BURNOUT-
Match Day and Mental Health.
Personal Perspective: Preventing burnout in medical school.
Reviewed by Kaja Perina

KEY POINTS-
March 17 is national Match Day: an important day for reflecting on medical school.
Doctors have some of the highest rates of work dissatisfaction and suicide.
Many factors that contribute to physician burnout begin in medical school with 11% of students contemplating suicide.
Exploring medical school experiences can help identify how to work upstream to prevent physician burnout and improve mental health.
March 17 is Match Day in the US. At exactly 12:00 pm EST, medical students all over the country, including myself, will be handed an envelope enclosing our fate: the residency program where we matched and will train for the next three to seven years, depending on specialty. For many of us (and our support networks), this is the most momentous day of our lives— a culmination of innumerable sacrifices and hours of studying. But as I look forward to a career in psychiatry, I can’t help but look back at the mountain we traversed and think about how our experiences have shaped our psyches.

Compared to other professions, doctors have some of the highest rates of work dissatisfaction and suicide; around 300 physicians die by suicide each year.1 What I find particularly shocking is that this shift begins in medical school as we become immersed in the intense, often unforgiving culture. Upon entering medical school, studies find that medical students experience lower rates of depression compared with age- and education-matched peers. Yet, during medical school, the prevalence of depression jumps. Almost 30% of students report suffering from depression or depressive symptoms at some time during medical school, and 11% of students contemplate suicide.2 A confluence of factors contributes to these acute changes: the sheer volume of work, lack of sleep, stress from continuous high-stakes examinations, isolation due to academic demands, fears about future capability, feelings of inadequacy, and a non-supportive work environment.3

Emotional and physical crises don’t happen on your timeline.
This past year, I was rotating on internal medicine, providing care for patients with acute hypoxia and congestive heart failure. Meanwhile, on a medicine floor just like mine across the continent, one of my grandmothers died of respiratory failure while the other was hospitalized with a failing heart. Each day, I saw them in the patients I cared for—my grief unexpectedly bubbling up. In medical school, I’ve had three family members pass away and a few health issues, some of these occurring dangerously close to critical exams. The administrators were supportive but could only offer me the option of pushing through or taking the entire year off (one week off meant too many missed requirements).

Medical school has an unceasing deluge of tasks unkind to the unpredictability of life and healing. Through this, I’ve learned the importance of being in conversation with myself to assess (and reassess) my capacity to carry on or my need for time off. I’ve found it similarly essential to communicate with faculty and access support resources to process difficult emotions and prevent compounding them, which can create fertile ground for future burnout.

Emotions and self-worth inevitably become intertwined with our professional roles.
As a third-year student on my surgical rotation, the attending urologist began grilling me on the embryological development of the testes. When I blanked, he would not let up with his questions. He emphatically punctuated the diatribe with, “even a preschooler would have more knowledge than you.” For the rest of the week, my gaze was locked on the floor. I turned inward, questioning my self-worth and whether I deserved to be in medicine.

What that physician said to me was unacceptable: everyone deserves psychological safety in their workplace. When discussing the problematic behavior of senior physicians, one of my classmates said, “**** rolls downhill.” Perhaps, but that does not mean we should have to sit at the bottom and eat it. Improving mental health in medicine requires addressing people who sustain (historically) toxic work environments. In addition to changing this culture, personal reflection can help disentangle our worth from our white coats.

At my core, I know I am a good friend, partner, and person, but these transcendent feelings sometimes become hard to remember. To spend as much time in the hospital/library and sacrifice as much as we do — time, money, relationships, sleep, mental health — means that the line between job and personhood becomes blurred. Cognitive distortions often form and are exacerbated by society convincing us our profession is a “calling.” Given this, it is invaluable to find time for the activities and people that remind us of our identity outside of medicine to re-calibrate our self-worth.

Solidarity can and should take many forms.
“You’re going to meet all your best friends in medical school,” I listened expectantly to my dad (a doctor), as we drove to the airport before year-one orientation. It didn’t take me long to realize that immediate, sorority-like friendship is not everyone's reality. However, after four years, I can attest that a closeness does develop with classmates. This bond was not immediately obvious to me, and it didn’t come from expertly navigating medical school’s new social norms and high-school-like cliques.

