Supporting the balance between well-being and performance in medical education.

To become a good doctor, medical students are required to continuously improve their performance. That performance is systematically monitored and those who are not able to achieve professional standards can be dismissed from medical school. What if the standards themselves, however, cause students so much stress they cannot perform to their full capability?

This very question is raised in a study by Stegers‐Jager et al. in the current issue of Medical Education. They compare students required to obtain at least two‐thirds of their year credits to continue their training with students who are required to obtain all year credits. When exposed to the latter (stricter) standards, students showed better academic performance (in terms of passing rates) than their peers without demonstrably higher levels of objective stress as measured by cortisol levels. The stricter standards, however, did result in higher levels of subjective (ie, perceived) stress and higher levels of both objective and subjective stress were associated with poorer performance.

The direction of causality in the latter relationships is up for debate, but it is noteworthy that students have separately reported that the constant pursuit of excellent performance is felt to jeopardise their well‐being and that the amount and intensity of performance assessments provide sources of stress throughout medical training. These relationships are complex. Although stress can interfere with performance by impairing functions such as attention and decision making, which are vital for clinical reasoning, it can also promote performance by motivating students to work harder. Performance can, furthermore, benefit from the enhanced memory and increased speed of brain processing that can occur in response to stress. It is thus too simplistic to say that stress must be reduced for the sake of performance. Rather we need to consider how stress optimally facilitates performance in order to support a healthy balance between well‐being and performance in medical education.

… We need to consider how stress optimally facilitates performance in order to support a healthy balance between well‐being and performance …

This balance is vital as stress‐related risks to performance threaten the quality of patient care. Specifically, the exposure to prolonged stress can lead to burnout symptoms that are associated with lowered professionalism (ranging from unprofessional behaviours to suboptimal empathy) and higher rates of safety incidents. , Patient satisfaction may also be at stake when care is delivered by burned‐out trainees. Trainees themselves report burnout (including its symptoms of exhaustion, cynicism and ineffectiveness) to interfere with their ability to provide optimal patient care. This is especially problematic currently as burnout appears to be highly prevalent amongst students and trainees. ,

This balance is vital as stress‐related risks to performance threaten the quality of patient care

So, what can we do about it? Trainees and students are less likely to burnout when they are supported by clinician teachers who adequately address stress in the challenging process of becoming a high‐performing doctor. Teachers may prevent burnout by creating a safe learning environment where mistakes are not considered as threats, but as opportunities for performance improvement. Continuous performance improvement can become an inherent part of medical education by embedding it in programmatic assessment protocols that promote achievement through frequent low‐stakes assessments that inform high‐stakes decisions about learners' performance (eg, pass or fail). Such a continuous process of performance assessment can be perceived as stressful by learners, which is why they value support from teachers with whom they can freely discuss uncertainties and stressful experiences. This opens a window of opportunity for teachers to proactively address stress and support the balance between well‐being and performance.

This opens a window of opportunity for teachers to proactively address stress and support the balance between well‐being and performance

It is not entirely clear yet how teachers can best take advantage of this opportunity. However, research has clarified that teachers do embrace their supportive role in the supervision of learners struggling with stress when engaged in programmatic assessment. Specifically, in the current issue of this journal, Schut et al report that teachers support learners by striving towards accessibility, care and partnership in their relationships with learners. Maintaining such relationships can, however, be as challenging as supporting optimal levels of stress in learners given that teachers also need to provide learners with critical feedback. When teachers worry about their relationships with learners they value opportunities to share concerns with peers. Peer support can indeed help teachers deal with the various demands of supervision, and may especially be fruitful when they face their own emotional demands in trying to help alleviate learners' stress.

Teachers are, furthermore, best able to alleviate stress when learners proactively discuss their needs in finding the right balance. Learners therefore need to be self‐aware of stress and self‐reflect on the balance between well‐being and performance, which could be facilitated, for example, by mindfulness practice. Learners should also be encouraged to identify role models who exemplify effective reflection on stress‐related threats to performance in an effort to advance understanding of how they might decrease perceived barriers to discussing an unhealthy balance between well‐being and performance. An experienced clinician teacher (one of my personal role models) once taught me that there are three drivers of performance in medical education: (a) a good example is the best sermon; (b) be your brothers' keeper, and (c) accept imperfection. These drivers can be translated into clinical teaching practice by: (a) role‐modelling behaviours that exemplify a balance between well‐being and performance; (b) supporting and caring for the balance between well‐being and performance of learners and peers, and (c) accepting that a perfect balance is unrealistic, yet worth striving for.

Teachers are … best able to alleviate stress when learners proactively discuss their needs in finding the right balance

Striving towards this balance is especially challenging in the face of the various demands of medical practice (eg, heavy workloads). These demands limit time and resources that teachers need to optimally support learner well‐being and performance. This calls for a better balance between demands and resources in clinical teaching practice; a balance that facilitates teachers in optimally supporting learners with diverse well‐being and performance needs.