Spotlight on student welfare
10 December 2020
Given the vast array of challenges posed by the pandemic, student welfare is more important than ever. For this term’s “Spotlight” interviews, the Undergraduate Teaching Team speak to both Dr Lois Brand and Dr Laurence Leaver, responsible for advising on the welfare of clinical and pre-clinical students, respectively.
Dr Lois Brand, Associate Director of Clinical Studies
What does your role entail?
It’s quite a varied role - I take the lead on careers advice, pastoral care and disability in the clinical school. The majority of my workload is pastoral care of the 420 students on the standard clinical course. Since taking on this role in 2014 I’ve been attempting to prioritise a more proactive approach to student wellbeing, but most of my time is taken up by responding to urgent student issues. There is an increasing number of students on the course who have a registered disability. Supporting them through clinical school is a challenging but frequently rewarding aspect of my work.
Last year we introduced the Clinical School Educational Supervision Scheme, allocating each new clinical student to a senior clinician for regular support and supervision. These supervisors each take on six students right at the start of the clinical course and meet with them three times a year until they graduate. This has been really successful, with great feedback from both supervisors and supervisees. We’ll be recruiting again for this role early next year, so if you’re interested in applying, do get in touch.
Could you give an overview of the pastoral support network available to Oxford clinical students?
Clinical students have a variety of sources of support, via their college and the university (e.g. college nurse, college chaplain and the student counselling service). In addition, Maheshi Ramasamy and I lead the pastoral care for the graduate entry course and standard course, respectively. All students now have an educational supervisor as mentioned previously, and this has been great for providing longitudinal support through the course. The Osler House Club, the clinical students’ social hub has its own Osler House peer support team, trained and supervised by the University Student Counselling Service.
What sort of issues do you commonly help students to deal with?
I guess the most common issues students seek support for are mental health problems. Other common problems are lack of motivation, problematic perfectionism, difficulty in adapting to the clinical learning environment, exam stress and exam failure. Of course, there are all the usual life-events that pop up from time to time with parents falling ill, bereavement and family break-ups. The clinical course is intense and densely packed, so we really encourage students to seek help early, so that we can put the necessary supports and adjustments in place. Sometimes unfortunately, the first we know of a serious health problem is when the student fails an exam.
What have been the most pressing challenges for students as a result of the Covid pandemic?
Life as a medical student since March 2020 has been extremely challenging. We closed the medical school in March, (the first time this has happened during peace-time) and didn’t re-open until July. This has meant that we’ve needed to compress the course significantly to make up the time lost and provide a graduate workforce to start work in the summer of 2021. The current fifth years have felt this compression most acutely and it coincides with a change in the structure to the course which was planned pre-Covid. Instead of six eight-week specialty rotations with an exam at the end of each rotation, they are now moving through a rotation every six weeks (in subsequent years it will be seven weeks per rotation) and taking a synoptic exam at the end of the year. The workload is intense and anxiety about the exam at the end of the year is already mounting.
The fourth years have also been experiencing a challenging first term in clinical school. They’ve had their initial clinical placement reduced from six weeks to just two and have spent the remainder of the term doing the laboratory medicine course remotely. This course, run brilliantly by Debbie Hay, gets rave reviews from students, but remote learning has made it a rather intense and isolating experience for many.
Clinical rotations have been far from normal, with students having to adapt to working with social distancing rules, reduced numbers of patients in clinics and staff who are even more stressed and busy than usual.
Overall, I think the biggest problem for the students has been loneliness and isolation. Most of us have established homes with family around us, but the students have neither this nor the grounding effect of a regular workplace or team.
Overall, how do you feel students have been coping with the Covid-driven changes to their course?
We have been so impressed by the ‘can-do’ attitude of the vast majority of the students. There have been so many challenges to adapt to, and it has been quite inspiring to watch as they’ve found ways of coping and adapting. One positive aspect of the pandemic has been the student volunteer workforce. Back in March, many clinical students were recruited to fulfil roles across the trust and beyond. They became our colleagues, worked alongside our established teams and were hugely valued and respected for their contributions. Many continue to combine their studies with ongoing work with staff testing or the vaccine trial group.
What advice would you give GP tutors about what to do if they have a student struggling with their workload or mental health?
I think the most important thing for the student to hear is that we acknowledge that these are extraordinarily difficult times for them. The students really appreciate it when the GP tutors take time to get to know them, and making an effort to really integrate them into the practice for the few weeks they’re there is more important than ever. If you think a student is really struggling and needs more support, then please do suggest that they get in contact with me: firstname.lastname@example.org. I’m usually able to meet with them (via Zoom) within a few days and I’ll work with them to organise any additional support they need.
Dr Laurence Leaver, Associate Director of Pre-Clinical Studies (ADPS) for Health and Welfare
For tutors teaching pre-clinical students, what advice would you give if they have a student struggling with their workload or mental health?
I think it’s worth getting to know students and ask them how they are getting on before every session. Gently ask them to talk about their experiences. They may not realise how ‘normal’ their concerns may be, especially about workload. It is very common for students to worry they are not good enough. It’s really useful to help them realise they are all fantastic and should believe in themselves; that they can succeed - they have been selected to be excellent, that they get excellent teaching and they will make excellent doctors; that the NHS needs them all; that the people they think are cleverer than them are also thinking they are not clever enough; and that the ‘bottom’ quartile academically in Oxford could overlap the ‘top’ quartile in another medical school.
