There is an unacceptably high level of stress amongst medical students and we know that this increases before exams and assignments. Does medical school need to be so stressful?
We have a responsibility as educators to examine whether the stress that assessment causes is worth the measurement of competency and the student learning that is gained.
Stress is thought at times to enhance performance and to build the resilience needed to work in emotionally charged and high-pressure clinical environments, but the cost of stress is high on both body and mind. All of us who have risen through the medical training system have not only witnessed this stress in others, but experienced it in our own bodies – experiencing some or all of the myriad of physical and emotional symptoms stress creates. Stress affects attention span and cognitive function, increasing the risk of poor exam performance. At a clinical level, it may cause errors of judgement affecting patient care. It may affect your ability to resolve interpersonal conflict, both at work and at home. As students, we learned to deal with it in both healthy and unhealthy ways, some using stimulants to keep them awake and alcohol to help them sleep!
Are we putting our students’ mental health at risk?
We undoubtedly have to ensure that doctors are competent to practice safely and effectively in their chosen fields, but we need to be mindful of the stress we create in assessing them. As well as examining assessment tasks for efficacy, they need to be examined for relevance and necessity. Is this task suitable to examine competency at this level? Does the time consumed by this task, detracting from time learning in a clinical environment, justify student learning and examiners’ needs for assessment of competency? Is it necessary to generate this level of distress or could the same student learning and examiners’ assessment requirements be met in less stressful ways? Are we guilty of overdoing assessment and putting our students’ mental health at risk?
Becoming a student again can make you a better educator
Last year I studied for my Grad. Dip. in Medical Education – so there I was at uni again. Just as it has been a gift as a doctor to experience being a patient, so it is invaluable as an educator to be a student.
My biggest obstacle was Moodle, a computer program which is indeed as confusing as crossing a cow with a poodle, and was a great source angst for this technophobe, challenging my ability to maintain equanimity and harmony.
I have been reminded of the time and effort that goes into each assignment and how frustrating this can be if the task itself seems irrelevant. How crushing it must feel when marks are poor and examiners’ comments less than favourable.
Looking back on my own training – has change been for the better?
For me the biggest hurdle was gaining medical school entry. I would have been devastated if I had not got in, but was sorely compromised when it came to physics, which reminded me of hieroglyphics and could surely have been taught better. I had nightmares about that exam for years. At medical school, unlike today’s students, we did have time to have fun.
There were 2 huge and 2 smaller exam hurdles to pass. It was always simply pass or fail, competent or incompetent, with a select few of the more “brainy” getting distinctions. This meant there was no atmosphere of competition or comparison, rather we co-operated with one another, preparing us for the team work of our future careers.
However the paucity of exams was considered to be ill conceived, in that the competency of a student who was under-performing on the day, for whatever reason, was not effectively measured. Assignment tasks and clinical competency assessments were brought in, so that those who performed poorly in an examination setting were offered an alternative form of assessment. Students also had no measure of progress which could identify learning areas needing attention, so more frequent exams were brought in.
While at one level this better meets the needs of the medical course, it has the potential to create a continuous level of stress, not unlike being in a war zone.
Students may be almost continually studying for exams or assignments, with little break. This means they gain less from immersion in the clinical setting, which stimulates self-directed learning. Students tell me that they have no time to sit in with the doctor or go to the ward because they have to study – this in a system where the foundation of medical education is based on patient contact.
When all assignments and exams are graded, this produces another level of stress amongst students who, by the very fact they gained entrance to medical school, are high achievers academically. Is it any wonder that our students are already suffering from burnout and its associated cynicism even before they are qualified?
Are we not wanting to generate enthusiasm and passion for Medicine?
Are we not concerned that the lack of self-care and self-compassion forced on them by this system is not conducive to them having the compassion for others our profession desperately needs?
Post-graduate studies are even more intense. I remember studying for the MRCP while working 80-100 hours on duty a week. Working impossible hours, studying for exams when we were aware only 30% passed AND trying to have a life was not an equation which worked.
Where was the self-care in that? Where was the space to have the compassion needed to connect with the little patients I worked with on the children’s oncology ward? I possibly had it easy – I was single and had no mortgage – others already had homes and families whose needs they had to juggle with work and studies.
Can we make assessment more supportive, confirming and evolving, rather than degrading and defeating?
Can we create an atmosphere of co-operation instead of competition?
Can we make student welfare and well-being a priority?
The consequences of an overstressed medical workforce impact not only on patient outcomes. For some the price is very high with years of anxiety, depression and burnout leading to broken marriages, ill health, alcoholism, questions of self-worth and at worst, suicidality.
Are we part of the problem?
There is no doubt that it is important for us to train students and young doctors to better deal with the stresses inherent in a career in Medicine and to support them to better support themselves. However it is imperative that we honestly explore the causes of stress, one of which undoubtedly is our method of assessment. We need to openly assess students’ stress response to different methods, intensity and frequency of assignments and exams, and adapt them accordingly. We need to explore different ways of effectively assessing competence, which are more caring and supportive, which promote student learning beyond the ingestion of the endless expanse of facts in medical science today.
Can a medical school which creates unacceptable levels of student stress support the development of the doctors our profession needs?
There needs to be a balance between study and down time, between action and repose, time to recuperate and to self-care, time to live a life beyond Medicine which is sustaining to the soul.