Realistic Expectations of Medical Training
This activity describes some of the challenges medical students typically face. In addition to being aware of the many rewards, developing realistic expectations of yourself and your medical training is important for well-being. For example, it helps to
- Set realistic, attainable goals for yourself, including the time a goal is likely to take.
- Be aware of what challenges you may face in medicine and medical training.
- Recognize the difference between what you can change and what you cannot change. Put your efforts into your responsibilities and what you can change.
Pre-Clinical challenges are considered first, followed by the challenges of clinical training.
Common Stresses of Medical School
Some challenges will always be a part of medicine and medical training and are difficult to change. Being aware of them and having skills to deal with them can make a big difference. Mindful awareness of challenges and their impact is a good place to start.
I. Medical School Stressors
The following is a list of medical school stressors identified by 985 students at six medical schools (Hill et al., 2018).
Factors contributing the most to their stress (a moderate amount or a lot), using a checklist of potential stressors were (n=985):
- Academic workload 88.1%
- Conflicts in work-life balance 47.8%
- Romantic relationship management 39.2%
- Inadequate study habits 37.7%
- Poor time management skills 30.9%
- Financial difficulties 26.8%
- Competition with peers 25.6%
In response to an open-ended question, the following stressors with a slightly different emphasis from the original checklist were also often identified:
- Performance pressure (35.4%)
- Time constraints/lack of balance (33%).
Consider which stressors have impacted you. Notice any effect that just thinking about these challenges has on you physically or emotionally (check breathing rate, pulse, muscle tension, and physical signs of your mood). It is normal to feel the effects of stress in your body. Fortunately, there are learnable, simple, evidence-based skills that help mitigate the stress effects and enhance well-being.
Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Med Educ Online. October 5, 2018;23(1). doi:10.1080/10872981.2018.1530558. PMCID: PMC6179084. PMID: 30286698.
Tips for Those Starting Medical School:
- Start with strong study habits from the beginning. Just pushing harder may not be enough; learn some study skills.
- Maintain health self-care including both actions taken and avoiding overextending
- Maintain and make friends
- Get your affairs (financial, health checkups) in order before school starts.
Performance Pressure and Competition with Peers
Medical school has a competitive atmosphere, more so than undergraduate education. Even medical students who had never been competitive in the past may find themselves getting caught up in the competitive spirit of medical school while at the same time finding it a harmful stress. A certain amount of competition can stimulate greater effort and use of self-discipline in studies.
Consider how much of the pressure is coming from yourself and review the following ideas for changing that.
Tips for Handling a Competitive Atmosphere
Reminding yourself of your mission and goal for being in medical school. Is it to be number 1 in the class or to be a good doctor?- Excuse yourself next time a group’s conversation turns competitive and take a walk outside to get some fresh air.
Tips for Working with Goals Realistically and Effectively
You may find that setting and achieving your goals in medical school differs from undergraduate education, because medical education is more challenging. Competitive goals that involve being the best may be difficult to achieve because many other medical students may perform as well as or better than you do academically.
- Think about the difference between goals and expectations. Which are more likely to feel upsetting if not reached or experienced?
- What are your expectations for your medical training or career? How would it change things to treat them as goals instead? Do some research to help you develop realistic expectations. Consult with medical students or residents who are a step or two ahead of you. Let go of unrealistic expectations, but keep worthwhile goals.
- Next, set realistic goals. Since many medical students underestimate the difficulty of reaching goals they set during medical training, try automatically adding a degree of difficulty and some extra time to your plan for achieving your goal (Bird et al., 2020).
- Now structure your goals so that they are more achievable. Break goals down into stages and small steps within those stages. Make the steps realistic, measurable, and achievable steps.
Do You Tear Yourself Down? Develop an Inner Guide Instead of an Inner Critic
Many medical students are highly perfectionistic, which is compatible with achieving high goals. However, it can be draining in situations where being perfect is difficult to achieve. Some students are highly critical and harsh on themselves when this happens, as if they have an inner critic inside who is not aware of how destructive this can be to self-esteem.
Challenge: If you have a harsh Inner Critic, listen for the next time it is active and see if you can be kinder to yourself. Think in terms of talking to yourself as a more benevolent mentor might talk. Try to follow the tips above for providing optimal feedback – to yourself!
Exercise: Use a journal to write down self-criticism and then rewrite it from the perspective of what a more benevolent mentor might say.
Thanking Your Mind: Taking the Power Out of Difficult Thoughts. Illustrates a brief technique from Acceptance and Commitment Therapy. By Dr. Russ Harris. Time: 1 minute 46 seconds.