I often tell them that the reason they should study hard is so that they will be good and confident doctors who can enjoy their jobs - not so that they will beat other people in their year; I remind them that nobody will ask or care about their marks once they are working on the wards. I remind them that doctors work in teams and in the workplace it’s OK to check things by looking them up or asking other people - in fact it is dangerous to think you know everything.
I think most tutors, whether GPs or not, know all this but sometimes don’t make time to say it. GP tutors are well placed to help students by listening and understanding problems and knowing what can be done about such problems. We should remember we are not their GP, but we are likely to know who their GP is and where else they can get help.
Could you give an overview of the support network available to pre-clinical students?
Medical students have much the same network of welfare support as other students. One difference is the ADPS role (me), and another difference is the need to be ‘fit’ to achieve the Outcomes for Graduates, which is determined mostly by Occupational Health. Also, the BMA provides free counselling to all medical students (and doctors) irrespective of whether they are members.
Most initial welfare provision is in colleges - including peer supporters, junior deans, tutors, chaplains, senior welfare advisers, college nurses, etc. Then there are University services such as the Counselling Service, Disability Advisory Service, Sexual Harassment and Violence Support Service (which also has a support service for students accused of sexual harassment), and the OUSU Student Advice Service. The University has a confidential harassment advisor network and can help with dispute resolution. Students can also get crisis support from Nightline. Outside the university, college doctors are very understanding of students’ needs and are able to access and refer to a variety of NHS and other local services.
Despite all this support there are clear gaps. I am very keen to support the idea of a Student Mental Health Service to improve access to psychiatric and psychological services, with a focus on conditions of intermediate severity, a focus on prevention, and focus on the specific needs of students. The service should offer support for a student’s entire university career, from acceptance of an offer until graduation (including during the holidays). Prof John Geddes is liaising with the University and the local NHS to try to set up such a service.
What sort of issues and problems do you commonly help students to deal with?
I have been surprised not to see many students with ‘typical’ anxiety and depression. I think most such students are already looked after well by their GPs and tend not to come to me in my ADPS role. I do have a wide range of cases though:
- Milder problems that students don’t feel able to go to their GP for, such as: ‘impostor syndrome’, exam stress, stress of failing an exam, poor motivation, procrastination, poor study skills, help with goal planning etc.
- Underlying problems which may have been assumed to be something simpler - for example someone treated for anxiety or depression when there is an underlying problem such as ADHD, PTSD, OCD or Autism. N.B. my role is not to diagnose but to help them ask for such things to be considered.
- Severe problems (e.g. ‘treatment resistant’ depression, bipolar or schizoaffective); usually such conditions have been referred to a psychiatrist but there may be issues of communication etc.
- Various disabilities including physical conditions (e.g. inflammatory bowel disease) which may be exacerbated by psychological problems.
All these problems can give rise to the need for adjustments (in the department or the college or both) or consideration of mitigating circumstances for exams, issues of hardship (including vacation residence) as well as advice on how best to get help from other services.
What have been the most pressing challenges for students this term, in view of the Covid pandemic?
It has been quite variable. One significant issue has been that the Part I and Part II First BM exams have been in September rather than Trinity Term and so students have had to revise over the summer vacation. This has highlighted some major inequalities. Imagine a student living in a small two or three bedroom house with both parents and loud younger siblings, all trying to work from home, sharing poor broadband and only one computer, who is also expected to be earning money. He or she will not get much work done. Even students with optimal home circumstances have started Years 2 and 3 feeling unrefreshed.
For some students it has been very helpful to rewind or repeat recorded lectures and learn at their own pace. For others it has been difficult to cope with anxiously spending too long going over and over a lecture - taking three or four hours when it would have been an hour if they had simply attended in person.
For some it has been easier to manage with routines at home, and for others it has been more difficult to cope with lack of social contact, or feeling ‘cooped up’, especially if needing to ‘self-isolate’. There may be fewer opportunities to share problems or ask questions informally, but there may also be more acceptance of regular video calls. There is the risk of lack of structure, reduced physical activity and resorting to alcohol or comfort eating. Being in a bubble may make people closer- but not necessarily closer to whom they would choose.
You are also a tutor on the Patient Doctor I Course and run all college teaching at Green Templeton. What attracts you to teaching medical students?
I love that students want my job. How can I complain about anything when they are so keen to do what I do? Of course, teaching helps you keep up to date and there is always something to learn (“to teach is to learn twice”). Students ask very interesting questions and also answer very interesting questions (not the same ones).
I want to make a difference to medical students so that they can start their career as doctors knowing enough to be confident. I want them to enjoy their job (and know they are good enough); doctors in training have enough stress without feeling like frauds (Imposter Syndrome). Part of this is that they learn the right things and part of it is understanding themselves and their colleagues and how to get the most out of each other: sometimes seeing the flaws in their tutors can help. Doctors work in teams; I want students to learn together in collaboration not competition. I ‘joke’ that if you must be competitive, please compete to be the most collaborative.
Seeing my patients give up their time (and bodies) for students to use for learning, is better than any present a patient can give me as their GP. Their confidence and hope in the next generation of medics is heartening, and that they trust me to teach the students is most affirming.
What would you say to GPs considering taking up a teaching role?
Do what’s right for you. It will help you see things from a different perspective, keep you current, give you an insight into hospital colleagues, new services and even gossip (students are excellent conveyors of news). Explaining to students and explaining to patients is not that different in some ways - just the level of prior knowledge (although in my practice sometimes it is the patient who has more). Sometimes the student is the best person to share a funny anecdote, when you ‘had to be there’ to appreciate it.