||
| Multiple social functions | “The ability to deal with the different sides of a person, for example, I am a mother, I am a woman, I am a teacher, I am a friend and I am a sister.”(P4) |
Many participants (n = 5) mentioned both institutional and individual aspects that could negatively impact the mental health of medical undergraduate students. They pointed out the study overload and the level of demand from students, who are often required to present good technical skills, but which are left aside in the emotional aspect, without allowing the student to express their feelings. Another aspect highlighted was the difficulty that medical schools have with more traditional courses without updating, and the lack of skills that do not allow professors to perceive the differences and learning difficulties among students. Furthermore, the inadequate perception that people have about medicine students and professionals as person free from weaknesses and financial problems (Table 2).
Table 2 Factors that affect negatively students’ mental health.
| Category | Issues | Examples |
| Institutional aspects | Academic curriculum | “There is an overload of study and content demands. The curriculum is rigid and does not allow the student to think about taking some combined subjects or in the way they would like, not to mention that the connection between some of the subjects makes it difficult for the student to understand the relationship.”(P4) |
| “Medical school institutions bring an aspect of negative tradition, such as demands.”(P6) | ||
| “We need to think about the differences between students. Things are taught as if people have to arrest them in the same way. This can be something that causes suffering.”(P2) | ||
| Infrastructure | “Lack of physical spaces where they can coexist, where they can feel that they belong as a group. A coexistence between peers that is not just in the classroom or laboratory.”(P1) | |
| Individual aspects | Emotional factor | “The emotional burden of dealing with the fine line between life and death. Not having the possibility of guidance or help, talking to a colleague or going to therapy. Lack of sleep and difficulty sleeping.”(P4) |
| Resilience | “The information they have via cell phone in two seconds. Any problem, they already have the answer. They do not know how to wait. They do not need to wait for anything. The information is all at hand. Now, information is not content, it is not wisdom or knowledge. They need to know how to connect it all, especially with the pressure of the medical world. We need to work on resilience” (P5) | |
| Competitively and expected performance | “The level of expectations and demand for performance from them is extremely anxiety-provoking, especially when it comes to not being able to meet expectations. They always have the feeling that they ‘owe’ the teacher. Competition between students is very present.”(P4) | |
| “Some professional colleagues speak in their own defense about the difficulties and demands ‘but I managed it during my training and you can do it too’. Often it is not out of malice. But he does it because he thinks it will help him. However, this acts as a big problem.”(P6) | ||
| Social aspect | Inadequate perception | “The financial difficulty and social difference, without an adequate place to live, living far from college.”(P4) |
| “There is a fantasy that doctors are Superman and Wonder Woman. It is on duty, but you do not need to eat, you do not need to sleep and you do not need vacations.”(P6) |
When asked about what could impact their mental health positively in medical graduation, they highlighted the need for coherence and pedagogical organization of the medical school and this can be understood by students, they need to identify the objective of a certain course, the importance of discussing a certain subject within that course, and this student be able to perceive the gains and objectives achieved in certain courses. Courses with well-formulated syllabi allow students to understand that medicine is not limited to the clinical environment.
These participants also understood the importance of students’ free time. Artistic practices were mentioned as well, such as the importance of medical schools exploring projects with music and dance (Table 3).
Table 3 Factors that affect positively students’ mental health according to participants.
| Category | Issues | Examples |
| Curriculum | Pedagogical organization | “Having a relationship between the course subjects is fundamental. There needs to be a teaching logic and a conversation between teachers from all years, otherwise it is just something completely cut up and the student will need to put together all these pieces that may not make sense.” (P5) |
| “At the beginning of each subject, having a pedagogical contract is interesting. Explain to the student what is expected of them, what they should be able to do at the end of the course.”(P3) | ||
| “The other thing is the scope of the course. There are possibilities in medicine that cover the most diverse personalities. I do not want to practice medicine, but I could be a researcher. It is possible for you to study medicine and not work in the classical field, and the medical course needs to present this to the student.”(P6) | ||
| “In practical activities where the student realizes that he is contributing. He needs to feel like he makes a difference. Being like a patient, going to the community, carrying out research and seeing its repercussions and consequences. The student needs to understand the theoretical-practical relationship.”(P2) | ||
| Free time | Leisure | “Explore the expression of artistic practices. Music, dance and theater should be explored in the course, as other medical schools do.”(P4) |
Most participants (n = 4) discussed the issue of the importance of teacher-student relationship and how the professor perceives that his position serves as an example and model for these future professionals, as well as the position of professor can help in identifying and managing problems of some students, especially when the group of students is smaller, and also enable the exchange of experience between teacher and student (Table 4).
