By Karla Arana
As a fourth year medical student going through the residency application process, I have been told that residency only gets harder, with increased responsibility and longer hours. Especially as a student applying to general surgery, many have warned me that the idea of work-life balance is not applicable to the field. Through conversations with residents and fellow medical students, I have noted that many find the clinical years to be the most mentally taxing. Between studying for step exams, studying for shelf exams, and constantly being evaluated by different teams on rotations, the stress can be difficult to manage. A study out of Harvard Medical School demonstrated the prevalence of depression in students at 27.2% and in residents at 28.8% (Study). In comparison, the prevalence of a major depressive episode among 18-25 year-olds in the general public is 9.3% (Study). Researchers have hypothesized different reasons for the increased prevalence of depression in medical students, including the competitive nature of the medical school curriculum (Study).
Many medical schools across the country have implemented pass/fail curriculums in order to help address medical student well being. It has been demonstrated that when compared to students with graded curriculums, students with pass/fail curriculums have less burnout, lower stress levels, lower rates of depersonalization and emotional exhaustion (Study). These findings have aligned with my own personal experiences as a student. At my institution, the preclinical years were a pass/fail curriculum, while the clinical years were a graded curriculum. The stress during the clinical years was much higher due to constantly being worried about how my performance affects my grade. In certain cases, a graded curriculum also encouraged students on the same team to become competitive towards each other.
My graduating class was also the first class to take Step 1 pass/fail. Many of my classmates still found the exam difficult, and many felt the pressure to learn the material well in order to apply it to the clinical setting and future shelf exams. While this change was implemented in order to alleviate pressure on medical students, it has transferred the stress to performing well on Step 2. Additionally, the shift towards a pass/fail curriculum and licensing exams has placed more importance on extracurricular activities and research. While steps have been made to address medical student burnout and stress levels, the pressures students face continue to persist.
While addressing how the medical school curriculum and institution affect student mental health and wellbeing, mental health stigma and access to care are also important factors to consider. A study published in Academic Psychiatry showed that out of students identified as needing services, the only group that was more likely to access care were those that were told to do so by others (Study). The study also found that students endorsed fear of academic/professional repercussions and stigma as reasons to not access care (Study). This demonstrates the need for discussions surrounding mental health to continue in medical schools and amongst medical students. As the medical profession continues to evolve, new stressors and demands will be placed upon students. In order to train the next generation of physicians, it is important to continue to find ways of improving access to mental health services and destigmatizing conversations regarding mental health.
Phillips, M.S., Steelesmith, D.L., Brock, G. et al. Mental Health Service Utilization Among Medical Students with a Perceived Need for Care. Acad Psychiatry 46, 223–227 (2022). https://doi.org/10.1007/s40596-021-01584-y
Reed D, Shanafelt T, Satele D, et al.. Relationship of Pass/Fail Grading and Curriculum Structure With Well-Being Among Preclinical Medical Students: A Multi-Institutional Study. Academic Medicine. 2011; 86 (11): 1367-1373. doi: 10.1097/ACM.0b013e3182305d81.
Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316(21):2214–2236. doi:10.1001/jama.2016.17324
Karla Arana is a fourth year medical student at George Washington University in Washington, DC. She currently serves as the medical student chair for the AWS blog subcommittee. She is currently applying to General Surgery, with an interest in transplant surgery. Her other interests include Global Surgery and community outreach.