Monday, August 2, 2010

How To Survive Medical School Part 2: Ask For Help

I have tread a few paths in life before I started medical school. I have studied three very different careers at university, all of which involved stress, personal criticism and hard work. (I finished one - I have a low tolerance for things I don't see any point in.) I had a career in which I worked in a stressful role and ended up in a semi-senior position before I jumped ship to study medicine.

None of this was anything like the kind of stress, personal doubt and anxiety that I went through as a medical student. I know that this is by far the norm. Medical students (and doctors) may be the types who are good at keeping up appearances, but don't let appearances fool you. If you are going through extreme levels of stress and personal difficulties, the odds are that you are far from alone.

I'm not an expert and there are other resources that do it better and in greater detail, but there are many reasons that people cope differently with stressful challenges. These are my personal observations, and others may have quite different and valid ideas. Everybody deals with things differently - it is part of the beauty and diversity of the human experience. You really have to make up your own mind on these issues and how you would deal best with them, but getting help is vital to learning how to reduce the stress levels and emotional distress you are experiencing.

There are many studies on stress and anxiety in medical students (and doctors) and you can find reviews of the data on Pubmed and other databases. It is an issue that often isn't spoken of openly, and more work needs to be done as it is an extremely prevalent issue that impacts on our profession and our lives.

Medical students on average are more likely to be obsessive personalities who need control and desire perfection. When you put people who have generally been very high achievers into a situation in which they are now not even certain of passing, it adds a lot of stress.

Add into this mix the ambiguity of the goals set for us, particularly in the first two years of study, tutors who can mercilessly rip apart your performance (because, as they will frequently tell you, if you are an underperforming physician you will kill and maim more patients) in a style that scars more than teaches (pimping portrayed on the medical dramas/comedies is real, and frequently less merciless than in reality), and an environment in which you not only may be an average student but may be failing in spite of your hardest effort, and the result is an environment in which the emotional reserves of the toughest student may quickly be depleted.

When you go into the clinical years, it is not uncommon to feel completely incompetent and clueless just about every time you walk into the hospital. To be frank, you know so little at this point that a little uncertainty is a good thing, but it should be to a point that motivates you to learn more and try harder, not crush you and make you doubt your ability to ever be a competent physician. In time, you get used to this feeling, recognise it as normal and know that you are only expected to be safe and ask for help when you need it. At the start of your clinical years it can be a hard pill to swallow.

About a year ago, Captain Atopic wrote a brilliant and soul-baring post about failure in medical school. I think that everybody who is considering medical school or is already a student should read it. He is an intelligent and capable student, and if it can happen to him, then it could have happened to any of us.

Maladaptive personality traits and tendencies are extremely common in the general population, and if you put people with these traits (i.e. most of us) into the stressful situations in medicine, your previous coping mechanisms may be stretched to the point where they no longer suffice. You can adapt to the stressors in a number of ways.

Ideally, students can learn resilience and bounce back quickly when something happens that upsets them and floors them completely. This is a skill that we should all try to gain, as it is a healthy way of coping with the knocks that life deals out. Still, sometimes the existing strength of our resilience isn't enough, particularly when many things overwhelm us at the one time and we stop coping.

You can develop a thick outer shell and a protective layer of cynicism about the whole process. This is the approach that is caricatured in the extreme in the medical characters Dr Cox from Scrubs or Hugh Laurie's character in House. A little bit of toughness and cynicism can serve you well, but letting it become your entire personal style is dysfunctional and can lead to great misery.

If a clinical teacher acts rudely or is unreasonable, you can learn to take it with a grain of salt. Being excessively cynical, antagonistic and tarring every clinical teacher with the same brush is maladaptive and unhelpful. You need to protect yourself and be able to distance yourself emotionally, particularly from the "heart-sink" patients who can be a great source of frustration to every staff member in the hospital. Treating every patient you encounter with the cynicism that House exhibits would be, quite frankly, abhorrent. There is a healthy balance, and you need to find it to cope.

