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.

Public Blog Redux

Hooray, the blog is public again, and hooray, I got to use the word redux in a title! (I'm slightly addicted to it after reading it all the time in the excellent Life In The Fast Lane.)

I have decided to make my blog public again, as I have kept to myself where I needed to over the past year.

Honestly, there is nothing on here that I wouldn't tell anybody anyway, so I'm not worried about somebody reading it and working out it is me. I may deny it when asked socially, depending on who does the asking.

Even when private, I don't say anything about patients or bitch about colleagues or particular hospitals or systems. I just consider this to be normal polite behaviour.

I have just come to miss the contact of being more open and public with the blogging community. I thought about (and briefly started) another blog under a different name, but it seemed better to just re-open this one and make the blog posts I wanted to make and post them here instead.

Thanks to those of you who stuck with me and logged in over this period. I appreciated your ongoing support and comments.

Now you get to read and comment without the rigmarole of logging in. ;)

How To Survive Medical School Part 1: Friends

So, you have passed the MCAT/UMAT/GAMSAT/interview, and accepted the offer. Congratulations. Good luck.

You have quit your job, graduated from your university degree, finished high school and tied off the loose ends of your previous life.

You have perused forums, delved into the medical school's official website, grilled doctors in your circle of family or friends, and maybe bought some books.

But where do you go from here? How do you survive? There seems to be so much that you have to do. When you stand at the bottom of that hill, looking up at the mountain of information, expectations, exams and tasks, it can seem like too much for one person to take on.

That is because it is. There are bound to be some rare individuals who went through the whole process without asking for help or looking for handed-down notes or pointers left behind by previous students, but they would be hard to come by, particularly as they would be so stressed and busy that you would never see them.

If you have gotten into medical school, chances are you are now in a group of people who are (on average) extremely intelligent and motivated. As cynical as we can be sometimes about some of the people we work or study with, they could not be where they are if they weren't very smart.

It is worth remembering that very few of these people got over the hurdles and through the hoops by themselves. You need your friends, and you need the help of students who have been there before you.

Before I had gotten into medical school, I had no idea how much medical students rely on each other and are willing to help each other to get through. Each year of students has relied on the advice and help from previous years, so they help the coming years of students to get through to return the favour.

This can be in the form of tutorials, study notes and summaries, past exam papers or just encouragement. The directions from the medical school about how and what you need to study can be overwhelming and almost impossible. Student advice can keep you sane and quite literally help you pass. If you haven't heard of anything like this, make sure you ask around. There is bound to be something that can make your life easier.

Having a good group of friends (even one or two buddies) can also help keep everything in perspective. If you are feeling the pressure and feel like it is all too much, chances are that many people around you are feeling the exact same way, even if they stay calm on the outside.

It really helps to have other people there who you can be honest with about what you are going through, and when you learn how they are coping, it gets easier for all of you. I don't need to go into why having friends is important and how wonderful it is to have people around you who understand what you are going through, I'll just say that making time for friendships is vital.

Don't forget to try to maintain your friendships outside of medical school. Sometimes it is lovely to go out to dinner with a group of people and know that there is no chance of them describing their latest complicated laparoscopic surgery or FB retrieval. I have friends who apologise for talking about the latest adventures of their toddlers, but I love hearing about it. Normalcy is refreshing.

There are also avenues to ask for more substantial help, but I will talk about that in another post as I think it deserves its own space.

Another piece of advice I have to give is to remember that the people who are studying with will one day be your colleagues. You will refer patients to each other, call for advice and one day one of you may be the other's boss. They will know and work with people who you may desperately want to impress.

They may also be your treating doctor or the doctor of one of your friends or family. If you think they are hopeless, feel free to remember their names, but don't tell them so to their face.

Don't burn your bridges. Be civil, even if you find somebody really grates on you. You don't have to be their best buddy, but remember that one day you may have to work together as professionals, so it would be good to not get to the point where things get nasty.

Even if you are an important consultant and head of your department, having everybody you work with despise you is a very bad idea, and as a medical student it will be a long time until you will seriously consider being in that kind of position.

Hospitals are very small places, rife with gossip and intrigue, and so are medical schools. It is not the end of the world if you don't get along with another person, but if you can avoid being outright hostile, I would at least try to be neutral. Good luck. Ask for help.

