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A medical student, Janet Constance Coleman-Belin, discusses her KevinMD article “The hidden cost of medical training: debt, depression, and despair.” Janet explores the challenges of medical education, including exorbitant debt, mental health struggles, and institutional shortcomings. She highlights trends in burnout rates among U.S. medical professionals and offers solutions to bridge the gap between student needs and available support. Listeners will gain actionable insights on improving well-being and fostering a healthier medical training environment. Janet shares her personal experiences and practical takeaways to help future physicians navigate the demanding journey.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Janet Coleman-Belin. She’s a medical student. Today’s KevinMD article is “The hidden cost of medical training: debt, depression, and despair.” Janet, welcome to the show.
Janet Constance Coleman-Belin: Thank you so much for having me. I’m feeling really honored to be here.
Kevin Pho: So tell us what this article is about for those who didn’t get a chance to read it.
Janet Constance Coleman-Belin: Absolutely. Well, medical training is challenging, and I think anyone in the clinician audience remembers that it’s a really tough road. I think it is really challenging because, I have been finding as I’ve been going through it, there’s a lot of pressure to view our stories very positively, to be able to be resilient, to bounce back after experiencing a lot of pain. And I think what’s tough is that that was the case sixty years ago, that was the case thirty years ago, and it’s still the case today. Not much has really changed in the grand scheme of things.
And so I wanted to write this in order to share a little bit about not just the medical student perspective, because that has been super well documented, that medical students are in a lot of pain, but also touching a little bit on the real lack of practical support that institutions tend to give in response. There tends to be more of a focus on individuals being resilient and bouncing back themselves, as opposed to: How can we create a healthy learning environment for everyone to be able to thrive?
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Kevin Pho: So talk about some of the specific challenges that you’re mentioning here.
Janet Constance Coleman-Belin: Let’s see. We’ll start at the very beginning, at first year. Faculty are in a really tough position because of really, really high clinical demands, increasing RVU requirements, battles with health insurance, so on and so forth. In addition, our faculty conducting research have very high demands on their research and in administration. Overall, academia has a lot of steps to it. And so then, adding on top of it, teaching to the medical students, which, from my understanding, isn’t necessarily well compensated, or rather, there aren’t a lot of financial incentives to do an excellent job teaching. And so from the beginning, I think that it can be really challenging to learn the really important information that we need to learn as medical students really effectively.
And so this means that as medical students, we’re often spending a lot of time tearing our hair out in the library, agonizing over tests. We’ve also been told, a lot of us, really up to the point of medical school, that we’re really smart, we’re really special, we’re really unique. And when we get to the point of being around a lot of other really incredible people, I think we then also face a lot of the impostor syndrome: Am I good enough? Do I deserve to be here?
Then when we’re in the hospital interviewing patients, we’re not useful initially. I think a lot of my peers and I struggled with this, which is: Here’s a patient who’s getting woken up every thirty minutes by nurses, by doctors, by physical therapy, by OT, by all of these folks, and then we’re medical students coming in and effectively practicing our interviewing skills. I think initially, at the very beginning, we feel not only like we’re not worth very much; I think we feel like we’re actively harming patients’ experiences. And that, I think, can persist throughout a lot of our learning, where we feel like we’re very much in the way. We’re making attendings’ lives harder, we’re making residents’ lives harder, we’re making fellows’ lives harder. And so, yeah, we feel like these sort of useless tails. And when we do help, we feel really proud of it, but there’s a skill to learning how to help, and I think that’s a pretty big learning curve.
Kevin Pho: Now, whenever you have these conflicted feelings, you certainly want to be useful as a medical student, but like you said, sometimes medical students are more of a hindrance, as you’ve seen. How do you and your colleagues and your classmates manage these conflicting feelings and these moments of tension?
Janet Constance Coleman-Belin: Yeah, I think it really varies. I’ve gotten a lot of positive feedback, and so I’ll comment on mine. However, I want to be very clear that initially I really fell into a lot of the pitfalls. So I would say that probably some of the biggest hindrances that we can cause initially as medical students are, for example, talking too much, talking when we’re not supposed to, asking a question at the exact critical moment, for example, in a surgery, asking what could be perceived as a very uninformed question. An example of that, I guess, is asking, “Oh, what are the complications of what you’re about to do?” Other examples are, on a busy clinic day, really asking to be involved but not doing our best to make lives easier for the attendings and residents.
