Do you feel panicked about your USMLE score? Does sleep come slowly – or in spurts – as your mind races with uncontrollable thoughts? Are you worried about how you will fit everything in? Do your days end with a feeling you should be doing more? Or do you begin your days with dread? Can you feel your heart pounding right now?
If so, you’re not alone. Although it’s somewhat taboo to discuss, anxiety among medical trainees is high. What’s worse is that panic or even moderate anxiety destroys productivity.
But what do we do about it? It’s tragically ironic that the people who feel most anxious are the ones who often feel less able to spend time dealing with that anxiety. Of course, we can recognize the adverse effects – poor concentration, sleeplessness, lack of joy, etc. But often, we feel powerless to deal with it.
In this article, I will discuss a quick, five-step method to calm yourself in any situation. These situations include:
- Panicking on the day of your test,
- Insomnia from intrusive thoughts,
- Problems concentrating during studying,
- Intense procrastination and/or prolonged breaks,
- Feeling “lazy” and unmotivated, or
- Any situation where emotions – big or small – threaten to derail you
Anxiety is (Really) Detrimental to Studying
You probably don’t need research studies to know that panic is terrible for test-taking. Of course, though, they exist.
What you may not have considered is just HOW bad anxiety can be. Of particular relevance to medical students is this study. In this retrospective study, students Washington University School of Medicine in St. Louis completed an anonymous survey asking for their Step 1 scores. They also recalled their MCAT score and their pre-Step 1 study period. Items included the number of questions they completed, the use of spaced repetition flashcards, and many other things.
| Standardized β | 95 % CI | p-value | |
|---|---|---|---|
| Honours | 0.347 | (0.136, 0.559) | 0.002 |
| MCAT | 0.28 | (0.0973, 0.463) | 0.003 |
| MCQ (# of questions) | 0.298 | (0.139, 0.457) | < 0.001 |
| Anki (# of reviews) | 0.195 | (0.0265, 0.3630) | 0.024 |
| Test anxiety | − 0.326 | (− 0.512, − 0.141) | < 0.001 |
You’ll notice that anxiety had a robust NEGATIVE correlation with Step 1 scores. In fact, in this particular study, anxiety had a stronger negative association than the positive association of having a high MCAT score.
Said differently, the positive benefits of NOT being anxious are as much as having a high MCAT score. So think about that the next time you’re tempted to think, “anything that isn’t studying is a waste of time.”
Anxiety is Common – Especially Among Those Who Bury Their Feelings
The first step in calming yourself down is to know that you are NOT alone. Anxiety is pervasive among medical trainees. A meta-analysis of anxiety among medical students worldwide found a global prevalence of 33.8%. Estimates of anxiety prevalence among the general population to be between 3% (DASS-21), 8.2% (GAD-7), or 25% (HADS-A). In other words, anxiety is more common (and likely much more common) among medical trainees than the general populace.
A Rose By Any Other Name: “I’m Not Anxious – I Just Can’t Sleep, That’s All!”
“What me, anxious? Of course not!” you might be thinking. You might be right. However, we should all be careful not to ignore our feelings. Otherwise, we risk falling for the “if I don’t acknowledge my feelings, they don’t exist” fallacy.
Trust me, I know. I had all the classic signs of anxiety in college – trouble sleeping, difficulty concentrating, and palpitations. However, I told myself, “I can’t be anxious; everything is going fine!” and soldiered on.
During finals week, though, it all came to a head. In short, I had a full-blown panic attack. I was hyperventilating, tears streaming down my face. It was only when I was breathing so hard that I was developing paresthesias and lightheadedness that I realized just how anxious I was – and how much I’d been ignoring the signs. Then, finally, it dawned on me that calling anxiety a different name – “on edge” was what I called it – didn’t change what it was. In fact, by not naming the feelings, they only got worse.
Ignoring Anxiety May Make It Worse
There are numerous reasons to suspect that burying your feelings may only make it worse. As we’ve discussed before, naming your feelings helps calm you down. In addition, the study comparing med student anxiety across cultures gives clues as to the effects of ignoring our feelings.
The table below shows the prevalence of anxiety among students in Asia, the Middle East, and elsewhere. Note how the rates of anxiety are substantially higher in the former two regions.
| Continent | Number of Studies, n | Pooled Prevalence, % | 95% Confidence Interval, % | p = 0.04 |
|---|---|---|---|---|
| Asia | 18 | 35.2 | 26.3–45.3 | |
| Middle East | 21 | 42.4 | 33.3–52.1 | |
| Rest of the World | 30 | 27.5 | 21.5–34.5 |
The authors hypothesize that these higher rates of anxiety are partly due to a cultural stigma against showing emotions and stigma towards mental illness.
