The Medical School Admissions Process is Long and Stressful. How are you Coping?

Earlier this month, Dr. Anne Thorndike, a physician in internal medicine at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School, wrote that physician burnout starts with the medical school admissions process, which takes almost twice the length of time as other graduate admissions processes. In an opinion piece for STAT, an online health, medicine, and scientific discovery publication, she called for a shortened admissions timeline for medical school applicants and says the current process is time-consuming, expensive, highly-competitive, and intensely stressful. 

Referencing a plethora of studies, she goes on to describe the stress that medical school applicants face prior to even beginning their professional journey. A 2012 study showed higher emotional exhaustion, a symptom of burnout, in pre-medical students compared to non-premedical students. In another study, 33 Black and Hispanic medical students interviewed from across the country described medical school admissions as “very negative” because it was overwhelming and required an “extensive investment of time.” A 2020 online survey found that 73 percent of 556 medical school applicants had depression or anxiety symptoms, with half reporting uncertainty related to the application timeline.

So, how can you manage effectively this daunting process as an applicant? We encourage you to explore and refine various coping mechanisms—exercise, mindfulness, talk therapy, and/or outside adventure activities—that work for you. Taking this step will be just as critical to any application prep course you will take. And you will certainly carry with you these practices into your future career in medicine. 

A recent article in the Washington Post covers the physical effects of stress and the practices that may mitigate its impact. Ahmed Tawakol, Director of Nuclear Cardiology at the Massachusetts General Hospital and Harvard Medical School, recommends regular exercise, and high-quality sleep which “...can reduce stress activity in the brain, systemic inflammation, and your risk of developing cardiovascular disease.” Others interviewed point to the power of deep-breathing exercises, muscle relaxation techniques, meditation, and/or yoga, which can actually decrease your body’s reactivity to stress.

As you prepare for medical school, consider carefully how your habits may help or hinder you. Then you can work to integrate stress-reducing practices and positive choices into your daily life.  

Related Blogs:

Medical Students Offer Recommendations to Improve Medical Schools’ Ability to Promote Student Wellbeing

Pre-Med Students Face Stress as Clinical Experiences Become Harder to Find

Narrative Medicine Helps Physicians Gain Empathy, Make Connections, and Accept Difficult Experiences

Narrative Medicine Helps Physicians Gain Empathy, Make Connections, and Accept Difficult Experiences

Creative writing may not be the first course that comes to mind when you think about a pre-med or medical school curriculum. But, writing—along with other arts and humanities courses—can play a vital role in preparing medical students for life as a physician. 

Rita Charon, along with a multidisciplinary group of scholars, founded the discipline of narrative medicine in 2003, in response to the increasingly bureaucratic direction of medical care. Narrative medicine’s goal is to recenter physicians on the humanity of their patients by providing tools to allow physicians to contextualize patients outside of the hospital setting and uncover ways to connect by considering a patient’s pain, stories, life, and loved ones. Charon describes narrative medicine as a “...commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.” 

The benefits of incorporating narrative medicine, or the study of arts and humanities into the medical curriculum are clear. In 2010, Columbia Medical Students were required to take a half-semester arts and humanities course in narrative medicine, and these students were then interviewed in focus groups about the experience. The findings, published in the Journal of Academic Medicine in 2014, were summarized: “Students’ comments articulated the known features of narrative medicine—attention, representation, and affiliation—and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure.” 

In addition to promoting empathy and connection, Pulitzer Prize-winning journalist Michael Vitez, Director of Narrative Medicine at Temple University’s School of Medicine, spoke to the value that writing can provide in helping students work through complex and painful experiences. He described a medical student who wrote a poem after a difficult day in her psychiatric rotation. “It helped her process her emotions and turn a really bad day into something valuable,” he said. 