Personal Mission and Purpose
Having a personal sense of purpose is important for having strength, perseverance, and resilience. Clarify your current understanding of your mission and purpose regularly. Writing it down in a journal can help you refine it. Remember to update it periodically. You can then refer to your written purpose and mission when feeling confused or overwhelmed. It may be helpful to carry it in writing or a symbol of it with you to remind yourself of it.
Personal Challenge Idea: Write your Mission and Purpose for your life and career in a journal for yourself and review it periodically.
Pressures from Family to Perform
Pressure from Parents: Most students in our focus group described pressure from parents and others to perform well adding to the stresses of medical school. Research into medical students who had parents with strong expectations regarding their going to medical school vs. those who did not found that students who had parents with high expectations had more negative attitudes toward medicine as a career after one year of school and to suffer from burnout in year 5 (Griggin and Hu, 2018). What use can you make of this data? Be clear as early as possible about what you want as a career. Counseling is one potential way of getting clearer about whether this is actually the career choice you want.
Furthermore, medical students are often asked by family to provide medical opinions and have to explain they cannot do that.
Work (Clinical Training, Studies) – Life Balance
Get used to balancing your training with the rest of your life early in medical school. The challenge to work-life balance has several peaks during medical training:
- Studying for Step 1 exams in 2nd year
- Transition to clinical clerkships
- Workload of residency
Importance of Work Life Balance
We asked several medical students from different schools the most important advice they have for other medical students. They all recommended keeping a “work-life balance” and mentioned the importance of:
- Time management
- Having an efficient and effective study program
- Taking time from studies for enjoying the rest of life.
Tips from Medical Students on Work-Life Balance:
“Start building a routine now so that medical school becomes a new part of your life and does not take over it.“
~4th year medical student
“Managing your physical, emotional, mental, and spiritual well-being is extremely important to your success in medical school. My favorite quote “You cannot pour into an empty cup” says it all. If you do not take care of yourself you cannot help others.”
~2nd year medical student
“Be balanced – Make time to do the things you love to do.“
~4th year medical student
“To look more impressive when it comes time to apply to a residency, you may want to join certain groups, shadow a specialist, volunteer at a free clinic, become a student leader, or help in a research lab. However, you will burn out if you try to do too many of these. Find out from 4th-year students or residents which extra activities matter most.“
~2nd year medical student
The following topics describe ways to balance your studies and clinical training with the rest of your life.
- Time Management
- Study Tips – Optimizing Your Studies While Maintaining a Work-Life Balance
- Play, Interests, and Entertainment
- Balancing Family and Medical School
The habit of setting priorities and focusing relatively more effort on higher priorities and less on the rest will serve you well throughout medical training.
External Resources on Time Management
Resource: Effective Time Management for Medical School: Blog on time management for medical students. By Code Blue Essays, a physician-founded company that provides expert editing of medical application essays.
Resource: Time Management in Medical School: Blog with three simple tips for medical students, 07/05/2018. By two 4th year student leaders at UCLA.
Resource: Time Management and Scheduling: Study methods. By the Albert Einstein College of Medicine
Tips for Optimizing Your Studies While Maintaining a Work-Life Balance
- Make study time a priority in your life. Schedule a time for studying each day and be diligent about following that plan. Make sure your study time has both a start and finish. Start with day one of classes, so you don’t get overwhelmed by the heavy workload. Attending lectures and taking notes can save you time because if forces you to pay attention in the moment; if you listen to a recording instead, you may be tempted to press pause.
- Prioritize information: Admit that there is too much information to learn it all at a perfect level. Notice that the information you are given in medical school is not all of equal value. Give information a priority and find a way to mark that priority in your notes or highlights. Focus more of your study time on the prioritized material. To set a priority, consider the relative importance of a concept. Consider whether the information will help you:
- be a better doctor,
- on an exam,
- prepare you for your personal career goals in medicine.
- Attend classes in person and look for the emphasis given to a topic by the professor. They tend to emphasize what is most important, information you would not get if you just read their slides for the lecture.
- Review test banks for licensing exams for questions related to the topic you are studying. Your teachers will tend to emphasize these topics on exams. This helps prepare you for licensing exams at the same time.
In addition to prioritizing what to learn, consider how well to learn something. For example, the names of a long list of enzymes you probably won’t remember in a year and will not use in medical practice and will be able to look up when you need them could be something to just put in short-term memory.
- Focus on what you don’t know: The first time you review your notes before an exam, highlight information you don’t know. With each pass through your notes, mark off what you now know in a darker color. Go over just the remaining light highlights right before the exam.
- Become aware of and use your study habits to your advantage. Identify your strengths in studying and use them; identify weaknesses in studying and try to improve them.