If you have experienced significant personal trauma from something in your life and haven't dealt with it, it may come back up again and result in worsening anxiety, even to the point where you stop being able to function. If something you haven't dealt with is just sitting there under the surface and you are simply getting by through ignoring it or pretending it isn't a problem, diving into the stress and demands of medicine will likely rob you of the reserves that you were previously using for denial, and so you can be overwhelmed by something that isn't even related to the course.

Depression and anxiety disorders are frequent amongst medical students, and should ideally be dealt with as soon as it is possible, but there are a number of reasons that this doesn't happen. One of these must certainly be the culture of silence that exists around these problems. Medical students don't want to admit vulnerability and worry that admitting they have had issues with anxiety or depression may be seen as weakness and that they may be perceived as not suitable or strong enough to bear the burden associated with their stressful careers.

You may already be experiencing burnout. The medical school experience alone will put you through most of the potential causes of burnout, so it is important to learn how to deal with these pressures now when you are more likely to have time and space to do so.

It is a dreadful irony that admitting to emotional distress and getting help and dealing with your problems can actually make you a stronger and more capable person in the long-run. Denying a problem with these things is like denying a physical illness. It doesn't just go away because you don't admit it is there, and it may well get worse rather than better.

There are many places that you can go to for help, depending on how you feel. If you think that you may need it, don't put it off. It can be as simple as having a chat with an appropriate clinical coach or teacher, and students will often know of one staff member associated with the medical school who can help them or refer them to more appropriate care.

Here is a short list of some resources that you should not hesitate to access:

1. Your GP. Every doctor or medical student should find their own GP - somebody they can go to regularly and talk to when they need support, as well as dealing with health niggles that crop up from time to time. It is great having somebody who knows you and is an independent professional. If you don't have one, you can ask around to find a GP who is interested in counseling or has a good reputation. The rewards of finding a good GP are well worth the effort. They are also great for referring you onwards if you need to see a psychologist or psychiatrist.

2. A psychologist. In Australia, you can claim a number of visits per year on Medicare if you are referred by your GP with a Mental Health Care Plan. It may only take a few visits to help you develop skills and strategies that can improve your quality of life and make the difficult times easier to deal with.

3. A psychiatrist. In Australia, you are more likely to be referred to a psychiatrist if you have an identified mental illness that is being treated with medication.

4. The University Union. Some university unions in Australia have staff counsellors who you can visit for a free chat. These counsellors can also help you with strategies or just be a sympathetic ear.

5. The School of Medicine. Ideally they should have somebody you can go to when you encounter difficulty, who can then refer you to another service. Some schools have a budget for this so that they may be able to pay for an appointment for you with an independent psychologist or doctor who can assess you and refer you for appropriate treatment.

Be aware that these resources can be hit-and-miss, but if you encounter somebody who didn't help much, don't give up and try a different tactic. Don't ever feel like you can't be helped. You deserve to be well as much as the patients you yourself will be trying so hard to help.

Other places to think of include:

6. Lifeline, and other anonymous phone counseling services.

7. On-line information such as Beyond Blue and self-help tools like Mood Gym. (Incidentally these are both worth a look even as a student with no current issues, as they are tools and sites to be aware of than can be invaluable to your patients.)

8. Books. Your library should have a good selection of these, and if you want to buy one for yourself, make sure you have a good look through them first.

9. Your friends and family. Sometimes you get to the point where you really need help from an independent professional, but never forget that your friends and family can be there for support, too. If you are brave and come out and tell them that you are having difficulty and are seeking help, you may be surprised at their positive and caring reactions.

10. Mindfulness training and meditation are also good skills to develop. Learning how to live in the present and focus your attention is a skill that can help improve your life and make you a better clinician. If you haven't tried mindfulness training before, it isn't as hippie-ish or crunchy-granola as you might expect.

It goes without saying that anybody who is having thoughts of hurting themselves should seek help and support immediately. You are worth being helped.

There are a number of great resources out there, and this is just a summary of my thoughts having gone through the mill of medical school. Things can get better, and you can come out the other side stronger than you were before you started having issues. Asking for help is a sign of strength, not weakness.


Sara said...

My mantra to myself when dealing with the bastardy types that like to be mean and humiliate was to remind myself "I have to live with him for this rotation. He has to live with himself all the time."

The Girl said...

That is so true.