Narrative medicine can also bolster physicians who are struggling with symptoms of burnout. “No one was talking about clinician burnout at that time. But, as narrative medicine programs began to spread across the country, some physicians trained in its principles began to see how it can protect clinicians from feeling a sense of depersonalization and other symptoms of burnout,” Dr. Charon told Neurology Today. In the same article, Sneha Mantri, MD, MS, and Assistant Professor of Neurology at Duke University School of Medicine, described how her struggle caring for critically ill patients during residency led her to seek an MS in Narrative Medicine. In her view, the degree gave her the tools to return to medical practice and deal with the “burnout-inducing frustration of treating chronically ill patients with difficult-to-manage symptoms” and replace it with empathy for the patient’s perspective and the reminder “that knowing medical facts is just one part of caring for a patient.”

If you are a premedical or medical student with an interest in the arts and humanities, pursue it! It will likely play an invaluable role in preparing you to analyze, contextualize, and show up for patients with empathy and understanding. And as you prepare your applications for medical school, residency, or fellowship, be sure to highlight the skills that you have gained through previous humanities coursework and experiences, and the perspectives you have gained. 

Examples of narrative medical texts here: 

“How to Tell a Mother Her Child Is Dead,” Naomi Rosenberg, MD, New York Times

“What We Talk About When We Talk About the Code,” Lilli Schussler, JAMA Cardiology

Related blogs:

Covid Crisis Brings Attention to the Need for Humanities in Medical School Curriculum

Legal Community Proposes Law Schools Incorporate Stress Management into their Curriculums

The first year of law school is a time of significant stress. Last week, Law.com reported on a post made in the r/lawschool sub-reddit by a user who described their experience as a first semester law student. The poster noted that because of stress, they suffered from unintentional weight loss, vision changes, headaches, acid reflux, and newly acquired tremors after the first semester. The thread quickly garnered many replies. While some expressed sympathy and concern, over 70 comments by other law school students described similar stress-induced physical ailments including weight gain, low energy, poor nutrition, constant fatigue, eczema, and anxiety.

Charles N. Todd, Dean of Students for the University of Chicago Law School, speaking to Law.com about the thread, described the first year of law school as “one of the steepest learning curves.” However, he continued on to say that, “I tell students all the time that it’s not going to get any easier. The demands of your time will not go away once you leave school. In fact, you’re going to have more things with family responsibilities, life, and work, so we really want them to learn how to develop healthy habits in law school so those will sustain them throughout their career.” 

The initial reddit poster followed up to share their decision to visit a doctor and noted their intention to create healthier habits the next semester. Dean Todd recommended taking small breaks throughout the day to incorporate healthy activity. “It doesn’t have to be this big interruption in your day, it could be a 10-minute break to color or to have some healthy food or do some stretches because you’ve been sitting a long time,” he said. 

Others in the legal community suggest that law schools should take more responsibility for student health. Janet Thomas Jackson, a law professor at Washburn University School of Law, calls for law schools to take an active role in promoting wellbeing and mental health within their student populations. In an article written for Bloomberg Law, she noted how frequently law students and legal professionals are impacted by depression. According to the Dave Nee Foundation, “Depression among law students is 8-9% prior to matriculation, 27% after one semester, 34% after 2 semesters, and 40% after 3 years.” Further, just as Dean Todd noted, the foundation’s data shows that stress and its associated effects do not necessarily recede after law school. Rather, lawyers are the most frequently depressed professional group within the U.S., and lawyers suffer depression at a rate 3.6 times that of non-lawyers. 

Jackson suggests that the legal community not accept this as inevitable; she proposes that law schools integrate discussions of physical and mental health throughout student’s tenure, starting at orientation. And prior to starting classes, law schools should educate students and their families on the “expectations and predictable stressors” of law school, resources for seeking help, and insight into healthy habits and effective stress management. She notes that students of color should receive additional support, including safe spaces and communities where they can share their experiences and feel a sense of belonging. Finally, Jackson recommends that self-care practices and physical and mental health be integrated into the curriculum. “In other words, law schools should play a primary role in normalizing discussions and actions around the mental and physical care of its students,” she said.  

