Stress, fighter pilots and medical students

In which Dr Aust offers, instead of bad science, a rather meandering anecdote.  Sorry.

En route back to Britain last week from our rather damp annual holiday, I couldn’t help noticing all the media coverage of the 70th anniversary of the Battle of Britain.

Like all children growing up in Britain in the 60s and 70s, I guess, I became familiar early on with the story of the Battle as it has passed into British folklore (or history).  I remember my mum taking my little brother and I to see the 1969 film version during a rainy holiday (another one!) on the Isle of Wight. At the time (the tail end of the 1960s) Winston Churchill was not long dead, and we children could all recite by heart his famous line about the Battle:

“Never, in the field of human conflict, was so much owed by so many to so few”

So the picture of young RAF fighter pilots pushing themselves to the limit to keep the Luftwaffe (the German air force) at bay in a knife-edge struggle against the odds was a very potent one in those days – and of course, there were many people still alive then who had been part of the battle. The struggle and the bravery of “The Few” seemed to embody what British people felt were “the British virtues”. Perhaps that is still true – though I was interested to find, reading the modern Wiki entry on the Battle, that the historians nowadays debate the version of it that I grew up with.

Anyway, the coverage this Summer reminded me of learning about the Battle of Britain some forty years ago – but also about another context in which I have come across the story being used.

Let me fill in this other context for you.

One of the things you get used to dealing with over the years, if you are a University teacher, is students who feel under pressure. Now, for people of my vintage there is a definite tendency, I think, to see University in hindsight as a right old lark. From the perspective of ten or twenty or thirty years spent earning a living, and dealing with all of life’s other vicissitudes, it is rather difficult to see the University years as a time of stress and pressure. Indeed, I think this view is common among most people looking back at their student years. When I learnt, rather late, to drive, I had a driving instructor who used to describe his one year at University before dropping out as “the best year’s state-sponsored drinking I ever had”. And I had a good laugh at this very funny David Mitchell piece from the Guardian last week.

Now, it is fair to say that things have changed in more recent years. The state in Britain is not sponsoring students nearly as much as it used to, and nothing like it was when I was young. Many of our students now have to have part-time jobs to help with their finances – though this seems to be far less common in “vocational” degrees, like medicine, that have more fixed time commitments during the week. We set a lot more formal assignments for students to do then when I was a student, and we set students exams far more often too. And many of our students are certainly worried about getting a degree results good enough to ensure they will be competitive in the employment market. So it is, I freely admit, not like it was when I was twenty years old.

Having said all of that, the first couple of years at University must still be, I think, one of the least stressful times work-wise in most people’s lives. In most UK Universities and courses, you merely need to pass the 1st year exams. You don’t have to get 80% – or even 60%.  In the 2nd year of UK science degree courses, the exams typically count in part towards the final degree grade (classification), but usually only a bit (often contributing something like 20-25% of the final mark). Meanwhile, in professional degrees, the 2nd year is another “you simply have to pass” deal. Depending on the particular degree, the pass mark for the year (or its component units) will typically vary between around 40 and 55%. There are sometimes “Distinction Points” for those who record the top marks, but mostly it is pass/fail.

Given all this, you would not think students in this part of their University course (the early years) would be that stressed.

Some of them, however, are.  Or they certainly feel, and tell us, that they are.

Medical students are a special example in some ways, partly for the following reason. People who reach medical school are typically those who have been used to being the top, or near the top, of the class throughout their years in the school system. Conversely, they are not used to failing things. But obviously, the step up from school to University is a significant one. And now you are in a group where everyone has been selected as being from the top echelon at school. Anyway, there is a top of the medical school class, and a bottom. And some people do fail medical school exams in the 1st year.

The good news for them is that they get another chance.

Further good news is that, if you are going to fail one set of exams in medical school, the best ones to fail are probably the first lot that you do. Everyone knows there may be an “adjustment”, both for academic or personal reasons, in the transition from school to University. Away from home for the first time, for instance. Busy socialising, for another. Getting used to working without teachers and parents prodding you along for a third. As a result of this, you typically get cut a little slack if you are a student having a few bumps. You have to pass the resit exam, but the initial failure does not get you written off as a no-hoper, or even a problem case.

