These days, everyone seems to be talking about stress, burnout and wellness. Nowhere is this more a topic of conversation than in medical schools, and for good reason: medical students face unique stresses and suffer from higher rates of depression than their age-matched peers. For example, it’s estimated that up to 27% of medical students experience clinically significant depression, compared to nine percent among 18- to 25-year-olds in the general population.
What makes medical school so stressful? To start, you have a group of very smart, high-achieving, idealistic young people who are accustomed to being at the top of their class, who soon discover that won’t be possible for most of them in medical school. Then there is the sheer amount of information to learn, which can be overwhelming—to say nothing of the unique stress of learning to take care of patients and becoming a doctor. Next, most students have left their friends and family behind to come to medical school, so they experience a sudden loss of their supportive social network during a transition that is exciting yet stressful. And finally, these students are a medically healthy but psychiatrically at-risk group for the simple reason that three-quarters of all mental illnesses that we see in adults occur by the age of 25. And depression and anxiety disorders typically have their onset in life during late adolescence and early adulthood.
Put all these factors together and it’s easy to understand why medical school is stressful. But stress, especially the good type, can be healthy and promote psychological resilience—the ability to adapt to stress and adversity, and bounce back from it both psychologically and physically. It’s bad stress that we want to avoid. What’s the distinction?
Credit: Stephanie Diani
Stress is the body’s and brain’s response to challenge. The key to good stress is that it is something you can manage and even master. We all have experienced the relationship between a challenge and the degree of stress we feel in response. It follows the famous “inverted U” function: as the pressure goes up, so does performance—but only to a certain point. Beyond that, anxiety rises and performance starts to drop. So there is a sweet spot for stress: too little and you are bored and understimulated, too much and you are anxious and overwhelmed.
When humans experience acute stress, we respond by secreting the hormones cortisol and adrenaline, which help us respond to the demands of the situation. A burst of cortisol mobilizes glucose for energy and enhances immune function, while adrenaline increases attention. But chronic stress—when adrenaline and cortisol levels are persistently elevated—is harmful and leads to serious medical problems like obesity, diabetes and hyper- tension, while also impairing various cognitive functions. A brief pulse of cortisol can enhance neurogenesis (the growth of new neurons) in the hippocampus, which is critical to learning and memory. But chronically high cortisol levels have the opposite effect, causing those neurons to shrink and impair cognition. Also, chronic stress typically causes insomnia and sleep deprivation, which can disrupt the formation of new neurons in the hippocampus, a brain region that is critical to memory formation. So if you like to pull all-nighters to study, think again: your sleep-deprived brain is a poor learner.
I’ve seen all of this first hand over the 18 years that I’ve been director of Weill Cornell Medicine’s Student Mental Health Services. We are passionate about our mission to promote student mental health and focus on treating common psychiatric problems—like depression and anxiety—that are a source of pain and dysfunction in our students.
What about stress and burnout? It isn’t possible—or even desirable—to protect students from normal everyday stress, like disappointing academic performance or social rejection. And every day, good stress helps foster resilience. It shows students that they can deal successfully with difficult challenges, which enhances their self-esteem and sense of general fitness. There is also preclinical evidence that the neurotransmitters norepinephrine (which is released during acute stress) and serotonin play an important role in resilience. Of course, there are some unacceptable stresses—like bullying and sexual harassment—that have no place in the school or work environment and which all institutions must do all they can to eliminate. We want to help our students learn to distinguish healthy from unhealthy stress and develop various coping strategies to keep stress manageable, such as exercise, meditation and healthy eating. That is one of the goals of wellness initiatives.
Another important role of wellness programs is to remind students of what most of them probably know, but forget when they feel overwhelmed by school: that you have to find a reasonable balance between work and life. You cannot study all the time, socially isolate yourself, neglect your hobbies and expect to feel happy and well-adjusted. Exercise and social contacts don’t just make people feel better; they contribute to resilience by raising the level of brain-derived neurotrophic factor (BDNF), which promotes neurogenesis. (We know BDNF has this effect in animals and may do the same in humans, too.)
When I orient the incoming medical students each summer, I always tell them this: you are embarking on four of the most exciting—and stressful—years of your life. We care about you, and we have every confidence that you can handle adversity because you wouldn’t have made it this far if you couldn’t. Will you feel stressed and overwhelmed at times? Of course; that’s entirely normal. You have to find a way—and it takes some time to figure it out—to balance your work with the rest of your life. Don’t forget your friends, families and hobbies. They are important to keep in your life for many reasons, including the fact that they will help you adapt to stress and become more resilient. If, along the way, you are having difficulty that you can’t handle, please come and talk with me and we’ll help you.
So can medical school ever be stress-free? Of course not. But there is a lot we can do to promote mental health and resilience in all our students.
Dr. Richard Friedman, a professor of clinical psychiatry, is Director of Student Mental Health Services and Weill Cornell Medicine and a contributing opinion writer for the New York Times.
This story first appeared in Weill Cornell Medicine, Summer 2019