Related Blogs: Law School Students Still Not Receiving Adequate Mental Health Support

Pre-Med Students Face Stress as Clinical Experiences Become Harder to Find

The stress of applying to medical school has always been significant. A Kaplan survey of 400 pre-med students, taken in early 2020, found that 37 percent “seriously considered” changing their plans for a medical career due to stress. Just over a quarter (26 percent) said that they experience stress “pretty much always,” and another 45 percent said “frequently.” Over half (57 percent) said that self-medicating with alcohol or drugs is common for them as they work to grapple with the demands. 

And experts say that the pandemic is only increasing these stressors. “I don’t think we can underestimate how COVID-19 is impacting the mental health of the entire population, never mind students who are preparing to apply to medical school,” said Carol A. Terregino, MD, and the Senior Associate Dean for Education and Academic Affairs at Rutgers Robert Wood Johnson Medical School. “There are fewer opportunities to engage in the humanistic activities, to shadow and volunteer to demonstrate one’s passion for medicine because of the pandemic and more time to focus on metrics and study for the MCAT (Medical College Admission Test). And that isn’t necessarily a good thing.”

This sentiment was echoed in a Yale News interview with pre-medical students. Students spoke of their experiences with the closures and re-openings of “wet labs,” with seniors claiming to be overlooked in favor of younger students who could commit to multiple years of research. Students also reported difficulties finding opportunities to shadow doctors, or volunteer at local hospitals. “If you’re trying to volunteer at the New Haven Hospital or the HAVEN Free Clinic, it’s hard to do so because of COVID restrictions,” Courtney Li, pre-med class of 2024, explained. “There was definitely a time period where they weren’t accepting volunteers.”

In response, Dr. Terregino provides a calming perspective to applicants. “Medicine is stressful. Getting ready for medical school is stressful. But I’d offer that one can temper their stress knowing it’s more than just grades and MCAT scores that admissions committees are looking for, and there is a full understanding of the limitations on experiences placed by the pandemic. Personal development also counts.”

So, what should pre-medical students do? 

As limitations exist, so do opportunities. Showcase your adaptability by making the best of challenging times. We recommend considering the following experiences if you are not able to find in-person shadowing or clinical roles.

• Contact current or retired physicians in your network, or access your university’s alumni network, to interview them and learn more about their specialties, experience, and advice for aspiring physicians.

• Leverage your university network, including current and retired professors and alumni, to look for in-person or virtual research opportunities.

• Pursue virtual shadowing opportunities.

• Engage in volunteer work to demonstrate your commitment to serving others and working with diverse populations.

• Consider study abroad and summer programs that provide shadowing or clinical experiences.

Continuing to pursue learning and development opportunities, even in less-than-ideal circumstances, will still prompt meaningful evolutions in your perspective and will help convince the admission committee of your commitment to the study of medicine.  

Positive Learning Environments and Regular Feedback Result in Lower Levels of Depression Among Medical Residents

The impending physician shortage, coupled with the problem of physician burnout, has led to important discourse over the treatment and training of future physicians. Medical training programs are looking to improve wellbeing among medical students and residents through various avenues including reduced tuition, investments in wellbeing programs, and mental health resources. But are they doing enough? A recent op-ed published by the AAMC, by Srijan Sen, MD, PHD, suggests medical residency programs need systemic changes on top of the current efforts focused on building individuals’ resilience and wellbeing.  

Dr. Sen, along with collaborator Connie Guille, MD, analyzed data collected via the Intern Health Study to highlight the negative impacts of residency on interns’ health and propose data-based solutions for a healthier environment. The Intern Health Study, a longitudinal study that includes responses from more than 20,000 medical trainees, shows that the rate of depression increases “Five-fold within the first few months of residency” and remains higher throughout training with “about one out of four residents screening positive for depression at any given time during residency.” Dr. Sen goes on to note that beyond the questionnaire responses describing stress, there are physical indicators as well. “Telomeres, a cellular marker of aging, shorten five times as much during internship as during a typical year of life…” And, what’s more, a compromised physician is more likely to make medical errors and to provide lower-quality care to patients.

