Helping students cope successfully with challenges academic and personal is the goal of Laurie Raymond, director of the Office of Advising Resources and assistant clinical professor of psychiatry at HMS. Raymond, who helped organize a symposium on resilience in medical students on April 1, talked with Focus about stressors among medical students and the support network that aims to help them be successful.
Focus: Beyond obvious stressors like sleep deprivation and workload, what factors prompt HMS students to seek stress relief?
Raymond: Medical students undergo an enormous period of personal and professional growth while at HMS. They must spend a large majority of their waking moments studying basic sciences during their first two preclinical years and then, in the last two, clinical years, caring for patients in affiliated hospitals and clinics.
I have found that what constitutes stress for a medical student is highly individual, but there are some common themes. In striving to maintain a balance between their professional training and their personal lives, students often experience “role strain.” This form of strain reflects at least four major developmental challenges, all of which involve negotiating relationships—first, with their families of origin; second, with friends, partners and children; third, with their sense of self; and fourth, with professional peers, house staff, attending physicians and patients.
With respect to their families, many medical students have long played significant roles in their family’s cohesion and well-being, serving as sources of emotional support, self-esteem and inspiration towards success. In medical school, students reach an age when grandparents and parents may become seriously ill or die. In moments of family crisis, students feel pulled between responsibilities for their families and for their patients. Within each of five academic advisory societies at HMS—the Peabody, Holmes, Castle, Cannon and London Societies—timely support from experienced Society masters and associate masters can be critical in allowing students to spend adequate time with their families, cope with their grief, and return to clinical tasks when they are ready. Creating flexibility in scheduling and encouraging students to take care of their needs are important lessons in self-care.
Similarly, in relation to friends, partners and their own children, medical students vary in the degree to which they have developed family and local support systems. Medical school is often a time when students deepen their intimate relationships; some are considering commitments to another person for life. Maintaining these relationships— and dealing with broken ones—also requires time and energy, either for repair or for resolution. Here again, support and wisdom from the Societies, administrators, faculty, mentors and peers, as well as flexibility in scheduling, can often help students gain perspective and also seek more formal counseling if needed.
In relation to themselves, many students have experienced high levels of achievement and success before coming to medical school. It can be a shock for students to encounter difficulties in learning as the pace and volume of information presented to them increases dramatically. The range of intellectual, interpersonal and clinical skills required to effectively deliver clinical care takes time for students to master and may be much more difficult for them than they expect.
During this time, Societies, administrators, faculty and mentors often play important roles in helping students accept disappointments in their performance. Students whose identities were previously formed around their achievements can learn to separate who they are from what they need to learn—to use criticism as an opportunity to improve rather than deny or avoid it as an attack on their sense of self.
During medical school there can be many occasions for exposure to personal vulnerability. A student may have a first major depression or serious physical illness, for example, or may “hit the wall” when previously compensated attention- or learning-related difficulties or disabilities are uncovered or heightened by the challenges of medical training.
In addition, for some students, particular clinical experiences may reawaken past traumatic life experiences that may require time to understand and integrate. Societies, administrators, faculty, mentors and peers can help students accept periods of vulnerability, during which their own professional identities are being formed and personal sense of self is being more maturely and realistically reshaped.
Finally, in relation to becoming involved with patients and their families, students may experience positive, rewarding emotional engagement, followed by grief when those patients succumb to their illnesses. At HMS, a third-year Patient-Doctor course affords students opportunities to talk about these losses and other upsetting clinical events together with their peers and faculty.
House staff and attendings who take the time to address students’ feelings about situations involving patients also are highly valued for instilling in students greater confidence in sharing painful moments with patients. Learning to share rather than to isolate one’s emotional core is an important element of maintaining resiliency and optimism in clinical work. The tendency toward “burnout” so often described in clinician and trainee populations includes elements of emotional exhaustion and depersonalization. These can understandably result from clinicians and trainees feeling alone and unsupported in the face of difficult, unprocessed emotions during daily clinical encounters.
Focus: Support seems to matter the most.
Raymond: That’s right. Timely support makes a big difference in how students weather the various challenges of their training. At HMS, the pass-fail preclinical years and Problem-Based tutorial structure are designed to help entering medical students learn to work as a problem-solving team at the preclinical, basic-science level without reactivating a pre-medical focus on getting the best grades. Two entertainment events in the preclinical years encourage students to celebrate working together in a non-academic, playful way. Fabric, a spring event for first-year students, is a multicultural festival of songs, dance, jazz and theater designed for revisiting, accepted applicants. The Second- Year Show is an enormous effort in the fall that engages most of the second-year class in song, dance and orchestra, directed largely at spoofing preclinical faculty and classes.
From orientation on, the notion of getting help for academic, personal, emotional and medical issues is addressed and encouraged by faculty, administrators and the Societies. For example, the Vanderbilt Hall gym on campus and the Wellness Center, in Cambridge, as well as individual student organizations offer teaching in mindfulness meditation, dance and yoga.
During the third year, known as the Principal Clinical Experience—a key facet of education reform at HMS during the last four years—students do clinical work at one hospital for the year. This allows monitoring of their progress and a level of mastery across many core specialty clerkships. Students are assigned a hospital-based mentor with whom they can engage in personal conversations about their clinical experiences and training progress. With this new system we have found that students become better known to their faculty. As a result, their problems can be more readily remediated.
Focus: For medical students, as for the rest of us, then, coping strategies are highly individual.
Raymond: Yes, that’s very true. A host of support systems are available, but getting help can still be difficult for students who are not well connected to peers, who feel uncomfortable or unfamiliar with having to ask for help, or who are afraid to acknowledge their own difficulties. These students may not discover what’s available until they encounter a specific stressor, perhaps as late as their third or fourth clinical year.
While Societies, administrators, faculty and mentors offer many opportunities for relationship building, we don’t know as much as we’d like about how and when students make use of each of these resources. This would be a useful thing for us to listen for and understand better.
For more information, students may contact Raymond at Laurie_Raymond@hms.harvard.edu.
To read more about the science of resiliency, click here.