I feel this solidarity as I hurry down the hospital hallways and lock eyes with another fourth-year student. We nod to each other with understanding eyes. This bondedness developed through the unspeakable amount we’ve jointly experienced: from innumerable lectures/exams to difficult rotations where we endured doctors with the emotional intelligence of sea sponges, fluid-filled nights on OB/GYN, or the heat of multi-hour skin grafts on burn victims where they keep the operating room hot. Our closeness is less High School Musical and more Lord of the Flies.

Not everyone’s journey is the same.
Although medical school is notoriously demanding, such demands are shaped by intersectionality and not necessarily borne equally. At my White Coat Ceremony, over a third of students received their white coats from a family member already in medicine– a revolving door of privilege. Medicine has historically been (and remains) a white and high-income space.4,5 Despite more individuals from underrepresented backgrounds entering medical school today, the environments that students arrive to learn in have largely stayed the same. The necessary anti-racist institutional culture, financial resources, mental health support, and representative mentorship that allow students to feel supported are not yet robust.

This cultural disconnect is consequential: one study of medical students found that increased microaggression frequency from colleagues and senior physicians was associated with a positive depression screen in a dose-response relationship.6 The Association of American Medical Colleges (AAMC) is working to increase the number of students underrepresented in medicine. But the goal cannot merely be representation, rather it should be to create a new culture and system where students can thrive. The floor needs to be open for students to describe their experiences while institutions work to address systems that impact their mental health and potential.

It is hard to pause and look back when constantly moving forward.
I remember the shell I became and the neuroticism that set in while studying for the US medical licensing exams (USMLE). For weeks, I sat studying for 15 hours a day, not leaving my apartment, and attempting to sleep while gripped by the stress of my exam score determining my ability to match into the specialty of my choice. After completing our first USMLE (Step 1), my classmates and I were ecstatic, scrambling to organize parties to celebrate before our fast-approaching clinical rotations.

I’ve taken over 400 exams since starting college and, somehow, it hasn’t become less stressful. The stakes have only felt higher as the sunk cost and bearing on my professional future grows. And as the competition for medical school and residency increases, a student must not only have impeccable grades but also be a renaissance person (do ground-breaking research, start a non-profit organization, climb Mount Everest, found a start-up, win a Nobel Prize, etc.); expert extrovert (winning over each resident, doctor, interviewer evaluating us); and world-renowned used car salesman (packaging oneself in countless application essays and interviews). Then, once you finally get into medical school or match into your dream residency or fellowship, they tell you to relax and enjoy it. How is a person whose cortisol and productivity have been running at such a high-octane level supposed to simply chill?

It’s hard to flip the switch into Zen mode– it takes time for our bodies to let go of cumulative stress. Yet, the demands in medicine never stop, and the habits we convince ourselves are temporary often carry over. Unlearning conditioned behaviors is hard, making it vital to learn how to pause (guilt-free) despite the inundation of to-dos early in our careers.

Understanding mental health on an intellectual level is different from questioning its applicability to oneself.
Although physician suicide is the most acute and devastating issue surrounding mental health in medicine, the downstream impacts of medicine’s high stress and isolation are much more expansive. Students around me have struggled with anxiety, eating disorders, exercise addictions, and substance use.

As medical institutions address the external factors contributing to trainees' mental health challenges, students should also feel empowered and accountable to lend and seek help– dismantling stigma in the process. When we think about physician burnout, we must work upstream and broaden our conceptualization of mental health risk factors and what struggling looks like (a student can still score in the top percentile on exams). We can all play a part in preventing physician burnout by creating a culture of reflexivity, support, and accountability– and joining together to advocate for more robust mental health resources and workplace protections.

Academic Achievement Isn’t the Only Way to Succeed.
The real road to success is wide open.
Reviewed by Tyler Woods

KEY POINTS-
An increasing number of students feel pressure to get straight A's.
The pressure to excel turns toxic when students feel their self-worth is contingent upon constant academic achievement.
Kids are happier and healthier when they are motivated by their own interests.
I’ve been a lot of things in life.

