Nichole Bernier
Like drinking from a fire hose. That’s the longstanding analogy used to describe the deluge of information aimed at medical school students studying to become doctors.
Medical school has long been synonymous with anxiety and achievement, intense training, and acute pressure. Certainly, graduate work by nature involves hard work and stress. And throughout all of higher education, mental wellness has been a growing issue for years.
“The stress level of graduate school has definitely increased over the last 10 years,” said Paul Barreira, MD, Associate Professor of Psychiatry at Harvard Medical School and Director of the Graduate Student Mental Health Initiative. “If you look at CDC data for rates of depression and anxiety among 22 to 26-year-olds, the grad school population is three to four times higher.”
But for those on the medical track, studying involves mastery of a knowledge base with direct life-and-death consequences. “The question is, ‘How much more does medical school experience contribute on top of that existing student anxiety?’” Barreira asks.
To call that the million-dollar question is only a bit of an exaggeration, since the vast majority of medical school graduates walk away with more than $200,000 in debt—one of a number of factors that make medical school infamously stressful.
Medicine and mental health: The struggle is real
Medical students experience higher rates of anxiety, emotional stress, depression, and suicidal ideation than the average person. The mental health of entering medical students, which has been demonstrated to be similar to that of the general population upon entry into medical school, declines significantly in the next two years, according to 2014 research published in the Journal of the Association of American Medical Colleges. Medical students have also been associated with higher rates of substance abuse; in 2016, the Mayo Clinic surveyed 4,000 medical students, and found that nearly one in three met the criteria for alcohol dependence or alcohol use disorder.
“Twenty years ago, people didn’t really talk about wellness at medical school. It was just a grind that we have to go through to get where we want to get,” said Anne Larkin, Senior Associate Dean and Vice Provost for Educational Affairs at the University of Massachusetts Chan Medical School. In recent years, she said, a few factors have amplified the conversation. First, there’s the increasing importance of the Step One exams, the first significant stress bottleneck in medical school, an eight-hour test typically taken at the end of the second year. And second, the growing student appreciation of the impact of anxiety. Simply said, mental health is talked about much more. “Students are much more open now to being able to recognize when they are letting the stress of medical school impact their lives. They don’t want to feel horrible and depressed all the time. So they actively seek out help much more than students ever did 20 years ago.”
There are also generational and social changes that come into play, including the downstream effects of so-called helicopter and snowplow parenting. “For young people who grew up with parents more involved than previous generations, and help they could rely on through difficult periods, that has an impact. The ability to self-soothe has changed, and we’re seeing a lot more young people in distress,” said David Henderson, Psychiatrist-in-Chief at Boston Medical Center (BMC) and Chair of the Department of Psychiatry at Boston University. “You also have the issues in the media, and police violence, and then you throw in the health issues of the pandemic, which just made everything crazy. So we’re seeing a lot more young people, medical students in particular, in emotional distress.”
According to basic tenets of emotional intelligence, if stress isn’t well regulated, it’s difficult to learn; an anxious brain is less available to process new information. And a hallmark of medical school is the sheer volume of information that needs to be absorbed. The colossal amount of information is particularly daunting for students who might not excel in rote learning.
“The amount of stress I felt in those first years came because I’m someone who struggles with didactic classes and standardized testing,” said Fiona Dore, a 2022 graduate of UMass Chan Medical School, now in her surgery residency. “On top of that, I’d taken three years off after undergraduate school. And though that made me feel incredibly strong clinically, I worried that I’d forgotten how to be in the classroom, how to study, how to take tests. I’m someone who used to play rugby and that physical activity helped me deal with tension, but I didn’t have a team anymore as an outlet. It all caused me to spiral a bit, frankly.”
The fast pace required to synthesize so many diseases and so many drugs contributes to med school’s reputation as “a pressure cooker,” said Rachel Cary, who just finished her first year at Rutgers Robert Wood Johnson Medical School. “Everyone’s a different learner. I work hard, and I try to know everything to the best of my ability. I see some of my classmates getting really weighed down by these random extraneous details. But I’m not a perfectionist. They told us in orientation that you will always feel like you could study more for an exam, which is true. I think by nature medical students are a self-selecting population of detail-oriented people, which makes that truth hard to swallow.”
