Group for the Advancement of Psychiatry - The Story of GAP

Publication

The Medical Student Survival Guide

GAP Committee on Medical Education
June 2003

This publication is also available in MS-Word and in Adobe PDF format

TABLE OF CONTENTS

Foreword

Statement of Purpose

First Take Your Own Pulse

Stressors 

Preventive Maintenance

First Aid and Getting Help.

Final Thoughts

Online Resources

Chapter 1 Introduction

Every car comes with an owners manual.  Take care of it, change the oil regularly, have a mechanic look at it when you hear noise in the engine, and the car should serve you well for years.  Medical students need an owner's manual as well.  The four years of medical school are exciting but stressful. Medical students need to take care of themselves so that they can make the trip and enjoy it as well.  This guide to surviving medical school is designed to help do just that.  It is written by the Committee on Medical Education of the Group for the Advancement of Psychiatry (GAP).  All of the members of the Committee have been medical school faculty and have interacted closely with medical students for many years.  Our experiences suggest that students who do the best job surviving medical school:

  • Understand something about what they were like before they get to medical school;

  • Recognize the stressors they might face during medical school;

  • Take steps to care for themselves during medical school, in order to minimize stress; and

  • Acknowledge when they might need extra help to deal with stressful       circumstances.

The volume of material to be learned in the next four years is several times greater that most of you have experienced before.  Feeling helpless and pressured to learn more are normal. The expected and unexpected challenges and experiences you will face, sometimes in a state of near exhaustion, can at times be overwhelming.  But, you are not alone.

Despite the fears, anxieties and distress you will confront, the privilege of becoming a physician is worth your efforts.  Learn what you need to learn in medical school and you will be prepared for a lifetime of learning. You will read scores of books during your medical school years read this one first for a smoother ride!

Chapter 2 First, Take Your Own Pulse

The way we cope with medical school depends to a great extent on what we're like before we ever get to medical school.  We enter medical school with different temperaments, coping styles, attitudes, prejudices and life experiences.  They can help or hinder us as we try to make our way down the road to becoming physicians. Understanding the individual ways in which you tend to cope with stress, and what types of situations might be particularly difficult for you, can help you best negotiate the trials and tribulations of medical training.  Sometimes, we're not aware of our coping styles and attitudes.  Sometimes, it is hard to admit to ourselves that we have a particular characteristic or that we harbor a particular attitude.  But, even if we're aware of those characteristics and attitudes they can still affect the way we deal with situations.  Here are some things to think about to begin a process of self-discovery.              

Temperament How do we tend to react?

Every individual has his or her unique temperament.  Some people tend to become anxious, while others have a low threshold for irritability.  Withdrawal is a coping style for some people, while still others may become sad periodically.  Whatever tends to happen to us when we are in stressful situation is likely to happen during medical training.  To begin to understand something about your own temperament, think about how you tend to behave during exam times, what happens to you after a break-up with a significant other, or how you react after a disappointment or criticism.  You can even ask loved ones for some insights into what you tend to do when things get rough.  This type of self-discovery process can help uncover strengths as well as problem areas. Traits such as being able to ask for help, not being embarrassed to admit that you don't know something, working well with others, being able to use humor, and being able to enjoy friendship and leisure activities are invaluable tools for coping with difficult situations.  Knowing how you tend to react can help you:

  • Predict what your responses might be

  • Avoid situations you might find difficult

  • Know when to look to a strength to help with a weakness 

  • Know how to look for appropriate resources to support you when you anticipate problems

Attitudes and Expectations What do we ask of ourselves?

Most of us worked hard to get into medical school.  Once accepted, we continue to have high expectations for ourselves.  While these may help us constantly strive for excellence, they can sometimes cause undue stress, especially as overwhelmed medical students.  Acknowledging these expectations and feelings can be the first step towards not letting them get the better of us.  Here are some attitudes some of us have, but may not be aware of:

The Best or Bust. 

Those of us who get to medical school have often spent much of our lives being at the top academically, or we would not have been accepted.  But always being at the top, or always needing to be at the top, can be very stressful.  The constant push to be the best may become overwhelming, given the sheer volume of material to learn during medical training.  We experience information overload!  But, since everyone around us has also been the best, we have all had to face the fact that we cannot be the best in every endeavor in medical school.   For many of us, this comes as a shock since medical school may be the first place we have had to grapple with this realization.  It's important to remember that just because we're not at the top doesn't mean we're at the bottom.