Afraid of the dark. A war reporter. A jilted bride. A military wife. A mistress. A party-school student. An Ivy League professor. A mom on the Upper East Side of Manhattan.

I love to listen. I have a lot to say. But when I meet a mom, the first question she asks is often the only one.

“Where does your son go to school?”
Marty goes to a Montessori school. Most kids who apply get a spot. The only thing that’s wrong with the school is other people’s perceptions.

"The school doesn't seem academic," one mom said.

“Kids play, but what do they learn?"
Source: Becky Diamond
Marty showing us a book he wrote on different species of hawks. At Marty's school, academic demands increase slowly each year.Source: Becky Diamond
It’s not a sought-after school that parents think will put their kid on the path to Harvard or Yale.

Many parents think that the only way their child will succeed is if they go to an elite school, said neuropsychologist Bill Stixrud, an assistant professor at the George Washington University School of Medicine and co-author of the best-selling book The Self-Driven Child.

“There is this message that there's one path to being successful. It's a narrow path and if you [veer] off, you're screwed,” he said. Many parents “are imprisoned by this psychotic thinking that is out of touch with reality.”

But competitive schools are in style.
What seems significant might not matter
When I was in sixth grade, in the 1980s, the popular kids wore the coolest clothes. I wanted what they had.

“Mom,” I said. “I need Gloria Vanderbilt jeans.”
Trendy items were pricey. My mom was a social worker whose clients paid on a sliding scale. My dad was a scientist, not a CEO. We went to Macy’s in the mall. I tried on the $35 designer jeans.

“They’re too expensive,” my mom said. I walked home with $15 Levi’s that felt comfortable. But I cried because they didn’t have the right label.

“Becky,” my mom said. “What matters is how you feel on the inside, not how people judge your outsides.” She was right. But I still wished that my dad worked on Wall Street.

Forty years later, motherhood feels like middle school. When I tell moms the name of Marty’s school, they look at me like I’m wearing Levi’s. I’m surprised at how much I care.

There’s a reason.
“We’ve evolved to go after the wrong stuff,” said Yale Psychology Professor Laurie Santos in this podcast. “Craving is a brain function,” but it doesn’t do us any favors when it comes to feeling satisfied. According to Santos’ research on success, people seek what their mind perceives will make them feel powerful and strong, not necessarily happy.

Maybe that was well-made weapons in the Middle Ages or designer jeans in middle school. Today, it’s selective schools.

Education is a journey, not a brand destination
My dad was a rocket scientist, but I couldn’t care less about calculus. When I got B's in high school, I didn't feel like a failure.

For college, I went to the nation's top party school, the University of Colorado at Boulder,

“You love the outdoors,” my Ivy League-educated dad said. “Follow your passion. You’ll succeed.”

I hiked, biked and learned to rock climb.
“I’m scared!” I said to my partner on a 300-foot route in Eldorado Canyon.
“Trust yourself!” He shouted. "You’ve got this!”
I got comfortable stepping into the unknown and became unafraid of feeling fear. I touched granite so often that my grades weren’t great.

“Find subjects you love," my mom said. I took history classes and got A’s.

According to Dr. Stixrud, when kids are motivated by their own interests, they feel more in control. They are happier, healthier, and work harder.

I graduated with honors and worked at a highly regarded think tank in Washington, D.C. and for top news networks. Now, I teach journalism at prestigious universities, and I write this blog for Psychology Today.

The name of my college has never held me back.

Achievement isn’t only academic
Marty excels, but not on someone else’s terms. Instead of studying for tests, he has other plans.

“Let’s go to the National History Museum and look at fossils,” he said after school recently.
He saw a docent near the dinosaurs.
“Excuse me,” he said. “Is a Stygimoloch a Pachycephalosaur?”
She googled it. “He’s a mini paleontologist!”
He’s a good friend, too. At a birthday celebration, Marty noticed a boy who didn’t get a party favor.
“You seem sad,” he said. “Take mine.”
And he gets people to giggle. One afternoon he wanted me to play with him.
“Stop texting!” he said. I was on a group chat with my besties from Boulder.
I put the phone down to answer the door. When I returned, someone had been added to the chat.
“Becky, who is this person?”
“Sh-t, Marty added my husband’s ex-wife!”

