Between a rock and a hard place

Helping medical students cope with the rigours of undergraduate training

Much has been published about the stress and hardship endured by medical students during their undergraduate training. Several determinants of this stress have been investigated, such as financial hardship, relationship difficulties, and heavy work schedules. ² Medical staff attitudes and poor teaching techniques stand out as affecting students' self esteem. They influence their academic progress, personal lives, careers, and, ultimately, patient care ^{1 3}

The debate about the causes of this stress and about whether it is possible to alleviate this suffering continues. Unfortunately, it is still believed by some that training should be an “initiation rite” into medicine and abuse a feature of it,⁴ and the literature continues to justify that abuse, which is sometimes sexual.⁶

Studies have outlined student abuse by teaching staff, describing incidents where students were made to feel small and patronised, often publicly. In one report over half of the students studied reported mistreatment during their medical education and more women than men cited instances of public humiliation.⁷ Whether this is a consequence of abuse occurring more frequently towards women students is not known. It may be that women feel more able to discuss difficulties than men do.⁸

Being “taught by humiliation,” where students are publicly criticised for their lack of knowledge and personally insulted or abused, is undoubtedly a mutual “learning experience” for all doctors at some point. Despite many recent advances in medical education there are still marked numbers of medical teachers who use negative reinforcement supposedly to stimulate learning. Some students perceive this negative feedback in a particularly condemning fashion.

The phrase “self fulfilling prophesy” describes how one student I interviewed felt about a teaching experience: “Well if somebody's decided that you might not be a doctor, you're going to be rubbish anyway, it just helps you to become more of an idiot.” ⁹

Some medical teachers are not naturally gifted to facilitate students' learning. Others conduct themselves in such a manner as to concern most students and cause a great deal of distress to a minority. The importance of appropriate role modelling for all students where students observe how best to deal with difficult patient and doctor interactions and are helped to develop professional attitudes is emphasised.¹⁰ Unfortunately, some students will not have a good relationship with their teacher and may find this devastating. “There were an awful lot of negative comments about my performance and it was noticeable that there was no positive feedback. They may forget exactly what they said but you take it on board especially when it's about your performance. I will dwell on this for ages.” ⁹

Students try to cope by using disengagement strategies, such as not turning up and mentally switching off.¹¹ They should realise that such strategies are associated with increased anxiety, depression, and decreased motivation. Engagement strategies, such as seeking support from friends, rationalising by thinking through events, and self direction where the student personally attempts to alter the outcome, tend to have a more favourable outcome.¹²

The core curriculum for medical students should include details about appropriate coping methods.¹³ Alternative support systems of mentoring, particularly for women students, developing self help groups, and strengthening the tutor system need further exploration. The provision of a professional counselling service that is seen by the students to be independent of the medical school may also be necessary.

Students need medical teaching staff to respond more directly and efficiently to their difficulties. This requires a higher specification of teacher training both in effective instructional methods and pastoral care of students. Appropriately trained and practising teaching staff should then be recognised and accredited in a standardised way.

It is time to break the cycle of an abused student becoming an abusing teacher. In this era of evidence based medicine the excuse “it was good enough for me” does not stand up. We have looked at our medical curriculums, now we need to look at our teachers, because in producing tomorrow's doctors we also form tomorrow's teachers.

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2. Archer L, Keever R, Gordon R, Archer R. The relationship between residents' characteristics, their stress experiences, and their psychosocial adjustment at one medical school. Acad Med 1991;56:301-3.
3. Rosenberg D, Silver H. Medical student abuse. An unnecessary and preventable cause of stress. JAMA 1984;251:739-42.
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