 If we work hard enough, we should be able to understand it all.

At times, this is a useful attitude; it helps give us an extra push from within when we need it.  However, when taken to an extreme, it can also lead to workaholism, frustration, unrealistic expectations, and self-defeating behaviors.  Although we may be accustomed to understanding all the material that is presented, there is no way we can completely master the volume of material that we encounter during four years of medical school.  Understanding your wish to do so can help you to set more realistic goals and save yourself unnecessary self-criticism.

 A doctor has to love everything about medicine

Many of us have known for a long time that we wanted to be physicians.  Most of us worked extremely hard to be accepted into medical school.  Unfortunately, even if you have relatives who are physicians you can't actually know what it's like until you begin yourself.  Along the way, some of you will find that it's not what you imagined it would be.  This can be difficult. You might even discover that there are aspects of medicine that you don't enjoy, or that you dislike or fear.  Some of these reactions are transient and related to being overtired and stressed.  But some reflect likes and dislikes that will persist.  Feeling that you can't possibly read another chapter in a textbook, review another handful of class notes, look at another pathology slide, or see another patient doesn’t mean that you don't belong in medical school.  It may mean that you had bad day, that you need a vacation, or that you'd rather go into urology than pathology.  Rather than being frightened by these attitudes and feelings, acknowledging and making peace with them can help guide you towards the field or specialty that will be most satisfying and enjoyable in the years to come.

A doctor has to always love taking care of patients

Being close to people can be a great joy, but it can also be a burden.  They cry, complain, nag, wheedle, demand, threaten, and arouse our sympathies and our desires to rescue them from the deterioration of their health or from death.  There will be times when you're angry at a patient or a patient's family and there will be times when you just want all the people who are making demands to go away.  Some people find it too frightening to acknowledge these feelings, because they think that having such thoughts and feelings means that they won't become a caring doctor.  Actually, the opposite is true.  Harboring those feelings without acknowledging them can lead too much greater resentment than allowing yourself to experience them and to realize that most professionals who take care of sick people have similar feelings from time to time.

Family expectations – What do others expect of us?

How you cope in medical school is also the product of your past and present life and family experiences.  Sometimes family members can be extremely helpful by providing support, being good role models, and giving us love.  But sometimes even the most supportive families have expectations that put pressure on an already burdened medical student.  It may be hard to acknowledge that your family is adding to your stress, particularly if your family is sacrificing emotionally and/or financially to help you.  But acknowledging this does not mean you love or appreciate them less. Here are a few ways that family expectations may affect you.

Financial issues

Some families think that their status in society or their financial well-being will magically change if one of their children becomes a physician.  Many families put themselves into debt in order to finance their medical student.  If your family harbors this type of wish, you may feel that your familys financial security depends on your success.  Obviously, this can add tremendous pressure to an already stress-filled situation.  You may also feel guilty if you need to take a break for fun, or if your choice of specialty doesn't match your family's wishes.

Now you can answer all of our medical questions!

Often, families think that just because you are in medical school you should be able to answer all their medical questions or worse, function as everyone's doctor.  Requests for everything from cures for the common cold, to prescriptions, referrals and second opinions are frequent burdens for the newly minted medical student.  Your wish to succeed for your family and come up with the right answers may lead you to put yourself in a position you're not ready to assume.  Realizing that your family may not understand that you still have vast amounts to learn may save you from many compromising situations.  It takes strength to help your family understand that you are not yet a physician, and certainly not their physician. Because of the emotional ties you have with your family, it is best that you not serve as their physician, but rather use your knowledge of the medical system to refer your family members for care.  As medical students, there is no reason not to ask faculty members to help identify such physicians.

The family business

Those of us who have other family members who are doctors may feel pressure to enter the family business. Some may feel pressure to follow in their parents footsteps.  Some may worry that they only got into medical school because they had a physician parent.  Parents or siblings may be more understanding, but they may also feel that you shouldn't complain because, was tougher when I did it.  Medical students with relatives in medicine may find it more difficult to complain about the profession, or to admit that they don't like or feel aptitude for some aspect of medicine.

