We demand much of our medical students and junior doctors. We currently train them in an environment that is stressful – competitive, harsh and overwhelming for them at times. Is it possible that training them in an atmosphere of trust, respect and kindness would better support them to become the confident, competent and compassionate doctors we so need in our profession?
Mental Health of Medical Students
The Beyond Blue Study(1) of the psychological status of Australian medical students reports an unacceptably high incidence of stress amongst medical students, often accompanied by mood disorders and burnout. This is of great concern and challenges all of us involved in medical training to ask how we have contributed towards this and whether there are ways we can better support students. These are our future doctors. That they should suffer from stress, burnout, emotional exhaustion and cynicism before they even leave medical school does not bode well for the future of Medicine.
A recent publication(2) reported finding that graduate entry medical students experience more stress than their undergraduate entry counterparts. Exploring this further may offer some insight into the problems and may possibly offer us some solutions. Logic would perhaps have said that the younger students coping with the transition from school to university, from home to independent living, would possibly be experiencing a more stressful period than their older colleagues.
The Pressure Starts Well Before Medical School Entrance
This is so for both groups of students. All courses require a history of high academic achievement and in the case of graduate entry programs require performing well in the GAMSAT test. Many of the students are very high achievers, setting extremely high standards for themselves. In my memory, being accepted into medical school was probably the major academic hurdle of my career. Not reaching the starting block was simply not a possibility and even now I have difficulty contemplating that, having such a strong belief that Medicine was my chosen path.
The Culture of Medical School
Medical school itself is often unforgiving. Students used to achieving high grades in high school may find themselves fighting hard to achieve at the same level amongst highly competitive peers. This perhaps at a time when they are coping with the physical and emotional upheaval of living away from home for the first time.
The demands on students increase as they become more immersed in clinical work, where they are expected to work long hours as well as submit demanding assignments and sit difficult exams. The breadth of knowledge in medicine has expanded to such a degree that students have difficulty knowing where to start, let alone when enough is enough.
“We have been given 100 core learning areas. Each has about ten subjects and I estimate each subject takes me 5 hours to research and learn…It is overwhelming.”
And where is the space to learn that knowledge is only the starting point in effective and compassionate medical care? Care and compassion are foundational to Medicine and should be foundational in our medical training.
Some researchers(3) have suggested that it is the personality make-up of many medical students that contribute to the level of stress and anxiety. While this is a possibility, are there ways this stress can be limited? The culture of Medicine itself, which until recently has failed to address teaching through intellectual intimidation and bullying, adds to the pressure to achieve and the sense of lack of self-worth that accompanies a sense of “failure”. A GP friend and I (with a combined experience of over seventy years) who discussed this recently, were surprised to find we both still had a sense of never being good enough and a nagging fear that we would be found out!!
Does stress need to be a requisite of medical training?
Our patients deserve doctors who are not only expert diagnosticians, but approach patients’ care with compassion and a deep understanding of their physical and psychological needs. Modern parenting understands that children brought up in a loving and caring atmosphere will usually do better in life. In contrast, there has been a belief in Medicine that we will produce better doctors if they are hardened and toughened from day one. To be a medical student or an intern can be an ordeal by fire – only the toughest surviving, and often losing their belief in medicine as a caring profession on the way.
Quite apart from academic pressures and the “pressure cooker” atmosphere in hospitals, students’ personal lives contribute to their stress.
Post-graduate students are in the main self-supporting, compared to undergraduates who may be living at home and financially supported by their parents. They may have been used to being on a good income, and may have mortgages and family. Many go through medical school living in relative poverty. If they are supplementing their income through working, this takes away from study time, putting on extra pressure. They and their families make a significant sacrifice in order for them to study medicine, often struggling financially, and losing quality time together. There is an enormous pressure to pass exams because to re-sit may be financially impossible. None of this encourages them to care for themselves in a way which reduces stress and burnout. If we are to teach that to care for others you first need to be compassionate towards yourself, we are failing by miles.
Medical schools need to take students’ personal lives into account. Having blanket attendance rules may not be completely appropriate. Some students are told at the start of the year that they can take no more than 3 sick days off, or they will have to repeat the year. This makes them feel sick just thinking about it, and puts them under added stress from the start. In a small tutorial group of 8 students, 2 of the men’s wives were expecting babies. They had thought that to have their families while still students would be preferable to absentee fathering when they became interns. With astonishing lack of compassion on the part of their supervisors, they were told they could not take time off to be with their partners when they gave birth. This was at a time when parliament was debating giving 2 months paid paternity leave to all men. The very principles of adult learning we are taught to apply as educators, respecting adults’ ability to self-regulate their learning, are eroded by this kind of behaviour.
In hospitals, medical students often feel right at the bottom of the pecking order, where they feel they are in the way and of little value to the team. This is sometimes verbally expressed to them by hospital staff. One student told me how he dreaded each new rotation, where he had to repeatedly establish his own credibility.
What Do We Want of our Future Doctors?
What characteristics and skills do we want in our future generation of doctors? (the ones who will be treating us when we are old and frail!). If we choose not to treat our students with kindness and compassion, if we do not demonstrate this in our teaching facilities and hospitals, if students continue to reach internship already stressed out, is it really possible to make our professionals not only competent and confident in their medical skills, but the compassionate and caring doctors our patients expect and deserve?
We go into medicine because we care about people and we want to care for them. We want to be caring doctors. We want to be cared for by doctors who care for us as people, not just as patients. Some doctors are caring, but this is in spite of their training, not because of it. If we want our doctors to be caring, it is up to us to systematically care for them as students and as people, every step of the way.