Jayne Garner, Lecturer, School of Medicine, University of Liverpool

Published in JHH15.1 – Transformative innovation in healthcare

I work with undergraduate medical students as a lecturer and as a personal tutor. The increasing pressures on medical students (academic and financial) have resulted in a noticeable rise in mental health and stress-related issues. In addition to support services, it is vital that medical schools develop new and innovative ways to promote wellbeing.We have used music to do this in Liverpool, and created something unique for our students and staff to share.

Why did we do this?

Improving student wellbeing is an ongoing challenge for educators. Rising fees, financial insecurity and fast-changing employer expectations place an increased burden on students long before graduation. Course requirements alongside work and personal commitments have resulted in rising mental health problems for those studying in higher education (Gil, 2015).

This phenomenon is not confined to the UK. A recent systematic literature review suggests that university students experience substantially higher rates of depression than those found in the general population, concluding that more research on effective interventions for managing student depression is necessary (Ibrahim et al, 2013) An Australian study examined psychological distress in students compared with the general population, finding significantly higher rates of mental health problems among those at university. Predictors of distress included studying full time, financial issues, and being aged between 18–34 and female (Stallman, 2010).

These issues particularly affect medical students and doctors. A meta-analysis relating to depressive symptom prevalence among resident physicians estimated 28.8% of this group would encounter symptoms (Mata et al, 2015). It has also been acknowledged in health education literature that medical students have reported above average issues relating to mental health, a reflection of the stress they face over the duration of an academically tough and emotionally challenging course. A recent national survey of medical students by the British Medical Journal (Billingsley, 2015) found that 30% of respondents had experienced or received treatment for a mental health condition while studying. Furthermore, of these students 80% said the support available to them was either poor or moderately adequate.

There is evidence that stigma associated with mental health issues both exists and affects medical students’ willingness to access appropriate support services. A study by Chew-Graham et al (2003) found that medical students worried about seeking help because it could be recorded on their education or employment record and affect their future progress. Hooper et al (2005) found that issues relating to failure, coping, stress, anxiety and depression were perceived to be barriers to a successful career and could be viewed as signs of weakness. Regulatory bodies such as the General Medical Council (GMC) recognise the importance of wellbeing and require effective support mechanisms for medical students.

However, the stigma and culture of medicine can perpetuate the myth that seeking help is negative and a sign of personal weakness. These entrenched cynical attitudes have been termed the ‘hidden curriculum’ in medicine (Hafferty, 1998), and remain a barrier to fully understanding and adequately addressing good wellbeing for medical students. How to effectively promote wellbeing to sceptical students and ensure that accessing support services is not seen as a sign of failure is a key challenge for medical educators nationally and internationally.

A new medical school curriculum

The University of Liverpool implemented a new curriculum in 2014, moving away from problem-based learning to a spiral, integrated system. Several initiatives were introduced alongside this change, including an increased emphasis on the importance of accessing wellbeing support and services. A dedicated team based in the School of Medicine sought to encourage students to speak up about any problems, issues or anxieties they were facing. Given previous evidence on student reluctance to access this kind of support, we promoted the service ensuring that students knew it was confidential and would not appear on their academic record. To develop the wellbeing agenda across the medical school further, we began exploring different approaches to encourage positive wellbeing.

Action for positive wellbeing

As part of Well Being Week 2016, we sought to further bring students and staff together in the creation of a shared experience. Using a SurveyMonkey link posted via the school blog and the electronic Well Being Newsletter, we asked students and staff to nominate a song that helped them feel better, and compiled a playlist. We also asked them to complete a brief survey including why they felt their song promoted happiness and wellbeing. As has been identified in previous literature, music and memory link together and by giving this playlist a positive focus, we sought to emphasise the importance of wellbeing. The creation of the playlist also allows ‘sharing’ between staff and students, another important element to enhance student and staff experience. Most importantly, we thought it would be fun.

What happened?

In total 11 songs were nominated. One was excluded due to offensive swearwords in the lyrics. For future reference, this did highlight the importance of being specific about what might be classed as unsuitable. Choices varied from current artists such as Drake and Bruno Mars to classics like Curtis Mayfield and The Bee Gees. Interestingly, no Beatles songs were submitted even though we are in Liverpool. In terms of their explanations for their choice of song, answers were very insightful, offering a range of perspectives. Two respondents described how their song had lifted their spirits when life presented challenging situations:

‘A song that can’t help but make you smile in the face of desperation. The lyrics illustrate the rewards of perseverance through a difficult time.

Another offered further explanation of how their song represented individual freedom of expression, and offered an escape from the oppressive elements of daily routine:

Because this song is all about retaining your spirit, the dreamer in you, and not having it stifled by your everyday life.’

Three respondents linked their song to physical expression and dancing; this again offered an opportunity to enhance wellbeing as part of the ‘be active’ agenda specified by MIND:

I always listen to this song when I’m a bit moody and it really makes me smile again and also, although a bit sad, dance around my room.’ ‘

First because it is so funky, second because you have to dance to it’ ‘

Whenever I hear it I just have to get up and dance

Nominated songs were seen to find positive aspects in everyday occurrences and help with motivation to complete assignments or simply distracting from the weather:

‘Got me through research and scholarship by keeping me focused.

‘A song which celebrates the fact that it’s stopped raining is very important in Liverpool

All the responses emphasised the positive influence of music, how it can lift moods, promote positivity and get people enthused and engaged.

The survey went on with a request to complete the statement: ‘Music is medicine because…’. The open structure of the question elicited a range of answers. The power of music to provide escapism was mentioned by two respondents:

You can lose yourself in its rhythms and melodies and be momentarily transported away

It’s escapism.