Difficulties with significant others

Even significant others who are very loving and supportive may have times when they are fed up with the demands of your medical education.  Weekends spent studying, nights in the hospital, erratic hours and no ability to control your schedule could drive even the most flexible partner to distraction.  A significant other with a demanding job or academic pursuit in another field may feel that you should be able to have more flexibility than you are realistically able to have.  When both partners are medical students, other difficulties may emerge, related to differences in study habits, expectations, needs, fears, capacities, and interests.  There may even be times when you feel competitive.   Realizing that these issues are likely to occur at some point during medical training can help you to help those you care about, understand and support you.

Once you have a better idea of how your temperament, attitudes and expectations affect you, you will be more prepared to move on with the business at hand, learning to take care of others.

 

“Stressors”

Common Stressors

We all know that medical school can be stressful.  In this section, we will cover some of the stressful events or stressors that affect most medical students, sooner or later.  Stressors should be thought of as challenges which, when weathered successfully, help us to grow into competent physicians.  Whether they help us grow, or grind us down, depends on how well we make use of good first-aid and preventive maintenance.

I'm flunking; I can't do this!

This may be the most common and worrisome thought experienced by medical students.  It is ever present and always intimidating.  There are may different times when you will feel that you will fail: the first day of medical school, before a major exam or boards, on rounds during clinical rotations, just to name a few.

The fear of failure is a universal stressor. We all experience it at some point, despite objective ways that suggest it may not be as bad as we fear. Good and bad performance is often a subjective judgment¦and the faculty makes the call.   That means we don't have much control.  For better or worse, medical schools are authoritarian institutions.  Therefore, if we perform poorly, we feel “dumb.”  Since medical school is challenging, it is not uncommon for most of us to feel, from time to time, that we are doing poorly, even if we are doing well. 

Everyone is smarter that I am!

Medical school is very competitive.  The level of competition is often more intense than it was in college, because everyone wants to be the best and the stakes are high.  Not only are our careers at stake, but our actions directly affect the lives of our patients.

Information Overload!

The experience of medical school can be like trying to take a drink of water from a fire hydrant. The reason we think there is too much work is that there really is.  Four years is not long enough to learn everything we need to know when peoples lives are in our hands.  However, everything does not have to be in your head all the time; you have books, computers, colleagues and faculty to learn from and use as resources. 

Work overload will vary during medical school.  There will be facts to memorize, labs to complete, lecture material to wade through, and exams.During clinical rotations there are too many patients to work up, too may menial tasks to perform, too much reading to do, and not enough hours in the day.

If The Best or Bust and If I work hard enough, I should be able to understand it all philosophies are part of your attitudes, this stress can throw you off base.  Get help fast if it starts.

I'm different than everyone else

It is challenging enough to be in medical school.  Imagine the additional stress you feel as a woman, an ethnic minority, a physically challenged or homosexual student. Feeling different from classmates, as well as from the rest of society, can be one of the greatest stressors encountered in medical school.  This stress is accentuated if differences interfere with the way people react to you.  While medical schools attempt to include cultural content and experiences in the curriculum, this knowledge does not always change misconceptions and related behaviors.

I'll pass out during Gross Anatomy Lab!

By the time you read this guide, you will probably already have met your cadaver, even given him or her a name and learned, to your dismay, that he or she was not constructed strictly according to your Netter's Atlas.  Although dissection is a powerful experience initially, before long you work on “the body” with little thought of what you are really doing.  Regardless of what anyone thinks, though, it is a “rite of passage.” We are virtually the only group empowered by our culture to have this special experience, to learn directly from the dead the secrets of our construction.

 

Do I have All these Diseases?

When you study disease processes in pathology, complemented by your physical diagnosis course, you suddenly find that you are experiencing the symptoms of illnesses that you have just studied.  It is not unusual to think the worst when a symptom occurs.  So when you are studying brain tumors you are convinced that the onset of a headache is sure to be an astrocytoma.  When studying about tuberculosis, the first time you cough you look for blood in your sputum to rule out T.B.  When learning about acute appendicitis, every ache in your abdomen means you must check your lower right quadrant for rebound tenderness.  Excessive sweating, even on a hot and humid day has you checking for sighs of thyroid hyperactivity.  A birthmark that has not changed in color or size raises concerns about a melanoma.  You may question whether you are becoming a hypochondriac. Rest assured that you are not alone reaching the conclusion with each new illness that you study that you may be facing the fatal form.  Sharing this experience with classmates usually lends itself to a good laugh by you and your classmates as they often have gone through the same experience.  You have caught “medical student disease.”