But some students take any failure very personally. And each year, at least a couple of those that have failed the first Semester exams fetch up in the Faculty offices complaining that they are having problems with stress.

Now, views on how to approach discussing this with students differ. Back in the 1950s, in the era of the Dirk Bogarde Doctor movies, such a student would no doubt be told to “Pull your socks up, work harder and stop talking such utter nonsense.”

We don’t do that any more.

We are sympathetic. Really, we are.

Indeed, we in the University are rather more sympathetic than some in the medical profession itself might be. Hardliners in medicine (which might at times include Mrs Dr Aust, for instance if she has had a bad week in the medical trenches) have been known to offer the view that if a person can’t cope with failing their 1st year medical student exams and having to resit, then they are going to be about as much use as a junior doctor (a job that undoubtedly is stressful) as the proverbial udders on a bull.

So one take on the stressed 1st year student who failed their exams is that they perhaps benefit from being gently reminded that it is a minor setback that they can hopefully address and overcome, regroup and move forward, worse things happen at sea etc etc.

So, sympathy, but also a gentle steer that failing an exam isn’t the end of the world, or really that stressful in the greater scheme of things, and you need to get things in some perspective.

Which brings me back to where I started – with the Battle of Britain.

You will see why in a minute.

At a medical school where I worked, the person who for many years saw the students having “difficulties” (including those who were feeling stressed) was called the Senior Tutor for Students. The occupant of this role was a slightly crusty (but actually very wise) Yorkshireman, honed by many years of teaching gross anatomy whilst also working as a GP in a local health centre. By the time I met him, this chap, who was one of the best medical teachers I have ever come across, was in his 50s and already a legendary figure among generations of undergraduates.

One of his more celebrated routines for talking to 1st year students who were complaining of stress problems went something like the following.

————————————————————————————-

(Fixing student with deep hooded gaze over his glasses)

” Yes… well, How to look at this.”

A pause.

“Consider, if you will, A Battle of Britain fighter pilot in the Summer of 1940, fresh from training school. Solo flying hours on a Spitfire… perhaps a handful. Sleep in the last week… perhaps 20 hours in all. Chance of returning from the next day’s sorties against the German fighters, perhaps two out of three…”

Longer pause.

That (word very slightly emphasised) would be stress, I’m sure we could agree”

Another pause.

“Now…. you are a first year medical student…..”

————————————————————————–

Which is, I hope you will agree, the stuff of legends. I have certainly met doctors who could still remember, a dozen or more years later, themselves or their friends being on the receiving end of  this spiel.

And finally, with another teaching year at the University about to start, with all its inevitable minor vicissitudes – not to mention the uncertain economic future for the University sector –  I shall be taking my own advice.

I shall be doing my very, very best to keep it all in perspective.

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22 Responses to “Stress, fighter pilots and medical students”

  1. jenjen1352 Says:

    Brilliant! Must use that one on sprog when I get the opportunity. Thanks :)

  2. mandas Says:

    The great Australian cricketer, Keith Miller, was a pilot during WWII. He was interviewed by Michael Parkinson many years later, and was asked about coping with the pressure of playing Test cricket. He responded:

    “….pressure is a Messerschmitt up your arse, playing cricket is not….”

  3. draust Says:

    Cheers, Mandas. I’d heard that Keith Miller story and I almost put it in the post, given the parallels – but it was already getting too long. Anyway, good to have it in a comment, and glad to have an excuse to say something more about it.

    Funnily enough I was talking about exactly this story just a couple of weeks ago with my dad, who is old enough to have been a child in London during both the Battle of Britain and the Blitz. I told him the Miller line, and he was very taken with it. Though he is not a cricket fan particularly, he remembered Miller very well, probably due to Miller’s prominence in the 1945 Victory Tests and the 1948 Australian Tour of England, both of which happened when my dad was in his teens.

    I remember we were trying to remember what kind of planes Miller had flown – pleased to say I correctly guessed/remembered Mosquitoes.

    There is a lot of stuff about Miller on Wikipedia and elsewhere – I especially like this little transcript from an ABC Australia broadcast when his death was announced, which seems to sum him up rather well.

