USMLE Step 1: The Stigma around Self-Care and Wellness

Medical school and residency can be the most stressful and anxiety-provoking times in a young doctor’s life. Long hours of studying, competition with peers, fear of failing or not being good enough, the stress of board examinations, lack of sleep, lack of self-care, and learning to communicate tough treatment outcomes and make difficult decisions with patients; there are many aspects of medical training that can lead an individual to develop self-doubt, anxiety or depression.

According to the Journal of the American Medical Association (JAMA), almost 30% of medical students suffer from depression or symptoms of depression. In addition, 1 out of 10 medical students reports experiencing suicidal thoughts. That means medical students could be up to five times more susceptible to depression than the general population. Medical students are three times more susceptible to mental health disorders than the average college student. However, they are often the last ones to ask for help. 

USMLE Step 1 study

The USMLE Step 1 examination, taken by most medical students at the end of their second year, is one of the most significant assessment metrics. It is also the first in the three-part series and medical students are constantly comparing their study habits and their practice scores to their peers. As a result, the Step 1 examination is the most anxiety-provoking exam.

The Step 1 scores largely determine medical students’ options in both the residency program and specialty choices. The performance pressures surrounding the Step 1 exam lead many students to undertake a grueling study regime filled with sleepless nights trying to cram in every last bit of knowledge. However, this may actually end up doing more harm than good. Research has shown that intense amounts of stress may be counterproductive in learning and academic performance, suggesting that an essential part of performing well is developing a healthy mindset leading up to the test.

Mental health in general has a large stigma in the medical community because medical students, residents, and practicing physicians do not want to appear “weak" or "broken". Ironically, the very people whose role it is to help others discuss their mental health, often struggle in silence themselves instead of immediately seeking help.

Many medical students would rather deal with their anxiety or depression on their own instead of taking time out of their busy study schedule to seek help and practice self-care. Self-care and wellness are important and oftentimes overlooked among medical school students, especially when they are preparing for examinations.

Practicing self-care as a medical student

Over the years, awareness about self-care and mental health among medical students and residents has grown; however these important topics are still not taught and are not sufficiently covered at every medical school and within every residency program, leading to a huge deficit in practicing self-care in the medical world.

The University of California, San Francisco (UCSF) has developed the Medical Student Well-Being Program, “which advances a different way of thinking about our own health and well-being”. The director of this program, a psychiatrist, asks medical students about varying aspects of their life during their first clinical interview.

Some of the questions that she asks are as follows:

  • How much sleep do they need?
  • What does a healthy diet look like?
  • What kind of exercise do they enjoy?
  • What activities give them pleasure and meaning?
  • How do they remain in contact with family and friends?
  • Have they been able to make new connections with classmates?
  • Are they in intimate relationships? How have their studies impacted those relationships?

Sleep, a healthy diet, relationships, hobbies outside of medicine, and stress relief are all important aspects of remaining mentally, physically and emotionally healthy during medical school and residency, especially when you are studying for the boards.

Whether you enjoy spending time outdoors, cooking, arts and crafts, photography or going to the gym, finding a hobby that you are passionate about and practicing that hobby on a regular basis can result in an elevated mood and decrease stress levels.

Kristen Fuller
Kristen Fuller trekking in Fuller Ridge, California

If you find that you are in a strained relationship, or you are dealing with some personal issues that are having an effect on your mood or academic performance, remember that part of taking care of yourself is asking for help. This could include seeking help from a professor, a counselor, or maybe even communicating with someone in a leadership position within your school or residency program about what you are struggling with. Being self-aware of your battles and finding a solution in a timely manner can drastically improve your academic performance, your overall health, your board scores and allow you to treat your patients in a more compassionate manner.

How to manage stress while preparing for your USMLE Step 1 exam

Preparing for your USMLE Step 1 exam is stressful, regardless of how easily you retain knowledge or how savvy a test taker you are. This board exam requires hours of studying each day for many weeks or months and students spend hundreds to thousands of dollars on test prep question banks and courses to properly prepare for the big day. Although it is true that a solid USMLE Step 1 score is highly coveted for residency applications, this score is not the only determining factor of whether you will match at your top choice program.

