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ISSUE 30 • APRIL 2020
Mental health
in Aotearoa
CARING FOR OURSELVES AND OUR PATIENTS
Experts’ advice on How does publishing
maintaining medical
V as a medical student impact
V
student wellbeing your future career?
Crossover trial on How to pass Otago’s
V
the best mode of
V fifth year exams
salbutamol delivery
Plus our usual statistics primer,
Māori health and book reviews
EDITORIAL ARTICLES ACADEMIC ARTICLES FEATURED PIECES REVIEWS CREATIVE ARTS
You are
here
to help,
so are we.
Let’s talk.
Like you, MAS is here to help. So we’d like to
Join the
conversation
share with you and students like you, our
nearly 100 years of providing NZ’s
professionals with insurance, investment,
lending options and trusted financial advice.
By joining the ‘Conversation’, each month you’ll
receive helpful tips and tricks, health,
wellbeing and financial advice and chances to
win prizes, including a $250 Prezzy Card.
Text ‘JOIN’ to 3118 or visit
mas.co.nz/jointheconversation
to join the conversation.
nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
Contents
4 Editors’ welcome
Gisela A. Kristono, Nicky Dunn
INVITED ARTICLES V 6 Running your mind and life effectively when there is no life
instruction manual
Bruce Arroll, Vicki Mount
8 Waking up to the importance of sleep: why that extra shut eye
is key to medical student wellbeing
Kieran Kennedy, Tony Fernando
11 Stress and suicide in medical students and physicians
Annette Beautrais
15 Choosing a career in psychiatry: expect the unexpected
Susanna Every-Palmer, Sarah Romans, Alice Law, Jess Henry, Mat-
thew Jenkins, Mark Lawrence
19 Primary care provision for mental health
Samantha Murton
ACADEMIC ARTICLES V 21 The effect of mode of inhaled salbutamol delivery on
measures of small airways obstruction in asthma:
a comparison of treatment delivered via spacer and nebuliser
Aqeeda Singh, Jan Cowan, Jack Dummer
26 ‘Tis but a scratch: discussing the future of eczema treatment
in the wake of a psoriasis revolution
Leina Tucker-Masters
29 Pumping up a new revolution of diabetes management:
insulin pumps and emphasis on psychological aspect of
diabetes care
Isabel See
33 BMedSc(Hons) abstracts
Various Authors
43 Publication in a medical student journal predicts short- and
long-term academic success: a matched-cohort study
Ibrahim S. Al-Busaidi, Cameron I. Wells, Tim J. Wilkinson
FEATURES ARTICLES V 48 Medical student journals: promoting academic research
and publishing
Ibrahim S. Al-Busaidi
50 The value of mentoring and the ASMS‑NZMSA
Mentoring Programme
Josephine Stonyer
54 You are not alone: an interview with the
Chief Executive Officer of Chnnl, Dr Liz Berryman
Mustafa Sherif, Oliver Dugeña
N Z Med Stud J, Issue 30, pp. 1–2, Apr 2020 1
nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
57 Health politics and Māori equity: euthanasia, cannabis,
and the abortion law reform
Emma Espiner
61 Parametric vs nonparametric statistical methods:
which is better, and why?
Robin Turner, Ari Samaranayaka, Claire Cameron
63 Can we be doctors and still have a life?
Samantha King
66 A guide to Otago fifth year exams
David Wang
69 Elective report: otolaryngology — head and neck surgery,
Miami, Florida, USA.
Natalie Bell
MEDIA REVIEWS V 71 Mind that child by Dr Simon Rowley
Nandini Dubey
72 War doctor by David Nott
William H Cook
CREATIVE ARTS V 74 Is it Christmas yet?
Libby Whittaker
75 Anatomy of the neck
Bhanuka (Barney) Rathnayaka
76 Information for authors
2 N Z Med Stud J, Issue 30, pp. 2–2, Apr 2020
nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
Acknowledgements
Editorial Board Expert Reviewers
Gisela Kristono Steven Yoo
Editor-in-Chief Web Editor Professor Assoc Prof Dr Steven Ritchie
Otago Auckland Warwick Bagg Denis Loiselle Auckland
Auckland Auckland
Nicky Dunn Chris Varghese
Deputy Editor Indexing Manager Hon. Assoc Prof Dr Louise Reiche
Auckland Auckland Paul Jarrett New Zealand
Auckland Dermatology
Sameer Bhat Jennifer Zhou Society Inc.