 

These classes are ridiculous!

In medical school, basic scientists teach many of the beginning classes.  Some of them have interests that seem far from the practice of medicine.  For example, some enthusiastically describe microanatomy and biochemical subtleties that do not seem to have much to do with why we’re here.  They invite us to join them in their enthusiasm by asking us to carry out esoteric experiments in their labs and by memorizing whole sequences of physiologic processes that are hard to understand and still harder to pronounce.  It helps if we remind ourselves that these are the building blocks of medicine.  Basic sciences introduce us to the inevitable tension within medicine between the knowledge of science and the art of healing.  We need both!

There is too much sickness

The media frequently focus on illness, and the grisly medical scenes depicted are often unreal.   Most people are unaware of the extraordinary variety of ways our bodies can be mis-assembled, broken, infected, worn out, or riddled with tumors.  As medical students, textbooks and clinical experiences introduce new material to this “scene” every day.  Most of us handle this stress with denial, by saying to ourselves,  â€œThat looks awful.”  Good thing I’ll never get it.”  Or, “Fortunately, I’m the wrong age, sex, race, occupation, or religion to get hit with that one.”  So we are usually not consciously aware of this stress. Occasionally, we become overwhelmed, and may experience it in a number of ways – from feeling depressed to getting “medical student’s disease,” we may even believe “we have it.” 

Who’s in Charge?

In the clinical years, medical students are at the bottom of the pack – attending physicians, fellows, residents, pharmacists, social workers, nurses and ward clerks all seem to outrank us.  We feel powerless in this hierarchy.     Rounds, the hallmark of medical training, consists of group visits to patients’ bedsides.   While rounds are instructive, the experience can strike terror into the heart of the “lowly” medical student who is asked to play   â€œWhat am I thinking” by those who are senior who press forth with increasingly complex questions until you reach the limits of your knowledge.  You may be embarrassed, feel unsure or even dumb, but try not to let it get to you.   All of use have experienced it and may continue to in the current system.  It doesn’t mean you are really dumb if you fail this humiliating test.

Excuse Me, Doctor

You may look behind you when the first nurse or patient addresses you in this way.  You may feel like the ultimate imposter but, at the same time, hope that someone does believe you have something to contribute. Take heart, most patients in teaching hospitals are familiar with the student role.  Often short white coats and nametags serve to identify students.  Nevertheless, in the minds of many patients, there is no important difference between a medical student and a “real” doctor.  A student may be the person who spends the most time with the patient, listening and offering support, and patients may view their students as the most important member of the team.  This can be enormously rewarding, but also very stressful.

Sir, please drop your pants

Three values most of us learned before we entered medical school are:

  • Respect other people’s modesty

  • Do not touch strangers

  • Do not inflict physical discomfort on anyone

Doing a thorough physical exam, which might include a rectal or pelvic exam,  violates all three of these values.  Take heart.  All of your classmates will be experiencing anxiety in these situations.  Before you get to your first patient, you will have practiced every part of the physical exam on your classmates or trained/paid actor/patients.  Gentleness, practice, respect and reassurance all have a powerful impact on minimizing your discomfort and the discomfort of patients.

This patient is driving me up the wall

Most people going into medicine really do want to take care of people.  That’s why most of us are surprised when we first find ourselves disliking and/or dangerously close to exploding at a patient.  Remember, “patient” is a role that everyone experiences, usually transiently at some point in their lives.  Both nice and difficult people can become difficult patients when they are stressed or in pain.  Many patients do not recover rapidly or they experience chronic debilitating conditions.  To be in the hospital, patients have to be quite ill or in need of a procedure, both of which are stressful and uncomfortable.  Fear and anxiety have an impact on disposition and interaction.

