|Year : 2021 | Volume
| Issue : 2 | Page : 152-156
Medical student reflections: The impact of changing aspirations and expectations on wellness
Dhwani Ravi1, Reuban Roshy1, Jaee Milind Naik1, Suhas Chandran2, Sanju George3, Priya Sreedaran2
1 St. John's Medical College, Bengaluru, Karnataka, India
2 Department of Psychiatry, St. John's Medical College, Bengaluru, Karnataka, India
3 Centre for Behavioural Sciences and Research, Rajagiri College of Social Sciences, Kochi, Kerala, India
|Date of Submission||27-Mar-2021|
|Date of Decision||14-Jun-2021|
|Date of Acceptance||17-Jun-2021|
|Date of Web Publication||30-Jun-2021|
Dr. Sanju George
Centre for Behavioural Sciences and Research, Rajagiri College of Social Sciences, Kalamassery, Kochi - 683 104, Kerala
Source of Support: None, Conflict of Interest: None
As healthcare workers around the world teeter on the verge of burnout, exhaustion, and mental illness in the wake of the COVID-19 pandemic, this article seeks to discuss the wellbeing of a significant demographic: The medical students. We describe the effects of expectations on medical student wellness, whether regarding themselves, their college experience, their future, the profession, or the people around them. Recognizing these as potential sources of problems and future burnout, we propose possible interventions that could rectify these issues and promote their well-being.
Keywords: Medical student, medical student expectations, mental health, wellness
|How to cite this article:|
Ravi D, Roshy R, Naik JM, Chandran S, George S, Sreedaran P. Medical student reflections: The impact of changing aspirations and expectations on wellness. Indian J Soc Psychiatry 2021;37:152-6
|How to cite this URL:|
Ravi D, Roshy R, Naik JM, Chandran S, George S, Sreedaran P. Medical student reflections: The impact of changing aspirations and expectations on wellness. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Oct 28];37:152-6. Available from: https://www.indjsp.org/text.asp?2021/37/2/152/320208
| Introduction|| |
There has been a rise in the prevalence of burnout and mental illness among medical students in India and the world., This raises the necessity to critically evaluate the source of this problem and systematically address it. The new competency-based medical curriculum has made undergraduate medical education more holistic and integrative. We believe that this should be taken as an opportunity to prioritize student wellness.
William Shakespeare said, “Expectation is the root of all heartache.” The authors feel that this rings true even with respect to medical education. In this paper, we discuss the expectations and aspirations of medical students. We deliberate upon the significant impact of transition into medical college from high school, the overwhelming nature of the quantity and quality of the coursework, student outlook on the future, and perceived support systems for students. We finally examine the impact of these factors on student wellness and propose some methods to address them.
| A Time of Transition|| |
From the comfortable workload in school, one is thrown into the vast expanse of medicine, where there is no dearth of information, all in a language that seems completely foreign to a novice in the field. In addition, medicine attracts highly driven, competitive, intelligent, and goal-oriented candidates, who frequently were the high-achievers in their respective schools; thus, students must strive harder for academic success. Many medical students also have the desire to reclaim with a vengeance all of life's pleasures that they sacrificed in preparation to enter the medical college. While these academic and extracurricular expectations and demands can in themselves be overwhelming, the real challenge lies ahead: The medical profession itself.
The habits formed while preparing for the competitive medical entrance exam often become exaggerated: Many medical students sleep only for 4–5 h per night, eat irregularly and unhealthily, and don't make time for fitness or other healthy leisure activities.,, These factors can contribute to poor physical and mental health among medical students' and perhaps also their patients' health, as research has shown that healthier physicians are more likely to advocate better for healthier lifestyles in their patients.
| “More the Knowledge, More the Learned Helplessness”|| |
Medicine forces one to confront human suffering. As ace competitors, most medical students have grown up as healthy children, with limited personal exposure to illnesses before entering medical college. The sudden thrust into the world of pathology and disease, mortality, and the fragility of human life can be overwhelming. It is understandable that this immersion leads to many medical students developing health anxiety (Medical Students' Syndrome). Health anxiety symptoms have been reported in up to 70%–80% in some samples, and in India, in 1 in 7 medical students.,,, A 2nd-year medical student said:
”A glance at a health anxiety questionnaire told me all I needed to know: My answers tended to be “often” or “always” for almost all the questions.”