Table 4 Impact of my position on students’ mental health.
| Category | Issues | Examples |
| Teacher-student relationship | Proximity | “I am with the students in a very small group. This gives me the possibility of getting closer to them. In that space we have plenty of time to talk about any topic. This is cool because they bring institutional, personal, training issues and doubts, as a place for listening and exchanges. Which even helps to seek guidance for individual care or therapy.”(P6) |
| Model | “I need to be a model. The teacher-student relationship has a lot to do with the doctor-patient relationship. I really want to teach my student, in the same way that a doctor needs to listen and welcome the patient.”(P6) | |
| “By being a model for students, we need to guarantee quality in communication.”(P1) |
As a result of proposals to improve the mental health of upcoming medical students, professors warned of the need for improvements and proposals for new teaching strategies and technologies linked to teaching pedagogy. Student needs to be considered whenever a change is planned. These participants believed that having leisure options is appropriate during medical education. The lack of a common area for students to interact is perceived as detrimental to student social interaction (Table 5).
Table 5 Proposals to improve mental health for future medical students.
| Category | Issues | Examples |
| Teacher training | New learning models | “Perhaps it could be interesting to have a group that could look into more longitudinal issues and work on improvement proposals with students and teachers, of the most diverse types.”(P1) |
| “Seek other models and proposals for this teacher to be more qualified. Investing in teacher training is essential. We need to invest more in mentoring, in the cultural aspect and healthy coexistence between students.”(P6) | ||
| Listen to the student | “We need to know what students really need, not just us proposing it.” (P5) | |
| Free time | Leisure | “An excellent space where students can exchange experiences and conversations are parties and interaction spaces. These are conversations that are not formal and without that pressure on the student about what and how to say.” (P6) |
Discussion
In this study, results reveal the importance of medical faculty observing the behavior and speech of students who are often ignored in institutional decisions or even in the classroom, the place that can highlight the losses and particularities of these students. It is necessary to be aware that positive factors can be reinforced, such as socialization and sports. A pedagogical reformulation that makes sense for the student’s learning process. This needs to be considered in the curricular proposals of medical schools and put into practice by the medical faculty who need to be constantly updating methodological teaching strategies, according to participants 4,15,16.
Faculty and medical schools need to have a partnership in order to promote changes in traditional curricula that do not prioritize a pedagogical teaching logic that values the student's knowledge, without the need for a requirement to performance that generates in the student an anxious state and without stimulating competitiveness among peers 17,18,19.
However, the participants highlighted that controlled and assertive anxiety is part of the existential life of human beings and people need to know how to deal with this issue in order to adequately control their mental health. Professors considered the emotional and social aspects, which characterize quality of life, as an attribute for understanding the concept of mental health. These aspects are fundamental when thinking about educational strategies that go beyond the technical-practical knowledge taught to medical students 5,17,19,20.
In addition to educational strategies, the human aspect of the teacher-student relationship allows the faculty provides positive care for students, as according to participants they are a model for good professional performance and a reference in seeking help when the student faces a problem, especially when the group or course has a smaller number of students 21,22. However, it is known that much of what happens in education is only partially understood, both by teachers and students. Education is a dynamic enterprise and procedures designed to optimize teaching sometimes have adverse effects. Thus, it is important to work in smaller groups so that disappointments are expressed and understood by both. Medical faculty cannot forget to understand the dynamics of education and learning, ways to motivate students and tools to facilitate learning 10,18,21.
Therefore, peer teaching and mentoring program are understood here as strategic recommendations for medical education. Since both proposals are distinct from more conventional teaching methods and allowed experiences that contributed positively to the personal and professional growth of medical student, and also enabled the growth of leadership, communication and teamwork skills via participation of medical school students in these programs 9,22. Another suggestion is to change the traditional curriculum. Some schools have already added subjects such as "Self Care Skills", "Accessing Help", "Emotional Intelligence" in their core components. These schools realized that developing mechanisms to deal with their own mental health impacts on physicians’ communication and patient care in the future 21.
There are some limitations and strengths with this study. The final sample was small, although representative for a qualitative study based on a focus group. All participants involved in this study are employees of a single university, which may limit the generalizability of the results to their peers at other universities. To generalize the results of this study, repeating this study in conjunction with other medical schools will provide a broader population from which to draw inferences about the results. However, this study was able to recruit a very diverse sample of medical faculty, so many of the issues discussed are common to most trials, and these results have the potential to inform the development of better models of mental health care for a wide range of studies on medical education.
Conclusion
This qualitative study indicates that medical professors' perception of students' mental health includes emotional aspects, but also institutional issues that need to be reviewed, such as changes the traditional curriculum and modernization of educational strategies. The human aspect of realizing the student's individuality and working in small groups of students can promote good mental health, according to participants. This work suggests that development of programs for exchange of longitudinal experiences may allow students and faculty to learn from each other and thus collaborate with improvements in medical education. Future work should examine how additional aspects of teaching and learning environment, including modernizations and investment in faculty training, will benefit student mental health.