That patient’s a crock

These are patients who don’t get better despite our most impressive diagnostic and therapeutic efforts, or who have physical complaints but no observable or measurable signs of pathology.  Warning:  Be careful when a patient is labeled a “crock,” because it may be a problem that medicine cannot yet document. Also, whether or not the crock’s problem is medical, emotional or both, it is still a real problem.  Pain is painful, itches itch and depression is depressing.

No way, I’d ever do that!

 A patient in the clinic or hospital is in a vulnerable position.  Just like a two year olds, patients may push boundaries and test limits.  They may ask questions you cannot answer or want you to make decisions for them, or to tell them an uncertain prognosis.   Remember, you are not the physician responsible for their care.  That physician must help address these concerns or questions.  Sometimes, patients are seductive and suggest that you are attractive or desirable to them, you may also be attracted to a patient.  It may be difficult to resist, but it is essential to do just that. As a patient’s physician, you cannot be their lover.  Patients’ are in a dependent role and may not be able to make informed judgments about personal relationships with their caregivers.

It's A Balancing Act

As we noted, balancing personal and professional lives is a challenge.  Although support from significant others can be invaluable, late nights and the seemingly endless journey through medical training can take its toll.  Many things are in short supply: limited money, limited energy, and limited time.  Families and friends may even believe that we don’t want to be with them or don’t care about them. Relationships require ongoing verbal understanding, patience, respect, caring, negotiation, and compromise.

Someone may die

Despite our best efforts, some of our patients will die.  We all know this, but coming to grips with the reality of death, particularly with the loss of someone we are caring for day in and day out, is always painful.  The first time “we lose” a patient (notice the verb and the subtle and usually erroneous implication that we have been careless or forgetful) is usually the hardest time.

It is difficult for many reasons.  We have come to know and value the patient, it can be doubly hard if the patient is our age, or reminds us of a friend or family member we love.  The death of a patient also underscores our feelings of helplessness and inadequacy.  We may even feel guilty if we feel some secret relief at seeing our patient’s suffering finally ended.    Before medical school, many of us had never seen anyone die, and we are reminded of our mortality.  Our first patient’s death shatters a favorite myth: If we just study long enough and work hard enough, we physicians can rescue everybody from death.  Accepting limitations and understanding that caring is vital, especially when cure is not available can be painful, but it is at the heart of medicine.

Life Intrudes

Even in medical school, life intrudes.  Family members become ill or die, partners break up, and financial issues can cause hardship.  At such times, remember, seeking help is not a sign of weakness, and can be vital in resolving a problem.

Preventive Maintenance

All of us can rise to an occasional challenge – cram for an exam, pull an   all-nighter studying, work throughout the night with a very sick patient, or endure long and arduous work during a catastrophic event.  But none of us can remain well balanced or practice good medicine without periods of recovery.  Because the study and, later the practice of medicine, consists of a series of strenuous challenges, it is vital to have a plan for preventive maintenance.  But alas, our educational institutions, as well as the mystique of medical practice, all seem to value the extraordinary physician who works long hours without a break, who puts his or her personal and physical welfare second, ignoring bodily or emotional needs and functions.  Our system encourages behaviors in students and physicians that would be of concern if we saw them in our patients.  We exhort our patients to eat healthy food, maintain ideal weight, get sufficient sleep, exercise regularly, engage in recreation, avoid smoking, alcohol and other substances of abuse; at the same time, many of us do not come close to practicing what we preach.

Just as we need to bring our automobiles in for five thousand mile check-ups, we need to follow our own advice regarding health promotion.  We must care for ourselves in order to care for our patients!

Stay Connected

Among the most important tasks in medical school is to build and maintain connections.  Life should not end just because you are in medical school.  Don’t precipitously abandon your spouse, partner, lover, friends, or family.  Their love, interest and support for you is potentially the most important support in your life.  Paradoxically, for medical students as well as physicians, there are more external obstacles to being good spouses, partners, lovers, or friends than for many other groups in our society.  The nature of our work can take us away from them and leave us isolated and exhausted.  Maintaining relationships (never mind beginning and developing relationships) takes time and energy.  Early in our careers we are not only short of money, but also short of emotional availability because of the time and energy demands of our work.  We have to be particularly careful that our careers do not seduce us away from the people we love.  Consciously carving out time, and energy, for these important people pays dividends, and saves relationships.