  4. beegt Says:

    I remember being very stressed about failing exams at university in the 60′s in the UK. “Finals” were only once a year and those students that failed had to do the course the next year or do the whole year again and they may not have had their grant renewed.

    Here in Canada a 3 yr degree is typically 90 credits of course work and the grade at the end is the average of the grades for each credit (grade point average). In order to be admitted to the subsequent years a student must maintain a specific grade point average which increases year by year. Stress starts halfway through the first session, at the midterm exams, for the students with goals of getting a graduate scholarship or a good job in their field. However, for the others it is relatively easy to finish with a C average and all employers know this. So by the end of the second year the classes can be easily separated into the stress-free “party” group who just want to pass and the “stressed-out” keeners who know that they need at least a B+ average to be taken seriously. Sadly, the last year is very hard for those who realise too late that their C average is not going to be worth much.

  5. draust Says:

    Thanks, beegt.

    You can see a similar distinction in the UK student population these days, I think – but it is more of a three phase diagram here. What I mean is that we have the permanent party animals/wasters, we have the super-keen-from-day-one, and then there is a big broad group in between who were partying (mostly) in year 1, making more of an effort in year 2 as they realise that their degree grade is actually going to matter beyond University, and then getting serious in the 3rd and final year.

    In the UK the general view at the moment is that to be at all competitive in the job market you likely need an “upper 2nd” / 2i or better. In general terms that corresponds to an average score of better than 60% across the 2nd and 3rd years of the degree. In my University approximately two-thirds, or maybe a little less, of our biological science year group manage this at present.

    As you say, one of the sadder sights is students who cotton to all this a bit too late, and leave themselves with too much ground to make up in the final (UK 3rd) year. Although in our system the 2nd yr marks/GPA only typically contributes 20-25% of the final grade (the rest hangs on the final yr scores), it is a big ask to reach 60%+ if someone is dragging a really poor 2nd yr average, say notably below 50%.

    Medicine and the other professional degrees are different, of course, being pass/fail – though scoring “Honours” and “Distinction” points (in UK degrees) will be some help to the best students later, since it effectively badges them as one of the top 10% of the year group. However, to get the degree you just have to pass. Hence the rather snarky old joke about:

    Q: “What do you call the person that graduated lowest in their class at medical school?”

    A: “Doctor”

  6. Gregory Daly Says:

    Just as a note, all three years of my physics degree, that I completed this July, counted towards my final mark, the split was 10, 30, 60 for the 1st, 2nd and 3rd years respectively. The sciences and maths were the only degrees to have this, the rest just had to pass the 1st year and then a 40, 60 split.

  7. draust Says:

    Thanks for that, Gregory – interesting to hear how it varies in different Univs and Faculties/subject areas.

    It has long been common for the 2nd year to count towards the final mark for UK science degrees – certainly was already the case when I did my (Chemistry and Biochemistry) degree in the early 80s – though 30% of final mark would be at the high end of 2nd yr contributions. Certainly 40% depending on the 2nd yr (for the other programmes) is a lot for the UK.

    The “amount” of the degree that depends on the final yr, and also on the exam (as opposed to coursework) elements, is a topic of frequent discussion in UK Univs. Students used to modular UK A-levels, with re-sittable modules and lots of assessed coursework, are often uncomfortable with assessment largely via exam (as are their parents!). However, University teaching staff tend heavily to the view that it is the exam performance under a time limit, and tackling extended problems/topics, that really sifts people out and shows you who has both knowledge and thinking / problem-solving skills. Hence the retention of final year written exam papers as the main assessment process, at least in the research-intensive UK Univs.

    Having the first year contribute to the final mark is much more unusual (at least in my experience). Certainly it is not common for the Russell Group Life Science programmes I am mostly familiar with. Having the 1st yr count towards finals is, though, the kind of measure that I hear discussed from time to time as a way of addressing perceived problems like “students don’t take the 1st yr work seriously enough”. I wonder how long your Univ has been doing it?

  8. Gregory Daly Says:

    Well just so you know, I went to Warwick and I know from talking to post docs that they have been doing this for over ten years, I think it was partly to make people take their first year a bit more seriously.