For some medical students, the pressure to stack up competitively against peers—to stand out favorably and be assured you aren’t lagging toward the back of the pack—is a source of pressure that, for some, is even more potent than their own perfectionism. And if no one else seems to be struggling in the same way, the pressure is compounded by a sense of isolation.
“In the first two years, everyone else seemed to take the studying in stride, be figuring out what they wanted to specialize in, and making the connections for work experience,” said Thomas*, a medical student in Philadelphia. “I felt like I was missing out on all the achievement benchmarks. It was like I wasn’t just struggling to excel in classes—I was failing to figure out what specialty I wanted to go for. It was like adulting FOMO [fear of missing out].” Thomas thought about taking advantage of peer counseling, but worried about appearing unprofessional. “These people could be peers and colleagues in my field someday. I didn’t want to take the chance they’d look back with the impression that I didn’t have the stuff to handle it,” he said. “And frankly, I was too tired to deal with dealing with it.”
Resisting a rest
Research has long shown that sleep plays an important role in learning and memory, and that lack of quality sleep can worsen the symptoms of many mental health issues. Yet historically, medical students wear sleep deprivation as a badge of honor. “When students humble-brag about how little they slept, it just reinforces and justifies the culture. The old-school doctors have an attitude of, ‘I went through it, therefore, you should go through it. This is what it takes to see if you’re a good doctor,’” said Thomas. “But I actually think the tide is starting to turn, and the ones who really get bragging rights are the students who have decent sleep and quality of life, and still get good grades and reviews.”
Sleep, many students are beginning to realize, is actually a non-negotiable part of a successful, sustainable life balance. “Sleep is something I really prioritize because I do feel the brain effects of fatigue. I think that over time, the effects of not getting a lot of sleep are prominent,” said Rachel, who in addition to being a medical student at Rutgers, is a Second Lieutenant in the National Guard, following four years of ROTC at Cornell University. She knows prioritizing sleep is going to be a challenge when she reaches her residency. “I know there are logistical constraints, but it’s so important. There are lives at stake. If you’re functioning off no hours of sleep, you’re not in a mindset to make hard decisions about patient care.”
Exhaustion is an omnipresent concern among medical students, who can’t help but see the storm clouds of residency on the horizon. Current regulations set by the Accreditation Council for Graduate Medical Education (ACGME) cap residents’ working hours at 80 hours per week (averaged over four weeks), and daily shifts at 24 hours. To many people that’s an unthinkable schedule, but to residents, it marks an improvement over the way things used to be. Current limits were imposed nationally in 2003 after the death of 18-year-old Libby Zion, who died after a mistake made under the care of overworked residents and interns.
And while medical professionals applaud the restrictions—for the sake of both patients and residents—there is a tutorial reason so much experience is squeezed into so few hours. It’s to increase new doctors’ exposure to the greatest range of experiences, under supervision—before they are in a position where the buck stops with them, as attending physicians.
“There needed to be restrictions on the hours, which is great. But that also reduces students’ exposure. The consequence is that when they finish their training, they’re not going to be as fully independent as doctors were 10, 20, 30 years ago,” said Henderson. “We’re finding that in our newer faculty. And we have to provide supervision for them, whereas before, we would never have to do that. Now, they will have had a better learning experience and come out whole, which is well worth it. It might take them longer to become better doctors, but they will be better in the long run.”
Hard work, surprisingly little pay
One thing rarely considered in the collection of medical student anxieties is money. Yet a staggering 89 percent of graduates walk away with an average of $216,000 in debt (compared to $160,000 for law school grads). And for the first years following graduation, their salary isn’t much more than the baristas who caffeinate them. This is because most residents’ salaries are subsidized by Medicare, and the positions are treated like an extended on-the-job training, a bumpy section of road en route to long-term career benefits.
But rising doctors who are struggling with rent and other responsibilities might not see it that way. “We make about $13 an hour, which is difficult to support housing for residents in or near cities,” said James, who has the additional responsibility of supporting a young family. “The national housing definition of ‘cost-burdened’ as a hardship is when you spend more than 30 percent of your paycheck on housing. I happen to know this because I screen my patients for that, because it’s a marker of stress from housing instability. By that very definition, many of the residents caring for them meet that criteria.” He recalls talking with colleague who was coming home from a 30-hour shift at the hospital, and went through the McDonald’s drive-thru. “He saw a Help Wanted sign offering $15 per hour, and he just started breaking down in the parking lot.”
