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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: 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 costs of medical training, debt, depression, and despair.” Janet, welcome to the show.

Janet 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 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, as I’ve been going through it, there’s a lot of pressure to view our stories very positively, to be resilient, to bounce back after experiencing a lot of pain.

And I think what’s tough is that this was the case 60 years ago, it was the case 30 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 to touch on the really 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 we can create a healthy learning environment for everyone to thrive.

Kevin Pho: So talk about some of the specific challenges that you’re mentioning here.

Janet Coleman-Belin: Let’s see, we’ll start at the very beginning—first year. Faculty are in a really tough position because of really high clinical demands, increasing RVU requirements, battles with health insurance, and so on. 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. Then adding on top of it the teaching of 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—means that, from the beginning, it can be really challenging to learn the important information we need to learn effectively.

As a result, we’re often spending a lot of time in the library, agonizing over tests. We’ve also been told, up to the point of medical school, many of us, that we’re really smart, really special, really unique. Then, when we arrive and are surrounded by many other incredible people, we face imposter syndrome: Am I good enough? Do I deserve to be here?

When we’re in the hospital interviewing patients, we’re not useful initially. Many of my peers and I struggle with this feeling. Here’s a patient who’s getting woken up every 30 minutes by nurses, doctors, physical therapy, OT, and so on. Then we come in, as medical students, and are essentially practicing our interviewing skills. Initially, we feel not only like we’re not worth very much; sometimes we feel like we’re actively harming the patient’s experience. That can persist throughout our learning, where we feel like we’re in the way—making attendings’, residents’, and fellows’ lives harder. So, yes, we can feel like these useless tails. When we do help, we feel really proud of it, but there’s a skill to learning how to help, and that’s a big learning curve.

Kevin Pho: 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. How do you and your colleagues and your classmates manage these conflicting feelings and these moments of tension?

Janet Coleman-Belin: It really varies. I’ve gotten a lot of positive feedback, so I’ll comment on my experience. However, I want to be very clear that initially I really fell into a lot of pitfalls. Probably some of the biggest hindrances we can cause as medical students include talking too much, talking when we’re not supposed to, or asking a question at the exact critical moment—for example, in surgery, asking what could be perceived as a very uninformed question, like “Oh, what are the complications of what you’re about to do?”

On a busy clinic day, we might really want to be involved, but not do our best to make lives easier for the attendings and residents. In managing that tension, a lot of what I’ve learned—and a lot of what I’ve received positive feedback on—comes down to knowing when to speak, when to stay silent, and when to ask questions. For instance, opening supplies at just the right moment, making obstacles disappear as the attending or resident is moving around, so they don’t even realize that what they need is already there. We basically become these friendly ghosts.

In addition, connecting with patients and finding joy when we can is hugely important. I will note, though, that I’ve felt empowered to connect with patients the most when I’m on teams that celebrate that role—teams that say, “Yes, please do go spend time with this patient,” or “Please bring your empathetic listening skills.” That has made me feel very valued.

Kevin Pho: It sounds like there’s a learning curve to the art of being a medical student—when to ask questions, when to be inquisitive, when to back off—and this is something that can really only be learned on the fly. It’s not explicitly taught to you.

Janet Coleman-Belin: Exactly. And I’m sure you remember—it’s a complicated role. Someone told me recently, a fellow did, that the myth of medical school is that it gets better. That hit me pretty hard because medical school has a lot of challenges, and I discuss them in the article. However, in many ways, we are somewhat protected these days, especially with regard to a lot of reporting. I’ve seen attendings in particular be fearful of us. They don’t want to say or do something that could be construed as politically incorrect or worthy of being reported. That, in turn, can serve as a barrier to connection and humor, because then it’s a fear-based team environment at times.

On the flip side, there are people who don’t really care so much, like one of the residents I mention in the article who told me, “Don’t even bother reporting me; so many people already have.”

Kevin Pho: Talk to us about some of the behavioral health stresses that medical students are facing, even when learning the art of being a medical student, and the support systems that medical students today have.

Janet Coleman-Belin: I’ve been reflecting on this a lot because I’ve been wanting to offer strategies or solutions. I think one of the biggest challenges—the part that can be very psychologically damaging—is that we’ve gone our whole lives, many of us, without having to justify why we’re becoming doctors. There haven’t been many people saying, “Oh, how are you going to make a living with that?” or “Are you sure this is what you want to do?” For many of us, becoming a doctor seems like a universally accepted good decision.

So when we arrive and we’re treated like we’re nothing—or worse than nothing, that we’re harmful or making things more challenging—it’s psychologically damaging. That’s one of the biggest issues, in my view. And it’s a lot of personal work to detach ourselves from the outcome of a test or a rotation grade. But when we internalize these experiences, it’s painful.

One of the most helpful experiences I’ve had recently was a resident telling me, “Even if it’s just for today, you are an integral member of our team,” and then really treating me that way. I was given tasks that I could handle, or if I didn’t know how to do something, I was taught. For example, if I was asked to do a procedure, and I said I didn’t know how, I’d be pointed to a resource—like a video—and then they’d support me through the first one. I really believe that almost anyone can be taught how to do almost anything. That definitely includes medical students, who really do want to help—we just need to be taught how.

Kevin Pho: That feeling you received from the resident who made you feel valued as part of the medical team—how commonplace is that among your classmates? Is that happening the majority of the time, or is it an outlier event?

Janet Coleman-Belin: That is a great question. I would say it is very rare to hear on rotation, “You’re doing a great job.” Very rare. Even from some of my letter writers—like a surgery preceptor who wrote that I was in the top 5 percent of medical students he’d ever worked with, which was an amazing compliment—it’s not something I necessarily felt day to day while we were working together.

I think there’s an element of not wanting to appear to play favorites, or not wanting to look unprofessional or unobjective. But I don’t think it’s often that we hear, “You’re doing great.” Also, something that would have helped me earlier in my training, especially now that I know I want to go into surgery because I love suturing—on my emergency medicine rotation, I did it every chance I got, and I loved it—would have been to hear early on, “Hey, you’d be great in surgery. We want you here.” Of course, only if it’s genuine. But for someone who’s underrepresented in a field, or maybe doesn’t look the traditional part, hearing explicitly “We want you here” can mean so much.

Kevin Pho: Now, against that backdrop, medical students also have financial burdens and pressures as they pursue medical training. Talk about that additional financial pressure and how that influences your education.

Janet Coleman-Belin: Absolutely. 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 grateful for that. However, I do know people who are looking at over 300,000 dollars in debt—some from medical school, some from undergrad, and for some, post-baccalaureate premed programs as well. It’s really debilitating, and it can certainly influence students’ choices of specialty. It can place a lot of pressure to go into high-paying fields.

I also think it can be very trapping. My mental health got so bad last June and July that I was really considering leaving the program, even though I was so close to finishing. But the only reason I felt I could even consider leaving was because I’m not crippled by debt. I know people who have been in really intense mental health distress who don’t have that option. If they leave, they still owe hundreds of thousands of dollars. That’s a huge financial burden hanging over them, even if staying in medicine is hurting their mental well-being. It’s a really painful decision.

Kevin Pho: We’re talking to Janet Coleman-Belin. She’s a medical student. Today’s KevinMD article is “The hidden costs 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 Coleman-Belin: Well, thank you all again so much for listening. I know this isn’t a very sunny or pretty topic to talk about, and I just want to emphasize that medical students want to help. You all trained once as well; you were in the position of being a medical student. You wanted to help, and so do we—we just need to be taught how. Please value us as members 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 Coleman-Belin: Thank you so much. I really appreciate it.