We hypothesize that this could be due to the differing views and level of acceptance of people with mental illness in different cultures. For instance, it has been described that people in the Middle East value ‘concealing emotion’. Sharing how one feels with another is uncommon in Middle Eastern cultures, leading to stigmatization towards seeking help from a mental health professional [106]. In Asian cultures, being diagnosed with a mental illness is thought to reflect the patient’s family weakness and is perceived to be shameful [107]. In contrast, it was found that people of Caucasian descent have a lower rate of stigmatization towards mental illness than other socio-cultural groups [108]. Hence, the leaders of medical schools have to take into consideration the unique sociocultural context in developing strategies to tackle anxiety among medical students.
The “Oh F#@& to OK” Speed Drill
So to summarize so far:
- Anxiety is pervasive among medical students – especially those who bury their feelings.
- A low level of anxiety is associated with a boost as considerable as having a high MCAT score.
Since that is the case, wouldn’t it be wonderful to have a way to calm our panicked brains?
Most of us consciously or subconsciously know how to calm ourselves down. However, these methods often involve distracting ourselves and, moreover, they take a long time. For example, have you ever gone to the gym to “blow off steam”? It works, but it’s not particularly time-efficient.
The solution? The “Oh F#@& to OK” Speed Drill.
As described by Mark Goulston in Just Listen (affiliate link), the speed drill is the fastest way I’ve found to calm oneself whenever overcome with powerful emotion. I’ll explain it here, although I highly recommend Goulston’s book to anyone looking for an emotionally intelligent way to improve interpersonal effectiveness.
“Oh F#@&” (The Reaction Phase):
In this phase, your natural reaction will be to run away from the negative feelings. We all have an instinct to avoid the things causing us discomfort and avoid the discomforting feelings themselves. This avoidance takes many forms – checking our email, watching a video, working out, talking to friends.
Fight that urge. Instead, use “affect labeling” and name your emotions. Example:
“Oh F#@&. I can’t believe I just bombed that UWorld block. I am terrified that I won’t get my score up in time. What if I can’t be a doctor? Will I fail out of medical school? What if I can’t get into the residency I want – or even ANY residency?”
If you’re alone, say this out loud. If you’re by yourself, say it in your head – or write it down.
Do NOT talk to other people for the first few seconds (at least). Instead, put all your attention to acknowledging your anger, panic, or other strong emotion.
As you name and acknowledge those feelings, you should feel yourself start to calm down. fMRI correlates back this up. Affective labeling causes the frontal lobe activity to increase and the amygdala to calm down.
“Oh God” (The Release Phase):
After acknowledging your big emotions, take long, deep breaths in through your nose. Keep your eyes closed and keep breathing until you start to feel your muscle relax and face un-tense.
“Oh Jeez” (The Recenter Phase):
Keep breathing. Keep doing this until you are completely calm.
“Oh Well” (The Refocus Phase):
Start to think of your plan. What can you do to control the damage and pick yourself back up? For example, if you just bombed a UWorld block, most people’s first instinct is to:
- Do more questions (repeat what they’ve been doing), and
- Assume every question is a lack of knowledge.
Instead, as you’re now calm, you might consider that roughly 50% of questions you miss are often due to errors of question interpretation rather than lack of knowledge. So your plan might be to calmly review your missed questions and evaluate which questions were due to a lack of content mastery – and which were interpretation “unforced errors.”
For more on question interpretation, see this article.
“OK” (The Reengage Phase)
If your eyes are closed, open them. Then, take the first step to implement your plan.
Practice the Speed Drill Before You Need It
Goulston’s advice is to practice the speed drill BEFORE you need it. In other words, recall a particularly stressful time, and run through the steps of the exercise. You’ll find that it will become faster and more reflexive with practice.
In my own life, this has been a life-changer. Times, when I would usually panic and reflexively try to run away now are mere blips. Fights with my wife where I might have done or said something I regret now proceed much more calmly. I find myself accomplishing even more, as well, as I can recognize more easily when I am figuratively (or literally) running away from uncomfortable things.
So, take 5 minutes right now to run through the speed drill. Who knows? It might even change your life.
Concluding Thoughts
We probably don’t need studies to tell us how detrimental anxiety is for test-taking. But, unsurprisingly, they exist and show the dramatic adverse effects panic and fear have when we’re preparing for high-stakes examinations.
In coaching students to overcome their anxiety to master USMLE content, I’ve learned several unexpected things. The biggest thing has been how often I – and others – subconsciously avoid uncomfortable things.
How often do you get to a difficult passage of a text and then find yourself on Youtube? How many difficult Anki cards do you see before you start checking your email? These subconscious avoidances of uncomfortable things lead to a substantial waste of time if you’re anything like me.
Overcoming panic and anxiety can be a massive boon to your Boards performance – and sanity. Even better, you may find that the tools that can help you with your Boards can also apply to many more aspects of your life.
What do you think? Do you feel anxious about your USMLEs? Have you tried the speed drill? How often do uncomfortable things knock you off-track and cause you to waste time? Let us know in the comments!