Some people will say residents are there to be trained, and the early years in medicine are about paying your dues. But depending on the city, James said, those dues could be extraordinarily more taxing, and the workload heavier.
“In New York, the doctors’ unions aren’t as strong as other medical unions. So a lot of responsibilities that aren’t really within the scope of being a doctor, like blood draws and patient transportation, land on your lap because there’s no one else there to do it.” The year James was looking into where to match, two residents in New York committed suicide, one of them in the specialty James had chosen. (Suicide is the second leading cause of death among residents, and the first among male residents.) James said he recalls that transition year between medical school and residency as the first time mental health considerations weighed among factors affecting his career. And it influenced his choice of locations where he did, and didn’t, want to practice medicine.
“When we think about the social determinants of health, we’re not just thinking about physical health or mental health. We’re thinking about financial health, and savings, and retirement savings, and that differs across employees and races. There’s a lot of underpinnings there,” said Lisa Kelly-Croswell, Senior Vice President and Chief Human Resources Officer at BMC. The hospital has resilience clinicians on staff, people who are dedicated to supporting employees who might be struggling, and one of their modes of support is writing a “prescription” to use the hospital’s food pantry. The benefit was started for its patient population during the pandemic, but became available to its employees too, including residents. “There’s a broader definition of diversity in terms of social economic status, and our resilience clinicians do counseling related to housing as well, and economic mobility. There’s a lot of data about the things that play into health and wellbeing, so we pulled it into a book for employees called the Thrive Guide.”
Prioritizing wellness
Like the Serenity Prayer, the factors that impact medical students’ physical and mental wellness might be reduced to a few key categories: the things they can change and the things they can’t, and the courage to seek wellness avenues available.
“Counseling services are definitely more in demand. It’s like, ‘What are you doing to help me and my fellow residents with mental health support?’” said BMC’s Lisa Kelly-Croswell. “It’s almost like it went from a stigma—no one in medicine wanted to talk about it—to, You’re not talking about it enough. So now we have a wide range of specialized programs that are targeted at behavioral mental health.”
Even free counseling can seem like a luxury when it feels like there’s never enough hours in the day. But students like Fiona at UMass found therapy made all the difference. She took notice of the free counseling services advertised around the university, and at the end of her first year, decided to get ahead of the anxiety with a better mindset and habits. “I really needed to talk with someone else because I wasn’t finding a good way to deal with the stress on my own. I realized my biggest stress was coming from imposter syndrome, and the majority of pressure was coming from my own perfectionism. Having that insight and sounding board from someone else was invaluable.”
Stigma, however, remains a consideration, and some state licensure exams include questions about applicants’ psychiatric history. “There’s still a lot of stigmatizing language in the board certifications, and the language changes state to state,” said James. “If you are under the care of a mental health provider, that can actually limit your ability to practice medicine in some states, and it leads to a lot of people not seeking out this kind of mental health care.”
U.S. courts have decided that the wording of some of these questions violate the Americans with Disabilities Act. A 2018 article published in The Journal of the American Academy of Psychiatry and the Law examined application forms, state by state, and found that 32 licensing bodies indeed asked questions well outside the acceptable limits. “Our original investigation of these questions found that the majority [of medical boards] still ask questions that are unlikely to meet ADA standards,” the study concluded. “The judicial and Department of Justice developments, however, may compel them to abandon these questions. If not, legal action will enforce ADA compliance. This change will significantly benefit applicants who need psychiatric treatment.”
One-on-one counseling aside, other avenues to prioritizing mental health are expanding on medical school campuses. In 2019, the UMass Chan Medical School created a new Vice Provost position to focus on increased wellness at an elevated level within the community.
“Caregiver burnout and resilience are critical issues being addressed by many health systems,” wrote Dr. Flotte, provost and dean of the School of Medicine, of the position, “and we endeavor to equip our graduates with the tools they will need to lead successful, fulfilling careers.”
Like BMC, the UMMS also offers a food bank, as well as an emergency fund for students in acute financial need. “We use everything at our disposal to make sure that students are supported, not only with counseling services, but with all of the other wellness programming that we have,” said Larkin. “We have very, very few students who end up leaving—our attrition rate is very low—and a lot of students who end up taking extra time to get through the degree. And that in and of itself is very important. This is about having competency to care for students, it’s not about getting through school in four years. So, if a student needs a little extra time, we are totally fine with extending their time in medical school.”