Sounds simple, but it can be very difficult.  Medical education covertly, if not overtly, promotes delayed gratification, and the sacrifice of convenience and comfort.  We all have been conditioned into making medicine our first priority, an almost universal hazard in medical education and patient care.  We often feel that we have no control of our time.  The experience of lack of control is more negatively stressful than is fatigue.  For practicing physicians, monitoring office hours and patient workload, arranging for coverage with time off for some weekends and holidays, as well as scheduled vacations, and ensuring time for healthy recreation are key.  But, students, too, can plan their days and weeks to include social interactions.   It will help you cope now and throughout your careers.  Nonetheless, advance planning is necessary so that personal life is not the first thing to go in a pressured period.

Find Friends in Class

This is probably the most important thing you can do to ensure your survival and enjoyment of medical school.  Many schools support social activities and trust building (everything from picnics to Outward Bound) as part of an initial orientation.  Many of these can expand into formal or informal on-going activities.  More formal support groups can also be helpful.  Retreats, get-togethers for students and partners can build rapport and help alleviate stress and isolation.  Classes, small labs and other study groups naturally promote partnerships.  Talking about one’s life and stresses is itself a major de-stressor.  Isolation adds to the stress of a massive workload, and many demands.  Colleagues and friends provide consensual feedback, validation and promote balance.  Study groups are a highly effective adjunct to the learning process as well as encouraging the teamwork that will be necessary throughout your career.

Take Care of Your Body

Fast food, vending machines, too little sleep, and too much sitting may all wreak havoc on your pursuit of health.  Too much caffeine can cause anxiety, interfere with sleep and cause fatigue.  Cooking takes time, but shared meal preparation and finding more healthy snacks (an apple a day) can set the stage for continued health and energy.  Take advantage of the preventive services offered by the student health service or the dean’s office: ranging from immunizations to classes in yoga and meditation.     

Exercise Your Body

Medical school requires longer class time than most of us have ever before experienced. We may sit or work in labs for 8-10 hours a day, and then spend another four to eight hours of evening and night time study at home or in the library. Finding time for exercise may seem like an insurmountable obstacle, but exercise can help in many ways.  The release of endorphins minimizes the impact of stress. Physical activity improves bodily function and helps clear the mind.  Exercise can be both social and fun.  Find enjoyable activities, particularly those that include companions.  Even if you are not gifted athletically, you can walk, jog or run in a group; play soccer or basketball; swim, ski or skate together.

Exercise Your Mind (in new ways)

Contrary to prevailing mythology, medical school is a good time for finding new interests or enhancing old skills.  Whether it is the evening game of scrabble, practice on a musical instrument, reading the newspaper or detective stories, or creating fiction, poetry or art your mind will benefit from new activity.  About the last thing on your mind as you enter medical school is playing or having fun.  Although some faculty subscribe to the dictum, ‘the harder you work, the better you will do in medical school, this statement is not totally inaccurate, but it is also not entirely correct.  We know that medical school is demanding and difficult, but all work and no play will merely exhaust you and subject you to the law of diminishing returns.  A break allows you to return to work refreshed.  Developing the ability to play or disengage from your work should be cultivated in medical school.  Hobbies or activities learned or continued in medical school will contribute to balance now and throughout your professional life.  Consider participating in the many student-generated activities that happen in medical school: follies or talent shows, movies, dances, and get-togethers.  But, plan to get away as well.  Take advantage of the community in which your school is located.   Attend theater and concerts; visit museums and historical sites; attend sporting events.  Discounted fees for students are often available and many events are at low or no cost.

Contribute to Others

Few activities are more satisfying than assisting others in need.  Tutoring elementary school children, teaching painting, music, health education, or swimming, being an athletic coach for young people, assisting in a nursing home, volunteering in a clinic or soup kitchen – all bring the dual satisfaction of doing good and meeting a community need.  Many medical schools have formalized service-learning programs, or can help connect you to facilities or groups in need.  Additionally, joining with classmates in these activities not only does good, but encourages friendships and other support.