We howled and so did she. I saw her later at a family event. “Your son is really something. Where is he going to middle school?"

Pressure to get on the path
Marty’s school ends in fifth grade. He and his classmates applied to middle schools in a process that felt more like college.

For Marty, there was a snag. As I wrote in this blog, he was recovering from Celiac Disease, which caused debilitating fatigue and brain fog. Marty was catching up while his classmates raced ahead.

After school, kids went to test tutoring, squash, soccer, Russian math and chess. Friends missed birthday parties to practice violin.

“Childhood has been turned into a period of resume building,” said Boston College child psychologist and Psychology Today blogger Peter Gray, who co-authored a recent study published in the Journal of Pediatrics that found kids spend so much time studying and in adult-supervised activities that they aren’t building social and emotional skills.

Anxiety among kids is at record levels, said co-author David Bjorklund, a Florida Atlantic University Psychology Professor. “There has been a lot of pressure toward academic learning and to do well on tests, which is not in a child’s best interest.”

Marty wanted to play but I couldn’t find a friend who was free.
“Billy is busy. He has tutoring and test prep.”
“Sam can’t see friends until the ISEE test is over.”

The ISEE (EYE-see) is the Independent School Entrance Examination, a three-hour standardized test that kids take to get into private schools. Students who compete for spots at the most selective schools must learn 6th and 7th grade material by the middle of 5th grade, according to several educators involved in the application process.

“ISEE test preparation for most students requires a tremendous amount of new instruction,” said Brad Hoffman, a board-certified educational planner who runs My Learning Springboard, a tutoring and education consulting firm. “We remind families who are wading into a private school process [that] it needs to be handled with appropriate balance.”

It's hard to feel steady when parents feel their child’s future is at stake.

We’re giving kids the wrong message
I have nothing against Harvard. But there is a winner-take-all mentality that creates a distorted definition of success and even "winners" lose.

Psychologists who work with top-performing students say their self-esteem suffers. Suniya Luthar’s 2004 study, The High Price of Affluence found that teens attending selective schools were more at risk for anxiety and depression than the national norm.

“They feel a relentless sense of pressure,” Luthar wrote in this article for Psychology Today. Too many kids get the message that they aren’t good enough. When the ISEE was over, Marty and a friend played.

“Where are you going to middle school?” Marty asked.
“My mom wants me to go to a good school,” the child said. “But I’m not gifted.”
“You’re smart.” Marty said.
“No. I needed nines on the ISEE (the top score). I only got sevens."
Later, Marty said: “Mom, I want to go to a good school. What are the bad ones?”

Epilogue
Marty applied to three three middle schools that didn’t require the ISEE. He wrote five essays, took two math assessments, and answered questions about social justice, extra-curricular activities, and life challenges.

“Describe a difficult situation and what you learned,” an admissions director asked.
“Ramen is my favorite food,” Marty said. “But I can’t have it. I have Celiac Disease. I’ve learned that I can be happy when things don’t go my way.”

I don’t know what grades Marty will get in middle school but he’s getting a great education.

Balancing the Potential for Harm With Our Capacity for Good.
Thinking about proportionality in public health.
Reviewed by Ekua Hagan

KEY POINTS-
Public health leaders must have a clear-eyed view of the potential harms of any step they are considering so the harm doesn't outweigh the good.
Public health recommendations must account for the disproportionate burden of poor health experienced by marginalized groups.
Different populations have different definitions of harm, which is important for public health to take into account.
In public health, we can find ourselves in positions where proportionality is of core importance. Public health often makes recommendations to policymakers that involve “asks” of the public. We propose actions that entail some restraint or sacrifice in exchange for less risk of harm. We saw this during the pandemic when public health played a role in the adoption of lockdowns, mask mandates, and vaccination requirements.

