Alina Syros, MPH, and Alexander Gibstein, BA are first-year medical students at the University of Miami Miller School of Medicine.
Eva Urrechaga, MD is a fourth-year general surgery resident at the University of Miami.
Undergraduate medical education and residency training represent one of the most physically and mentally demanding educational paths. A multitude of hazards potentially affects the wellbeing of future physicians. This article discusses contributing factors to this immense stress and provides recommendations to alleviate them. Though not comprehensive, the article addresses overarching issues and recommends further reading on the topic. With the increasingly common transition of training to an online platform in the wake of the COVID-19 pandemic, depersonalization of the entire education process has increased, making these issues more prescient.
From the time medical students take the Hippocratic oath, their work and personal life blend together. With the potential for 80-hour work weeks, students’ work-life balances are deconstructed, both physically and mentally. During clinical years, students carry their patient experiences home with them, worrying about their welfare and outcomes. This new psychological stress occurs during the never-ending professional trajectory: admissions into medical school, success in courses, evaluations from faculty, and optimizing residency application, all in an increasingly competitive environment. Half of the medical students have experienced burnout during their education . Most notable of the associated hazards are physical and emotional exhaustion. Educators, clinical instructors, and students themselves must first acknowledge these issues, then study and implement the skills to approach the demands of medicine and navigate this field with perspective and a toolbox of coping mechanisms.
Beginning in the preclinical years, medical students pull all-nighters for exam studying, then begin exhausting work weeks during clinical rotations and into residency. During this entire time period, trainees must perform continuous independent learning for board examinations. Hobbies, relationships, and daily self-care routines are often crowded out. Due to time demands, most students experience some degree of sleep deprivation, leading to increased fatigue, compromised patient care, and decreased mental hygiene . Unfortunately, but not surprisingly, many medical trainees experience anxiety and depression .
The emotional burden of medical education is exacerbated by the fact that many students leave their homes and social networks behind in order to achieve their professional goals. This burden worsens during clinical rotations where students spend time with either sick or dying patients (second victim syndrome). Students must juggle patient care and medical knowledge acquisition while contending with the hidden curriculum of medicine. Medical professionals carry an immense amount of emotional weight, which overwhelms many individuals. Mistakes will invariably occur, leading to disappointment but also adverse patient outcomes. To add to the fire, most students contend with massive debt that will impact the next few decades of their lives.
Physical and emotional exhaustion culminate in severe problems such as dematriculation, substance use disorder, and most tragically, suicide. Physicians commit suicide at a rate 2.5 times higher than the general population . To put this into perspective, studies have shown that suicide kills more physicians than diabetes, pulmonary disease, or homicide . Even more frightening, the suicide rate among medical students is three times that of their peers . This emphasizes the hazards of a medical education and the critical importance of recognizing and treating them.
Although physical and emotional burnout occurs commonly during medical education, multiple tools exist to combat the problem. One of the most important factors in alleviating these hazards is awareness and recognition of obstacles and stressors. A better paradigm, one of prevention, involves cultivating wellness in medical students. Wellness can be achieved through a variety of outlets, including exercise, compassion training, and generating a sense of community and place.
Many studies show enhanced ability to cope with stress through physical release and activity. Exercise reliably relieves stress by changing one’s physiology; recent data suggests this process is driven primarily by endocannabinoids. While only 20-30 minutes of aerobic exercise provides a calming effect, authorities recommend 150 minutes of aerobic exercise per week to markedly reduce stress . Although medical students and residents have exceedingly busy schedules, this goal is achievable with use of high-intensity interval training in short bursts (eg. fifteen minutes in the morning and fifteen minutes in the evening). Furthermore, people who engage in consistent aerobic exercise will see a difference in sleep quality, countering the plague of sleep deprivation in the medical community. Any incremental improvement in the quality and quantity of sleep can have positive impacts in medical trainees.
Promoting wellness is not just done through physical exercise, but also through exercising (and resting) the mind. By engaging in meditation and practicing mindfulness, one can continue to enhance overall wellbeing by improving mood and decreasing stress . Specifically, mindfulness-based stress reduction is an evidence-based practice that leads to improvements in anxiety and depression . Relatedly, yoga is a multifaceted outlet to satisfy both physical and mental health. It has been shown that autonomic imbalance is associated with anxiety [6, 7]. While stress causes an imbalance of the autonomic nervous system by decreasing parasympathetic activity, yoga improves overall health by down-regulating the hypothalamic-pituitary-adrenal axis and sympathetic nervous system. Medical students enrolled in an 11-week yoga program had statistically significant increases in their ability to manage energy levels, emotions, behaviors, and self-compassion . Overall, this led to decreased stress as well as improvements in sleep.