Proactive Learning In Clinical Training and Medical Practice
The transition to clinical training from pre-clinical requires more self-directed learning (Cho, 2017). This requires:
- Planning (goal setting, reflect on your existing skills and gaps)
- Monitoring yourself (track your attention and do self-testing)
- Self-regulating (follow your plan, modify it as needed).
External Resources on Study Skills for Medical Students:
Study Skills: Includes study tips for reading vs. lectures and how to get the most out of a study group. By Lesa Medoff, PhD, Education Specialist at Stanford School of Medicine.
Lessons in Medical School Study Strategies: Includes tips on making the shift from undergraduate studying to medical school studying, how to study efficiently, and how to adapt your studies to your learning style. By Medical School Insiders, a medical education company run by a team of doctors.
Study Tips from the Perspective of a Medical Student – Includes 3 common study mistakes and tips. By Des Moines University Medicine and Health Sciences. Highlight:
- “You must understand the material by translating it in your own language. You must then review the material over and over again.”
Learning Your Way
The following information and external resources help in developing a personalized best way to study.
Education Planner helps you understand your study habits and learning style so you can modify habits and adapt your studying approach to match your learning style. By EducationPlanner.org, a career and college-planning website/PHEAA, a national provider of student financial aid services. Learn about your:
Learning Style: One of the following ways of learning may help you learn more easily, effectively, and enjoyably. If so, it is called your learning style:
External Resource: Learn Your Learning Style to Maximize Your Med School Study Power (Davidson, 2018): Describes learning styles and offers tips on how to leverage your style to help your studies. By Med School Tutors, a commercial medical school tutoring company with medical student, resident, and attending tutors.
- Cho KK, Marjadi B, Langendyk V, Hu W. Medical student changes in self-regulated learning during the transition to the clinical environment. BMC Med Educ. March 21, 2017;17. doi:10.1186/s12909-017-0902-7. PMCID: PMC5361773. PMID: 28327147.
- Davidson, Z. Learn Your Learning Style to Maximize Your Med School Study Power. August 29, 2018. Med School Tutors.
- Education Planner. EducationPlanner.org, a public service of the Pennsylvania Higher Education Assistance Agency (PHEAA). Copyright © 2020
Play, Interests, Entertainment
Tip: Take a little time to do something non-medical regularly:
It’s easy to lose perspective when focusing much of your attention on your medical education. Try taking an hour or two off each week to do something completely unrelated to medicine. Expand your horizons, for example, by taking the time while you are still in a university setting to join clubs or societies or attend special lectures on topics completely unrelated to medicine or new to you. Or enjoy something you used to enjoy.
Balancing Family Life with Work
Balancing Medical School and Family Life – by Prospective Doctor. A guest author offers several tips in this article on how to help make it work. Briefly, the basic steps outlined are:
- Be sure to spend some time giving your family your full attention. They can tell when your mind is somewhere else.
- Keep your commitments
- For children, find some special time that they can count on from you such as reading a night time story.
Work-Life Balance Resources
Video: Junior doctors look back on their time in medical school and offer advice on how to achieve work-life balance. Work-Life Balance – How to Survive Medical School #05. (Abdaal, A, 2018) Length: 16 minutes
Work- Life: A list of external resources on Work-Life Balance while in school including multiple resources on balancing work with family life. Also resources in the following categories: Test Yourself, Finding Balance, Personal Productivity, and Spirituality. By WellMD, a source of support for wellness for physicians at Stanford Medicine.
The financial challenges medical students typically face include finding a way to pay the costs and support themselves, coping with unexpected financial challenges, and repayment following training.
Costs of Medical School
- In the 2020–2021 school year, the median tuition, fees, plus health insurance for U.S. public medical school was: $39,150 (in-state), $63,546 (out-of-state), and $64,053 (private medical schools)
- There is a fair amount of variation in tuition from school to school.
- The mean debt for medical students graduating in 2020 was $200,000.
- Some schools (e.g., Weill Cornell, Columbia) offer debt-free financial aid to qualifying students, that is, there is nothing to pay back upon graduating.
Source: Shammassian Academic Consulting (includes list of tuition for each school)
Resources for Student Financial Concerns
- Financial Aid – Association of American Medical Colleges (AAMC) “FIRST” resource: Financial Information, Resources, Services, and Tools. Information on Paying for Medical School, Managing Your Finances During Medical School and During Residency, Financial Aid Fact Sheets
- Loan Repayment/Forgiveness/Scholarships – Searchable database on state and federal loan repayment, loan, scholarship, and other programs database
- Refinance Student Loans – Example of one company
Other Resources for Realistic Expectations in Medical School
- The Princeton Review – What to Expect in Medical School
- USNEWS – Why Medical School May Not Be the Path for You
- AAMC – Navigate Your Journey from Pre-Med Through Residency and What Medical School Is Really Like
- American University of Antigua, College of Medicine – 10 things you didn’t know about medical school.