  9. Dr Aust Says:

    Checking out the threads/discussions on student sites like thestudentroom it does seem to vary from place to place whether 1st yr marks count directly toward the degree grade in UK Universities. And 10% seems to be the largest 1st yr contribution anyone has mentioned.

    I guess there could be a reason physical science degrees might be particularly inclined to push students to take the first year more seriously, which is the 2nd and 3rd years requiring basic concepts and techniques (e.g. in mathematical analysis?) taught in the 1st yr. Of course that (yrs 2 and 3 build on what you learn in yr 1) is true for all degrees, but maybe it is especially true for ones with a strong mathematical content.

    Even in my Univ’s system the first yr marks can make a difference for some things. People who want to do “placement” degrees have to get a better than 50% average in yr 1, even though the basic pass mark for yr 1 is 40%. And failing any unit, even by 1% (39%), gets you tossed from the placement degree programme. I know one Professor of Pharmacology who is fond of telling the students:

    “You are only as good as your latest set of exam results.”

  10. wilsontown Says:

    At St. Andrews, it was a bit different, and maybe this is more general to the rest of Scotland as well. The first degree (which is a BSc for science students, but an MA for arts and humanities) is 4 years long, and the first two years don’t count for the final degree classification. However, in the 2nd year you do need to get at least 2:2 marks to be offered a place in the Honours program. Then the final two years are 50/50.

    If you had good A-levels (as opposed to Scottish Highers), you could enter directly into year 2, but this was generally thought to be a bad idea.

    All of this does make you wonder how comparable degrees from different institutions really are.

  11. Allo V Psycho Says:

    I think I have a slightly different perspective, perhaps based on the fact that I regularly deal with those stressed medical students!

    First (and least important) our med students’ first year performance does contribute to their final ranking.

    Second, I think medicine is more stressful than most other HE courses. For instance, med students have to deal with dismembering human corpses, in particularly gruesome circumstances (and for no clear clinical benefit, in my personal view). Course work has long hours, and the ‘amount to be knowed’ is infinite. And students now meet patients from week 2, so performance fears can relate to the fear of killing someone through an error in the future (‘If I can’t do drug dose calculations now, someone might die in my F1 year).

    Third, students failing with ‘stress’ often have very significant external life events which are challenging by any standards. I can recall the deaths of children, terminal illnesses, financial ruin and so on.

    Fourth, most common, and often associated with mental health issues such as clinical depression, are what I call ‘failures of morale’. Every student admitted to medical school is bright enough to pass, but some get themselves into a negative feedback loop affecting their self image and esteem, and cease to be able to cope with work.

    Points 3 and 4 account for the majority of ‘stress reporting’ students I see, and for them, ‘Pull yourself together – others have had it much worse’ would be unhelpful advice, at best. Such advice might work on students who have had a minor failure of self-awareness, or have many minor problems – but these are unlikely to be in major difficulty. Mrs A may normally come across minor whining, and yes, ‘pull yourself together’ might work in generally happy and healthy students who have just got things a bit out of proportion. But I would be very concerned if a pastoral tutor was taking this approach with students in difficulty.

    Finally, imminent violent death is a very high level definition of ‘stress’. I regularly see academic colleagues who are significantly overworked, who are set impossible and sometimes contradictory tasks, who feel and are powerless, and who are not well paid while also having insecure job prospects, and then are badly treated by managers to the point of bullying. If I cannot describe some of them as feeling stress merely because no one is firing 20 mm cannon at them, I do not know what language I can usefully use…….

  12. English Pensioner Says:

    The meaning of the word “stress” has changed. When my daughter was accused of causing stress to one of her staff who is now off work, she was asked what she had done to cause it.

    Apparently, on taking over the section, she asked all members of staff to observe better timekeeping. This apparently caused severe stress to this man who was one of the worst offenders; as she said to me: “I didn’t get round to asking him to actually do some work whist he was here”!

    But a Doctor has provided a sick note, my daughter tells me that his absence makes no difference to running of the department, and the taxpayer continues to pay his salary. So all’s well.

  13. Dr Aust Says:

    Fair enough, Allo.

    Students certainly do have real problems and sometimes serious ones, of course. I’ve certainly encountered students (including in my “pastoral role” as a personal or PBL tutor) with your #3 and #4, as I guess have all veteran academics. Hadn’t really considered your #2 things so much, but thought-provoking, esp. the “What if…?” aspects for the medical students.