Academic Editor Social Media Manager
Auckland Otago
Student Reviewers
Mustafa Sherif William Cook
Academic Sub-Editor Academic Events Kaleb Addy Ellie-May Jarvis Jim Wang
Auckland Officer (Auckland) Otago Otago Auckland
Auckland
Rahul Makam Benjamin Anu Kaw Jacob/Jake Ward
Features Editor Anu Kaw Alsop-ten Hove Otago Otago
Auckland Academic Events Auckland
Officer (Otago) Saloni Patel Dr Cameron Wells
Oliver Dugeña Otago Matthew Cowie Otago Auckland
Features Sub-Editor Otago
Otago Libby Whittaker Uma Sreedhar Andrew Xiao
Proofreader Joyce Guo Auckland Otago
Michaela Rektorysova Otago Otago
Media Reviews Editor Chris Varghese Vithushiya
Auckland Samuel Haysom Auckland Yoganandarajah
Otago Otago
Commercial Board Advisory Board Thanks to
Mark Dewdney Dr Mariam Parwaiz Medical Assurance Society
Designer University of Auckland
Forethought.co.nz Dr Cheyaanthan Haran University of Otago
New Zealand Medical Journal
Neeraj Khatri Aleksandra Turp Royal Australia and New Zealand College of Psychiatrists
Finance Officer Royal New Zealand College of General Practitioners
Otago Dr Logan Williams New Zealand Dermatology Society Incorporated
New Zealand Medical Students’ Association
Niket Shah
Production Manager
Otago
Editorial Office
Website: http://www.nzmsj.com
Email: nzmsj@nzmsj.com
Facebook: https://www.facebook.com/NZMSJ
All other correspondence to:
New Zealand Medical Student Journal
c/- Medical Education Group
University of Otago Medical School
PO Box 56, Dunedin, New Zealand
N Z Med Stud J, Issue 30, pp. 3–3, Apr 2020 3
nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
EDITORIAL
Editors’ welcome
Gisela A. Kristono, Nicky Dunn
Tena koutou and welcome to Issue 30 of Te Hautaka o Ngā Akongā Students’ Association, writes about their mentoring programme that
Rongoā, or the New Zealand Medical Student Journal (NZMSJ). We was launched last year and its successes so far. As part of our inter-
are excited to share another issue with our readers that contains high view series, Mustafa Sherif and Oliver Dugena interviewed Dr Eliza-
quality work conducted by medical students and academics. beth Berryman about her wellbeing app, Chnnl, and her experiences
working as a junior doctor. Finally, Dr Samantha King from the Medical
A brief introduction to the articles in this issue Protection Society discusses the important topic of medical student
The theme of this issue, “Mental Health in Aotearoa”, is a topical issue burnout and tips for avoiding burnout. Our brilliant range of feature
and significant to all New Zealanders: as health professionals, family articles does not end there. Our regular statistics primer gives an
members, friends, and for ourselves. We are extremely grateful to all informative and clear background into parametric versus non-para-
of the invited authors who have written such insightful and interest- metric data and analyses. We thank Associate Professor Robin Turner,
ing articles for us on the topic. Professor Bruce Arroll and Dr Vicki Dr Ari Samaranayaka, and Dr Claire Cameron for producing another
Mount’s editorial provides useful advice on how to look after our fantastic primer for us. We also have another great Māori health re-
mental wellbeing; Drs Kieran Kennedy and Tony Fernando discuss view from Emma Espiner, this time focussing on three topical medico-
the importance of sleep; and Professor Annette Beautrais writes an legal issues: cannabis, euthanasia, and abortion. David Wang writes an
important piece on stress and suicide, with a section detailing how informative piece on the dreaded Otago fifth year exams and shares
to care for each other and ourselves. Dr Sam Murton kindly writes his advice based on his experiences going through them last year. To
about mental health provision in general practice and the mental round off, Dr Natalie Bell shares her elective experiences with an
health of general practitioners. Finally, Drs Susanna Every-Palmer, Sa- otorhinolaryngology department in Miami.
rah Romans, Alice Law, Jess Henry, Matthew Jenkins, and Mark Law- This issue also features reviews of two fascinating books medical
rence discuss an informative editorial on why medical students should students may wish to read in their spare time. Nandini Dubey reviews
consider psychiatry as a career. Mind that Child, an insightful book on Auckland neonatologist Dr Si-
We received an impressive range of academic articles for this issue. mon Rowley’s journey as a doctor. William Cook shares his review of
Aqeeda Singh et al. compare two methods of inhaled salbutamol de- War Doctor, which contains stories from Mr David Nott and other sur-
livery in relation to improvements in small airway function and found geons’ experiences of working as a doctor in war-torn environments.
that use of metered-dose inhaler and spacer resulted in better out- Both of these books may enrich a medical student’s perspective and
comes compared to nebuliser. We are proud to publish Leina Tuck- understanding of medicine and career paths.
er-Masters’ essay that discusses medications for psoriasis that could Finally, we would like to congratulate Libby Whittaker and Dr
potentially be used for eczema. This essay was the winner of this Barney Rathnayaka for winning this issue’s Creative Arts Competi-
year’s Wilson-Allison Memorial Prize presented by the New Zealand tion. This competition is an ongoing collaboration with NZMSA to
Dermatology Society Incorporated. Dr Isabel See wrote a case report showcase our fellow medical students’ creative talents. Libby wrote a
on Type 1 diabetes with an important discussion on diabetes manage- well-crafted poem related to one of her clinical experiences, while Dr
ment, which won the W E Henley Prize in Clinical Medicine (present- Rathnayaka created an artwork of the structures of the neck to help
ed by the University of Auckland) and David Scott Prize (presented him study anatomy during medical school.
by the Middlemore Foundation) in 2018. This issue also presents the
2018 Bachelor of Medical Sciences with Honours abstracts from Uni- Important note
versity of Otago students, and the 2019 ones from the University of As mentioned earlier, mental health is a pertinent topic to discuss in
Auckland. Finally, we are grateful to BMC Medical Education and Dr the medical field – hence the editors’ desire to focus on this topic as
Ibrahim Al-Busaidi et al. for allowing us to republish their article that our issue theme. However, some of the articles discuss aspects of
investigates the association between medical student publishing in the mental health that may be distressing to some readers, such as sui-
NZMSJ and future careers in academia. We believe these are im- cide. If any readers feel distressed while reading this issue, we strongly
portant findings supporting medical students’ involvement in research, encourage you to seek support using one of the contact details or
and hope that this article will encourage more students to publish resources on the following page in Table 1.1 If you wish to find more
their academic work. We were pleased with the opportunity to also resources for a specific mental health condition, we suggest visiting
have a feature written by Dr Al-Busaidi that complements his repub- the NZMSA website for their comprehensive list of resources.1
lished article, expressing the importance of medical student publishing
and the role that medical student journals can have in aiding with this. Thanks and conclusion
We also have three feature articles related to our theme. Jose- The Editorial Board would like to thank the Universities of Auckland
phine Stonyer, the Wellbeing Officer for the New Zealand Medical and Otago for their ongoing financial and academic support towards
4 N Z Med Stud J, Issue 30, pp. 4–5, Apr 2020
nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
the journal. We would also like to thank the Medical Assurance Socie-
ty and the Royal Australian and New Zealand College of Psychiatrists
for their funding and Professor Frank Frizelle for his financial support
towards the Verrall Award. The winner of this year’s award will be
selected from this year’s NZMSJ issues (30 and 31), and will be an-
nounced at the end of the year. We would like to acknowledge the
NZMSA, the New Zealand Dermatology Society Incorporated, and
the Royal New Zealand College of General Practitioners for their
ongoing support. Finally, the authors would like to thank the Advisory,
Editorial, and Commercial Boards, and our reviewers, as they have
worked hard and supported us behind the scenes to enable this issue
to be published.
