Wednesday 7 March 2012

Dealing with Residency Match (pre match) Stress

Though this article uses match induced stress/anxiety as basis for identifying and dealing with stress, these techniques are universally applicable to any anxiety provoking situation

Abstract: Obtaining a residency in US for a foreign medical graduate is extremely stressful and anxiety provoking. The chance of matching into a program or specialty of their choice is small given the sheer numbers of applicants. The entire process evokes anxiety and is tremendously nerve-racking. Though there is an extensive body of literature studying the role of stress during residency, formal studies assessing the impact of this stress on physician starting residency in US are lacking, it is a general consensus that many international medical graduates (IMGs) feel that this is the singular most important aspect of their professional life. This article discusses some strategies to recognize the stress inducing patterns and mechanisms to cope with it.

Fig. 1: Contributing factors of increasing residency application stress

What makes match so stressful?
Every medical student graduating from school tends to seek postgraduate medical training. This phase of application is protracted, costly, tedious and expensive. While the rate of unsuccessful matches for American graduates is low, the fraction of unsuccessful international medical graduate numbers in tens of thousands. The question then is why does it matter so much if we match or not? What makes the US medical postgraduate residency an extremely formidable stressor? Listed in figure 1 are some factors, which makes losing a residency match seem like the end of the world for IMGs. Firstly, USMLE and residency in US is a humongous investment. It is not only an investment in time but also effort and money. Expense is a big issue, because as of January 2012 according to USMLE steps cost 790$ for step 1 and step 2 CK and $1375 for step 2 CS, this is for US centers and international centers may have higher fees. This brings the total expense of qualifying exams close to 3000$. For many international graduates dollars to local currency conversion is a problem because it costs that much more for a new physician student to spend. For example, 3000$ is approximately 150,000 Indian rupees, 270,000 Pakistani rupees, 128000 Philippine peso, 18000 Egyptian pound etc. Big expense for a long-term gamble. Career aspirations and glamour of being a doctor in USA also raise the stakes for the match. Lastly, apparent perception of lack of opportunities back home also fuels a big impetus of highly trained and qualified physicians hopeful to come to US

Fig. 2 Unchecked anxiety leads to unresolved issues

What can we do about the nervous tension?
First step is to identify that match induced stress exists and recognize it. If a person has good coping skills and is able to take the level of stress with healthy attitude then such applicants will find that this is just another part of life. Perseverating on match related issues until the match day for all and after the match day for those who do not match induce a vicious cycle of stress-anxiety-poor outcome. Neglecting this aspect can lead to two possibilities where anxiety increases to a point leading to implosion of the problem (called nervous breakdown). On the other hand, sub optimal solution can lead to a nagging chronicity, which then manifests as chronic stress. Neither situation is healthy and appropriate methods as needed to deal with stress of this magnitude.

Fig 3. Methods to deal with stress (click image to open in new window)

Ways to deal with stressors
Though article deals with residency match induced stress, these methods are applicable to pretty much any area of life where anxiety-provoking situations are common. As indicated in figure 3 an appropriate response to stress would be either to control it or find an alternative or to delete it. For those who are technologically perceptive, [ctrl + alt + del] is the keyboard short cut to access the reboot sequence on windows based system.

Controlling the anxiety is possible with a well-trained mind. Some folks are natural at it and have a high threshold for induction of a response. For others, same degree of control can be obtained by training and exercising meditative techniques. Chanting, focusing on breath or music are helpful examples used in strengthening the mind against the corrosive influence of anxiety. There are autosuggestion methods, which can also be used to shore up the mind against influence of stress.

Second method to deal with match anxiety is to find an alternative. As explained in the figure 3, this can be to either deviate your nervous energy to productive pursuits or distract your mind from the nervous energy. Deviating is better, as you can pursue a new talent, learn a new skill or even take up a new hobby, which will eventually help you in life. Distraction is a short-term fix that can be very useful. Going on a vacation to take you mind off the current issue is an example of distraction. Problem with this method is that, if the resolution of problem is far in the future then you are worse off after the distraction than before. In addition, distractive methods cannot be used indefinitely.

Finally, deletion of the anxiety-provoking situation can be done with either removing the stressor (which in this case is residency match process) or the stresee (which in this case is you). Removing yourself is not an option. You can temporarily suppress the event, which is a good short-term measure of dealing with stress. Again, final resolution of the stressor comes once the match is through and the results are out.

In conclusion, residency match in US evokes fear and stress that are major stressors for applicants in this process. Recognition of the degree of stress is important along with effective ways to deal with stress. Ability to deal with this magnitude of stress distinguishes a successful applicant for the rest because, they can bounce back from a setback and face the issue again.

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