Fools rush in

I keep running into doctors who used to want to do psychiatry for the same reasons I do, and didn't go into it in the end because it was too draining emotionally.

These same people keep trying to talk me into following radiology.

I enjoy imaging, don't get me wrong. There is something really nice about looking at a picture and understanding what is in front of you, and being able to label the anatomy with certainty, understand the physics and the likelihood of the pathology.

I'm just confused. Fortunately I have an elective scheduled where I do four weeks of each, one after the other. This will help me make up my mind.

God knows, maybe I'll end up in a completely different field. This would also be okay. :)

I'm starting to think that I really should take my time getting into something and pay attention to the old proverb of "Fools rush in".

And the good news?

I got my first preference for internship!

I'm so relieved. And a little scared.

I think it will all become more real when the paperwork starts to arrive.

OSCEs

I finished the last of our exams for this rotation today!

They went okay and I think I passed all of them. I know I did well on the last OSCE, as the examiner told me so (the patient ovarian torsion due to a dermoid), and I looked over the first case and worked out that I covered what I needed to cover (discovering a twin pregnancy that then goes into early labour).

For those of you who haven't done a medical school OSCE, it goes like this:

You walk into the room and meet the examiner. They are a consultant (i.e. attending doctor if you are in the USA) and they are sitting in the room looking at notes that you can't see. They say hello, introduce themselves and you exchange pleasantries until the bell/buzzer/knock on the door tells you that it is time to start.

They introduce the case with a simple statement (e.g. Jane Doe comes into your GP office complaining of X) and you have to take a history from them, say what you want to examine, organise texts and talk to the patient as if it were a real situation, except you are being examined and drilled at the same time and have nothing to refer to in front of you.

There are generally multiple patient encounters, so after you are finished with the first encounter (and the examiner has finished prompting you, mostly to help or sometimes the occasional examiner will mess with you a little), they lead into the next encounter which follows on in time from the first. This might continue on in a different location, at a different time, for example, "Jane Doe comes into the emergency department and you are a resident there, her results from her GP read as follows" and you then have to continue care of the patient. And so on and so forth.

It is challenging because it is a foreign situation, sitting in a room talking with an examiner rather than being in a hospital/office with a patient in front of you. It is harder to remember to do the basic things that you would do out of habit, such as get a drip running or call for help from the registrars of the other disciplines if it isn't immediately apparent that they are needed.

If you get a helpful examiner, they can help you along by describing the situation in more detail for you, and leading you to answer things rather than forget them, because if they describe the situation more and you know the answer then you are familiar with what you have to do but have just been put off by the format.

You should still be able to pass without that help, but I won't ever knock back a couple of extra marks for things that I actually know but would have otherwise forgotten to mention due to nerves and the strangeness of the situation. ;)

It is actually kind of fun if you can relax enough to enjoy it. That said, I'm glad I'm done with this lot. Now I only have two big exams, both of them multiple-station exams, and I'm done with medical school. It is very exciting.

Exams, again

We have our exams this week for O&G. They consist of a long T/F paper, and two OSCEs where we are given a fake patient (who can be male and is also the examiner and an O&G physician to boot!) in a structured assessment situation.

I'm mildly nervous, but much less than I would have been a year ago. We have been through so many exams in the past few years that it seems so mundane and normal.

The thing that is starting to weigh on my mind is internship. I have two lots of rotation exams (including this one), one elective rotation, one MSAT at the end of it all, and then I am technically a (junior) doctor.

In studying for these exams, I keep seeing myself actually being in these situations in a year or so. This is helpful for study, as it really makes it stick, but on the flip-side it is also scary.

Quite a lot of girls I went to highschool with are now experienced nurses in the system, with over ten years on the job. I have lost contact with them over time, but it would be very strange to interact with them in a work situation, particularly as a junior doctor. I actually think that most of them would be good to work with, and if things get uncivil, we can threaten to show the rest of the staff pictures of each other in dreadful 90's garb and fluffy hair. ;)

I'm also possibly going to be doing internship at the hospital where I have worked for years in my previous profession, which will also be odd. On the bright side, I have a good reputation there in my other role, so hopefully that will make the transition a bit smoother.

I have worked and studied in the same corner of the world for my whole uni and working life. As Mr TGWTBS has said, it will be a bit of an adventure if and when we get to go elsewhere, in the not-too-distant future.