We hope NZMSJ readers will enjoy the assortment of engaging
articles that Issue 30 brings, and find the content useful for their own
wellbeing. We would like to congratulate all of the authors who have
contributed towards this issue and encourage all readers to submit
their work to NZMSJ for our future issues.
References
1. New Zealand Medical Students’ Association. Welcome to the NZMSA Wellbeing Page
[Internet]. New Zealand: New Zealand Medical Students’ Association. 2017 [cited 2020 Feb
23]. Available from: https://nzmsa.org.nz/index.php/wellbeing/
Table 1: New Zealand mental health resources and support contacts1
Organisation or resource (brief description) Contact details or website link
Suicidal Crisis Helpline (24/7 service) 0508 828 865
1737, need to talk? (national mental health and addictions helpline) 1737
University counselling services Auckland: https://www.auckland.ac.nz/en/on-campus/student-support/
personal-support/student-health-counselling.html
Otago: http://www.otago.ac.nz/studenthealth/index.html
ePhysicianHealth (for a variety of conditions) http://ephysicianhealth.com/
HelpGuide (for a variety of conditions) http://www.helpguide.org/
Keeping Your Grass Greener (wellbeing guide) http://mentalhealth.amsa.org.au/wp-content/uploads/2014/08/
KYGGWebVersion.pdf
Computer Assisted Learning for the Mind www.calm.auckland.ac.nz
(for mental resilience, healthy relationships, and finding a purpose in life)
Beating the Blues http://www.beatingtheblues.co.nz/
(cognitive behavioural therapy programme for depression and anxiety)
MindTools (strategies to reduce stress and develop positive coping skills) https://www.mindtools.com/pages/main/newMN_TCS.htm
Centre for Clinical Interventions (for chronic worrying and anxiety) http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=46
5nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
INVITED EDITORIAL
Running your mind and life effectively
when there is no life instruction manual
Bruce Arroll, Vicki Mount
We have no operating manual be present and accepting of such thoughts. Accepting a thought is not
The problem with humans is that no life operating manual is issued the same as condoning the action that may have caused it, but instead
at birth, leaving individuals to work out the rules for themselves. This allowing it to be present.
acquisition of life skills takes time and a lot of trial and error, and many
never figure it out. The following article attempts to provide the man- Self-compassion
ual you should have been given at birth. Difficulties with being able to be kind to oneself are commonly behind
people with persisting distress issues. There are ways of determining
The brain lacks a delete button this. The third step in the mindful anchor process is to show yourself
I first heard this comment at an Acceptance and Commitment Thera- some self-compassion or self-kindness. One way I do this in my thera-
py (ACT) conference in Wellington in 2015 when one of the founders, py sessions is to ask the person to think of someone they love with all
Professor Steve Hayes, stood in front of the audience and noted that their heart and then imagine they are looking into that person’s eyes. I
there is no delete button in the human mind, so we need to hold our then ask, “How do you feel about that person? What would you give
negative cognitions lightly.1 He then held his hands in a cupped form that person? What things would you do with that person?” Then, I ask
by his waist to demonstrate how we can hold things lightly. I consider the more difficult task: “Imagine that person is you.”
this to be one of the most profound ideas that I have come across. If If the person stalls at that point and says that they cannot do that,
the central role of the human brain is to keep you alive, then it makes you know they have an issue with self-compassion. I then ask, “What
sense that it won’t let you forget “dangerous” things that have hap- is the emotional tone of the conversations you have with your mind?”
pened to you in the past, so that you are forewarned and forearmed In many distressed patients, it can be very negative and harmful. I ask
to deal with them should you be in that situation again. This applies if it is a sergeant major or a personal trainer in their mind; if it is the
to physical dangers, such as driving a car and crossing a street; and first, would they prefer to have a personal trainer doing the talking?
psychological dangers, such as having difficulties with a family member For those who acknowledge they have self-compassion issues, I refer
or work colleague. them to Dr Kristen Neff’s website, which has an assessment tool
This is all explained by a theory of language called Relational Frame and many useful resources.4 I also ask them to consider cultivating
Theory.2 The human mind can pull together a series of negative ex- the voice of self-kindness in their minds when thinking more negative
periences from the past, culminating in a disproportionate response thoughts. I have personally found this to be very helpful in my own life.
to an otherwise benign trigger. For example: you failed a maths exam The example I like to give is the motorway scene when someone cuts
when you were eight, had a distressing argument with your mother in front of me and I am contemplating engaging in some road rage. I
when you were 16, and crashed the family car when you were 21 now say to myself, “Bruce, cultivate the voice of self-kindness in your
years old; then your boss is grumpy with you at work, and you spiral mind,” and I find myself instantly feeling relaxed.
downwards. Pulling together seemingly unrelated events is a uniquely
human ability, as we do not think other animals can do this, and is Experiential avoidance
a function of our skills at using language. Our human language can Experiential avoidance is broadly defined as attempts to avoid
enable our minds to bring back the past into the present and cause thoughts, feelings, memories, physical sensations, and other internal
us grief. It can also do wonderful things for us, such as develop good experiences. The ACT theory suggests that we can fuse with a neg-
friendships with other humans. In a sense, our human language is both ative thought, and our minds try to avoid such thoughts. This sets off
our best friend and worst enemy when operating this way. our sympathetic nervous system and gets us ready to fight or flee. If
this persists, we can become behaviourally avoidant, which means we
How to hold things lightly start avoiding people and places. Kirk Strosahl, one of the co-found-
There are several ways of holding things lightly. One is to cup your ers of ACT, states that “life constriction precedes (or accompanies)
hands by your waist and physically hold the thoughts lightly as de- mental health issues.”5 This is a very profound and important point,
scribed above. Another is the “mindful anchor”, which is a more for- and I find that reversing this (with behavioural activation – see be-
mal way of doing this.3 Another suggestion is that when a belief such low) generally is accompanied by an improvement in patients’ mental
as “I am not good enough” arises, say to yourself, “I am having a health. Avoidance is considered the key to mental health problems.
