The Vital Signs for Medical Students

Supporting you through medical school

Vacancies: Medical Students

Top of the class at school? Hard-working? Compassionate? Driven? Perfectionist? Earned A*s at A-level and at least one Gold D of E Award?

This exciting opportunity offers the chance to spend 5-6 years with other medical students, all attempting to cram incredible amounts of knowledge whilst negotiating the demands of university life and regular exposure to emotional trauma.
You can expect five years of personal, academic and financial constraints, and look forward to leaving university with no relationship intact. And then a set of applications, which could have you sent pretty much anywhere doing pretty much any job, awaits. But you will get primary access to the bizarre medical complaints of your friends, family, family friends, and family friends’ families.

We are particularly looking for resilient individuals who enjoy black humour and have the ability to put bad experiences in firmly closed boxes. In general you will be expected to work out your own survival strategies and continue heedless to all internal warnings.

Does this sound like the opportunity for you? Get in touch with your A-level results, as well as a comprehensive list of how you have filled every hour of your spare time since primary school, and we’ll put you through a gruelling interview process and get back to you!

Just think, a career in the NHS could be yours!

Why medicine?

The patient thanked me for the small, but appreciable role I had made in their recovery. It made my day.

Student on A&E placement, with assistance, who helped suture a man’s wound after he had accidentally punched his hand through a window
 

Medicine is a fantastic career. It’s inspiring, stimulating, worthwhile, varied and challenging. Few other careers train students to think scientifically while empathising humanely.

We spend many years becoming versatile, skilled, trusted and respected professionals. To witness the spectrum of raw human emotion and have the power to comfort and heal is medicine’s greatest privilege, yet medical careers can be blighted by frustration, stress and unhappiness.

Embarking on a journey as a medical student can be difficult, fraught, pressured and uncertain.

This document tries to address those difficulties should they arise and offer some strategies to ease them. Remember, being a medical student can be great fun and hugely rewarding.

Different from other students & the challenges of medical school

The patient was inconsolable. I tried my hardest, but nothing was going to take away his metastatic pancreatic cancer and weeks-long prognosis.

Med student asked to take blood from patient with dismal prognosis
 

Medical students have many of the same problems as other students. Homesickness, feeling overwhelmed, work crises, difficulty managing finances and time, not looking after oneself, relationship trouble and social isolation are experienced by all students, regardless of degree.

Learning medicine is not always easy. We witness life, death and everything in between. We are often competing, routinely tested, and have to juggle relentless clinical commitments with revision, teaching, a social life, and time to relax, all while upholding professionalism. Our lives often lack routine. Frequent rotation around placements creates a sense of continual change and lack of control. No sooner have we settled into life on one team, we’re back to square one with the next. There is pressure around publications, audits, posters and conferences. We are even examined on how we examine!

The Hidden Curriculum & the Curriculum Gap

Medical students are simultaneously insiders and outsiders to medical culture. They observe the culture that has become invisible to doctors over time.

The Curriculum Gap is the dissociation between what is taught at medical school and how medical students see practice on the ward. For example, we might be taught the protocol for a needlestick injury, only to discover that when it actually happens, no one takes any action. Different teachers may also teach the same topics in contradictory ways – medicine is a highly artistic science!

The Hidden Curriculum is the learning that occurs through medical students’ informal, interpersonal interactions with peers, teachers, and others, and via cultural and structural influences that exist in medical training institutions. This complex web of experiences can lead to:

  • Loss of idealism
  • Hierarchy prominence
  • Ritualised professional identity
  • Emotional suppression
    • i.e. dissociating oneself from normal emotional responses to suffering and death. Suppressing emotion can be pragmatic in the short term, but may cause the erosion of empathy.

Hidden Assessment is a term used for the elusive criteria by which examiners mark, in addition to (or instead of) the stated criteria.

40% of medical students will do something they perceive as “wrong or improper” for fear of poor evaluation or not fitting into the team. (Feudtner, Christakis & Christakis 1994)

The Hidden Curriculum stigmatises mental illness. Medical training often focuses on building stress-resistant individuals rather than to build a wellness-supporting environment.

Role models in medicine may be good (but can also be bad).

Academic stress

I couldn’t focus. Everyone else in the library was hard at work, being ‘hyper-efficient’. I just sat there. ‘There is too much information to learn’, I thought.