And so I think, in managing that tension, a lot of the skills that we learned, and a lot of the positive feedback I’ve gotten, including most recently, someone told me this, and I couldn’t help but laugh. My attending told me, “You didn’t get in the way.” And I thought that was a really poignant comment, because he said, “A lot of people do.” But again, we go from really wanting to come into medicine to do good. We want to help, we want to heal; that’s why we’re here. And so for the hallmark of success to be, “You effectively stayed out of the way,” is pretty funny.
I also think that as we go on, we learn other unwritten social cues, like knowing when to stay silent, how to open supplies at the exact right moment, how to make obstacles disappear as the attending and resident are moving around, so they don’t even realize that what they need is right in front of them when they need it. But again, we’re basically these friendly ghosts, is what I found in the best medical student, in addition to connecting with patients and finding a lot of joy when we can.
I will note, though, that in the times when I’ve really been able to connect with patients, it’s often on teams when I feel very empowered to do so, very set up for success, and very celebrated for my ability to just sit and converse about anything, even outside of medicine. On teams that have celebrated that, I felt very valued.
Kevin Pho: So it sounds like there is a learning curve to the art of being a medical student: when to ask questions, when to be inquisitive, when to back off. And certainly, this is something that could only be learned on the fly. This is not something that has been explicitly taught to you.
Janet Constance Coleman-Belin: Exactly. And I’m sure, I mean, you must remember, it’s a complicated role. Also, someone told me, a fellow told me recently, that the myth of medical school is that it gets better. And that hit me pretty hard, because then I started to watch, and it is. Medical school has a lot of challenges, and I discussed them in the article. However, in a lot of ways, we are protected these days, especially with regards to a lot of reporting. I’ve seen a lot of attendings in particular kind of be fearful of us and not want to say or do something that could be construed as potentially politically incorrect, potentially worthy of getting reported. And that, I also think, can serve as a barrier to connection and to humor, because then it’s kind of a fear-based team environment at times. And then again, there are a lot of folks who don’t really care so much. Like, one of the residents I mentioned in the article told me, “Don’t even bother reporting me. So many people already have.”
Kevin Pho: So talk to us about some of the behavioral health stresses that medical schools are facing, even when learning the art of being a medical student, and the support systems that medical students today have.
Janet Constance Coleman-Belin: I really think, I’ve been reflecting on this a lot, because I wanted to be able to even offer strategies for what to do. I think that’s a lot of feedback I’ve been getting: “OK, we see there’s still the problem. What do we do about it?” And this is coming from faculty, this is coming from deans, from administration.
And I think one of the biggest challenges of being a medical student that can be very psychologically damaging is, again, we’re going our whole lives, and most, not all of us, but many of us, I think, have never really needed to justify to others why we’re becoming a doctor. For example, there hasn’t been, say, a case that I’ve experienced where I’ve told people that I’m becoming a doctor and they say, “Oh, well, how are you going to make a living with that? What are you going to do?” We don’t have to really defend our decisions in that particular way, most of us.
And so when we’re here, and again, we’ve gotten here because we worked really, really hard to get into a good college. We worked really hard in college to be able to get into medical school, getting good grades, doing extracurriculars, doing clinical shadowing to see if being a doctor would be a good fit. And so when we come to a situation and then we’re treated like we’re nothing, or that we’re worse than nothing, that we’re harmful in a way or making things more challenging or difficult, it’s very psychologically damaging. And so I think that is one.
Because when I really step back, and I’ve been doing that a lot now, of looking at the end of the day, it’s a class, it’s a test, a rotation grade is just a letter on a transcript. These aren’t big, massive things, but to us, we internalize that they are. Which, you know, can be said to be a lot of our work, that we have to detach ourselves from the outcome of grades and whatnot.