- Peterson’s – A Brief Synopsis of Medical School – From First Year to Residency
II. Clinical Training Stressors
The Top Clinical Training Stresses
The following stressors often experienced by clerkship students were identified in research with 3rd and 4th year students at one medical school (Houpy et al., 2017). They are in order with the ones most often of concern at the top.
- Poor team dynamics – 82% of 3rd year students, 75% of 4th year students
- Difficult encounters with other staff- 58% of 3rd year students, 38% of 4th year students
- Systems issues- 45% of 3rd year students, 42% of 4th year students
- Dealing with difficult patients- 30% of 3rd year students, 38% of 4th year students
- Unanticipated deaths- 18% of 3rd year students, 31% of 4th year students
- Difficult family discussions- 10% of 3rd year students, 28% of 4th year students
- Chronic narcotic patients- 13% of 3rd year students, 15% of 4th year students
- Medical errors- 15% of 3rd year students, 13% of 4th year students
Tips for Transitioning to Clinical Training:
Develop skills and greater self-efficacy in:
- Applying clinical skills learned in pre-clinical classes in the real world context.
- Adopting a self-directed learning strategy including looking up and reading about or seeking experience with what you don’t know. You will need this skill throughout your medical career.
- Developing relationships with the clinical team, understanding the hierarchy
- Understanding your role and some clinic protocols, such as patient handovers. Learn your role in each setting as quickly as possible. Tip: Different specialties have different expectations.
- Dealing with the workload.
Learning clinic protocols and skills is like learning a new culture, language, and rules. It takes time. Take advantage of any programs offered that inform you of your future roles, rules/expectations, resources, and supports. Some clinics will provide you an introduction. If not, be proactive and ask a peer who has been through the clerkship for any tips they can share.
If, near the end of a rotation, you have missed an opportunity to learn something critical in a clerkship, be pro-active and bring it to a supervisor’s attention, in case there is still a chance to get that experience.
Potential Responses to Difficult Team Interactions: INTERVENE
The following is taken from research on a curriculum to foster medical student resilience published by Bird et al. (2020):
The following acronym describes steps to work with challenges when they occur in a team:
|N||Note the best management strategy|
|T||Think through other factors at play|
|E||Elect the encounter|
|R||Regulate the amount of feedback|
|V||Verify the common goal|
|N||Narrate specific examples and provide alternatives|
|E||Enlist help from others|
Details of the INTERVENE steps:
- Intervening early: Early interventions make a useful response easier. For example, a 3rd year clerkship student notices that the senior resident on a clinic rotation only talks with the intern about patient updates. So the student feels they are missing out on this educational opportunity. If they ask to be included in a timely way, they may get the educational experience they want; if they wait until the end of the rotation and complain when asked for feedback, they miss out on the educational opportunity.
- Note the best management strategy. Different situations call for different strategies. Options include:
- Avoid – Denying the existence of conflict. May be okay in the very short term, such as for 1 shift overlap
- Accomodate – Letting the other party decide
- Adaptation – Working with or around differences
- Compete – Aggressively pursuing ways to achieve your win
- Collaborate – Actively looking after your own interests but not losing sight of the interests of others. Best for 2 students on the same team. (Saltman et al., 2006; Bird, 2020).
- Think through the factors at play. Don’t take it personally. Examples of factors involved in difficult team interactions include personal factors that can lead to conflict (Lorenzetti et al., 2013):
- Attitudes and Mental health/Well-being status – Burnout, insecurity, uncertainty, negative bias, anxiety/depression
- Conditions – Time pressure, sleep deprivation, overwork, personal health problems, situation stressors
- Knowledge – Limited medical knowledge, limited knowledge about teamwork
- Skills – Difficulty with communication, easy frustration, difficulty expressing empathy, difficulty providing effective and respectful feedback For example, a senior clinician may neglect to take the time to teach you something due to a competing priority, such as a patient’s well-being. They may be caught up in the demands of doing their job well and not intentionally slighting you. They may be not well-trained in giving constructive feedback or have character flaws or limitations in emotional intelligence that have nothing to do with you, etc.
- Elect the encounter. Choose an appropriate setting and time for discussion of the difficulty.