thought that I am not good enough,” then, “I notice that I am having a The solution to this is behavioural activation.
thought that I am not good enough.” These are all steps to enable us
to get a perspective on the situation, and create an acceptance mode Behavioural activation
as opposed to a struggle mode when dealing with such issues. The Behavioural activation (BA) is a treatment or action that encourag-
idea is not to make the thoughts go away, but to allow the mind to es patients with depression or distress to approach activities they
6 N Z Med Stud J, Issue 30, pp. 6–7, Apr 2020nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
may have been avoiding. With a therapist, patients define goals and 3. Arroll B. Anxiety away: How to deal with anxiety [video on the Internet]. 2018. Available
“activity schedules”. The rationale is that depression or distress is a from: https://www.brucearroll.com/resources
consequence of avoiding particular activities or situations. There are 4. Neff K. Self-compassion [Internet]. 2019. Available from: https://self-compassion.org/
many ways of doing this, and it has been shown that low scores on
contact with friends and low scores on recreation are associated with 5. Strosahl K, Robinson P, Gustavsson T. Brief interventions for radical change: Principles
and practice of focused acceptance and commitment therapy. Oakland, CA: New
low mood My approach is to get patients who are distressed to make Harbinger Publications; 2012.
contact with their friends and start doing physical activity. The majori-
ty of distressed patients I see are somewhat or significantly better one 6. Masterson C, Ekers D, Gilbody S, et al. Sudden gains in behavioural activation for
depression. Behav Res Ther. 2014 Sept;60:34–8. doi: 10.1016/j.brat.2014.06.008
week later. There is evidence that two weeks after the initiation of
BA, 42% of “depressed” patients’ depressive symptoms are resolved. 6
BA and exposure therapy are two of the most effective psychological
treatments that are available. About the authors
Trust your experience and not what your mind is saying VV Professor Bruce Arroll, MBChB, PhD, FRNZCGP (Distinguished),
Humans are exquisitely designed to avoid physical pain, and because FRNZCUC (Honorary), is the Personal Chair and Elaine Gurr Chair
we are very successful at this, we trust the problem-solving function of General Practice and Primary Health Care, and the Head of De-
of our brains. Unfortunately, the problem-solving capacity is not so partment, Director of the Goodfellow Unit, for the Department of
good for personal pain, such as having a demanding boss or work General Practice and Primary Health Care, University of Auckland
colleague, or a difficult personal relationship. For many things in our
lives, learning not to trust our minds is a compelling way to learn to VV Dr Vicki Mount, BSc, BCom, MBChB, is a GP registrar at Mission
live with ease. For example, when we don’t feel like doing anything Bay Doctors, Auckland
and would rather watch TV and have a drink of alcohol, we need to
remember how we felt when we last went out or when we last did
exercise. In most cases that would be a more enriching experience
than drinking alcohol and watching TV. For personal pain, we need
a different approach. We need to approach issues rather than avoid
them, and hold negative thoughts lightly.
Values and living with ease
In the ACT model, we are not trying to make our negative feelings go
away. Instead, we need to be pursuing our values (those things that
are important to us in the long term). By attempting to approach our
values (they are directions and not destinations), we can aim to live
with ease. This is not the same as avoiding suffering, as we need to
accept that suffering is expected and okay and not to fight it.
Knowing your life dashboard warning light
Getting to know your life dashboard light can be essential to recognise
when you are starting to experience distress. In my own life, I usually
like to go to the gym for a workout. When I start feeling stressed, one
of the first signs is that I do not want to go to the gym (remember:
life constriction accompanies mental health issues). I have learnt that
when the dashboard light starts flashing, I now go straight to the gym
and generally feel a lot better afterwards.
In summary
Recognise there is no delete button in the brain. Its role is to keep you
alive and not forget negative things that have happened to you. Avoid-
ance is the source of much of our human suffering. For personal pain,
we need an approach modality and to learn to hold uncomfortable
feelings lightly. When we get stressed, we need to keep our worlds
expanded, keep in contact with our support people, and keep doing
our recreational activities (including some form of exercise). Learning
to trust your experience, not what your mind is saying, is a powerful
skill to develop. Cultivating the voice of self-compassion in your mind
is a skill worth learning. Speak to your mind with the tone of the
personal trainer, not the sergeant major. Finally, please get to know
your life dashboard warning light, and take action when it comes on.
References
1. Hayes SC. Keynote talk presented at: Australia and New Zealand Association of
Contextual Behavioural Science Conference; 2015 Dec; Victoria University, Wellington,
New Zealand.
2. Törneke N. Learning RFT: An introduction to relational frame theory and its clinical
application. Oakland, CA: New Harbinger Publications; 2010.
7nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
INVITED EDITORIAL
Waking up to the importance of sleep:
why that extra shut eye is key to medical
student wellbeing
Kieran Kennedy, Tony Fernando
Sleep is one of the most fundamental of all biological needs. And activate regions responsible for the opposite. Numerous neurotrans-
whilst for most of us (depending on how many days out you are from mitters play a key role including serotonin, histamine, melatonin, aden-
that big exam) sleep seems to be a simple matter of closing our eyes, osine, and acetylcholine.3,4 Influences and feedback from other areas
it’s in fact a complex and wholly active process. Recent decades have of the body involved in breathing, position, temperature, vision, and
seen a notable rise in understanding not only of sleep itself, but the the auditory system form further parts of a complex system. As any-
importance that sleep has to our waking lives. Physically and mentally, one who has lain awake willing away that mental countdown (“if I fall
sleep is vital to functioning at our very best and is a key component asleep now I’ll get six hours”) knows all too well, psychological and
of health and wellbeing. emotional factors play a leading role here too.