In Larkin’s own classes, she likes to incorporate an atmosphere of openness about wellness by opening each class with a check-in for students—going around the room and sharing a high and a low from the week.
“What happened that was really good this week? And what happened that was really horrible? Around test times, what routinely happens is that students are consumed with fear, are anxious because they didn’t understand a particular lecture, or are angry at the rigidity of a tough professor. During those times, I really try to talk to them about the importance of taking care of themselves and recognizing good choices, like taking time off over the weekend to do healthy things. I don’t think students necessarily come away feeling better. But I do think the opportunity to articulate what’s happening in that moment is really important.”
That day-to-day reflection is equally important for residents, who often find themselves inundated with tasks that have little to do with patient care and seem to in fact get in its way.
Young doctors may have entered medicine with thoughts of care and empathy, but end up spending little time with patients—instead in back rooms inputting data to manage care. Residents in their first two years of training spent almost half their working hours at computers, according to recent studies at Stanford University and Columbia University, and less than 10 percent of their day with patients. “I think the reality of the healthcare system really puts a lot of doctors in moral distress,” said James. “If you think about the type of people who are called to this field, these are people who are then met with the expectations of a healthcare system that doesn’t align with the kind of human care they want to provide. That’s where the distress occurs, in all careers, all settings. That discrepancy between expectations and reality.”
When you only have 15 minutes to spend with each patient, then 20 minutes of notes to record afterward, you might struggle to connect with the reason you went into medicine in the first place. “Because once the joy is gone, it’s really, really hard to get back,” said Larkin. “And then on top of that, you can imagine that when you’re immersed in sickness and trauma and death, it’s easy to turn off. Because that’s the easiest way of handling it.”
Other ways of handling a lack of satisfaction, or moral distress, can lead to unhealthy sources of relief, including reliance on substances. Medical students see, hear, or experience firsthand the role of drugs and alcohol in dealing with being anxious, overwhelmed, or depressed.
“Whether you’re in medical school, any school, or no school, age 18 to 28 is a very challenging time for both substance use and mental health,” said Amelia Arria, Associate Chair of the Department of Behavioral and Community Health at the University of Maryland School of Public Health. As Director of the Center on Young Adult Health and Development, her research focuses on the impact of substance use, particularly excessive drinking and marijuana use, on academic achievement. Through her project, the Maryland Collaborative, she provides assistance and intervention strategies for a network of colleges across the state. She was recently approached by a group of pre-med undergrads who are part of an association of prospective medical students.
“They wanted to know more about what medical school students should know about substance use and behavioral health and arranged a webinar for me to give the group. I thought this was insightful, because a lot of people that age might have friends and acquaintances they are concerned about, even if they’re not likely to self-recognize at that age,” Amelia said. “How do drug problems develop? What are the precursors? What are the early warning signs? What can you do to engage someone who might be having an issue, and coax them into a process of self-reflection? I think it was their desire to be clinicians, and they know they’ll probably be dealing with this in their classmates and practices and colleagues. They’re going into a helping profession, and to their tremendous credit, they wanted to know, proactively.”
At the end of the day, there are things a medical student can do to prepare, to learn as much as possible in advance. This makes a “doctor-to-be” best equipped for all the things you cannot prepare for or control in the heat of the moment, under circumstances that are not ideal. But you work under them to the best of your ability and learn to be resilient. That learning and preparation process might be experienced as very stressful. Which is part of the process. For today’s medical students, the key is not to pretend it isn’t hard.
“I do think an important part of being a physician, and a medical student by extension, is being resilient in the face of bad things happening. In my own career, I’ve seen a lot of bad things happen to patients. If a mistake has happened, we have to be able to move on from that to effectively take care of other patients. So I think that notion of resilience, and being able to believe in our own self-worth, is a really important personality trait for medical students to have,” said Larkin. “It’s an important part of learning to get through the hazing, if you want to call it that, and that the dealing with stress is actually important to foster people who are emotionally resilient. So they are able to deal with the stressors, and the emotional responsibility that comes with being a doctor.”
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*Real names have not been used for students and residents who asked not to be identified.