- Regulate the amount of feedback. Think about what is most important. There are situations where it is appropriate to provide constructive feedback to another team member, keeping the team goal in mind, so that the team can function better and achieve its goal. In other situations, venting your frustrations when nothing good will come of it may not be a good idea; it may be best to talk with a trusted peer.
- Verify the common goal. See the larger mission for the team. Is the goal you are trying to achieve an agreed upon goal of the whole team? Junior members of the team can respectfully check with senior members to clarify their understanding the team goal. It may be that you need to be more flexible than you realized.
- Explore intentions. Don’t assume the intentions of others. Consider the possibility that what seems like an obvious intention may not be accurate. If it is possible to discuss productively and respectfully, exploring the intentions of the other person may be helpful.
- Narrate specific examples and provide alternatives. Point out specific examples of problem actions/behavior. Giving concrete examples is important, so that team members understand the problem. Offer an alternative that you think would be effective. Note that you cannot request a change in personality.
- Enlist help from others. When needed, get the right help involved. Some possibilities are the resident, intern, attending, chief resident, clerkship director, dean, ombudsmen, fellow students, career advisor, faculty mentor, supervisor, etc. However, many students say that they prefer to talk with peers about the stresses of medical school.
Source (with minor changes):
- Bird A, Tomescu O, Oyola S, Houpy J, Anderson I, Pincavage A. A curriculum to teach resilience skills to medical students during clinical training. MedEdPORTAL.2020;16:10975. https://doi.org/10.15766/mep_2374-8265.10975 Appendix D. Lesson Plan – Difficult Team References
- Bird, A. Tomescu, O. Pincavage, A.: A Novel Medical Student-Driven Multicenter Resilience Curriculum. Society for General Internal Medicine : 2018.
- Bird Amber, Tomescu Oana, Oyola Sonia, Houpy Jennifer, Anderson Irsk, Pincavage Amber. A Curriculum to Teach Resilience Skills to Medical Students During Clinical Training. MedEdPORTAL. 2020;16:10975. doi:10.15766/mep_2374-8265.10975. PMID: 33015355 PMCID: PMC7526502.
- Lorenzetti C, Jacques CHM, Donovan C, Cottrell S, Buck J. Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors. Am Fam Physician. March 15, 2013;87(6):419-425. PMID: 23547575.
Appreciate What Is Good on Your Team
Appreciative Inquiry Principles: To Foster Positive Organizational Culture (Review of an AMA course)
This course, offered by the AMA, aims to build a positive organizational culture in medicine by asking unconditional, positive questions to identify what is best in the organization. The subtitle sums up the general approach: Ask “What Went Well?” to foster positive organizational culture, as opposed to starting with or always emphasizing “What Went Wrong?” This approach can be applied to medical teams, for example, the one you are assigned to in a clerkship. The course recommends asking the following questions about an organization, for example:
• What is something that went well for you today?
• What was a success that you had recently?
• Can you tell me about a recent positive experience in your work or personal life?
• Has a patient or family member told you that you made a difference?
• How do you help to make our workplace more productive and positive?
• Have you noticed a team member go beyond the call of duty sometime this week?
• Can you recall a situation this week in which you had a chance to learn and grow?
• Think of a recent successful team project. What made the team so successful?
Try asking yourself the above questions about your team, especially if you are having difficult interactions with them.
May N,Becker D, Frankel R, Haizlip J, Harmon R, Plews-Ogan M, et al.AppreciativeInquiry in Health Care: Positive Questions to Bring Out the Best.Brunswick, Ohio: Crown Custom Publishing, Inc.; 2011.
AMA.Practice transformation series: using appreciative inquiry to fostera positive organizational culture. 2016.
From: AMA. Appreciative Inquiry. Stepsforward. AMA Ed Hub. August 31, 2016.
Evaluations: When Struggling with a Supervisor’s Critique
The following tips can be useful if your self-esteem and self-confidence feel like they have taken a hit after receiving a clinic performance report. For example, if you feel bad about making a mistake or were impacted by the way a critique was delivered, the following may help:
Tips for Dealing with a Harsh Critique:
- Focus on the part that will make you a better doctor and learn from it.
- Accept the things you can’t change, such as the supervisor you are assigned, their personality, or skill as a teacher.
- View the big picture. This is a temporary assignment. This is just one experience of many as you grow as a clinician.
- Remind yourself the difficult moment will pass.
- Use distractions. If you find yourself ruminating about it, try talking with a friend about something completely different.
- Focus on factors that you can control, such as your performance during the remainder of this rotation or in your next assignment.
- Choose your battles. Was there something you feel was inaccurate in the critique? What do you gain or lose by arguing your case?
- Turn to healthy coping strategies that have worked for you in the past.
