By Megan Riddle, PhD
“I was a little excited but mostly blorft. “Blorft” is an adjective I just made up that means ‘Completely overwhelmed but proceeding as if everything is fine and reacting to the stress with the torpor of a possum.’ I have been blorft every day for the past seven years.”
― Tina Fey, Bossypants
I believe I have spent much of medical school fairly blorft. Elevated levels of stress seem to be a universal medical student experience. Studies looking at medical students around the globe – from Pakistan and Malaysia to Greece and India – show we all struggle with elevated levels of stress1. Stress, as it is used today, was first defined in 1936 by endocrinologist Hans Selye as “the non-specific response of the body to any demand for change”2. That definition highlights the point that not all stress is bad – a certain level can actually be useful during medical school. Knowing the importance of Step I board scores was stressful, but undoubtedly drove me to study harder than I would have had I treated it as no big deal. However, sustained, elevated levels of stress can be detrimental to both mental and physical well-being. For example, stress levels have been found to be correlated with depression and anxiety amongst medical students3. The good news is that there are steps you can take to reduce and manage your stress.
Signs of stress
“Stress: The confusion created when one’s mind overrides the body’s basic desire to choke the living daylights out of some jerk who desperately deserves it.”
A typically easy-going friend of mine mentioned she has been feeling furious lately, ready to explode at well-meaning friends and colleagues for the smallest of perceived offenses. This Jekyll and Hyde feeling can be a classic symptom of stress. Too much stress can manifest itself in a number of different ways, both physical and emotional, including a short temper. Physical signs and symptoms include muscle aches, chest pain, tachycardia, GI distress, and frequent colds4. Excess stress can also impair memory and your ability to concentrate (the last thing you need when cramming for exams) in addition to feelings of moodiness and isolation. Patterns of sleep and eating are also often disrupted, either increasing or decreasing4. We often find fairly dysfunctional ways to cope – drinking too much, sleeping excessively, zoning out in front of the computer, procrastinating – which may feel like a decent short-term solution, but do little to help in the long run, sometimes only adding to the problem. If this sounds like you, close the YouTube cat video and keep reading.
A Stress Work-up
“For fast-acting relief, try slowing down.”
– Lily Tomlin
Create the differential: What are the causes of your stress? When I’m feeling overwhelmed, my response to this question is: “Everything!” That’s the stress talking. Try to be more specific than that. This might include big ticket items, like studying for boards or preparing for your first residency interview, or be the more day-to-day stressors like dealing with a new team of residents and attendings on your clerkship. Don’t forget to include non-med school sources of stress!
Make a diagnosis: Take a look at your list. You need to know what kind of stresses you’re dealing with in order to come up with a treatment plan. Your stress likely falls into a few different categories.
• Avoidable stressors – Some in this category might be better termed “glutton for punishment” stress. Do you really need to sign up to organize the free clinic’s fundraiser? These are things you don’t actually have to do.
• Modifiable stressors – If you can’t avoid the situation, make a separate category for angst-ridden situations you have to deal with, but may be able to modify. OK, so maybe you’ve already signed up to organize the fundraiser, but do you have to do it entirely yourself?
• Set-in-stone stressors – Yup, you have to take the boards if you’re planning to practice, ditto on filling out your ERAS application, and (probably) dealing with that attending whose expectations seem impossible to meet.
Work up a treatment plan
• Excise avoidable stressors: Once you’ve determined what on your list is removable, cut it out. This can take some effort. If leading the med student women’s group is causing you too much distress, send an email – you never know who might be eager (or at least willing) to take something off your plate.
• Palliate modifiable stressors: You may not be able to avoid it, but often there is something you can do to improve the situation. If you’re leading a club, learn to delegate. Feeling anxious about doing well with a new team on your clerkship? Ask about expectations up front. Being proactive can give you a greater sense of control and thereby decrease your anxiety.
• Take a second look at your prognosis: Your best option for dealing with the truly set-in-stone stressors may be to change your outlook (this can also be useful for the modifiable stressors). It can be easy to develop a doom-and-gloom outlook on the unavoidable stressors, but how accurate is your prognosis? You might find yourself thinking, “I will never remember all of these drug side effects and so I will fail the boards and then no residency program will take me and I won’t be able to pay back my loans and I will end up living under a bridge.” Given the stressor – memorizing drug side effects – how realistic is the prognosis – living under a bridge? Possible? Yes. Probable? No. Thoughts like these are fertile territory for a technique called cognitive restructuring. More than just positive thinking, in this process you reevaluate your irrational self-talk, challenge it (how likely is it?), and then change it. This takes practice.
• Give yourself a dose of relaxation and medicate with meditation: There are a number of techniques that can help to reduce your stress in the moment. Deep breathing, meditation, exercise, guided visualization, listening to music – all can help you find a moment of calm in the storm of med school. Just like medication, responses to these practices vary. Experiment until you find something that works to help you relax.
Call a consult: Talking about your stress can be therapeutic, and, if you find the right person to talk to what starts as venting may turn into a productive problem-solving session. This could be a trusted friend or mentor. If your stress feels unmanageable and debilitating, please consider seeking professional help from a mental health practitioner.
I try to take one day at a time, but sometimes several days attack me at once.
– Jennifer Yane
We have chosen to enter an intense, demanding field and a certain level of stress comes as part of the package. Despite our best laid plans, some days will feel insurmountable. However, we can take steps to manage our stressors, creating our own moments of calm so that we feel a little less blorft.
Megan Riddle, PhD is an MD-PhD student in the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program. She will graduate in May 2014 and then begin her psychiatry residency at the University of Washington.
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1. Saravanan C, Wilks R. Medical students’ experience of and reaction to stress: the role of depression and anxiety. The Scientific World Journal. 2014:737382.
2. What is Stress? http://www.stress.org/what-is-stress/. Accessed April 28, 2014.
3. Sherina MS, Rampal L, Kaneson N. Psychological stress among undergraduate medical students. The Medical journal of Malaysia. Jun 2004;59(2):207-211.
4. Smith M, Segal R, Segal J. Stress Symptoms, Signs, & Causes: The Effects of Stress Overload and What You Can Do About It. 2014;http://www.helpguide.org/mental/stress_signs.htm. Accessed April 28, 2014.