    I was exaggerating and simplifying the story a bit, of course… I’m confident the veteran tutor I was talking about, who spent many years in general practise and in student counselling-type roles, would have been able to tell the difference (i.e. between those with serious and those with minor problems). I’m sure he actually reserved the approach I described for what you term “minor failures of self-awareness”…! Of course, it is being able to tell the difference, sometimes from hints rather than details of what is said, that is the real skill.

    Agree too about stress on the job. Mrs Dr A deals with a lot of this as a doctor, and there is certainly far more of it about in academia than there used to be. There is some discussion of this (particularly relating to science researchers) going on here, inspired by this hilarious sketch from the comedians Armstrong & Miller. On the other hand, though, there is also the kind of thing English Pensioner recounts.

  14. Dr Zorro Says:

    Perhaps a degree of stress in the undergraduate course is no bad thing. Those who fail to cope at this stage are hardly going to be able to cope with the considerably greater demands they are going to face in the 40 years after graduation. Perhaps we should be diverting those who find life as a medical student excessively stressful into other careers.

  15. draust Says:

    Hi Dr Z

    Yes, as alluded to above, Mrs Dr Aust is largely of that view.

    A counter-argument, especially in year 1, is that 18 or 19 years old is very early / awfully young to tell what someone is really going to prove to be made of years down the line. And of course there can be a certain “adjustment / settling down period” in the 1st yr, see the things I mentioned in the post. Anyway, my feeling is that medical schools generally cut students more slack in the 1st yr than subsequently, for just these kind of reasons.

    The bigger worry tend to be the “serially in difficulty” type students. It is often, though, difficult to impossible to persuade these students that they might be better advised to consider something other than medicine. I’m thinking here of students who find it hard to cope even when there is no special reason (see Allo V’s examples above), and/or who continually struggle intellectually on the course year on year, despite all the support mechanisms.

    I’m not sure whether it is these kids’ sense of a vocation for medicine (a sense of vocation generally being a good thing) or the perceived stigma of dropping out of the medical course that makes them so hard to steer elsewhere. One theory over the years has been that, once beyond the end of yr 1, medical students have already invested too much time and effort to want to “”bail out” with nothing much to show – though often it is possible to transfer to B.Sc. programmes.

    Arguably one of the upsides of intercalating degree years (taking a year out of the medical course to do the final yr of a B.Sc. degree, for those who don’t know the term) done relatively early in the medical course (e.g. between yrs 2 and 3 in the standard scheme) should be that a student who then has a B.Sc. but who is not really cut out for medicine could leave at that point. They now have an Honours degree, so have something to show for their efforts over three years, and are on an equal footing with other B.Sc. graduates. But as I said, even students who are, shall we say, strongly and repeatedly advised that they are likely not to make it all the way through the medical course are often incredibly determined to cling on. This is another reason why pastoral roles like Allo V’s, and sitting on “Medical School Progress Committees”, are so difficult.

  16. Matthew Says:

    Most psychologists will tell you that stress is largely more about how you think about things, than about the events themselves, and 18 yr old students usually dont have the life experience to feel that a poor grade in their first year might be a trivial thing – even if you explain to them why it is.

    I suspect that despite Keith Miller’s bravado he probably experienced plenty of stress playing test cricket but his experiences as a pilot helped him brush it off. University should also gradually inoculate students to the stresses they would expect to experience when they enter the world of work.

    There is another stress for new university students, and that is the inevitably poor teaching they get. We always hear about how there is an adjustment to be made from having your hand held at school to more independent work at university, but that is mostly spin. The fact is that sitting in 30 hours of lectures a week with 300 other students is not a good learning environment. Students who really care about their performance will find it stressful to find that on the whole it isnt possible for them to do as well as they are able just because universities are underfunded, and the teaching staff often dont have much skill or interest in teaching.

  17. Toby Says:

    I got stressed reading [wondering if this piece or its repetitiveness would end before I did].

    Thankfully one of nature’s little tricks saved me when boredom struck early.

    Incredibly, 10 people wrote comments (aside from Dr Aust’s 6! The good Doc has no idea when to stop it seems). Did they all make it to the end?

