The Suffering Medical Students Attribute to Their Undergraduate Medical Education

Medical training stresses medical students, who negotiate a rigorous curriculum while struggling with the emotional demands of clinical care.1-4 Students enter medical school with better mental health than nonmedical peers but graduate with greater levels of depression and burnout, indicating medical education theatens student well-being.5 Little is known, however, about whether students perceive themselves to suffer as a result of their medical training.

Suffering is “an aversive emotional experience characterized by the perception of personal distress that is generated by adverse factors undermining the quality of life”6 that arises when events are perceived to threaten the integrity of the self.7 As such, suffering involves “dissolution, alienation, loss of personal identity and/or a sense of meaninglessness”8 and is an existential experience with subjective meanings and spiritual dimensions for the sufferer.9,10

While exploring medical student perceptions of their education about suffering,11 some participants reported personal suffering they attributed to their medical education. What they expressed differed from anxiety, depression, and burnout, as our students rarely used those terms. Rather, their suffering involved the culture of medical education and the personal transformation to physicianhood. This report summarizes these perceptions of student suffering and the activities that provided relief.

In April through May 2015, we conducted focus groups with students from each year of study at the University of Washington School of Medicine (UWSOM) and Penn State College of Medicine (PSCOM). We emailed invitations to all registered students to “participate in a research study to better understand medical student education about human suffering.” Participants gave informed consent and received a $10 gift card. We enrolled volunteers to fill an optimal size of 4 to 10 per group.12 Each school’s institutional review board approved our study protocol.

The authors facilitated groups at their respective institutions. We analyzed verbatim discussion transcripts using standard qualitative procedures, including an iterative, dialectical approach to coding, a constant comparison method,13 and an anonymous member check survey. We reported our methods in detail elsewhere.11

We analyzed student reports concerning personal suffering they attributed to medical education, including comments on the member check survey, using procedures similar to our initial analysis and informed by literature about suffering.

Fifty-one students participated in eight groups (Table 1). Women were disproportionately represented relative to medical school demographics. Students described aspects of their medical education contributing to their suffering, the resultant consequences, their efforts to adapt, and their perceptions of what helped limit or ameliorate their suffering (Table 2).

The demands of medical school isolated students from meaningful connections to family and friends. They perceived that the culture of medical education encouraged stoicism, particularly in the clinical years, and noted that their roles were often ill-defined with unclear expectations. Students suffered when their professional identity became confused with their personal identity, and work performance was equated to personal worth. Witnessing suffering in patients, families and colleagues wrought suffering among students.

These educational stressors created considerable emotional distress. Some participants worried about losing touch with their humanity and altruism, and they felt powerless to ameliorate the suffering they witnessed. Observing suffering that was inadequately addressed left some disillusioned with medicine.

Students used distractions to divert their attention from the pressures of medical training. Some suppressed and compartmentalized their emotions to avoid discomfort. Others reframed their experiences to gain acceptance of and find meaning in their suffering.

Students valued the support they received from preclinical small group sessions and self-care experiences and lamented that these waned as clinical exposure to suffering increased. They described the value of safely venting their distress and desired guidance for how to share their uncertainties, frustrations, and fears.

The struggles our students described embody the classic themes associated with suffering—isolation, hopelessness, helplessness, and loss,14 suggesting threats to their personal integrity congruent with the literature about suffering.7,8,15-17 Medical training tested our participants’ cognitive and affective capacities while isolating them from sources of support. Clinical training challenged their concepts of self and beliefs about medicine,18 triggering existential angst. Students who reported disillusionment with medicine may have implied a spiritual dimension to their suffering, but none explicitly mentioned this domain.

The adaptive mechanisms our students described align with Gross’ conceptions of emotional regulation,19 strategies by which individuals seek to control emotions. Our participants described regulatory processes of attention deployment (distraction), response modulation (suppression/compartmentalization), and cognitive change (reframing).4 Of these, reframing may be most beneficial, as suffering can be endured and alleviated through acceptance and investiture with meaning.20,21

Reframing—changing the appraisal of a situation—facilitates acceptance of and finding meaning in experience, both of which have been shown to reduce student distress. Teaching medical students to nonjudgmentally observe their experience through mindfulness meditation reduced their stress.22,23 Workshops developing personal insight and confronting suffering helped students discover deeper meaning in medicine.24 That student distress is relieved through practices known to alleviate suffering suggests that suffering may be a discrete student stressor.

As for supportive mechanisms that helped decrease suffering, students favor sharing emotions with peers undergoing similar experiences.25 Extending small groups and mentoring throughout clinical training would sustain preclinical initiatives and provide a forum for guiding students through the nuances of managing suffering. E-conferencing could help students in decentralized training sites debrief stressful experiences and receive support similar to what practicing physicians have experienced in Balint groups.26 Reflective activities that increased student insight regarding themselves and others could generate constructive meaning to their suffering.24,27

Our data documents that some medical students perceive they suffer as a result of their medical education. Our participants were a small percentage of students from two medical schools. Being volunteers, they likely had special interests in suffering. Their perceptions may not represent their classmates or other medical students. Their comments may reflect recall bias, and we cannot confirm their reports.

Further research is needed to determine the relationship between medical student emotions and suffering. Mixed-methods studies using qualitative methods to explore student suffering, standardized measures of anxiety, depression and burnout, and quantitative measures of prevalence and associated factors would be valuable.

We believe some degree of suffering is inherent to the personal and professional development of future physicians and may provide opportunities to help them become better doctors. Guiding students in processing their suffering, providing supportive networks to share their perceptions and feelings, and helping them to find positive meaning in their experiences may help to limit or alleviate their suffering. In the process, students may find deeper meaning in their work and be better prepared for patient care.