The Impact of Adversity on Medical School Students

Introduction

Modern medical education is characterized by student populations under increasing stress levels, particularly as universities diversify to accommodate wider-reaching student bodies. This population of learners faces increased pressures, overwhelm, and financial burdens while navigating both the educational and application processes for medical school and the coursework and clinical duties during their matriculation. It makes sense that they also face compounding emotional and mental struggles that seem to defy their certainty in their abilities and their motivations for medicine, while also contending with external and professional adversities.

Medical students are expected to exhibit robust mental and emotional constitution and academic fortitude, skills that the stressful and rigorous world of medical school would feasibly hone in each individual. When adversity strikes, some students may take it on the chin and move forward, showing little damage from their ordeal. The majority, however, seem to emerge from their tribulations with a slightly different focus with respect to their personal or professional life, or both. Negative situations and their perceived impact on an individual can shape personal and professional growth, especially among those who will guide the healthcare industry in the "real world."

This study seeks to uncover the relationship between adversity and personal growth among medical students. It examines the severity of adversity experienced and the subsequent outcomes thereof, not solely with respect to personal growth alone, but also extends its voice to students who were and are supported throughout their time in medical school during any significant life transition. The investigation into the relationship between levels of adversity and students' personal growth suggests that the topic of resilient attitudes among medical learners has not exhausted its potential for educating and enlightening those responsible for caring for our nation's future physicians on an organizational level. Holding value in understanding 'what goes on after the adversity has passed' is essential in enhancing and augmenting support systems available to current and potential medical students, as we continue to protect the integrity of physicians across the globe.

Study of Published Works

Adversity is any form of chronic stress. In the context of medical education, adversity could be something that a student encounters, such as a low score on a test, the death of a patient, a professor yelling at them, or simply being unsure of what task to prioritize next. Once encountered, the impact of an adverse event is largely dependent on an individual’s resilience levels. Two theoretical frameworks have emerged with respect to the study of adversity: the micro-level perspective and a more macro-level construct. In a more micro-level analysis, stress stems from encountering adverse emotional, physical, and psychological impacts. Coping responses are the direct consequence of being "stressed out." Combining stress and coping results in the concept of distress. Support systems can mitigate perceived stress levels and may, therefore, reduce psychological and other forms of distress. College-aged students have a variety of institutional support systems at their disposal.

The prevalence of burnout and associated mental health issues in medical students and residents has received significant attention. Some of this research can be classified as a symptom-centered approach where the analysis is centered solely on "what causes people to get sick and how can we prevent it." More recent studies have taken a more salutogenic approach and investigated the underlying differences contributing to why most people don’t get sick, rather than focusing exclusively on those who do get sick. The effect of adversity, such as burnout, on future professional performance has been investigated and found to be harmful. While there is an extensive amount of literature describing the impact adversity has on medical students and residents vis-à-vis burnout and/or other forms of psychological or physical malaise, there is no empirical research describing the immediate effects of adversity on a medical student. Nor has there been any empirical research published that has specifically investigated how medical students cope with adversity outside of the question of stresses related to situational ethical issues and responses. Finally, even though adversity has many recognized negative effects, it has also been proposed and has a rich research history as a contributor to personal growth.

Methodology

The research design was informed by the research questions and mixed methods in data collection and thematic analysis of data. There were parallel qualitative and quantitative arms to the research design. The reasons for adopting a mixed methods approach were to maximize the sample, capture the diversity of experiences, and ensure a more in-depth understanding of individual perspectives compared to multi-responses.

Students were recruited from each year in the course to participate. We sought representation from participating sites in city, rural, and regional locations. It was intended that data would be analyzed once data reached saturation by site and by year group, with additional sampling to be potentially conducted if early findings indicated a lack of representation of some population subgroups. Consequently, no formal power calculations were undertaken for each participant group. Data collection commenced in late 2009, and it is anticipated that data collection will cease sometime towards the end of 2010. Consent was granted from each of the participating three medical schools involved in the project, with these agreements initially being facilitated by the schools' Directors of Learning and Teaching in Years 1 and 2 in consultation with members of the project team. The participants in the trial felt that these approaches were robust enough to ensure informed consent was gained. The project has also gained ethical approval for experiments involving humans.