Optimal Feedback on Clinical Performance
The following principles for faculty/supervisors providing effective and supportive feedback to medical students (Ende, 1983) may or may not come naturally to someone put into a supervisory role. Medical residents, in particular, who are put in charge of clerkship students, may not have been trained in these skills or may find them challenging to achieve while learning new clinical skills themselves and providing patient care. Review these principles so that you understand the ideal way to provide feedback. Consider that if a supervisor does not follow these principles, it may be that they lack skill and are not making a personal attack. You may find it helpful to focus instead on the useful part of the feedback and what you need to do to advance your skills as a physician.
Feedback to medical students should help students and faculty:
- Work as allies with common goals
And feedback should be
- Well-timed and expected
- Based on first-hand data
- Regulated in quantity
- Limited to behaviors that are remediable
- Descriptive and non-evaluative
- Based on specific examples not generalizations
- About decisions and actions rather than assumed intentions or interpretations
Ende J. Feedback in Clinical Medical Education. JAMA. August 12, 1983;250(6):777-781. PMID: 6876333.
What Are Your Strengths and Positive Qualities?
- Take 2 minutes to answer this question: What qualities do you have that will make you a good doctor and succeed in achieving your mission or live congruently with your purpose? Writing it down can help.
- Look back at what positive qualities you wrote about in your application to get into medical school and use them to expand your list.
- Ask someone whose opinion you value and who you trust to list what they see as your strengths and positive qualities. Did they identify any that you need to add to your list? Notice any good feelings you have when hearing about these qualities.
- Put your list away, come back to it again later, and see if you can expand on it.
- Refer to your list regularly, especially when going into a tough situation or after experiencing a setback.
- Take one item from your list per week and think about how you can apply it to become a good doctor and, more specifically, achieve your mission and live congruently with your purpose.
Medical System Issues and Burnout
The medical system itself contributes stresses that can lead to burnout in staff and the effects may be felt by medical trainees. The AMA recently listed 12 such factors that drive up physician burnout (Berg, 2020):
- Attempts to improve the healthcare system, such as standardization, productivity targets, and cost controls can pressure physicians to act contrary to their values and decrease their sense of autonomy and control.
- Laws, regulations, and standards are sometimes created without considering the administrative burden which drains time from patient care.
- Healthcare reform and multiple payment systems’ complex rules, processes, metrics, and incentives are a source of administrative burden and financial pressures.
- Medical record documentation and coding requirements by multiple sources, sometimes inconsistent with each other, add another time-consuming burden.
- Quality measurement and reporting, in addition to the many benefits, add a duplicative performance measure that is not clinically relevant.
- Prescription drug monitoring programs, which help avoid polypharmacy and identify drug-seeking behavior, have state-run databases that vary and can be burdensome to use.
- Maintaining privacy and security of health information and protecting electronic health information adds steps to the administrative burden.
- Prior authorization process for medications, diagnostic procedures, and referrals varies with payers and often involves requests for additional information. This task is sometimes passed on to medical students. Aside from the administrative burden, this can interfere with timely patient care and autonomy in medical practice.
- Professional licensure at the state level often involves answering questions about physical and mental health status, which can result in physicians not seeking treatment for treatable illness out of concern for how it may impact their career. (See additional AMA resource on the effect of getting mental health treatment.)
- Maintenance of certification requirements for specialty practice is time-consuming and handled on one’s own time. This process is being evaluated for possible change.
- Professional liability insurance requires disclosure of mental health concerns, which is a barrier to seeking appropriate treatment. Malpractice lawsuits also contribute to burnout. Using emerging technology adds uncertainty and anxiety about liability risks.
- The patient-physician relationship has changed to a more patient-centered collaborative one, but a downside is less trust in physicians and the healthcare system.
What Is Worth Trying to Change?
Develop discernment about which issues are important enough to take on and bring to the attention of the administration. You may have more impact if you act with student organizations or other groups available for taking collective action. Learn about and consider what consequences there may be.
- Find out how it is handled when students meet with Deans or clerkship directors with problems. Does a person being reported get notified?
- Make informed decisions about how best to spend your energy. Is the issue one that is worth taking on? If not, keep your focus on your most important goals and let the rest go.
