The reason

Now that we have identified our maladaptive thought processes, it is important to understand why we think the way we do.

Early on in our medical education, we are taught to search the PQRST of symptoms.

This tab focusses on the P: provocation, or more precisely, predisposing, precipitating and perpetuating factors.

What are the factors that underlie our maladaptive behaviors? What factors are inherent (i.e. intrinsic) and what factors are a result of our environment (i.e. extrinsic)? Oftentimes, it is a combination of both.

INTRINSIC FACTORS (that relate to ourselves)

PERFECTIONISM AND OVER-ACHIEVING

Although there is a wide range of personality types in medical school, as a general rule, many students are high-achievers and perfectionists. Our need to strive for excellence is what got us into competitive post-secondary programs, and these same traits aid us in striving in a high-demanding workplace. So when does perfectionism become too much perfectionism?

It is worthy to distinguish between adaptive and maladaptive perfectionism. Individuals with adaptive perfectionism set high standards, but REALISTIC GOALS and are FLEXIBLE with these goals. On the other hand, individuals with maladaptive perfectionism set high standards, that may be UNREALISTIC, and/or demonstrate NO FLEXIBILITY with these goals, often leading to self-deprecating and feelings of inadequacy. [i]

Dr Pryor at Northwestern University, with the help of the Online Master of Arts in Counseling offers this non-clinical tool to assess whether you are an “unhealthy perfectionist”.

This is not a clinical assessment tool, and a real professional evaluation is encouraged.

“maladaptive perfectionists perceive higher rates of failure, experience mistakes as catastrophic, and tend to undermine their successes with lower levels of self-esteem also documented” [ii]

“Elevated levels of depression and anxiety amongst graduate students prone to maladaptive perfectionism have been found”

FAILURE AS AN UNCOMFORTABLE STANGER

Many medical students may simply be uncomfortable or foreign to the idea of failure and will constantly avoid “ruining a clean slate”. This concept can be related to a form of “behavioral inhibition” whereby students experience distress to novel situations and avoid these same situations. To get into medical school, students are often the first of these classes, have straight As, and thus the concept of failing is not present – it has never been an option. Trying to systematically avoid failure – whether consciously or unconsciously – can indeed lead to the maladaptive thought processes. This tendancy falsely emphasizes failing as bad, and never as a means to grow and build resilience.

Do you identify with the following statements?

· I have always been the first of my class

· I have never experienced failure or only experienced failure when I started university

· I experienced distress when I had my first failure in university

IDENTITY CRISIS: ME, MYSELF, AND MEDICINE

Medical students’ identity may be exclusively forged by their career. You may feel the need to act a certain way or talk a certain way because you are part of a certain group. Even without others imposing the identity of a professional on you, you may yourself appropriate that image and force yourself to be molded in a predefined way. You may internalize how you think doctors should act and take is a fact of life. You may see yourself pardoning maladaptive thought processes as “normal”, saying that they come with the “sacrifices” of a medical career.

You may also falsely assume that your place in medicine defines the person you are. Prior to starting your medical studies, you may have described yourself in terms of adjectives such as “altruistic”, “nurturing”, “curious”. The use of “health care professional” as a means to englobe these descriptive replaces our sentient nature for a rigid and homogenous way of working.

Do you identify with the following statements?

· Most of my conversations revolve around medicine

· I feel the need to excel in medicine because I do not think I would be good at anything else

· I often decide what to do or what not to do by thinking what physicians would do

· I often use my profession to describe who I am

· I invest all my time in medicine and allow no time for leisure as I see the latter as a waste of time

This need to be a certain way may stem from an internalized identity or even externalized (c.f., When you are imposed an Identity). It is in fact hard to disentangle one from the other.

LOW SELF ESTEEM AND IMPOSTER SYNDROME

While the exact prevalence of imposter syndrome in medicine may significantly vary depending on the study, ranging from 9% to 82%[iii], its presence is not contested. Imposter syndrome describes the internalized feeling of being an “imposter” in one’s own career, refusing to recognize our accomplishments as our own, and a constant feeling of inadequacy. Imposter syndrome may present itself at multiple stages in the medical profession: at the start of preclinical years, at the start of clerkship, when one begins residency, when one becomes a young attending physician, and all the stages in between. Imposter syndrome may lead to maladaptive thought patterns because it underlines a poor self esteem. We deem our accomplishments as not ours because we do not deem ourselves as worthy. Our triumphs are not enough because we do not deem ourselves to be enough.

In fact, research has shown that imposter syndrome is “often comorbid with depression and anxiety and is associated with impaired job performance, job satisfaction, and burnout among various employee populations including clinicians”. [iv] “Imposter syndrome is especially problematic because of its association with increased rates of burnout and suicide.”[v]

Do you identify with the following statements?

· I often feel like I am less than my colleagues

· I feel like I am alone in my struggles

· I often feel like I am not good enough to be a physician

· I often shy away from asking for help because I am scared of being seen as weak

COPING MECANISMS

Coping mechanisms are extremely variable from person to person, and have a significant impact on the way we deal with stress. We can divide coping mechanisms in two broad categories: active coping and avoidance coping. “Active coping strategies are either behavioral or psychological responses designed to change the nature of the stressor itself or how one thinks about it”, while avoidant coping strategies “lead people into activities (such as alcohol use) or mental states (such as withdrawal) that keep them from directly addressing stressful events”[vi].

Here are examples for each type[vii]

Medical students use both types of coping strategies; the extent of one vs. the other differs from one student to another. Research has demonstrated that students who predominantly use avoidant coping strategies tend to have higher levels of stress.[viii]

This concept may be compared to the previously mentioned concept of inhibited temperament.

The use of avoidant coping strategies maintains the novel aspect of stressors in medicine, thus leading to distress and negative thought processes.

