What Causes Toxic Stress in Medical School and How to Fix It

For two years, I served as a representative to my medical school’s student affairs committee. My job was to convey medical student concerns and problems. As part of that role, I had a lot of time to think about how and why many medical students experience depression and stress. Two recent articles have led me to write about the issue now: “10 simple solutions to stop medical student suicide,” and, “University of Kentucky trustees asked to revoke medical privileges of controversial surgeon.”

Many see medical student mental health as a simple problem: bad doctors and bad residents are mean and abusive. Punish them, fire them, and the problem will go away. But that’s like seeing the flooding in New Orleans after Katrina and thinking, “We should really have improved the sewage system.” It didn’t matter how good the drains were- once the levees broke, the game was up. We need to look at the problem in a manner similar to root cause analysis — something I’ve written about in the past. Of course, as we are not dealing with a single incident, the formal process is less applicable here.

Background

Let me posit that most medical schools have the following characteristics:


1. Medical students face fierce competition for residency spots. They are constantly told they risk not matching in their desired specialty, their desired program/geographical location, or at all if they do not perform at a very high level academically. In short, their dreams of what kind of medicine they wish to practice is determined by their academic performance relative to their peers.

2. Academic performance consists of two main parts: the step 1 exam taken after year 1, and clinical grades during year 3. (Some schools also have pre-clinical grades, which I will not go into here.) Clinical grades consist of some combination of:

• evaluations by residents and attendings
• shelf exam
• OSCEs
• other tests

Schools restrict how many students in any class can get the highest grade (honors) in a clerkship. This may be the top 5, 10, or 25th percentile. The next category (high Pass) will typically encompass 60 to 70 percent of the class, with pass or lower reserved for those students with serious deficiencies.

3. Evaluations by residents and attendings can be highly arbitrary, and small variations can lead to drastic differences. (80 to 94 percent is high pass, 95 to 100 percent is honors, etc.)

Analysis

What does a system set up like this result in? A perceived need to be “perfect.” Medical students widely feel the need to both be clinically good but also socially adept- to be able to get their residents to “like” them in order to get a good grade. Many feel that a single screw-up or forgetting of a “pimp” question is enough to ruin their chance for an honors — particularly from attendings who have limited contact with them throughout the rotation.

One student who I talked to felt so anxious about getting her resident to like her that she literally could think of nothing to say to her residents for days at the start of her rotation. Many students describe chronic, toxic stress from the need to be “on their game” and completely attentive to anticipating and fulfilling every conceivable need of their residents and attendings- in the hope of a better grade. This on top of the need to study at night, and the need to constantly volunteer to stay late, come in early, and do as much extra work as possible to demonstrate one’s capacity for work.

Now, is this rational behavior? Probably not. It’s impossible to say how much one’s social skills and ability to schmooze and hang out with the residents affects one grade; after all, the ones with the best social skills may also be quite good at conversing with patients. But, when small changes in evaluations (93 percent vs. 95 percent) can lead to large differences in grade (honors vs. high pass), many medical students face this chronic, toxic stress to be a social butterfly when they are with the residents — who they spend 10 to 16 hours a day with for weeks.

Added on top of this can be poor, “abusive” behavior by some residents and attendings. Such behavior I believe stems from the pain they face from taking care of patients in a system that treats them as cogs in a machine, but that is a post for another day.

But a far worse problem is this: medical students under such horrific, constant stress to seek approval and make their residents happy every second of every day are completely unprepared to deal with anything but the most gentle and kind negative feedback. When a resident makes a throwaway comment like, “You forgot to check the pathology. In a post-op visit, you must check the results on whatever we took out. It could be cancer. You could kill someone the next time you forget,” it becomes something that a medical student obsesses over for days.

What if that one incident will lead to that resident giving the student a lower grade? What if the student just ruined her chance for her dream residency in ophthalmology in the Bay Area? What if she ends up breaking up with her boyfriend because she won’t make AOA and be competitive enough for a couples match? What if she never marries or has kids and dies alone because she didn’t meet anyone because her boyfriend broke up with her, and she will be too busy to date during residency and too old after, all because she forgot to check the pathology in a post-op visit? (That sequence was slightly in jest, but really only slightly.)

But the reality is that mistakes that are normal and expected in the course of training become things that in medical students’ minds can never be allowed to occur — instead they push themselves to be perfect on day one — the perfect assistant, the most eager learner, the most knowledgeable person, and the funniest, charming, and perfect person to be around.

Thus I believe is the real source for much of the stress felt by many medical students in this country is ultimately the grading system and what it is used for: residency matching.

Solutions

Now, what can be done about it? The reality is that so long as medical students are judged in any way based on their clinical performance in the third year, and so long as that judgement is used to determine residency allocations, some amount of stress will continue to be present.

One thought is to simply get rid of subjective evaluations as part of clinical grades, and simply base clerkship grades on the objective shelf exam scores. This would certainly reduce stress that comes from being evaluated by residents. But, it would also lead to a loss of something important in the evaluation of a doctor. Medicine is art and science — and there are many medical students who are terrible test takers, but outstanding communicators, thinkers, and eventually doctors. These students would be lost, unable to prove their worth in any objective sense if grading was solely based on tests. Some more elite medical schools practice a softer version of this: They give very few, or a large number of honors, making the grade somewhat meaningless and relying upon the strength of their school’s name to help all of their students match. This option is not really available to any school outside of the top 10 to 15-ranked medical schools in the country, as judged by research funding, and again masks clinically astute students.

But another and more promising thought is to make evaluations less subjective. As part of an overall shift in medical education, grading would be changed from residents and attendings giving medical students a number from 0 to 100 (or some equivalent thereof). Instead, the medical student will have an online or paper card with items to sign off, like below:

“Is this student capable of performing an appropriate history and physical at a medical student level for a complaint of back pain?”

“Is this student capable of performing an appropriate history and physical at an intern level for a complaint of a complaint of back pain?”

“Is this student capable of performing an appropriate history and physical at a senior resident level for a complaint of a complaint of back pain?”

“Is this student capable of performing an appropriate history and physical at an attending level for a complaint of a complaint of back pain?”

When they meet the expectation, they get the appropriate box signed off. Then, instead of compiling a clerkship score, residencies would simply be handed a grid with the answers: where the student was a little behind, where they are a little ahead.

This I think is the best solution. While still somewhat subjective — how does one decide what an intern-level H&P is vs. a senior resident H&P? — it would significantly reduce subjectivity, it would give students who are clinically astute a place to shine, and would reduce overall stress levels. It would be entirely impossible for every student to function at an attending-level for everything. But here and there, there would be bonuses. The minimum expectation would be to have the medical-student level items all signed off.

Is this a perfect system? Of course not. So long as competitive and more desirable residencies restrict the number of residency spots, there will need to be some need to stratify medical students, and that will create competition and stress. But a more objective system where no one can be perfect will allow medical students to be less anxious about failing, and reduce the toxic stress. I have heard rumblings about such a system being in the works, and I can only hope that it will happen sooner rather than later.

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