This recent history reflects a dynamic that has long characterized what we do. As long as public health has existed, it has at times placed checks on individual autonomy in the name of the greater good of supporting a healthier society. From quarantines during times of plague to mandatory treatment for diseases like tuberculosis to taxes on harmful products like sugar-sweetened beverages, public health has supported measures that place impositions on the public.

In some cases, such as the extended restrictions on movement of the COVID-19 moment, these impositions created their own challenges for health. This places public health, a field which exists to shape healthier populations, in the difficult position of sometimes proposing measures which create tradeoffs for health. In order to be effective in our core mission, we, at times, impose restrictions on populations which, if too tight, could cause undue harm, but, if too loose, could mean opening the door to greater harm. Proportionality helps us to strike this balance; to advocate for policies that suit the moment, imposing on the public no more than is necessary to support health.

It strikes me that proportionality in public health is fundamentally about the question: What is the potential for harm and what is the potential for good in a public health action? As we navigate this philosophical space, the following three principles can, I think, serve as useful guides, helping us to better engage with proportionality in this post-war moment.

Prioritizing proportionality
First, proportionality has to be central to public health. Throughout the history of public health, we have, at various points, chosen to embrace certain concepts as core to our field. For example, as we became more focused on crafting policies that shape health at the population level, we began to have more conversations about advancing these policies while respecting individual autonomy. As it became clear that social exclusion and historical injustice are foundational drivers of poor health, we embraced the pursuit of equity as a foundational focus. Now, in this post-COVID moment, public health has, in many ways, more power than ever before to shape policy and engage with the public debate to advance our favored solutions.

With this newfound power comes the responsibility to place proportionality at the center of public health thought and action. We should never find ourselves in the position of recommending an action that might cause more harm than it prevents. This means having a clear-eyed view of the potential harms of any step we are considering. We need to engage dispassionately with the data to see both the costs and benefits of a given action.

The pursuit of equity
Second, it is important that our focus on proportionality is informed, always, by our pursuit of equity. Just as public health is centrally concerned with ensuring that all have access to the resources and opportunities that support health, it has a responsibility to ensure that no groups bear undue burdens.

This means that our calculus when it comes to the harm our interventions may cause must account for the disproportionate burden of poor health experienced by certain marginalized groups. This can help us avoid taking actions that may worsen inequities even as they might benefit the overall population. It is not enough for a given measure to be worth the inconvenience or harm it may cause the population at large. We must also consider how it may affect groups whose health is poorer than the average, or for whom the burden of our intervention will be particularly heavy.

Understanding various perspectives
Third, it is important to remember that our conception of harm is shaped by what we value. Proportion depends on being able to weigh the risks and benefits of a given measure, but, as I have recently written, risk is not a value-neutral concept. It is influenced by our biases, by the individual and cultural lens through which we view the world. This has implications for how we determine whether a policy or action is truly proportional.

Consider the example of alcohol consumption. It is, I think, fair to say that many in public health regard alcohol consumption as nothing more than a health hazard. For this reason, we may not regard efforts to ban or severely limit the sale of alcoholic beverages as anything less than an unalloyed good. We might therefore favor, of all possible actions to address the health harms of drinking alcohol, the strictest possible ban on the practice. But for many, consuming alcohol is a source of pleasure, and an activity tempered by moderation. This reality should change our understanding of proportion as we consider alcohol policy. Even if it does not change our position on alcohol, it should help us to think about how different populations have different definitions of harm and how it is important for public health to take these perspectives into account. And that should guide how we approach efforts to limit alcohol consumption, through changing what does give pleasure in the direction of more healthful pastimes, rather than simply imposing a ban heedless of how weighty it may feel for some.

I have been writing this set of essays in 2023 to the end of articulating a practical philosophy of health in what I have called a post-war period. This leads me to focusing on principles that allow us to maximize our capacity to support health while minimizing the harms our efforts may cause. Choosing to prioritize proportionality as central to our thinking can help us to do so. It can ensure we act, always, within the bounds of what is necessary to create better health for all, imposing on the public just as much as we need to, but never more than we must.