Analysis will consist of comparing, contrasting, and synthesizing interview data across each stage of medical school, with the aim of developing a clear thematic summary explanation of the students' experiences. This will be reported. Together, the methodological design described above offers a multi-faceted examination of the many axes of adversity impacting student learning and medical education more broadly, giving voices to students in each of the three years of undergraduate medical education and representing metropolitan, rural, and regional Australian experiences. There are, however, several limitations to this methodological decision. These include research focus, social approval, and the sensitivities of exploring insider perspectives on stigma. The approach of focusing only on individuals self-reporting experiences, and not seeking an objective standard, brings to the fore subjective interpretations of adversity that, while more nuanced, may be socially shaped. This method cannot give a valid estimate of the problem in the whole population of medical students. It is, however, anticipated that the adoption of this approach will provide insights into a range of resilience and unacknowledged stressors for exploration in the evaluation of subsequent interventions. The sensitivities of discussing stigma, such as mental ill-health and disabilities that are not visible, can cause discomfort for students and staff. Informal consultations with students have been held to discuss and overcome concerns relating to this, and more broadly, to the instigation of the broader project. In the first year, funding and personnel were not available to carry out a random selection of participants from the entire participation group, and so the online survey was open to all students in the selected year groups across the three participating universities. Students were invited to participate in individual interviews following completion of the online survey. Overall, the strength of this method is its ability to give voice to insiders, both ideal types of inductively conceptualized types of adversity sulking towards the individual. Why not more in-depth, collective, or formal research?

Findings and Analysis

A total of 832 medical student responses were included in the final analysis. The data collected reflect the impact of adversity on medical students and develop themes such as the intrinsic effect of adversity on mental health, with many students identifying the onset of mental health decline with the start of their medical education. Quality of life, empathy, and general satisfaction and passion for life were also significantly impacted by adversity during medical school.

1) The medical students in our study identify a significant psychological and emotional impact from the adversity that they face in medical school; it is exhausting and overwhelming. The presence of predominantly negative emotional descriptions in our data also seems to correlate with one of the predominant physiological responses to chronic stress. Psychological and emotional exhaustion may be representative of burnout rather than simply stress. Physiological responses, while not explicitly asked for or analyzed in this study, were present in some students’ comments as well. About a quarter of the respondents listed that adverse events had led to a decline or introduction of mental health diagnoses, including depression, anxiety, stress-related disorders, or depression treatment. Participant discontinuation of medications for preexisting conditions to combat the effects of adversity also suggests a larger mental and emotional toll. An additional subset identified a diagnosis of chronic or autoimmune issues during medical school, which they attribute to the stress of their training. Symptoms described by participants included tension headaches, migraines, skin issues, sleeping problems, and chronic pain, which was likely contributed to by stress.

2) The themes that emerged from our data included life effects such as changes in career plans, personal and professional empathy, and quality of life and career satisfaction. Findings demonstrate that adversity can have profound, damaging, and multifaceted effects on medical students overall. Given the strong and consistent clinical response seen in the descriptions of adversity from medical students, there appears to be a greater personal impact than has previously been reported. These findings add urgency to the examination of factors contributing to resilience in medical students and also contribute to a greater understanding of factors that can contribute to the development and thriving of medical students. This multifaceted, overwhelming impact is supported by our theoretical approach based on the transactional model of stress and coping. While the side of vulnerability and threat (problems) themselves have been previously described, the association of the impact this has on many other aspects of medical student and physician well-being is unique. Our data, therefore, provide deeper insight into the multifaceted, devastating experience of adversity that goes well beyond simple "stress."

Conclusion and Recommendations

The findings in this research identified that finding the strength to discuss adversity with others was important and helped the students to understand that the problems were not unique to them. There is significant quantitative evidence to show that experiences of negative life events affect the well-being and academic success of those who are not trainee doctors. The research discussed here supports this understanding, as it has shown that negative life events can result in academic delay for first-year medical students. However, it is not only the adverse life events that have the potential to disrupt the education of these students. Young doctors learning about their future practicing as medical professionals that the public expects necessitates exposure to new academic knowledge and the breaking of current beliefs. Yet caution is needed when interpreting this work, as there is no direct evidence that indicates that life events have an impact on medical students or doctors.

Indeed, active management mechanisms to ameliorate individual adverse effects are being advocated, such as measures at examinations to ensure that these students are assessed fairly. Nevertheless, there is a prevailing culture that medical students should be able to manage the problems that they encounter without it impacting their education. However, medical students who are better able to deal effectively with the problems may develop a psychological reserve or resilience with which to address subsequent adversity in an improved manner. Hence, there is an onus on operations to work towards developing resilience in students and to deliver services that will allow them to minimize the negative impact that lies in daily experiences, as well as to support those who have experienced an adverse life event but are unable to demonstrate resilience effectively. However, it is not possible by one study to assess the level of resilience in the students. That might be one area for further research that this study could indicate. In conclusion, although the adversity affecting first-year medical students does rapidly decrease, this is an area that warrants repeated future studies in this and other doctor groups. The negative impact on academic study and emotional well-being on a subset of these students was particularly concerning.

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