Other life improving affirmative reasons regarded a range of emotions that music can invoke, and while the majority of these were very positive, the power of music to cause sadness and tears was also acknowledged:

‘Lyrics can remind you of reasons to be grateful.’

It has the power to change mood.

It works on every emotion. It can make you cry, reminisce, laugh, feel warm inside.

A more detailed response further explained the significant impact music could have, relating to important events or simply assisting with the process of relaxing:

It touches people’s lives in so many positive ways, whether bringing back happy memories of a special song. Shared experiences at a concert or relaxing at home listening to the radio after a stressful day.’

The final three comments relating to why music is medicine explained the artistry and healing nature inherent to both disciplines:

Both can be considered an art form.

It soothes the soul, nothing else can do that!

It cures all kinds of stuff

The nominated songs compiled into a playlist for students and staff are available at: https://open.spotify.com/user/ drjaynegarner/playlist/0D5wIQN2NNcMNeZgDBvfdr This has been made available on the school blog and played in the foyer of the medical school building.

How does this fit in?

There is evidence in healthcare literature linking medicine and music for educational, therapeutic, clinical, cultural and humanism purposes. Investigators have linked music with emotion, memory and therapy as a tool in medical practice (Kobets, 2011) and identified how music, memory and cognition are intrinsically linked (Jancke, 2008).

Particular initiatives relating music to medical education offer insight and opportunity. The work of Ortega et al (2011) reported that faculty, staff and students playing together in a band promoted interpersonal relationships, improved communication and gave a level playing field for non-hierarchical feedback between band members. The weekly sessions served to enhance rapport, improve quality of life and enrich medical education. The authors concluded that this model of creating a musical ensemble was transferable to other medical schools and could ultimately improve patient care.

Specific focus on the use of music in the teaching of medical humanities was outlined by Newell and Hanes (2003) who emphasised that characteristics such as care, empathy, dignity, compassion and fostering relationships could be emphasised and understood by listening to music. Their eight-session course was seen to be academically valid by participants and potentially a way to assess humanistic qualities in residents and students.

Similarly, Modell et al (2009) conducted pilot studies providing first year medical students with a participatory music experience during a human physiology course. This intervention restored emotional wellbeing and reinforced a sense of community in the classroom. McLellan et al (2013) reported a small scale phenomenological study which concluded that music could help medical students appreciate holistically that the state of people’s health (either well or diseased) can be enhanced by a ‘non[1]technical’ intervention.

Given this range of approaches and evidence linking music and medicine, identifying new ways to merge these disciplines represents an interesting challenge for the future.

Does this matter?

While we cannot claim the playlist has directly affected the wellbeing of medical students, faculty and staff, it has provided a fun opportunity to create a shared experience. The comments from respondents to the playlist have also demonstrated the importance of music to positive wellbeing, something we will continue to champion as we continue to develop support services.

The medical school plans to produce new playlists, giving students and staff the opportunity to share new and old music. The playlist will continue to create something original and fun, enhancing wellbeing, improving staff and student experience and creating a shared musical memory. So, YES, it does matter!

References

• Billingsley M (2015) More than 80% of medical students with mental health issues feel under-supported, says Student BMJ survey. Studentbmj (online). Available at: http://student.bmj.com/student/ view-article.html?id=sbmj.h4521 (accessed 2 March 2018).
• Chew-Graham CA, Rogers A, Yassin N (2003) ‘I wouldn’t want it on my CV or their records’: medical students’ experiences of help-seeking for mental health problems. Medical Education, 37(10), pp 873–880.
• Gil N (2015). Majority of students experience mental health issues says NUS survey. The Guardian, 14 December. Available at: www.theguardian.com/education/2015/dec/14/majority-of-students[1]experience-mental-health-issues-says-nus-survey (accessed 2 March 2018).
• Hafferty FW (1998) Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med, 73(4), pp 403–7.
• Hooper C, Meakin R, Jones M (2005) Where students go when they are ill: how medical students access health care. Medical Education, 39(6), pp 588–93.
• Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C (2013) A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research, 47, pp 391–400.
• Jancke L (2008) Music, memory and emotion. Journal of Biology 7(21).
• Kobets AJ (2011) Harmonic medicine: the influence of music over mind and medical practice. Yale Journal of Biology and Medicine, 84, pp 161–167.
• Mata DA, Ramos MA, Bansal N, Guille C, Di Angelantonio E, Sen S (2015) Prevalaence of depression and depressive symptoms among resident physicians: a systematic review and meta analysis. Journal of the American Medical Association, 314(22), pp 2373–83.
• McLellan, L, McLachlan E., Perkins L, Dornan T (2013) Music and health. A phenomenological investigation of a medical humanity. Advances in Health Science Education, 18, pp 167–179.
• Modell HI, DeMiero FG, Rose L (2009) In pursuit of a holistic learning environment: the impact of music in the physiology classroom. Advances in Physiology Education, 33, pp 37–45
• Newell GC, Hanes DJ (2003) Listening to music: The case for its use in teaching medical humanities. Academic Medicine, 78, pp 714–719.
• Ortega R.A, Andreoli MT, Chima RS (2011) Is there a place for music in medical school? Medical Teacher, 33, pp 76–77.
• Stallman H (2010) Psychological distress in university students: a comparison with general population data. Australian Psychologist, 45(4), pp 249–257.

Acknowledgements

Thank you to staff and students at the University of Liverpool School of Medicine for their contribution.