Sometimes, it may be difficult to identify exactly what changes clinic leadership could make to meet the healthcare workforce’s needs. A review of research on developing resilience to combat burnout, written before the pandemic, identified factors that leadership can foster to help develop resilience in nursing staff: (Quick Safety, 2019)
Factors that leadership can foster to help develop resilience in staff
- Safe and positive work environment
- Enhance meaningfulness of work
- Invite participation in decision making
- Express confidence that employee can fulfill expectations and recognize accomplishments
- Facilitate goal attainment. Improve employee skills and knowledge and provide resources for effective performance
- Provide autonomy, minimize constraint of rules and restrictions, allow efficiency and creativity
Leadership strategies, such as debriefing and validation
What the Healthcare Workforce Needs from Leaders (IHI Multimedia, 2020)
The Institute for Healthcare Improvement recently published a list of what leaders in healthcare could provide to promote well-being in the workforce:
- Meet the needs of the workforce, including the basic needs of food, PPE, and childcare.
- Use effective and open communication, with inclusive listening sessions in which leaders show curiosity and empathy.
- Leaders acknowledge their personal vulnerability and humility.
- Lead the way in overcoming negative bias by asking “What is going or working well?”
- Normalize help-seeking
- Acknowledge losses by honoring them, while at the same time, present a path of hope for going forward.
- Discuss changes that may not have been possible in the midst of crisis, but that should be implemented to prepare for any future crisis.
Berg S. The 12 factors that drive up physician burnout. American Medical Assoc. 2020.
IHI Multimedia Team. How Leaders Can Promote Health Care Workforce Well-Being. 2020, December 10).
Quick Safety. (2019). Developing resilience to combat nurse burnout. The Joint Commission.
Challenges In Working with Patients
Clinical training includes how to help all patients, even those who present a challenge to the way you would like to help them. Developing this skill includes learning a patient-centered approach to treatment including respecting their values, understanding what motivates them, communicating effectively, and recognizing and helping patients with their fears and anxiety. Some of the situations that many medical students find challenging include:
- Patients with addictions who do not follow recommendations due to their addiction
- Helping patients who are known to have hurt others (See resource “Ignoring the Sins of Our Patients” below).
- Patients with personality disorders, including those who demand extra attention or seem to want to “pick a fight.”
- Patients who do not want to work with a medical student due to their low level of experience.
- Patients who do not want to work with a healthcare provider of a particular sex, race, or ethnicity.
- Patients who make inappropriate sexual advances.
Groups of Students That Experience More Mistreatment by Patients
Analysis of data from over 72% of graduating medical students obtained via the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire found that mistreatment (includes by administration, faculty, staff, patients, peers) was reported more often by:
(data is reported in this format: one episode/two or more episodes)
- Females more than males: 40.9%/28.2% vs. 25.2%/9.4%, p<.001 (format is one episode/two or more episodes)
- Minority students
- Asian: 31.9%/15.7
- Under Represented Minorities URM: 38%/23.3%
- Multiracial 32.9%/11.8%
more than White 24%/3.8% p<.001
- LGB students more than heterosexual students: 43.5%/23.1% vs 23.6%/1%, p < .001
External Readings on These Topics:
- Ignoring the Sins of Our Patients. Commentary by Amy Faith Ho, November 23, 2020. Medscape.
- Pushing Back Against Patient Bias – Stacy Weiner, January 17, 2020, AAMC.
- The Do’s and Don’ts of Calling Out Patient Behavior – Ethics, AMA, January 23, 2019
- How to Address Inappropriate Patient Behavior – By Healthleaders. 2018. Includes tips such as practicing phrases, such as, “‘let’s keep it professional”, so that you are ready to use them when needed.
- Medical Schools Need to Get Better at Addressing Structural Racism article by Yoshiko Iwai, August 2, 2020, Scientific American, Policy & Ethics | Opinion.
- White Coats for Black Lives: Mission – “To dismantle racism in medicine and promote the health, well-being, and self-determination of Black and Indigenous people, and other people of color.”
- The Prevalence of Medical Student Mistreatment and Its Association with Burnout – Research article by Cook et al., 2014.
Coping with Patient Death
Coping with Grief: How Physicians Can Heal After Patient Deaths – An article on the website Physician Practice.
- Create a safe space – It is important to acknowledge your emotions. Leadership can play a supportive role by creating opportunities for the expressing of emotions.
- Normalize grief support – Similarly, leadership can play a role in explaining that it is normal and accepted to access your organization’s formal grief support resources.
- Let go of guilt
- Prioritize self-care
(by Deborah Shute, September 23, 2019)
External Resources for Additional Reading:
- Doctors and Death: The Effect of Patient Death on Physicians – Lecture from UNC’s course Death and Dying III.
- Doctors grieve, too – A lesson I did not learn in medical school – A blog by a Pediatric resident on MedPage.com
- Physician Grief with Death – A review of the literature article by Randy A Sansone MD and Lori A Sansone MD, published in Innovations in Clinical Neuroscience, 20(4), 2012. Includes an overview of grief responses in physicians and ways of resolving the grief response.