Plan Your Career

Look for what you like and do best.  The life of a physician can be lived in dozens of ways.  In addition to the broad range of specialties from family medicine to emergency medicine to psychiatry and neurosurgery, clinicians, teachers, researchers, and administrators in medicine all have life styles that are quite different from each other.  Even clinicians in the same specialties can have varying professional and personal life styles.

Take a good look at what various physicians do on a typical day as well as over time.  Try to assess the attributes and life styles of the people who inhabit each professional niche.  Utilize school-based, community and national resources to evaluate your interests, skills and personal needs to choose a specialty area and career pattern that fits your expectations and personality.   But don’t bend to pressure for premature closure.  Give yourself time during medical school to explore who you are and what you want.  While you will need to consider family input (your mother was a surgeon and her father and grandfather were also), television and media models and other pressures, take them with a grain of salt.  The choice must be yours.  Remember, you, not they, will be the one to live your professional life.  If the fit is not a good one, you can spend your professional life disappointed and fighting your work, rather than enjoying and looking forward to each day.

Finally…

Be alert.  The values subtly and sometimes unintentionally, underlying your education will fight constantly against balance.   â€œKeep working” goes the saying, don’t squander your time, energy or money on anything frivolous. Yet, life is not either-or but a balance that will promote your professional and personal growth and lead to your comfort and success as a physician.

First Aid

What to do when prevention doesn’t work.

First aid means what to do till the doctor comes, or it can be translated as getting help!  In spite of your best efforts at prevention: maintaining a healthy life style, managing time, and keeping a balance, life events may produce stresses and strains.

Even in the most enlightened environment, the medical school experience is still stressful.  The combination of intense workload, long hours, and the responsibilities that come with clinical care can affect even the most centered and mature students. There are a number of strategies that provide resolution while promoting growth, strength and competence.  They can be divided into approaches that involve others and those that can be done alone, and include:

  • Talk About It

  • Sleep On It

  • Walk Away

  • Figure It Out

The best opening strategy is talking about it.  Whether it is a loss of a significant other, or poor performance on an exam, talking about it is helpful.  It usually feels best to talk with friends or classmates with whom you feel particularly comfortable, classmates who have gone through the same or similar stress and survived.  They will understand your experiences, as well as welcome a discussion, which opens the door for them to talk it out with you as well.  You will need to watch out for those classmates who want you to use their solution (what worked for them) whether it fits you or not.  Yet, comparing experiences can lead to a variety of viewpoints and approaches.  Other good choices for discussion are with those you love – spouse, partner, family member or friend from your pre-medical school days.  Not only do they care, but letting them share more fully in your life can strengthen these meaningful relationships.

Faculty can also be helpful.  They can provide support in understanding content, but their long term experiences also give them an understanding of what approaches others have successfully utilized.  Reputation counts, and other students can often identify those faculty who are particularly available and effective.  The Dean of Students office in many institutions can also serve as a support.  Some students avoid the administration for fear of stigma (‘will this be in my dean’s letter and negatively impact my chances of getting into a good residency?’), while others are suspicious of authority.  For many students, going to the dean’s office resembles being sent to the principal in elementary school, but deans and their staff can be resources.  They are familiar with the issues that arise in medical education, and the variety of student reactions.  They can address problems and they also know what has worked historically for students in similar situations.  They can be student advocates with sufficient clout within the system to address inappropriately stressful or demanding situations in a way that will improve the students’ experience.  For example, they can address facilities problems, i.e., opening hours for the library, or harassment issues.

If symptoms such as mood changes, anxiety, unexplained fears, sleep disturbances, appetite changes, headaches, irritability and panic feelings, don’t go away with the first aid we’ve recommended, help is available.  Premenstrual symptoms, eating disorders, and substance abuse also occur in medical students as they do in the general population.  Sometimes, a medical illness such as thyroid disease can present first with psychiatric symptoms.  If you experience unexplained highs or depressive symptoms such as inability to concentrate, persistent irritability or sadness, crying, even thoughts or plans of suicide, help is essential.  This can even include a medical leave. Many medical students use mental health services with very positive outcomes.  Use of these services during medical school should not compromise career plans.

Many schools have a student health service or counseling center with trained and experienced professionals who can provide assistance not only in resolving acute problems, but also in developing preventive strategies.  Additionally, they can prescribe appropriate medication if needed.  Such programs are confidential, with student information protected and not included in academic records.