This overwhelming reality of morbidity is coupled with the helplessness that as medical students, they do not have the tools to address this suffering yet. However, friends and family members will continue to ask students for medical advice, hand them scans and lab reports that they do not yet know how to interpret and deny them the opportunity to admit that they have not yet achieved the required proficiency!
| The Price of Ambition|| |
Students enter medical college with ambitions soaring, either their own or that of their parents. A 12th standard medical aspirant says, “Medicine has enthralled me for as long as I can remember. In my mind's eye, the life of a medical student is encompassed in a stark dichotomy: Rewarding but exhausting, challenging in the best way but at the same time in the worst way, glamorous in some ways but not in others.”
Yet, feelings of self-doubt slowly trickle in once one joins the course. It is difficult enough to keep up with the breakneck pace of the medical coursework, and then one is faced with the prospect of preparing for MD/MS entrances/courses. The demands of the “next stage” force students to overcommit, exploring opportunities like research and extra observerships, and/or coaching classes. This can contribute to fatigue and early burnout. As a final year MBBS student put it: “We are all struggling the underachievers just to get through, and the overachievers to cope with the weight of their ambitions and the work needed to reach there.”
| Looking at the Future|| |
As a child fantasizing about a career in medicine, it is easy to imagine being a deeply specialized surgeon or physician, without realizing the enormity of the time commitment and the complexity of the subject. However, as medical students are exposed to the immense amount of work required to enter the field of their choice, they are faced with uncertainty. Many prefer to settle for what they get, rather than fight for what they want. Some students choose to leave medicine entirely, opting for fields as diverse as Masters in Hospital Administration or civil services.
| Seeking Greener Pastures: A Desire to Survive?|| |
Doctors today face some unbelievable challenges. Statistics suggest that up to 75% of doctors have faced violence at work. One wonders if this is what medical students knew was their destiny when they signed up for medical colleges. One wonders whether they were prepared to be stigmatized and shunned for treating COVID-positive patients during the pandemic, despite being the only thing standing between the virus and the public.
It has been noted that doctors in India experience extremely high levels of burnout (up to >90%), stress and depression (up to 30%). Medicine is also the profession with high suicide rates. All these alarming statistics raise the question: Why would anybody voluntarily enroll in such a profession? Has the practice of medicine changed from a “noble, respectable” profession to an exercise in masochism? When students encounter such news, or worse, see their own seniors go through something like this, can they be blamed for wanting to leave the country, not to thrive, but to just survive?
As undergraduates, one gets to observe the intricacies of the Indian medical system and the workload that looms if one were to practice in the country. If the long hours of work during the residency in India were not daunting enough, the highly competitive entrance test becomes prohibitively intimidating for many, who move on to what seems like the path of less resistance abroad. With better pay, more humane working hours and a lower daily patient load, not to mention more stringently enforced rules to defend doctors from violence, the emotional wellbeing of doctors working abroad seems to be better accounted for than that of their Indian counterparts. To the young medical student, this plays a major role in deciding where he wants to make a career for himself.
| Medical Student Expectations on the Impact Senior Students can have on Their Wellbeing|| |
Seniors in medical college play a variety of roles in molding and facilitating the adjustment of medical students. At first glance, the curriculum seems massive to a young medical student. Not only do seniors act as a source of textbook recommendations and handed-down reading material but they also provide a perspective on the anxieties one may develop. Medical students find comfort in knowing that there are others who have traveled on the same path as they are about to and have made it through the ups and downs of it in the whirlwind of activity that is medical college. Seniors can point out which moments of the medical college experience are truly valuable in shaping one into a competent doctor. As the years draw on, juniors become seniors themselves and pay forward the same enduring support they received, resulting in a cycle of dependency and care.