Reflecting on the lead-up to finals
 

Medical students are, by definition, high achievers. Many have always been near the top of their class. Some people start to feel they don’t deserve to be there – the Imposter Syndrome.

Assessments and examinations can be relentless. This can make maintaining a healthy work-life balance difficult and give rise to feelings of overload and stress.

E-portfolios are increasingly being used and can exaggerate a sense of relentlessness and constant inspection and assessment. In addition, many believe they force students to work, and especially to reflect, in a certain way – possibly a way that is not natural for some.

Clinical stress

Am I meant to ‘fake it ‘til I make it’?

Thoughts on doing first cannula
 

Starting clinical work means confronting a number of new challenges. Patients will come from all sections and strata of society and are likely to be unwell and anxious – and possibly aggressive, confused, or in an altered mental state. You are confronted with sights that might be shocking, repellent and sometimes disgusting. You may have little preparation for these.

Clinical learning can seem haphazard, arising from random learning events. This can be hard for people used to structure and predictability.

Many people feel they are ‘thrown in at the deep end’ and feel a need to act confidently (when they’re not at all) in order to reassure patients.

Competition and comparison

Medicine is competitive. FY1 jobs are allocated based on your ranking within your year, and therefore your friends and colleagues are also your competitors.

Being surrounded by confident and outgoing people (and medical students in particular may be guilty of making out they are happier than they truly feel) can make people feel incompetent by comparison and can be a source of stress.

Recognising the signs and symptoms that all is not well

It was a struggle. Everyone else was going to the gym, working hard and having fun, whilst I was just miserable.

Reflecting on the hard times
 

Under pressure we often lose our sense of perspective and cannot always rely on subjective feelings. The following list has been compiled to help identify trainees in difficulty (Paice 2006). With a little imagination and stretching it could be applied to medical students.

Doctors may need additional support at any stage of their careers and you may recognise these in established doctors:

Seven key early warning signs

  • The ‘disappearing act’: not answering bleeps; disappearing between clinic and ward; lateness; frequent sick leave.
  • Low work rate: slowness in doing procedures, clerking patients, dictating letters, making decisions; arriving early, leaving late and still not achieving a reasonable workload.
  • ‘Ward rage’: bursts of temper; shouting matches; reacting badly to real or imagined slights.
  • Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.
  • ‘Bypass syndrome’: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.
  • Career problems: difficulty with exams; uncertainty about career choice; disillusionment with medicine.
  • Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.

Mental illness

He was rude, and the patient was visibly upset. I didn’t know how to react.

Reflection on a senior doctor’s replies to a patient’s questions
 

We’re supposed to treat the sick, not be sick ourselves. The medical profession still sometimes sees illness in its own as a weakness. There is a prevailing expectation that doctors and medical students should be infallible, especially with mental health. Like everyone else, medical students can experience mental health issues.

In one survey, 52% of students reported considerable levels of anxiety during their studies. In another survey carried out by StudentBMJ, 30% of medical students revealed they had experienced a mental illness. 15% said they had considered suicide at some point during their studies. Of those who had experienced medical illness, the majority (71%) said they were not well supported. You will almost certainly know someone who is struggling and not getting the help they need.

Prevention – mental hygiene

It is ironic that when we need to do the things that will help deal with a difficult time, it is the most difficult to do those things. Those activities will be individual and personal but can include exercise, music, socialising, spending time with family, hobbies and other activities.

Management guru Stephen R. Covey uses the metaphor of trying to cut a tree down with a saw that gets progressively blunter. “Sharpening the saw means preserving and enhancing the greatest asset you have – you”. So often we continue sawing because we feel we don’t have time to stop and sharpen the saw.

The key is to know when you are functioning less well or feeling overstressed, and to do something to improve the situation. This means monitoring yourself and being able to stop “frantically sawing away with a blunt saw”.

Developing a good degree of self-awareness will help you be a better doctor, and will have benefits in relationships outside work. This awareness may ensure that help is sought early and before any harm is done clinically, professionally or socially.

Students sometimes have specific issues to do with studying that are sources of stress. These include poor study skills, poor time management and procrastination, among others. Some institutions run courses to help with these and there are resources on line. Many people find the simple Pomodoro technique helpful in dealing with interruptions, distractions and procrastination.