Medical students and doctors have a love-hate relationship with
the sandman. Statistics show that medical students struggle when it Medicine and sleep
comes to sleep, reporting higher rates of fatigue, tiredness, truncated We likely didn’t need to tell you this one, but working in medicine
sleep, and poor-quality sleep than others.1,2 Similar findings occur in poses significant risks to good quality sleep. Stress, anxiety, pressure to
surveys and studies looking into the sleep of doctors. The impact perform, heavy workloads, and unrelenting rosters — common features
of long shifts, shift work, mental/emotional burdens, and demanding of life in medicine — are just some of the psychological and environmen-
specialty training programmes are staples to medical training, and are tal factors involved. Both during medical school and work as a doctor,
theorised to play a major part in disturbed sleep. Alongside these factors mount toward a fractured sleep cycle and chronic sleep debt.
statistics on how well we’re acing (or not) nap time, the impact of Medical students and doctors alike have been found more like-
fatigue and inadequate sleep on medical student and doctor perfor- ly than the general population to report disordered sleep and fa-
mance has also become clear in recent years. As modern medicine tigue,1,2 and demanding rotations, study, anxiety around assessments/
barrels forward, we’ve seen that sleep impacts not only on doctors’ tests, shift work, long hours, and on call work are often noted as key
and trainees’ cognitive capacity and motor coordination, but their contributors. Perfectionism, a tendency for obsession and rumination,
judgment and emotional regulation too. Protecting the sleep of the high levels of drive to succeed, and pressure to be seen as a valued
modern medical student is thus vital in ensuring student, clinician, and medical colleague are also risk factors for poor sleep and compro-
patient health and safety. mised mental health. It seems that even when it comes to lying down,
medical students have it tough.
What is sleep? As a path of study and career, medicine demands and selects for
The process of sleep involves a well-orchestrated process that links precision, empathy and compassion, high performance, motor coor-
neurobiological, neurochemical, and psychological processes. We dination, and cognitive prowess. Ironically (but not surprisingly), sleep
now know much more about how the brain regulates our circadian is vital to each of these mental faculties. Increasing evidence outlines
rhythm, sleep/wake cycle, sleep itself, and wakefulness than ever be- the impact that poor and disordered sleep has on mental, motor,
fore.3 Ongoing questions and research continue however, offering a and physical processes.5 In environments where communication and
clearer view of the complexity around one of our most fascinating, connection are as key to outcomes as memory, problem solving, and
fundamental, and primary functions. motor ability, a disregard for sleep within the medical system challeng-
Neurologically, the process of sleep involves more than a mere es the very foundation of effective performance and safe patient care.
shutting down of brain function or wakefulness, with sleep versus
waking existing as two parallel but deeply interwoven circuits. One The importance of sleep in physical and psychological health
seeks to act as the “on” switch, leading to cessation of sleep related Recent decades of research have shown the powerful (and often
processes and an increase in wakefulness; the other acts as the “off” bidirectional) influence that sleep has toward both our mental and
switch to promote sleep onset. Whilst historical views saw sleep as physical wellbeing. More and more, sleep is being seen as a key factor
an inactive state of lowered neurological activity, we now know that toward a healthy lifestyle. Sleep offers an important influence on the
regardless of how peaceful (or not) it might appear, processes on the physical body, with research showing a significant impact on nearly
inside are anything but restful. every organ system and physical process, and even small but accumu-
Coordinated and synchronous activation and inactivation of key lative deficits are theorised to have potentially significant impacts. The
brain regions are required to both initiate and maintain a healthy evidence is clear that sleep is a vital component to optimal physical
night’s sleep. Key areas include the suprachiasmatic nucleus, the hypo- and mental functioning; a component that people actually studying
thalamus, thalamus, brain stem, limbic system, and the frontal cortex.3 those very concepts seem hard pressed to come by.
Circadian rhythms and ambient light levels offer coordinated triggers Sleep deprivation exists as a significant risk factor and influence for
for sleep to inhibit regions promoting alertness and wakefulness, and many of our most common and disabling physical and mental disor-
8 N Z Med Stud J, Issue 30, pp. 8–10, Apr 2020nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
ders. From neurological health to heart disease, and even cancer rates all-nighter” and placing work before all else can even become a badge
and overall mortality, studies are increasingly displaying the alarming of honour. Though the consequences of occasional sleep deprivation
impacts that inadequate sleep has on the body.5 Mentally, our health may be minor and short lived, prolonged sleep deprivation (several
and wellbeing are similarly powerfully influenced by length and quality days or weeks) will result in poorer cognitive performance overall, not
of sleep. Complex mental processes including emotional regulation, to mention risks in driving or poor clinical judgment. If one’s goal is to
judgment, problem solving, and even thought content show significant perform better academically in a sustainable manner, having adequate
links to the amount of shut eye we’re banking.4,5 Alongside this, evi- and refreshing sleep should be part of any study routine.
dence has established inadequate sleep as an independent significant Blue light devices including mobile phones, tablets, laptops, and
risk factor for anxiety disorders, depression, psychosis, and mania.4 computers may be the biggest of all culprits toward our modern-day
Alarmingly, an increasingly emergent body of work now also strongly sleep debt. These devices are known to cause a phase shift in mel-
links disordered sleep to increased risk of deliberate self-harm and atonin release, and thus result in delayed sleep onset and potentially
suicide. Independent studies and collated meta-analysis now clearly poorer quality sleep. It’s no joke to say these devices are toxic when it
show disordered sleep as an independent risk factor for increased comes to sleep. In addition, using devices just before sleep can actually
risk of suicide.6,7 result in increased alertness and wakefulness, which further compro-
mise sleep integrity. Combine this with the naturally delayed circadian
Tips for a better sleep rhythm of young adults and it’s a powerful combination for a bad
Not only is sleep itself a complex process influenced by psycho- night’s rest. Cutting back on blue light exposure two hours before
logical, physical, and environmental factors, poor sleep in a medical bedtime and instead listening to podcasts or going back to the age-
student can also be attributed to various and complex reasons of its old practice of reading books can help with a quicker sleep onset, and
own. This can range from unhelpful routines and habits, to clinical deeper sleep.