However, finding the right seniors to approach can be difficult, especially early on in one's career. It is crucial for medical students to find seniors who have similar goals and aspirations as them. And yet, a large part of the medical experience must be faced by the students alone.
| Medical Student Expectations on the Impact Teachers/Mentors can have on Their Wellbeing|| |
The change in the teacher-student relationship from school to medical college is a large one. From receiving explicit instructions and being entirely dependent on teachers in school to being left to figure out one's own path in college, the adjustment might prove difficult for most. Yet, studies show that finding the right mentor during the medical undergraduate years can have a career-altering impact.,,, Mentors can help fill in the gaps in mentees' knowledge, guide them in developing a holistic approach to medicine, and help them feel better integrated into the medical system and less like they are at the very bottom of the food chain. This change in outlook can have a tremendous impact on the way they see their educational process. However, students rarely find the opportunity to interact with doctors who are not directly involved in their education process. If students are provided with the opportunity to pick areas of interest and work with faculty mentors that they can relate to they could grow into competent and dedicated professionals. Such a system would also help turn the system of education toward self-directed learning which is a cornerstone of medical education.
Postgraduate students and senior residents could also play an important role in this system of mentoring. Studies have found that training imparted by residents is just as effective as that by a senior clinician in the education of an undergraduate. Senior mentors offer benefits such as more experiences and learning related to a niche specialty and may be better equipped to offer career advice. However, a focus group discussion found that junior doctors had more experiences related to expectations and life immediately after medical school and student mentees ended up spending more time with them in contrast to the former. Mentorship by individuals who have passed through the same system improves the efficiency of the system and provides a personal touch to the mentor-mentee relationship. A recent study on a peer mentorship involving medical students and junior residents found that the perceived benefits are mutual. The junior residents receive valuable experience in the educational process, a chance to practice their professional acumen, and a sense of fulfillment and personal growth.
| Medical Student Expectations on the Impact Their Institution, University and the Medical Council can have on Their Wellbeing|| |
An exciting component of being a medical student is the idea of eventually being a member of a tightly-knit collective: The medical fraternity. With this sense of collectiveness come new expectations: Medical students expect to be regarded with importance and are expected to be accountable for their actions.
Yet, the reality may be duller. Medical education is somewhat removed from the medical profession itself, and the experience of being in medical college is more like being in school than like being in clinical practice. With the focus predominantly on examinations, attendance, and other education-centric priorities during the learning years, the jump from the final year to the internship can be a large, sudden shock.
Lately, as an intern, one is exposed to more paperwork than clinical work from the get-go. Clinical exposures like involving students in vaccination drives (Pulse Polio, and now the COVID-19 vaccine), disaster relief health camps, health awareness drives, and others offer an exciting glimpse of the path ahead and confer students with the sense of responsibility and accountability they so crave. It would be useful to structure the medical curriculum to ensure earlier and greater clinical exposure, at a healthy pace. The new competency-based curriculum has attempted to achieve this.
Another aspect that could help is the inclusion and promotion of nonacademic activities as an inherent component of medical education. This could include extracurriculars, humanities seminars, and so on. Such a change would greatly aid in the development of the communication skills of an individual, which is an integral part of medical practice and would make for a system that put out more eloquent, ethical, and well-rounded graduates.
We believe that the best way to take care of student well-being is to actively involve them in the formulation and implementation of such strategies. Our experience with student-led initiatives (e.g., conduct of mental health seminars and development of well-being booklets) suggests that these are very effective. Involvement in such initiatives enhances medical student wellbeing, as the process of actively thinking about and researching techniques related to wellbeing paves the way to the application of the same for others in their community as well as themselves.,
| Perceptions on Recreation and Substance Use|| |
Medical colleges do not exist in isolation, and medical students like other young people are learning the ropes of adulthood. Despite knowing about the stark differences between the life demands of medical and nonmedical streams, it is difficult for students not to compare their lifestyles. Sometimes they despair about whether they can live a balanced life like others around them – With both work and recreation in adequate amounts.
