Normalising disclosure or reinforcing heroism? An exploratory critical discourse analysis of mental health stigma in medical education

Abstract

Introduction: There has been a proliferation of initiatives targeted towards improving psychological wellbeing among medical learners. Yet many learners do not seek assistance due to stigma against help seeking. Understanding the prevailing discourses on the effects of mental health stigma in the context of medical education will improve insight on how to address stigma and improve wellbeing. In this study, the authors sought to explore discourses on stigma in medical education through a Foucauldian Critical Discourse Analysis. Methods:The authors assembled several sets of texts related to stigma in medical education. The initial archive consisted of social media discourse and was expanded to include digital news media. Next, the authors conducted semi-structured qualitative interviews with medical students, residents and faculty. Using principles of Critical Discourse Analysis informed by the writings of Michel Foucault, the authors analysed the archive to identify truth statements, representative statements and discursive effects.Results: Analysis revealed an emancipatory discourse of disclosure that normalised help-seeking, which conflicted with a discourse of performance. Results suggested that public disclosure remains challenging in private contexts due to a medical culture that rewards perfectionism and lauds heroism. Discourses on performance positioned disclosure as disruptive to the system's need to maintain its own hegemony. Overall, stigma was perceived as rooted within the structural power of the medical education system and society at large. Conclusion:Discourses on stigma in medical education hold implications for the teaching, learning and overall wellbeing of medical learners. The tensions between discourses on disclosure and performance have the potential to perpetuate further distress for learners and worsen asymmetries in power. Interventions to address stigma would benefit from understanding and addressing the role of power and hierarchy in maintaining and dismantling stigma.

Learner Experiences of Preceptor Self-Disclosure of Personal Illness in Medical Education

“…Alternatively, new, limiting rules were introduced when illness stories had unexpected lessons about the difficulties of medical leave. Our findings also support the analysis by Sukhera et al 6 that self-disclosure can reinforce heroism and promote silence; in our study, this presented as “back in my day” statements and applying expectations to students based on preceptors’ ability to work through illness. Other participants identified the need for institutional support in addressing stigma and ableism because self-disclosure remains vulnerable, uncomfortable, and risky for preceptors.…”

“…5 By the end of formal training, beliefs such as "doctors don't get sick," norms of working while ill, and concerns about incompetence associated with illness are pervasive. 3,6 These unspoken standards contribute to delays in seeking care, denial, shame, consistent role strain in the face of illness, and burnout. [7][8][9][10] Nevertheless, the space between physician and patient roles creates unique insights for practice, including developments in communication, empathy, career goals, and clinical acumen.…”

“…Medical school applicants grapple with disclosing mental or physical illness for fear of discrimination and navigate complicated accommodation processes after admission 5 . By the end of formal training, beliefs such as “doctors don’t get sick,” norms of working while ill, and concerns about incompetence associated with illness are pervasive 3,6 . These unspoken standards contribute to delays in seeking care, denial, shame, consistent role strain in the face of illness, and burnout 7–10 .…”

Mental health self‐disclosure: From stigma to empowerment

“…In this context, Sukhera and colleagues studied discourses about mental health stigma to understand how stigma and help-seeking for mental health challenges drive members of the medical education community to respond to their own and their colleagues' distress. 1 A compelling tweet from an emergency medicine physician, revealing that she sees a therapist and takes antidepressants, constituted an index case for which the authors followed subsequent Twitter conversations and analysed news articles, academic literature and interviews with medical trainees and faculty. Critical discourse analysis, 2 which uncovers how power relations among individuals and within institutions perpetuate inequities, revealed how DOI: 10.1111/medu.14816 mental health stigma is baked into medical education systems.…”

“…Long work hours, high patient volumes, personal risk for providers and inadequate staff support yielded high rates of stress, burnout and onset or exacerbation of other mental health conditions. In this context, Sukhera and colleagues studied discourses about mental health stigma to understand how stigma and help‐seeking for mental health challenges drive members of the medical education community to respond to their own and their colleagues' distress 1 . A compelling tweet from an emergency medicine physician, revealing that she sees a therapist and takes antidepressants, constituted an index case for which the authors followed subsequent Twitter conversations and analysed news articles, academic literature and interviews with medical trainees and faculty.…”