    Cya. Off to look up national death stats – annual rate of death by lecture by region.

    Whereabouts did you say the University of Snarkfield is Doc?

  18. draust Says:

    @Matthew:

    Thanks for the considered response – sorry I’ve taken so long to respond.

    I don’t disagree with your first two paragraphs – perceptive comments about stress, perception and Keith Miller. I take your point about Univ being part of the process of people without much experience of the world learning to cope with a bit of stress. That IS what we try to help students do, really – we always make time and listen sympathetically when they tell us they are having problems, and we try and respond appropriately, partly just by listening and advising but also by passing them along where necessary to people with specialised “pastoral” training or even to the University health system / Counselling Service. Anyway, we do try and encourage students to (i) develop and keep a sense of proportion and (ii) come up with ways to cope and to address their difficulties, as far as we can. When I sit listening I try my hardest to remember how I felt at age 19, or whatever, and I always tell students what the available support mechanisms are.

    I don’t agree with your final paragraph. The system is underfunded, and under pressure, but we really do do everything we can not to short-change the students. And I don’t agree about poor teaching. There have been mutiple clear-outs (mostly via early retirement) of the older and less “engaged” University teaching staff over the two decades I have been in the biz, and dire lecturers are now very rare. And when there are problems, we get to hear it loud and clear via Staff-Student Committees (and in other ways) and something gets done pretty sharpish. Whatever one thinks of the National Student Survey and similar things, they have made the UK Universities acutely aware of the dangers of giving students poor teaching, or even of students thinking they are being “fobbed off”. Over the last five years in my Faculty we have actually taken postdocs off doing tutorials and replaced them with the permanent academic staff, and we have reduced the sizes of our (science) tutorial groups, sometimes by almost half. We also have a system for “peer review” of teaching where we go and sit in one another’s classes (usually pairing someone more experienced with someone less experienced). Anyway, I don’t recognise the picture you paint of UK University teaching – though I do work in a Faculty that scored very highly in all the surveys and feedback ratings, so I suppose we may not be totally representative.

    The size of lectures is something different. It is an inevitable consequence of the increase in student numbers over the last two decades that lectures will get big. There is no way around it. The trick is to mix that with other kinds of teaching (lab classes, weekly small group tutorials etc). And it is certainly possible to give a good lecture to 300+ students. It takes more thought about presentation (and what to present) than a lecture to 40-50 students, and it is more of a “performance” than the smaller lecture. But that is one of the things academics learn to do.

    @Toby:

    Well, no-one HAS to read. Or comment. A touch of verbosity is an occupational hazard for academics, of course, in Snarkfield or elsewhere. And I like to reply to commenters – I’ve always been under the impression that was part of what blogs were for.

    @All:

    Talking of Battle of Britain fighter pilots and stress, I watched the excellent film First Light on TV last night. Re-reading Matthew’s comment reminds me that one thing students and a good number of the 1940 fighter pilots had in common was their youth – Geoffrey Wellum, whose memoir is the source material and who appears in the film, was only eighteen when he joined his squadron.

  19. draust Says:

    PS Heh. The reliably deluded Alliance of Registered Homeopaths have come up with their answer to the problems of stress in new students. You will perhaps not be surprised to find that their prescription is… homeopathy. And for parents of new students too.

  20. Nash Says:

    Of course the traditional way of coping with stress is booze.

    Medical students and the military are renowned for it.

  21. draust Says:

    And junior doctors too, of course.

    The other way junior doctors in the hospitals traditionally “decompressed” (and probably still do) was relating their war stories to one another, typically in the bar. One reasonably recent book which gives a good sense of this (and in general of how hospital life for junior doctors used to be, at least in Mrs Dr Aust’s time) is Michael Foxton’s Bedside Stories (reviewed here)

  22. Stuart Says:

    The stress bit reminds me of the comment in Randy Pausch’s “Last Lecture” (Google it then give yourself an hour to watch it). He tells an anecdote of how he was stressed preparing for part of his PhD. He tells his mum this and she says something along the lines of

    “I know, it must be very difficult for you. Just think, when your dad was your age, he was fighting the Germans in Normandy”

    Stu.

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