On the one hand, the newfound freedom of college life predisposes to curiosity regarding substance use, from which medical students are not exempt. On the other, recreational substance use may fit in well within the short spans of time that they get to destress between their tight schedule, deadlines, and relentless tests and evaluations. The numbers speak for themselves: Arora et al. concluded that nearly 20% of medical students in India use substances, while aware of their ill effects.
Some of them aggressively engage in recreational behavior almost as if to make up for the lost time. Medicine, however, unlike the other streams, offers little to no time for recover from frequent substance use without sabotaging one's progress in the course.
| Strategies for Including Wellbeing in Medical Curriculum – The Importance of Expectation Management|| |
Medical education is, without a doubt, difficult. Yet a large portion of this struggle stems from an expectation mismatch. No number of warnings regarding the intense workload come close to the first-hand experience, but providing aspiring medical students with an accurate picture of what to expect seems to be the best way forward. A newly joined 1st year MBBS student said: “The amount of work required might have been understated, but it might be because I did not take the advice (I received before joining) seriously.”
To this end, perhaps medical colleges could conduct short-term summer courses for aspiring medical students that give medical students not only exposure to the field of medicine but a scaled-down version of what the workload and student life would look like. Such programs are already in place in prestigious colleges abroad, and if brought to India would allow students to be sure of their decision to pursue medicine, or to not do so, with an informed first-hand personal experience, in addition to all the prerequisite information they gain from other sources., We note, however, that such programs would be effective only if made truly interactive and immersive. A final year BBA student noted: “I was inclined toward medicine since the ninth standard but at the time wasn't entirely aware of the commitment that it required. As I approached the NEET examination in the 12th standard, the stress was extremely high, and I was unable to cope with it. It made me wonder if I was cut out for medicine as after the examination, medicine required years of hard work and dedication.” A Cognitive Science major in the US agrees: “I thought I would have to give up absolutely everything outside of studying to keep up with the volume of work. I did not want to give up on my hobbies, and I did not want to spend so many years learning about a whole range of aspects of medicine when the brain was what I was really interested in.”
The new Medical Council of India curriculum brings with it a foundation course, intended to serve the very purpose of gradually introducing medicine to the student. It covers a variety of themes including the history of medicine, the roles, and responsibilities of a doctor in society, stress and time management, etc. Yet we question the efficacy of limiting such modules to the beginning of the course before students have had an opportunity to utilize the curated life skills taught to them. It might be more effective to have such sessions spread out across the 5 years of the course, to address the ongoing concerns of students as they experience them. The extremely tight schedule of the new competency-based medical education curriculum leaves no time during the “work-day” for extracurricular activities that could creatively stimulate students like poetry discussions or developing podcasts. Perhaps this could be incorporated through monthly or weekly extracurricular sessions after class hours if facilitated by students.
However, no amount of prospective expectation management will be able to patch up the inevitable shock that awaits one as one enters medical college. Thus, implementing changes at an institution-level that allow for all the stakeholders to be involved students, seniors, and teachers in the form of collaborative networks addressing wellness at all levels, and team-building exercises to strengthen bonds between students and seniors may be the real solutions.
The views expressed in this article, while supported and cited by studies conducted by others both in India and abroad, are those of the authors. We believe strongly that more studies are warranted to generate a sufficient evidence base to enact policy change. Further, the views in this article are shaped by the circumstances surrounding the COVID pandemic, its impact on healthcare workers and the related impact on well-being. While it is likely that the problems faced during pre- or post-COVID times may be different, the focus on mental health that the pandemic has fostered may set the ball rolling for long-term addressal of issues related to medical students' wellness.
| Conclusion|| |
While medical education offers students the unique opportunity to change lives, the course changes students' lives too. As Charles Dickens notes in “The Great Expectations,” a life of a good social standing and much wealth do not come with ease and without sacrifice. However, the authors believe that efforts should be made to prevent unnecessary sources of distress and to provide students with adaptive resources for life. The ultimate goal is to keep finding ways to keep students healthy, inquisitive, and compassionate as they eventually become doctors.