Burnout

The surgeon convinced me to keep quiet. It was the wrong thing to do.

Student injured by a surgeon’s needle during a kidney transplant, who was convinced to keep quiet because it “would be a lot of work for everyone”
 

Burnout can occur at any stage when our resources are overwhelmed by the emotional and physical demands made on us. The term was originally coined 40 years ago and has had growing acceptance and recognition as a genuine entity now supported by neuroscience. It is now included as a condition in ICD-10.

Although it is usually the result of a sustained period of exposure to stressors, the time frame can be variable. Factors known to affect doctors and medical students include workload, control, reward and recognition, community support, fairness and values. A sense of autonomy in the role seems to be protective.

The hallmarks of burnout are:

  • Emotional exhaustion – characterized by a feeling of emptiness and emotional blunting
  • Depersonalisation – manifested by a cynical attitude and negativity
  • Reduced personal accomplishment – doubts about personal and professional effectiveness

Early recognition and remediation is key. As is being prepared to seek help – it is a legitimate condition.

Getting help

Help can be found in many places. When our own psychological tactics are not enough to overcome anxiety or stress, many of us will go to family and friends first. Sometimes we need a medic, who understands the issues and challenges we face. Other times, the opposite: a non-medic can offer a fresh perspective and remind us of the world outside medicine.

University tutors can be ideal for helping resolve study-related concerns. Most medical schools have excellent pastoral and counselling services.

On other occasions we might choose someone completely independent from the medical school such as a private counsellor or our own GP (make sure you have one!).

The key point to remember is that there is no rule, no right or wrong, no one-size-fits-all. If your first port of call isn’t helping, find another.

While many university stressors can be managed by talking, venting, and maintaining a balanced and healthy life, we can also find ourselves in situations where more specialist help is required, such as mental health services. This can feel like a big step and is often met by reluctance – not least because of concerns about fitness to practice. In almost every case, a mental health condition does not prevent a student from completing his or her course and continuing a career in medicine.


Sources of help

View as an infographic

  • Friends & family
  • Academic support:
    • Academic tutors
    • Mentors
    • Other doctors you work with
  • Health and pastoral:
    • University pastoral support services
    • Independent counsellors
    • GP
  • Wider support:
    • Other university support services e.g. financial
    • General e.g. Samaritans
    • Dedicated e.g RMBF

Determinants of medical student health

View as an infographic

  • Individual characteristics
    • Age
    • Genetics
    • Past experiences
  • Lifestyle
    • Late nights, early starts
    • Work hard, play hard
    • Sports, music & hobbies
    • Drink, drugs & sex
    • Travel
  • Community & social networks
    • Frequent rotations break networks
    • Romance
    • Bullying & intimidating culture
    • Friends for life
    • Surrounded by high achievers
    • Competition
    • Medical hierarchy
    • Far from home
  • Living & studying conditions
    • Long hours
    • Respect & admiration
    • Job application uncertainty & lack of control
    • Inspiring teachers
    • Student accommodation
    • Exposure to emotional trauma
    • Worthwhile, rewarding & stimulating course
    • Stigma & barriers to accessing health services
    • Future career opportunity & choice
    • Professional responsibility
    • Academic challenge & workload
    • Debt & low income
    • Patient interaction
    • Increasing skill
  • Wider environment & culture
    • Junior doctor contract dispute causes unrest
    • Constantly changing face of medicine brings uncertainty for the future
    • Relative job security
    • Global financial crisis means tougher financial times for students
    • Future doctors remain highly respected members of society

Adapted from Dahlgren and Whitehead, 1992


About the authors

This guide is written by

  • Dr Joseph Butler, FY1, Milton Keynes
  • Dr Claire Greszczuk, ST2 in Public Health, Imperial College
  • Dr Lydia Yarlott, FY2, Medway Maritime Hospital
  • Dr Richard Stevens FRCGP, Associate Director and Coach at Thames Valley Professional Support Unit and RMBF Trustee

We are grateful for the help, comments and encouragement we have received in producing this guide. The quotes used are genuine comments made by medical students and are used with their consent.

Download this guide

The Vital Signs for Medical Students (.pdf)

More guides in this series

The Vital Signs: a guide for doctors seeking help and advice

The Vital Signs in Primary Care

Vital Signs in Anaesthesia

Returning to Medicine: a Vital Signs guide