But I think one of the biggest things that I found has been really helpful in recent times has been, for example, a resident told me on a recent rotation, “Even if just for today, you are an integral member of our team,” and really treated me like it and really valued me. And I felt like I wasn’t just a tail or a shadow to an overworked resident. I was considered useful, and I was given tasks that set me up for success, that were within my skill level to do. And even if they weren’t, I was taught how to do them. For example, if I was asked to go do a procedure, if I knew how to, and I said no, I was given a resource of, “OK, here’s a video you can watch.” I was supported through my first one. And I really believe that anyone, almost anyone, can be taught how to do almost anything, and I think that’s very much the case for medical students, too. And so we really do want to help. I just think we have to be taught how to help.
Kevin Pho: So that feeling that you received from the resident who made you feel valued as part of the medical team, how commonplace is that from what you heard among your classmates? Is that happening the majority of the time? Is that an outlier event? How often does that happen?
Janet Constance Coleman-Belin: That is a great question, a great question. I would say it is very rare to hear on rotation, “You are doing a great job.” Very, very rare. And even from some of my letter writers, one of them, my surgery preceptor, wrote that I was in the top 5 percent of medical students he had ever worked with, which was an amazing compliment and hugely impactful for my narrative evaluation, for my letter, for my career. But I really didn’t get that sense for a lot of the time that we were working together. And I think there is this element of not wanting to appear to play favorites, of not wanting to look unprofessional or unobjective. But I don’t think it’s often that we hear, “You’re doing a great job.”
And also, I think, something that would have been potentially really helpful for me to hear earlier on in my training, because right now I’m at the point where I’ve decided that what I really love to do is sewing people. Maybe that’s a very kind of macabre way of putting it, but I just love to do it. I could do it all day. On my emergency medicine rotation, every laceration was sent to me, and I just really relished that action. And so at this point, I know that surgery is what I’m going to pursue. However, I don’t recall early on in my experience ever being told, “Oh, you would be a great surgeon. You’re going to be a great surgeon.” And that’s OK. I think, again, I empowered myself and decided that, outside of external validation, I’m going to try to do what I want to do. However, I think hearing that earlier on would have meant a lot, especially for anyone who’s underrepresented in a field or maybe doesn’t look the traditional part. I think really explicitly hearing, “You would be great in this field. We want you here,” and only, of course, if that is meant.
Kevin Pho: Now, against that backdrop, medical students also have financial burdens and pressures as they pursue medical training. So talk about that additional financial pressure and how that influences your education.
Janet Constance Coleman-Belin: Absolutely. I think I’m going to be very honest that I am not in the exorbitant debt position that many of my classmates are, and I’m very, very grateful for that. However, I do know people who are looking at over $300,000 in debt, and that’s from medical school, that’s from undergrad in some cases, that’s also from postbaccalaureate pre-med programs for folks who realized after completing undergrad that they wanted to continue into medical school. And so I think it’s really debilitating, and I think it certainly sways individuals’ specialty decisions of what they’re going to pursue in the future. I think it places a very high burden on very high-paying specialties.
I also think it can be very trapping. I was in a position, and I’m being very honest and vulnerable about this, where my mental health got so bad last June and July that I was really seriously considering leaving this program, even despite being so close to finishing it. However, I know that the only reason I was able to, honestly, have that choice, which in some ways might have been the correct choice for my mental health at that time, was because I’m not crippled by debt. There are a lot of people I know who had really, really intense mental health distress who aren’t able to leave, or rather, who, if they do, run the risk of entering whatever they’re about to do next, which, who knows what that is, with $300,000 in debt, even any debt, really. That’s a really hard decision to then make: Do I leave what is going to be a painful but certainly assured, stable, high income for something that is maybe better for me, or even if I need to? And so I do know a lot of people who are trapped.
Kevin Pho: We’re talking to Janet Coleman-Belin. She’s a medical student. Today’s KevinMD article is “The hidden cost of medical training: debt, depression, and despair.” Janet, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Janet Constance Coleman-Belin: Well, thank you all again so much for listening. I know that this isn’t a very sunny or pretty topic to talk about, and I just want to really emphasize that medical students want to help. I know you all, too, trained. You were also in the position of being a medical student; you wanted to help. And we need to be taught how to help. So please value us as a member of your team, and please set us up for success.
Kevin Pho: Janet, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.
Janet Constance Coleman-Belin: Thank you so much. Really appreciate it.
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