Dr. Sen references a 2019 study that reviewed over 50 internal medicine programs using residents’ feedback and information collected in national databases. The findings show variation in the depression rates between programs; more importantly, the variation showed consistency with some programs regularly registering high and others low. When Dr. Sen compared the programs, the findings showed that while the volume of hours, type of work (administrative versus patient care), and work-family conflict all impact the rates of depression, another critical component differentiating the high and low depression programs was the type of learning environment.  “A key factor among low-depression programs was residents reporting that their inpatient rotations were a positive learning experience. Another was receiving timely and appropriate feedback from faculty. Both of these factors indicate that a focus on education, and specifically directed education from faculty, makes a major difference.”

The findings are particularly pertinent given an article published last week in the NY Times by Perri Klass, MD. The article, which is in response to a recently published JAMA Pediatrics article (Walking on Eggshells With Trainees in the Clinical Learning Environment), speaks to the difficulties that many faculty members feel providing feedback to trainees. While the medical community is working hard to end the harassment and bullying of residents that typified many interns’ experiences historically, some feel the pendulum has swung too far and that they are unable to provide criticism, tough feedback, or make interns feel discomfort without retribution or poor evaluations.

Dr. Klass quotes Dr. Janet R. Serwint, professor emerita of pediatrics at Johns Hopkins, who says, “When I look back at my career and my life and how important some of that feedback was, and it was hard for the giver to give to me, I’m sure, but they did it in a respectful way… I worry that the balance is swinging in such a way that it’s all about, oh, you are wonderful.” During her time as the vice chairwoman of education and the residency program director, she said that some faculty would mention problem residents, but often they had not broached the issues directly with them. “It’s the discomfort, or the worry of retaliation and evaluation.” Furthermore, Dr. Melanie Gold, lead author of the JAMA article, goes on to say that she has also struggled with interns unwilling to experience discomfort during medical training. Her examples include a student who complained to a course director about transgender health’s inclusion in the curriculum and others who, due to religious objection, were unwilling to even observe a patient consultation. Dr. Gold went on to say that many faculty members feel ill equipped to engage in the resulting difficult conversations.

While these articles are written from differing perspectives, they describe a shared desire by residents and faculty for meaningful feedback and instruction. Given that discomfort is an inherent condition of medical training, the data would suggest that some programs are able to navigate this discomfort better than others. Dr. Sen says that “Faculty members also need to learn trainees’ specific strengths and weaknesses and then provide thoughtful, specific feedback that truly supports their learning. Programs ought to encourage faculty to invest the time necessary to support learners and reward them for doing so.”

Following this discourse is important for future medical students and interns who are applying to medical school or residency programs. Applicants can distinguish themselves by showing that they understand the role that feedback—positive and negative—plays in preparing for a medical career. Demonstrate this understanding by using interviews and essays to describe situations where negative feedback spurred improvement, learning, and connection with others despite discomfort. Just as faculty must be willing to consider how best to promote learning, trainees must demonstrate an openness to the criticism and discomfort necessary and inevitable in the preparation for a medical career.

Further, when evaluating programs, applicants should take into consideration the learning environment. Observe the interactions between faculty and interns, and question current and former program participants about how and at what frequency feedback is offered. It may also be worthwhile to engage administrators or admissions representatives on how the program structure trains and supports faculty in providing feedback, facilitating difficult conversations, and creating a positive learning environment. While more visible wellbeing investments can be compelling, it is critical to look closely at the structural elements of a program that data shows matter to the lives of residents: hours worked, tasks performed, work-life balance, and the learning environment.

UNC Kenan Flagler Provides Alumni with Strategies to Avoid Post-MBA Burnout

Earlier this month, the Financial Times published an article on workplace wellbeing and burnout. The article included the results of a reader survey on how employers support employees’ mental health. Two-thirds said that their work had a somewhat to extremely negative effect on their health. Forty-four percent said that they did not think their organization took mental health seriously and half said that they either didn’t know where at work to go or had nowhere to go if they needed support. While the survey respondents were self-selecting, the results show a significant issue with employer support of mental health, including stress, burnout, anxiety, and depression.