Although medical education is uniquely demanding, small changes accumulate benefits much like compound interest. When physicians prioritize self-care, future patient outcomes improve. A positive and empathetic perspective can minimize the negative effects of the demanding path of medical education. By staying grounded and preemptively addressing these challenges, future students can continue to find satisfaction and fulfillment throughout the arduous path. Evidence shows that a positive perspective and attention to wellbeing increase productivity, learning, and cognitive function . Actively practicing a “stress-is-enhancing” mindset generates sharp increases in positive affect, heightens attentional bias towards positive stimuli, and enhances cognitive flexibility. Remarkably, a stress-is-enhancing mindset can improve responses to both challenging and threatening stress . With this, there is a trend toward enhancing professional engagement. Rather than just combating burnout, the goal is to increase a sense of personal accomplishment .
Finally, educators and students must acknowledge that many members of the medical community experience similar distress at some point in their careers. Reliance on a strong social support system is another key alleviating factor for the stresses that medical students face. Medical students with stronger support systems (family, friends, and peers) have a diminished risk for depression . Furthermore, this study found that spending time with loved ones was identified as one of the self-care behaviors that students use as a coping mechanism .
As critical as the outside support system, an on-campus medical “family” allows students to have a healthy community. Like social bonding with loved ones, bonding with classmates is key but has unfortunately been hindered by the remote learning platforms now used by the majority of medical schools due to the global COVID-19 pandemic. Most medical institutions now offer resources to students, trainees, and physicians to counteract burnout and support emotional, spiritual, interpersonal, academic, and community wellbeing. These programs allow members of the medical community to support one another and receive professional support from trained counselors, advisors, and faculty, efforts that help to destigmatize physicians who seek help.
The above hazards of medical education contribute to burnout and even death in providers and patients. We can all play a role in acknowledging these challenges and working to study and implement solutions. This moral imperative requires vigilance from all stakeholders to protect the wellbeing of current and future physicians and patients. Reader: you cannot take care of others before you take care of yourself.
- Mian, Amir. Medical Student and Resident Burnout: A Review of Causes, Effects, and Prevention, Clinmed Journals, clinmedjournals.org/articles/jfmdp/journal-of-family-medicine-and-disease-prevention-jfmdp-4-094.php?jid=jfmdp.
- Patel, Rikinkumar S, et al. “A Review on Strategies to Manage Physician Burnout.” Cureus, Cureus, 3 June 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6682395/.
- Jackson, Erica M. “STRESS RELIEF: The Role of Exercise in Stress Management: ACSM's Health & Fitness Journal.” LWW, journals.lww.com/acsm-healthfitness/fulltext/2013/05000/stress_relief__the_role_of_exercise_in_stress.6.aspx
- W, Chmielewski J;Łoś K;Łuczyński. “Mindfulness in Healthcare Professionals and Medical Education.” International Journal of Occupational Medicine and Environmental Health, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/33223537/.
- C;, Behan. “The Benefits of Meditation and Mindfulness Practices during Times of Crisis Such as COVID-19.” Irish Journal of Psychological Medicine, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/32406348/.
- Cocchiara, Rosario Andrea, et al. “The Use of Yoga to Manage Stress and Burnout in Healthcare Workers: A Systematic Review.” Journal of Clinical Medicine, MDPI, 26 Feb. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6462946/.
- Fares, Jawad, and Youssef Fares. “The Role of Yoga in Relieving Medical Student Anxiety and Stress.” North American Journal of Medical Sciences, Medknow Publications & Media Pvt Ltd, Apr. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4866480/.
- Tala, Alvaro. “Positive Medical Education: Are We Focusing on the Right Things While Teaching?” MedEdPublish, www.mededpublish.org/manuscripts/1867.
- Crum, Alia J., et al. “The Role of Stress Mindset in Shaping Cognitive, Emotional, and Physiological Responses to Challenging and Threatening Stress.” Anxiety, Stress, & Coping, vol. 30, no. 4, 2017, pp. 379–395., doi:10.1080/10615806.2016.1275585.
- Gengoux, Grace W., and Laura Weiss Roberts. “Enhancing Wellness and Engagement Among Healthcare Professionals.” Academic Psychiatry, vol. 42, no. 1, 2018, pp. 1–4., doi:10.1007/s40596-017-0875-1.
- Ayala, Erin E., et al. “What Do Medical Students Do for Self-Care? A Student-Centered Approach to Well-Being.” Teaching and Learning in Medicine, vol. 29, no. 3, 2017, pp. 237–246., doi:10.1080/10401334.2016.1271334.