conditions including depression, anxiety, and alcohol use. And for all A common cause for delayed sleep onset is a very busy mind,
those who’d raise their hand to the midnight in-bed scroll, the neg- and this will be one medical students know all too well. Constantly
ative impact of blue light emitting devices prior to sleep cannot be thinking about how the day went and worrying about exams and
underestimated. assessments actually promotes alertness and inhibits sleeps onset. En-
Depression and anxiety account for about half of chronic insom- gaging in mind calming activities half an hour or so prior to bed can
nia in adults, and so if someone has persistent poor-quality sleep for slow down the hectic and busy mind of medical students. Mindfulness
more than a few months, an assessment for depression and anxiety meditation, writing a gratitude journal, progressive muscle relaxation,
is recommended. This can be done through a GP or psychologist at breath-based yoga, Tai Chi, or reading religious or spiritual material
Student Health and Counselling, and/or through self- assessment using before going to bed has been shown to calm the mind and set it up
various validated scales (e.g. Beck Depression Inventory and PHQ9). nicely for a solid night’s sleep.
Identifying potential causes for sleeping issues is vital; a sole focus on
treating the insomnia without addressing the underlying psychological Final word
condition is inadequate care. In the gruelling years of medical training, good quality and ade-
In most cases of insomnia — characterised as poor-quality sleep, quate sleep should be held as priority. Once in a while, losing sleep
prolonged sleep onset, or disturbed sleep — simple behavioural ap- because of impending deadlines and assessments can’t be avoided,
proaches can be very effective. Sometimes called sleep hygiene, rec- but we should remember that this should be an exception and not
ommendations include cutting back on caffeinated drinks and smok- a norm. The consequences of prolonged poor sleep cannot be un-
ing, a regular bedtime and waking schedule, and optimising the sleep derestimated, and for those navigating their way through the maze
environment. of medical school, getting adequate sleep should be prioritised and
However, for more persistent cases of insomnia, sleep hygiene may protected. When it comes to performing cognitively, emotionally, and
not be very effective. Behavioural approaches, part of the cognitive physically at our peak, and practising as balanced doctors, we need
behavioural therapy for insomnia protocol, can be particularly helpful now more than ever to wake up to the true importance of a good
for medical students struggling with sleep. One behavioural approach, night’s sleep.
called sleep compression or sleep restriction, recommends that a
person with insomnia limit the total time they spend in bed. In this
approach, the amount of time recommended in bed is estimated by References
calculating the average amount total time spent actually asleep per night.
After about a month of following this protocol, a significant number of 1. Correa CC, Oliveira FK, Pizzamiglio DS, Ortolan EVP, Weber SAT. Sleep quality in
patients improve through this simple intervention. An alternative and medical students: a comparison across the various phases of the medical course. J Bras
Pneumol. 2017; 43(4):285–289.
equally effective behavioural approach is stimulus control, where the
insomnia sufferer is instructed to go to bed only when sleepy (e.g. nod- 2. Ayala EE, Berry R, Winseman JS, Mason HR. A cross-sectional snapshot of sleep quality
ding off, unable to keep eyes open). If the person wakes in the middle of and quantity among US medical students. Acad Psychiatry. 2017 Oct;41(5):664–668.
the night, this protocol recommends they get out of bed, and return to 3. Moszczynski A, Murray BJ. Neurobiological aspects of sleep physiology. Neurol Clin.
bed only when feeling sleepy. These interventions work only after a few 2012 Nov;30(4):963–985.
weeks of implementation, and so pushing through is key. Online pro-
4. Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s synopsis of psychiatry: behavioral
grammes that incorporate evidence-based approaches like A Mindful sciences/clinical psychiatry. 11th ed. Philadelphia (US): Lippincott Williams and Wilkins; 2014.
Way8 and Sleepio9 offer effective behavioural approaches for insomnia.
Alcohol is a commonly imbibed substance by medical students, 5. Lock AM, Bonetti DL, Campbell ADK. The psychological and physiological health effects
of fatigue. Occup Med. 2018 Nov;68(8):502–511.
and (a surprise to many) is actually a well-known cause for insomnia.
Though alcohol can be helpful in relaxation and quicker onset of sleep 6. Malik S, Kanwar A, Sim LA, Prokop LJ, Wang Z, Benkhadra K, et al. The association
initially, that evening drink is notorious for causing middle-of-the-night between sleep disturbance and suicidal behaviors in patients with psychiatric diagnoses: a
systematic review and meta-analysis. Syst Rev. 2014 Feb;3:18.
awakening and for fracturing normal sleep cycles. Recommendations
for anyone suffering from insomnia always call for the importance of 7. Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal
stopping use of alcohol for four to eight weeks to see if alcohol is the thoughts and behaviors. J Clin Psychiatry. 2013;73(9):e1160–1167.
primary cause or is making insomnia worse. 8. A mindful way [Internet]. 2019 [cited 2020 Mar 4]. Available from: https://amindfulway.com.au/
A modern-day trend among young people is delaying bedtime due
to rising study pressure. In some circles (medicine included) “pulling an 9. Sleepio [Internet]. 2020 [cited 2020 Mar 4]. Available from: https://www.sleepio.com/
9nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
About the authors
VV Dr Kieran Kennedy is a Senior Psychiatry Registrar & Neuropsy-
chiatry/Epilepsy Fellow at the Department of Consultation-Liaison
& Emergency Psychiatry, Alfred Mental & Addictions Health, Alfred
Hospital, Melbourne
VV Dr Tony Fernando is a Consultant Psychiatrist and Sleep Specialist
at the Department of Psychological Medicine, Faculty of Medical and
Health Sciences, University of Auckland
Correspondence
Dr Kieran Kennedy: kieran.kennedy@hotmail.com
10nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
INVITED EDITORIAL
Stress and suicide in
medical students and physicians
Annette Beautrais
Note: The following article discusses suicide, depression, and other mental major psychiatric risk factors for suicide are mental disorders and sub-
health conditions, which may be distressing for some people. If you are stance use disorders. There is a higher prevalence of psychopathology
worried about your own or someone else’s mental health and would like to among medical students and physicians than the general population.
