The responsibility of our role as medical educators: Cows, coffee and custard apples – should I have taken up farming?

I recently took part in a “rural taster”, an exercise in which medical educators and medical students spend time together in the country. Part of the role of the “rural taster” is to encourage students to choose to spend a year of their medical training in a rural setting, so that they may develop an enthusiasm for working outside of the city.

This year we had a small, but lovely, bunch of students. All postgraduates, they had a variety of life experiences from pharmacy to engineering, a variety of talents from dancing to landscape painting and a variety of dreams from taking over a parent’s country practice to aid and development work. We were not allowed to place them in the emergency department any more, as another first year had fainted at her first sight of blood, causing chaos.

I remembered going down a coal mine in Wales as a student – dark, wet and claustrophobic, but it gave us a little insight into our pneumoconiosis patients work-life. So I thought some farm visits, focusing on farm injury, could be fun. We watched as cows were put through the crush and heard enthusiastic accounts of organic farming of custard apples from John, a surgeon turned farmer who told stories of his own experiences of farm accidents. They learned how coffee is picked, processed and then drank freshly roasted and ground coffee, learning about safety measures and poison regulations. Later they patted llamas and donkeys, ate home-made cheese and chocolate cake and climbed trees to pick mandarins and jack fruit –giving a new meaning to rural taster! (Being gluten/dairy/caffeine free made this rather torturous for me). The highlight of the days was getting down and dirty in the milking shed under the bemused supervision of our host Warren, who had a giggle at the fumbling attempts at putting on milking cups and after two hours showed us that maybe Medicine is a soft option after all.

It was a lovely day, giving me many opportunities to talk with these students about Medicine and about “life, the universe and everything”.

I was reminded of why I love working with medical students. All of them were hugely enthusiastic. They said they were loving their course which, especially for those without a foundational degree in medical sciences, can be overwhelming in the pre-clinical phase. It was especially gratifying to talk with them after their first day on the ward. We had sent them to Ballina where the physician is a wonderful role model – both a fine clinician and a kind and compassionate man. They were excited to see all they had learned in theory translated into a patient living with a disease, seeing the principles of effective communication being delivered by an experienced doctor and for the first time coming to understand the value of the doctor/patient relationship in healing. Medicine can never be taught only on simulation mannequins.

I was at the time reading what has become a best seller in England – the diary of a junior doctor –This is Going to Hurt.(1) I thought of sharing it with them, but then thought better of it – time enough for that in the future. I found it very raw to read, bringing back the exhaustion, tensions, fears and thrills of those long gone days. It was raw in the doctors’ emotional reactions, raw in descriptions of patient suffering and very raw in that black humour doctors share that we would not usually air in public. Underneath this you could feel the pain and perhaps disappointment this young doctor experienced before he changed his career path. It could have been so good. As I spoke to these “new to medicine” students I wondered if the author had ever been so enthusiastic and if he spoke to them now, would he feel they were deluded. I reflected on how things could change so drastically from the ideas and ideals of these new students to the jaded and disillusioned view of the author, and possibly of many other doctors.

I have loved my own medical career, and while I still do, it is impossible not to be realistic about the flaws in the system, not only the health system but in the training of doctors. How can we best prepare them for what is to come, support them to be confident and competent doctors, ready to work in what is a tough system?

The figures from the Beyond Blue study of Australian medical students reported that:

• 43% have a high likelihood of experiencing a minor psychiatric disorder and 2% have very high levels of psychological distress. The general community mean score for high psychological distress is 2.6%
• 2%, including 31.8% of Indigenous medical students, have had suicidal thoughts in the past year
• 3% are moderate risk drinkers while a further 4% are high risk drinkers
• 3% are experiencing emotional exhaustion (2)

A meta-analysis of the prevalence of depressive symptoms amongst medical students showed the overall prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. Among medical students who screened positive for depression, only 15.7% sought psychiatric treatment.(3)

As educators we should at the very least aim to explore the reasons behind these figures and to influence change where change is needed. There is no doubt that a doctor’s well-being is not only associated with how they care for themselves physically and mentally but how well they are prepared academically, psychologically and spiritually to deal with the suffering of others. Current medical training is very demanding – the curriculum being almost ridiculously elastic, creating a massive load which seems to have few boundaries – or perhaps this is simply the view of an ageing clinician who looks at the multi-choice exams in horror, thankful that I am not sitting the exam and wondering what on earth use holding the minutiae in the mind is going to be for practising doctors. They can look it up on their phone and anyway in the next decade what is absolute truth now will be largely obsolete as medical knowledge expands.

What we can do to train our students to be the compassionate, caring, competent doctors our communities need is to support them whole-heartedly – to show them caring, compassion and understanding. This is not to molly-coddle or spoon feed – these are adult learners – rather to be aware of the academic and personal stress they may be under. They are not only students but sometimes parents, partners and workers as well. The demands of medical training put huge pressure on their personal lives, sometimes leading to relationship breakdowns. Their financial situation is tenuous at the best, sometimes creating intolerable distress. And we pile on assignments, tasks, learning objectives as though they are in some way super-human.

It is our role as medical educators to support our students in a way that helps prevent them from becoming burned out and cynical before they even qualify. It is our role to be aware of the dangers of depression, anxiety and suicidality and to watch over them for this. It is our role to keep alive that love for Medicine, that love for caring for patients, that permission to care for themselves, because this is what will be sustaining for them in their careers ahead.

I would like those young students to feel as enthusiastic and excited by Medicine as they do today when they qualify, when they are working, and forty years down the line, as I do. Medicine is a great profession and great people go into Medicine … rather than being worn down by the practice of medicine as is the current state of affairs, as medical educators let’s support our young students and doctors to stay great and to grow our profession from the inside out, for the great benefit of us all.

References:

1. This is Going to Hurt by Adam Kay published by Pan Macmillan
2. https://www.beyondblue.org.au/media/media-releases/media-releases/action-to-improve-the-mental-health-of-australian-doctors-and-medical-students
3. https://www.ncbi.nlm.nih.gov/pubmed/27923088