I recently listened to a heated but friendly debate among medical students about why some of their peers seemed to struggle far more than others. The underlying assumption was simple enough: they had the same twenty-four hours, sat for the same exams, moved through the same clinical rotations, and endured the same demands. If everyone was being asked to do essentially the same thing, why did some people seem to fall apart while others carried on?
I found myself thinking that the easiest way to expose the flaw in that question was to imagine two students who, on paper, had lived through exactly the same day.
Two students walk out of the same examination room after sitting for the same board exam, moving through the same clinical rotations, and enduring the same brutal feedback session from an attending physician just two nights earlier. One goes home, eats dinner, sleeps soundly for eight hours, and returns the next morning ready for the next rotation. The other has slept no more than two hours a night for the past week, his hands have not stopped shaking since he left the testing center, he is taking medication for panic disorder and depression but has told almost no one how severe the past month has become. The possibility of taking a formal leave of absence feels, to him, like a professional cost he cannot afford.
From the outside, these two students appear to have been given the same circumstances. Internally, they may as well have been living through entirely different events.
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Three explanations, each partly true
This stark divergence in resilience often leads outside observers to speculate about the root cause of such a profound psychological difference. One contingent of onlookers will invariably argue that the struggling student carried a latent vulnerability long before ever applying to medical school, suggesting that the pressure of the training program merely exposed a pre-existing flaw. A second group will propose the exact opposite, maintaining that the individual was entirely stable until the unique, unrelenting pressure of this specific medical environment finally broke a psyche that had held steady for years. A third perspective might look deeper into the profession itself, questioning whether the very traits that draw individuals to medicine in the first place, an exacting drive, a hyper-focused work ethic, and low tolerance for personal error, inherently carry a much higher baseline risk of psychological vulnerability than that of the general population. Each explanation contains a piece of the truth, and the problem begins when we assume that one of them must be the explanation.
Robert Sapolsky, a neuroendocrinologist who has spent his career studying stress and behavior, offers a perspective that clarifies this exact dynamic by arguing that no single explanation can ever fully account for a specific behavior. In his view, treating biology, environment, or personal history as separate, competing arguments misses the reality that each explanation simply represents a different distance from which to view the same continuous chain of events. The examination may have been the immediate trigger for one student’s hands to shake, but it cannot explain the entire response any more than a hidden genetic vulnerability can. Both are connected points along a much longer developmental sequence.
Moving backward from the moment
To understand why one student remains steady while the other unravels, we have to move backward from the moment itself. Seconds before the shaking begins, the brain is responding to an immediate perception of threat. Hours and days beforehand, sleep deprivation, accumulated stress, and the body’s repeated exposure to pressure may already have changed the conditions under which that moment is experienced. Over months and years, experiences have shaped patterns of expectation, threat, confidence, and fear. Further back still are childhood environments, early relationships, temperament, biology, and the countless experiences through which each person learned what failure meant and what it meant to be safe. The point is not that one of these explanations is the “real” one, but that all of them belong to the same story.
The quiet divide among students
That same backward logic points to something else too, a quiet divide that exists among the students themselves. Those who remain steady and rarely notice their peers falling apart are seldom acting out of genuine unkindness or cold indifference. More often than not, their lack of awareness stems from the simple fact that they don’t have access to the particular internal reference point that would allow them to understand why this particular situation is so destabilizing for someone else.
Meanwhile, the individuals experiencing severe mental anguish have to navigate an entirely different set of psychological calculations. They vividly remember being exceptional, highly capable students long before their medical training began, and they constantly torture themselves wondering how they transformed into someone who cannot survive a single week without falling apart. This suffering is frequently compounded by profound cognitive distortions, leaving them feeling as though they are selfish people merely extracting knowledge from their patients’ bodies and charts rather than offering anything meaningful in return, ruminating that failure is worse than death, while watching their classmates function normally begins to look less like an inspirational example and more like a magic trick they can neither replicate nor comprehend.
The environment is real, but it does not land evenly
The environment itself is not irrelevant. Traditional medical training historically demanded a singular, total devotion to clinical work, a standard that was already brutal enough on its own terms, and in recent years an entirely new tier of expectations has layered directly on top of that baseline endurance, immense pressure to publish research constantly, cultivate a distinctive professional brand, and maintain a highly visible, idealized personal life. An environment this demanding does not land on every student the same way, because the same feedback session that reads as useful information to one student registers as confirmation of personal failure to another, and the same sleepless night that feels like a minor inconvenience to one person becomes the start of a downward spiral for someone else. The environment is real and heavy for every student who passes through it, but the weight it carries and the meaning it takes on depend entirely on the history of the person carrying it.
What the hallway cannot see
None of this was ever really about the two students. It was about everyone standing in that hallway who watched one moment and believed they had seen the whole story. The sameness of the environment creates an illusion that the experience inside it must be equally shared, so when someone stumbles under a curriculum that seems identical for everyone, it becomes easy to read that stumble as a personal defect rather than a difference in history. What gets missed in that reading is everything Sapolsky’s timescale asks a person to notice, the years and decades of biology and circumstance that walked into the room long before the exam did, invisible to anyone who only had the exam itself to look at.
Even the students who appear to be handling everything with ease are not proof that the pressure is manageable for everyone equally. They are simply further evidence of the same pattern, different histories producing different outward results from an identical set of demands, which means the very existence of students who seem fine is not a verdict on the ones who are struggling. It is only another data point in a much longer and largely invisible sequence that nobody in that hallway can fully see.
This essay is cited in the KevinMD record on medical school.
Ronke Lawal is the founder of Wolfe, an AI-native mental health infrastructure that combines neuroscience, behavioral psychology, and safety-focused AI to eliminate clinical blind spots in global mental health care. Her career spans Bain and Company’s social impact and private equity practices and finance leadership at technology startups, a three-year arc that revealed what she identifies as a $20 billion failure in digital mental health: cultural incompetence at scale.
As the architect behind Wolfe’s clinical intelligence, Lawal builds clinically intelligent systems that integrate neuroadaptive signal processing with therapeutic architectures, designed to detect clinical risk and intervene on trauma before the cascade reaches crisis. She is focused on solving what she calls “algorithmic malpractice” in mental health care: the industry’s willingness to deploy AI that engages vulnerable populations without the clinical intelligence to do no harm.
An MBA graduate of the University of Notre Dame, Lawal writes on AI, neuroscience, behavioral psychology, and health care equity, dedicated to wielding AI to reduce human suffering and save lives. Her work is cataloged on ORCID and Zenodo, and she shares updates on LinkedIn.