There are some individual approaches as well.  Since medical students tend to be individualists and problem solvers, it is no surprise that individual solutions may be the first if not only approach.  These really provide “first aid” in that they are immediately effective and can defuse a problem before it develops a life of its own.  On the other hand, being able to involve others in resolving a problem can promote more long-term solutions.

Walk Away and Sleep On It are helpful responses for initial and rapid relief.  Gaining perspective and distance can lessen the impact of a stressful event.  We all know that fatigue does not lead to performing at our best.  Sleep buys time and perspective as well as physical recovery.  It often makes the difference between mild annoyance and full-blown crisis.

Figure It Out

This approach consists of brief conversations with yourself and includes such questions as:

What stress event(s) caused this reaction?

What kind of reaction did I have and why?

How did my pre-set cause me to react to this particular stress?

Did anything seem helpful?

Did anything make it worse?

This strategy while often done alone, can also be part of your conversations with others in talking it out. It may be most useful to combine several approaches – especially walking away and sleeping on it, then utilizing opportunities to talk about it and figure it out.

As useful as these strategies are, you should recognize that there are other less successful, if not downright destructive approaches, that may seem to be easier and effective.  They include:

  • Ignore the Problem

  • Work It Off

  • Self-medication

Each seems to promise a quick fix, but in the long run only worsens the difficulty.

Ignore The Problem

While this approach initially seems effective, ignored problems tend to hibernate, not disappear or resolve on their own.  This approach prevents you from learning enough about your own vulnerabilities and strengths to give yourself warnings when you are about to suffer a similar experience.  It may lead, to your being increasingly sensitized to the stress-related encounter, rather than being broadened or instructed by the process.  Not sharing your experience with loved ones may keep them from learning about or understanding your experiences, minimizing their ability to be supportive to you.  In the long run, this approach can cause avoidance of growth and may lead you, unwittingly, to seek professional roles that are more secure but less rewarding than others you might have enjoyed.  It can also have the opposite effect, leading you to push yourself unknowingly into dangerously stressful situations or roles, because you need to maintain a sense of mastery of stress.

Work It Off

This approach also may seem to be an immediate solution, and it is frequently used by medical students as well as practicing physicians.  Channeling overwhelming emotional energy into work is a great way to get work done, whether it is studying medicine or caring for patients.  Unfortunately, this approach doesn’t promote learning or future prevention, and it may distance you from friends, family and other loved ones.  As in walking away, it can be useful first aid, if you also take time to figure out the cause of your reaction.  Working it off can lead to some bad professional choices later in your career, if it is the only aid you allow yourself.

Self-medication

This approach is, alas, all too frequent and it is generally combined with overwork or ignoring the problem.  There are many medicating agents available in our society. Alcohol is the agent of choice for many, but marijuana and prescription drugs are not far behind.  Although self-medication may seem useful for numbing the pain that come with all kinds of stresses, as well as for momentarily relieving loneliness or boredom, it is particularly hazardous for physicians and medical students.  We tend to lead the kind of high demand, high stress lives that make self-medicating look attractive, especially the secret kind that helps us maintain the façade of being strong competent physicians while covering over inner shakiness.  More important, this approach does not address the cause of the problem, nor enable us to prevent it in the future, and with frequent use, we become increasingly dependent on the substance for day-to-day productivity, often requiring greater amounts to achieve the desired result.  We become addicted.  Since we have easier access to drugs than most people, it is simpler to choose this route, and it is certainly more dangerous.  It can lead to accidental death.

Becoming proficient at effective first-aid strategies allows and builds the cultivation of back-up support and good preventive maintenance into your life-style.  The more you understand the causes of your responses to stress, the easier it is to develop more effective prevention and resolution.

Final Thoughts

Taking care of yourself is not a selfish act but rather one that will serve you well as you continue your personal and professional growth.  Becoming proficient at knowing yourself, building good preventive maintenance into your life style, and using the first-aid strategies outlined in this guide will help you run smoothly for your exciting trip through medical training!

Online Resources

American Medical Student Association

Deans Council of the Association of American Medical Colleges

American Psychiatric Association

Submitted by the GAP Committee on Medical Education