seek help about these issues, please see the resources at the end of this A meta-analytic review found that 27% of medical students reported
article or in the Editors’ welcome on page 4. depression or depressive symptoms, and 11% reported suicidal idea-
tion.7 However, of those students who reported depression, only 15%
Suicide is the second most common cause of death for medical stu- sought professional mental health care. Seeking help for depression
dents, after accidents.1 Once they have graduated, physicians have is stigmatised in the general population in many cultures, but is ampli-
higher rates of suicide than the general population, and are consist- fied within the health profession,20 suggesting that depression, anxiety,
ently at the top of rankings for occupational groups at risk of suicide.2 and stress are probably significantly under-reported and untreated in
However, we should be careful to avoid alarming medical students students and physicians. A study of medical students found that they
with these statistics. Suicide is the second leading cause of death for all viewed mental health problems with greater stigma and they report-
young people, not just medical students, and the higher rate of suicide ed more reluctance to seek help if they were themselves distressed.20
among physicians is substantially accounted for by their ready access A study of physician suicides found that, compared to people in the
to lethal means of suicide. general population who died by suicide, physicians were less likely
Nevertheless, the problems of stress, depression, drop-out, burn- to be in treatment and three times more likely to have had a job-re-
out, and suicide in medical students and physicians are well-estab- lated problem prior to their death.22 Toxicology findings suggested
lished.3 In the last few years, concerns have escalated,4–11 resulting in psychiatric medications were 20–40 times more common in physi-
multiple calls for action to improve the mental health, wellness, self- cians, raising the possibility that they might be self-medicating rather
care, and resiliency of students, in efforts to prevent these problems than seeking psychiatric treatment.21,22 These studies suggest that the
persisting into practice.12–15 Physician burnout has been called a public professional culture of medicine encourages stoicism, and discourages
health crisis,12 and an increasing number of hospitals are appointing those with poor mental health from seeking help.
Chief Wellness Officers to promote physician wellbeing. In the Unit- Aside from psychiatric illnesses, a range of other interrelated in-
ed States there are an estimated 400 physician suicides a year.16 In dividual and work factors can contribute to poor mental health in
response, in 2017, the US National Academy of Medicine launched medical students and physicians. These include:
the Action Collaborative on Clinician Well-Being and Resilience, a Personality factors: Medicine requires academic excellence. People
network of more than 60 organisations committed to reversing ris- who gain entry to medical school tend to be high achieving, perfec-
es in clinician anxiety, burnout, depression, stress, and suicide.17 The tionistic, conscientious, and anxious, and tend to have high expecta-
American College of Emergency Physicians (ACEP), along with related tions of themselves.23,24 This may particularly be the case for females.21
professional organisations, has dedicated September 17 annually as These characteristics may predispose to depression and anxiety.
National Physician Suicide Awareness (NPSA) Day.18 Study pressures: Academic demands and pressures to succeed
Suicide is often an endpoint of stress and distress. Rates of suicide create stresses during training. A study of medical students found
among physicians are estimated to be about 70% higher for male that stress increased as people progressed through training, and that
physicians than for men in the general population (including men in women reported more stress than men.18 Younger students with lim-
other professions), and, for female physicians, 250% to 400% high- ited life experience and coping skills may be more vulnerable to stress
er than for women in the general population.16 (While suicide rates and depression.
for male and female physicians are generally similar, the male rate of Care providers and problem solvers: Physicians respond to illness,
suicide in the general population is higher). However, these figures distress, crisis, and trauma, and support people and families upset by
may under-estimate the extent of the problem, since there is general illness and death. They are expected to be supportive and compas-
agreement that suicide among both medical students and physicians sionate, and to be problems-solvers, not people who have problems
is likely under-counted.3 themselves. These demands and expectations can result in stigma and
The particular pressures of medical education are assumed to difficulty admitting the need for help and then asking for help. Female
contribute to the stress, depression, and burnout that arise during physicians seem to be more vulnerable to trying to meet multiple,
medical training. Once students graduate and begin working as physi- competing family and work demands.21
cians, organisational structures and work-related pressures (including Isolation: Long hours studying may lead to social isolation for stu-
clerical burdens associated with electronic health records, microman- dents and registrars. Students and physicians who work in rural areas
agement, multiple healthcare reforms, and complaints), are named as may face social and professional isolation. The time requirements of
the leading contributors to stress.19 In the general population, two the clerical workload of electronic medical records, shift work, larg-
N Z Med Stud J, Issue 30, pp. 11–14, Apr 2020 11nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
er workloads, and the business demands of modern healthcare (and good sleep practices, meditation, and social activities) should be em-
budget deficits), have reduced the time available for collegial connec- phasised as a component of professional responsibility.
tions and social support.25 Wellness and mental wellbeing: There is increased interest in well-
Exposure to death: Medicine involves death, and extensive expo- ness and mental wellbeing in the general population, and within health
sure to death may shape attitudes to ending suffering and contribute systems. This focus provides an opportunity to promote wellbeing
to considering suicide as a rational solution. among medical students, and a platform to treat mental health as be-
Work-related stresses: Occupational pressures include long study ing equally as important as physical health. Some medical schools are
or working hours, after hours on-call schedules, heavy workloads, working with students and specialist services to co-produce suites of
administrative and regulatory work demands, frustrating bureaucra- wellbeing interventions including focusing on suicide education, “men-
cy, risk of errors, impact of errors, unexpected outcomes, dealing tal health weeks”, conversations about how to broach difficult topics,
with distressed patients and their families, patients who die, trauma and education to widen opportunities for reflection. While there is
and disaster, emotional (compassion) fatigue, conflicts with work col- not yet a comprehensive longitudinal evaluation of whether these
leagues or staff, and poor work-life balance. All these work stress- measures improve student mental health, they seem logical inclusions
es can lead to burnout, depression, and anxiety. Work stresses may in a holistic wellness approach.