 The article warns us that the problem runs across sectors, but may be particularly relevant to graduates of law, business, and medical schools; the authors note that “Fields such as law, finance, and consulting seem particularly prone to intense, demanding workplace cultures, but the issue affects people in all sectors. One doctor dies by suicide every day in the US.” Similarly, Blind, an anonymous social app for tech employees, surveyed its users in May 2018 and 57 percent of the 11, 487 respondents said that they were burned out. Only five of the 30 tech companies represented had an employee burnout rate below 50 percent, and 16 of the companies had a burnout rate higher than the average (57 percent). Later surveys, also by Blind, found that 52 percent of tech workers responded that they do not have a “healthy work environment” and that 39 percent of tech workers said they were depressed.

The FT survey also found that reasons behind burnout clustered into four themes: overwork, cultural stigma, pressure from the top, and fear of being penalized. The article suggested that many experts point to an epidemic of overwork resulting from the common expectation that employees be available and responsive to client needs 24/7. “In his book, Dying for a Paycheck, Stanford professor Jeffrey Pfeffer posits that this crisis is getting worse over time, amid stagnating wage growth and an increasing reliance on the gig economy. ‘We are on a path that is completely unsustainable,’ Pfeffer says. ‘The CDC [Centers for Disease Control] tells you that chronic illness is 86 percent of the $2.7tn US healthcare spend. Many come from stress-related behaviours. If you’re going to solve the healthcare cost crisis, a piece of that solution has to go through the workplace.’”

In an acknowledgment of the intense positions that many post-MBA graduates find themselves in, Robert Goldberg, an affiliate UNC Kenan-Flagler faculty member, recently led an interactive session for UNC alumni to build awareness of and strategies for preventing burnout.

First, Goldberg encouraged alumni to explore various “energy zones” which, described below, he adapted from The Power of Full Engagement (Loehr & Schwartz, 2003).

• Performance zone: Passionate, enthusiastic, engaged, optimistic, alive, challenged, and absorbed

• Survival zone: Anxious, impatient, angry, irritable, defensive, fearful, and frustrated

• Burnout zone: Hopeless, exhausted, sad, discouraged, lost, empty, worried, and depleted

• Recovery zone: Calm, peaceful, grateful, relaxed, receptive, relieved, rested, and renewed

Goldberg said that to stay in the performance zone, you must enter the recovery zone before you enter burnout. As such, those in intense professions may need to spend time recovering every working day. This can be done using various energy management techniques, including physical (stepping away from the desk at regular intervals), mental (prioritizing competing demands), emotional (feeling valued and appreciated), and spiritual (connecting work to higher purpose). 

Finally, Goldberg addressed the importance of “personal resilience” to maintain strong performance, defining resilience as “the ability to become strong, healthy, and successful after something bad happens.”

Goldberg shared the following five factors, summarized below, for building resilience capability:

• Perspective: Take some space to view a situation, accepting the negative aspects and finding opportunities. “Recognize what can be changed and what can’t.”

• Emotional intelligence: Become present in your emotions and name what you’re feeling. Don’t feel guilt or shame over the emotions that you experience, but give yourself time and space to process them.

• Purpose, values, strengths: Be aware of the purpose that you find in your work, and how it relates to your larger moral compass. Use this awareness to stay centered during chaotic times.

• Connections: Form relationships with your friends and colleagues and give and receive support from this network.

• Managing physical energy: Take care of yourself. Exercise, eat well, and have hobbies and activities to engage in apart from your work.

Graduate students, particularly within business, law, and medical school, may want to consider incorporating these strategies into their lives now. Building healthy and sustainable stress management habits, within the hectic graduate school environment, will be good preparation for managing career stress, avoiding burnout, and maintaining wellness in the future.