There have been many candidates with low Step 1 scores or who have failed on their first attempt who have matched in residency and successfully gone on to practice as a physician. There is so much pressure on Step 1 scores, that many medical students do more harm than good to their scores by studying excessively; mentally and emotionally exerting themselves in order to attempt to score in the highest percentile. You need to ensure a balance between studying and self-care.

Healthy tips and tricks for USMLE Step 1 board preparation

  • Set a reasonable study schedule and STICK TO IT - (studying for 8 hours a day, 7 days a week is not reasonable)

  • Allow yourself at least one full day off a week from studying

  • Maintain a healthy sleep schedule (average 8 hours of uninterrupted sleep each night)

  • Exercise at least 30 minutes a day

  • Spend time outdoors

  • Eat a healthy, whole-food balanced diet (avoid unhealthy snacks and processed food)

  • Enjoy a glass of wine or beer but be cautious to not excessively drink (binge drinking is common in medical school and residency and is dangerous)

  • Establish positive relationships with your peers, friends and family and spend time enjoying yourself with these people

  • Make sure you are studying in a mentally, physically and emotionally pleasing environment (if you do not like the library then do not study in the library)
  • Limit your caffeine intake to two cups of coffee each day

  • Recognize your emotions and stressors and talk about them with someone you trust

  • Set realistic goals (if your practice scores are in the 120’s then set a realistic goal of 125, do not shoot for 145 if you have not scored within that range)

  • Spend enough time each day and each week doing whatever makes you happy (whether it is running, listening to music, cooking or practicing yoga)

 Kristen Fuller in Peru

The stigma associated with mental health within the medical professional community

Each year, an estimated 300 to 400 doctors commit suicide. That’s the equivalent of losing an entire medical school student body to suicide annually.

In recent years, the issue has received more attention, in particular after two first-year medical residents jumped to their deaths from the top of buildings in New York City within days of each other in 2014. The public nature and timing of the deaths prompted national headlines and articles in academic journals, but the cases were not wholly surprising to administrators at residency programs and medical schools.

A 2003 study published by the Journal of the American Medical Association concluded that “the culture of medicine accords low priority to physician mental health” through discrimination in medical licensing, hospital privileges, and professional advancement.

Andrew Shaw, Student Senate President at the University of Nebraska Medical Center, said even when a program is supportive of students struggling with mental health issues, the stigma is still present. “There’s just this thinking that you’re not supposed to be sick,” Shaw said. “You’re helping people get well. You’re supposed to be well yourself.”

Residency program directors (depending on the specialty) are becoming more aware of the stigma surrounding the stress, anxiety and mental health issues that are associated with this profession, which allows medical students, faculty, and residents to also be more open and communicative about these issues. However, the stigma is still present across the medical professional community.

The only way to continue to eliminate this stigma is to educate each other on the importance of mental illness and self-care and to encourage each other to seek help and treat each other with kindness and compassion instead of competing with each other in an already dog-eat-dog world.

Kristen Fuller
Kristen Fuller
About the author

Kristen attended her Family Medicine Residency at the University of Tennessee, Memphis and has always been a strong advocate for mental health and living a full life, outside of medicine. Currently she practices per diem in the Emergency Room in Southern California but spends most of her time writing content for a well-respected mental health and eating disorder treatment center.

She also enjoys writing board prep questions and content and working with magazines such as Psychology Today, NAMI and Eating Disorder Hope.

Kristen spends her free time leading hiking and backpacking trips for her women’s hiking group and writing for her outdoor women’s inspired blog GoldenStateofMinds. She finds that the outdoors is the best type of therapy an individual can receive.

If you're keen to find out more about how to ease the burden of your Step 1 preparation, we have a variety of useful advice about the USMLE Step 1 Exam in our Ultimate Guide

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