occur alongside, or contribute to, personal, relationship, and family Depression and suicide prevention education and resources:
stresses, and exacerbate risk of mental health problems. Recent evi- Medical students should be educated early in their training to recog-
dence suggests generational differences in work pressures, with older, nise depression in themselves, their peers, and patients. Gatekeeper
but not younger, physicians more frustrated by the demands of elec- suicide prevention training programmes can increase skills and confi-
tronic health records.26 dence to recognise and triage colleagues who may be at risk.28 Today’s
Access to lethal means of suicide: People tend to use for suicide medical students have been exposed to increased rates of suicide in
the means which are most readily available and with which they are their peers, profession and communities, and via cybermedia. Educa-
familiar. Physicians share high suicide rates with nurses, dentists, and tion early in their careers can help assuage anxieties about the difficult,
veterinarians: all have ready access to lethal means of suicide including and increasingly common, issues of depression and suicide, and how
drugs in particular, and all have knowledge, experience, and expertise to approach peers and patients about these issues.
in using those drugs. Overdose is a common method of suicide for Stigma reduction, and normalisation of help-offering and
people in the health professions. help-seeking: Given a physician culture of stoicism and stigma which
Suicide contagion: Medical student and physician populations are discourages help-seeking for depression, promoting wellbeing pro-
small. People know each other and learn of suicides within the pro- grammes may be a more effective approach than encouraging peo-
fession. Suicide contagion tends to occur in small, socially enmeshed ple to seek treatment for depression. However, both approaches
communities and the medical profession is one such community. are needed. Destigmatising and de-penalising help-seeking, providing
Knowledge of another’s suicide may increase suicide risk in someone student support and mentoring programmes, promoting early inter-
who is vulnerable and identifies with someone who has died by sui- vention, and encouraging use of face-to-face counselling and online in-
cide. In turn, these deaths may reinforce beliefs that suicide is charac- tervention programmes such as Cognitive Behavioural Therapy (CBT),
teristic of the profession and those beliefs may further increase risk. are all positive practices. Peers who offer help to fellow students and
The excess mortality for suicide in the medical profession stands in normalise help-seeking can drive a culture change to reduce stigma
contrast to physicians’ lower risk of cancer and cardiovascular disease. and provide a more supportive environment.
Presumably, physician’s knowledge of the risk factors for cancer and Provide support for vulnerable groups: Females, international stu-
heart disease, prudent self-care, and ready access to early diagnosis dents, Māori and Pacific students, young doctors, and people working
and treatment contribute to their lower risk of these diseases. Suicide, in rural areas are at higher risk of developing mental health problems.
too, is preventable in many cases. As with physical health, suicide pre- For vulnerable groups, additional support systems and education
vention depends on early recognition of the major risk factors, good should be implemented to enhance mentorship and provide access
self-care practices, and early treatment. to mental health services.
Improve the learning and working environments: Most of the
Initiatives to reduce stress, depression, and suicide initiatives to reduce stress focus on people – education, self-care,
Initiatives are underway to improve medical education and work and destigmatising help-seeking for mental health problems. These
practices to address the problem of poor mental health. As with pre- interventions show small reductions in symptoms of common mental
vention efforts in the general population, initiatives in the medical pro- health disorders among physicians, and could be expected to have
fession must focus on ways to recognise, and manage mental health similar reductions in medical students.29 In addition to addressing
problems when they occur, and address institutional practices which individual risk factors, interventions focussed on workplace environ-
contribute to stress. In the general population, no single programme ments might also improve student and physician mental health. These
or intervention is adequate. Best evidence suggests that multi-level, initiatives are the responsibility of employing organisations and pro-
systems-based approaches are more likely to be effective, generating fessional bodies and include organisational strategies and leadership,
small gains from each intervention and an additional gain from the workloads, work hours, resources, workplace culture, administrative
synergistic impact of having several programmes operating in concert. burdens, and regulatory licencing and reporting requirements. Few
A similar multi-faceted approach is required to address the multiple studies have examined the impact of changes in organisational struc-
precursors and risk factors linked with student and physician poor tures and work practices on physician mental health. However, it is
mental health.27 It is logical to begin to address these issues very early logical to conclude that both people-focused and work interventions
in medical training in the hope of preventing and arresting problems are needed.
before they persist into practice. Medical students can advocate for Enhance connectedness: Having supportive close relationships
inclusion of preventive initiatives in their training programmes. A com- and feeling socially connected are effective buffers against stress
prehensive approach includes the following initiatives: and suicide.30,31 Promoting social activities and developing supportive
Early education about self-care: Good self-care practices, and ed- communities of medical students can help mitigate the stresses of
ucation about stress and burnout should be integral and integrated medical school. In the healthcare workplace, enhancing professional
components of medical education, introduced within the first year social connectedness and teamwork can increase job satisfaction and
of student training, and reinforced each year with programmes to reduce burnout.31
enhance wellness and encourage resiliency. The importance of estab-
lishing good lifestyle habits to help manage stress (including exercise,
12nzmsj The New Zealand Medical Student Journal Issue 30 • April 2020
Medical students: advice about care of peers 11. Bailey E, Robinson J, McGorry P. Depression and suicide among medical practitioners in
Students and colleagues who work closely with each other may be Australia. Intern Med J. 2018;48(3):254–258.
well-positioned to notice subtle changes in behaviour and demeanour. 12. Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA. A crisis in
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always trust your intuition, take the issue seriously, and do something Safety Network; 2019 [cited 2020 Feb 01]. Available from: https://psnet.ahrq.gov/issue/
crisis-health-care-call-action-physician-burnout
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fortable about intervening with a particular colleague, find someone 13. Kalmoe MC, Chapman MB, Gold JA, Giedinghagen AM. Physician suicide: a call to
who does. Signs that someone may be at risk include talking about action. Mo Med. 2019 May-Jun;116(3):211–216.
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line (free text or call 1737), or the local DHB Mental Health Crisis Physicians; 2019 [cited 2020 Jan 30]. Available from: https://www.nyacep.org/practice-
Team, to refer the person or to ask for advice. Both 1737 and the DHB resources-2/resources/wellness/457-national-physician-suicide-awareness-day-
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