We would like to thank the students who contributed their anecdotes to our paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wolf TM. Stress, coping and health: Enhancing well-being during medical school. Med Educ 1994;28:8-17.
Farrell SM, Kar A, Valsraj K, Mukherjee S, Kunheri B, Molodynski A, et al.
Wellbeing and burnout in medical students in India; a large scale survey. Int Rev Psychiatry 2019;31:555-62.
Zappetti D, Avery J. Medical Student Well-Being: An Essential Guide. New York City, USA: Springer Publications; 2019.
Azad MC, Fraser K, Rumana N, Abdullah AF, Shahana N, Hanly PJ, et al.
Sleep disturbances among medical students: A global perspective. J Clin Sleep Med 2015;11:69-74.
Vibhute NA, Baad R, Belgaumi U, Kadashetti V, Bommanavar S, Kamate W. Dietary habits amongst medical students: An institution-based study. J Family Med Prim Care 2018;7:1464-6.
] [Full text]
Rao CR, Darshan B, Das N, Rajan V, Bhogun M, Gupta A. Practice of physical activity among future doctors: A cross sectional analysis. Int J Prev Med 2012;3:365-9.
Frank E, Carrera JS, Elon L, Hertzberg VS. Predictors of US medical students' prevention counseling practices. Prev Med 2007;44:76-81.
Singh S. Medical Council of India's new guidelines on admission of persons with specified disabilities: Unfair, discriminatory and unlawful. Indian J Med Ethics 2019;4:29-34.
Rohilla J, Tak P, Jhanwar S, Hasan S, Gaykwad R, Yadav R, et al.
Health anxiety among medical students: A comparison between preclinical and clinical years of training. J Educ Health Promot 2020;9:356.
Reddy IR, Ukrani J, Indla V, Ukrani V. Violence against doctors: A viral epidemic? Indian J Psychiatry 2019;61:S782-5.
Grover S, Sahoo S, Bhalla A, Avasthi A. Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study. Indian J Psychiatry 2018;60:175-88.
] [Full text]
Al-Samghan AS, Amanullah M, Batool F. Mentoring in medical education: Impact on the undergraduate students. Br J Pharm Med Res 2020;04:2132-44.
Busari JO, Scherpbier AJ. Why residents should teach: A literature review. J Postgrad Med 2004;50:205-10.
] [Full text]
Guhan N, Krishnan P, Dharshini P, Abraham P, Thomas S. The effect of mentorship program in enhancing the academic performance of first MBBS students. J Adv Med Educ Prof 2020;8:196-9.
Kukreja S, Chhabra N, Kaur A, Arora R, Singh T. Introducing mentoring to 1st
-year medical students of a private medical college in north India: A pilot study. Int J Appl Basic Med Res 2017;7:S67-71.
Ng KY, Lynch S, Kelly J, Mba O. Medical students' experiences of the benefits and influences regarding a placement mentoring programme preparing them for future practice as junior doctors: A qualitative study. BMJ Open 2020;10:e032643.
Rotheray S, Watts D. Peer mentorship for medical students and junior doctors. Med Teach 2012;34:673-4.
Medical Council of India. Competency based undergraduate curriculum for the Indian Medical Graduate. 2018;1:3-4.
Salana K, Maty S, Hage R. Alive and well: Encouraging long term health habits through implementation of student driven wellness programs in medical schools. Glob Adv Health Med 2020;9:2164956120973622.
Chandran S, Sreedaran P, Ravi D, Roshy R. Breathe: A Handbook for the Wellbeing of Healthcare Workers during the Pandemic and Beyond. Bangalore, India: St. John's Medical College Hospital; 2020.
Chandran S, Deshpande S. Surviving COVID-19 as a Medical Student. Sec. 3. Bangalore, India: Indian Medical Association; 2020. p. 96-97.
Arora A, Kannan S, Gowri S, Choudhary S, Sudarasanan S, Khosla PP. Substance abuse amongst the medical graduate students in a developing country. Indian J Med Res 2016;143:101-3.
] [Full text]