Surprisingly, you may actually feel like your coping strategies are adaptive if you circumvent feeling negative emotions. Similarly, you may accept negative thought patterns as being normal. This is why it is important to identify these patterns.

Do you identify with the following statements?

· I blame myself for my failures

· When an exam is coming up, I act like if it does not exist because it helps me feel more relaxed

· I often turn to alcohol when I am stressed

EXTRINSIC FACTORS (what is imposed on us)

Our negative thought patterns can also stem from how we are instructed to think. But by whom? The medical system, your attending physician, your patients, your colleagues, and even your loved ones…

THE EXPECTATION TO BE PERFECT

While medical students may feel the need to be perfect, imposing this on themselves, perfection may sometimes be expected and even imposed on them.

For instance, take the last time you thought you might have failed an exam. Did someone in your surrounding automatically tell you that it is impossible for you to fail? Do people in your surrounding always assume that you will great straight As? You may also get comments like “You must be very smart if you are in medicine!”

When you start clerkship, some attending physicians may get angry if you forget to ask a question during history taking, or if you forget a step during your physical examination.

This need to be constantly on your “A-game” can lead to the same negative thought processes as intrinsic perfectionism. However, as they do not stem from within, they are egodystonic, i.e. not in harmony with their own desires, thus adding even more distress to the medical student.

THE EXPECTATION TO NEVER FAIL

Perhaps your surroundings don’t expect you to be perfect, but to the least, they may expect you to never fail.

This is an important concept because from the first day in medical school, failure is often demonstrated to the extreme: missing a diagnosis or being unable to save a patient’s life. You are expected to pass every single exam, and eliminatory OSCEs are present in practically every single medical school in Canada. Patients also rely on you to not fail them with a missed diagnosis or a wrong treatment, and their lives are often at stake. Medical students may feel distress when faced with this expectation. Failure can lead to feeling inadequate and fear of having disappointed those around them. The decisions of medical students are often fixated on never falling short.

Some may argue that the previous points are acceptable and even necessarily in medical training. Others may question this same training. The aim of this paragraph is not to question whether it is justified or unjustified for medical students to have little room for error, but rather to simply point of its existence.

BEING IN A PROFESSION THAT FOCUSSES ON PRODUCTIVITY

Medicine is a career that is rewarding, but also demanding. When you start clerkship, the maximum hours worked per week can go up to 70 hours, which often exclude study time: this represents almost the double of the maximum hours of work of other jobs. Some residency programs have 24-hour call shifts. Physicians receive phone calls at any hour of the night. Despite this heavy schedule, several news articles have been written, stating that physicians do not work enough hours. This kind of statement may perpetuate this notion of never working enough and can lead to a constant feeling of inadequacy.

THE NEED TO STAND OUT

Even before we enter medical school, we have pressure to stand out: having the perfect academic record, perfect letters of references, a unique personal statement, and stellar interviews.This form of approval seeking transforms into periodic exams, small groups and OSCEs. As early as our first clinical rotation, we are being evaluated in a clinical setting. Although our title is still “student” and our primary goal is to learn, we have the constant stress of being evaluated. There are expectations for us to stand out from the very beginning. The thought process of medical students may be molded by the constant need to stand out and to receive that “stamp” of approval.

THE STIGMA OF ASKING FOR HELP

In medical school, we are taught to be problem solvers, to be resourceful and try to find answers on our own, before asking for help. This way of thinking becomes so ingrained that we internalize it... and even apply it in our personal lives. When dealing with hardships, some students may be resistant to seek help because of associated stigma. As a result, people may feel ashamed, see it as failing oneself or even as a sign of lacking strength – when in reality, help-seeking behaviours are a sign of courage and capacity for introspection.

As much as our society has advanced in acknowledging and supporting mental health issues, we still have room to grow. One of our goals in this website is to promote the existence of mental health struggles among medical students and practicing physicians, and advocate for self-care.

THE RESPONSIBILITY OF MEDICINE

A career in medicine comes with numerous responsibilities. We are often reminded of what we can and cannot do. What we should or should not post online. What we can or cannot comment on a news article.

We are reminded that whatever we say is linked to the medical profession. We are told that we cannot make decisions that may bring shame to the profession. Patients may also view physicians and medical students as required to maintain a certain social “image”.

Again, some may argue that this concept is reasonable, while others may encourage a clear division between personal life and a professional career. What is irrefutable is that students may have a certain thought process or make specific decisions only because they are taught to act a certain way.

SOCIAL MEDIA: TOO CLOSE FOR COMFORT?

Medical students are not immune to the advantages and disadvantages of social media.

We are living in a world where we are exposed to snapshots of people's lives that appear to be perfect. People choose to share the highlights of their lives, which lead us to believe that it is their constant reality. We may feel like we are alone in our struggles or that we are not achieving as much as others. This can lead to negative thoughts patterns.

[i] https://www.oxford-review.com/blog-research-perfectionism/#adapt

[ii] https://journals.sagepub.com/doi/pdf/10.2304/plat.2013.12.1.4

[iii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174434/

[iv] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7174434/

[v] https://onlinelibrary.wiley.com/doi/epdf/10.1111/medu.13956

[vi] 16. Krohne HW. Vigilance and cognitive avoidance as concepts in coping research. In: Krohne HW, editor. Attention and avoidance: Strategies in coping with aversiveness. Seattle (WA): Hogrefe & Huber Publishers; 1993. pp. 19–50. [Google Scholar] [Ref list]

[vii] You want to measure coping but your protocol's too long: consider the brief COPE.

Carver CS

Int J Behav Med. 1997; 4(1):92-100.

[viii] https://pubmed.ncbi.nlm.nih.gov/22901439/