III. Challenges of 4th Year Medical Students and Looking Forward to Residency
Some challenges become easier by the 4th year of medical school, such as getting along with other clinical staff, however, others that arise from more interaction with patients and more clinical responsibilities may increase.
Common Challenges Experienced by Physicians in Practice
Medical students and residents increasingly experience some of the following challenges experienced by practicing physicians as they gain in responsibility.
Common Sources of Conflict Among Physicians (Saltman et al., 2006).
- Information mismatch:
- “The results you gave me were for the wrong patient” (skills)
- Inadequate information:
- “I don’t have the patient notes in front of me” (organization)
- Information overload:
- “The patient has three large files!” (organization)
- Ambiguous jurisdictions:
- “I don’t know who has the sign off on that issue.” (prohibitive environments)
- Ambiguous instructions:
- “The duty registrar told me not to do that” (skills and environment)
- Communication barriers:
- “They never return phone calls.” (skills)
- Unresolved prior conflicts:
- “We always have a problem with the trust about the final report.” (priorities)
- Over dependency of one party:
- “We will have to wait until our budget is handed down.” (priorities)
Saltman DC, O’Dea NA, Kidd MR. Conflict Management: A Primer for Doctors in Training. Postgrad Med J. January 2006;82(963):9-12. doi:10.1136/pgmj.2005.034306. PMCID: PMC2563732. PMID: 16397073.
Tips for Transitioning to Residency:
Develop skills and greater self-efficacy in:
- Having collegial relationships with the multi-professional clinical team and understanding your role.
- Responding to increased pressures to treat patients quickly.
- Developing clinical skills expected of new residents that you might have missed during medical school rotations. There may be some holes in your training, because the rotations during school are brief and varied.
- Developing new clinical skills including patient management skills (dealing with violent patients or patients with mental illness, patients using non-allopathic medications), calculating drug doses, and performing new administrative tasks (e.g., obtaining consent for procedures and investigations, preparing certificates).
- Coping with
- Having more responsibility
- Adjusting to feeling less supported
- Managing uncertainty
- Making mistakes
- Sudden death of patients.
- Developing resilience and maintaining wellness.
Resources for Transitioning to Residency
- 5 things they don’t teach you in medical school (What you need to know about residency) by Chad Ball
- What is something one learned as a doctor that they never taught in medical school? (22 responses) by Quora
IV. Career Regret vs. Burnout and Potential Career Pivots: Taking Charge of Your Career
A minority of physicians regret their career choice. The rate of career regret by medical residents in one study was around 14% (Dyrbye et al., 2018); the contribution of the sometimes exhausting demands of residencies should be considered, however. The regret in this study was significantly associated with burnout symptoms, however, the direction of causality wasn’t addressed.
If you find yourself regretting your career choice, counseling may help you clarify the issue of whether you truly regret your career choice for yourself. It can help to take an attitude of taking charge of your career, by focusing on the parts you can control. Are there changes in the workplace or your contract that you could request that would improve how you feel about your work? Are the problems temporary? Also, be sure to notice the good parts of your career. If there are too many problems or a poor fit that you cannot change, and you find it really isn’t the right career for you, consider changing to something else.
Potential Pivots to Non-Clinical Careers
The following careers and places to work are some of the non-clinical options available for physicians who would like a change:
- Pharmaceutical companies
- Managed care companies
- Healthcare consulting firms
- Public health, local or federal, e.g. the FDA and CDC.
- Medical writing
- Healthcare tech, software, and app companies may have positions for physicians such as Chief Medical Officer or consultant
Partial Career Pivots
Working only part time in the clinic or in combination with another type of work may provide enough of a career change for some clinicians dealing with career regret:
- Consider locum tenens practice part-time and spend the rest of your time doing other things you love.
- If administration is appealing, consider a Medical Director position with some limited part-time clinical work
Resources on Career Regret
Medical school remorse. Do you have physician career regret? Article in Medical Economics. 2018.
Do you regret going into medicine? A Reddit discussion.
Regret After Leaving a Medical Career Behind Article published in 2019 by a physician. Includes a discussion of early retirement and a forum with comments on the subject. Source: Physician on Fire
Career Regret – Why Did I Go Into Medicine? A Lift blog by Dr. Brad Tanner
Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. September 18, 2018;320(11):1114-1130. doi:10.1001/jama.2018.12615.
Herrin J, Dyrbye LN. Notice of Retraction and Replacement. Dyrbye et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018;320(11):1114-1130. JAMA. 26 2019;321(12):1220-1221. doi:10.1001/jama.2019.0167. PMID: 30912842.Retraction and Replacement.
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