Today we reach the end of another newsletter series. We have spent the last four newsletters talking about the stress of graduate medical students. For this final installment, I will share the cognitive techniques we give to students during the second recommended workshop. 

Cognitive techniques for stress reduction

These techniques come from cognitive behavior therapy, which hypothesizes that people’s emotions, behaviors, and physiology are influenced by their perception of events. It is not the situation that determines what people feel but how they perceive it.

The cognitive model goes this way: 

A SITUATION leads to a THOUGHT which leads to a REACTION (emotional, behavioral, physical).

Here is an example:

Situation: Get a “C” on an exam

Thought: “I’m stupid, and I’ll never make it in grad school.”

Reaction: Sadness, helplessness, ashamed to ask for help

But let’s look at it another way:

Situation: Get a “C” on an exam

Thought: “This test was hard. Now I know I need to prepare differently.”

Reaction: Mild disappointment, but also optimism. Able to ask for help or advice.

Focusing on thoughts

You may barely be aware of these thoughts; you are far more likely to be mindful of the following emotions or behaviors. Even if you know your thoughts, you most likely accept them uncritically, believing they are true.  Quick, evaluative thoughts are often “automatic,” meaning they do not result from deliberation or reasoning. They spring up spontaneously and are often relatively brief.

To help yourself identify those thoughts, ask yourself, “What was just going through my mind?” when:

• You begin to feel dysphoric.

• You feel inclined to behave in a dysfunctional way (or to avoid behaving adaptively).

• You notice distressing changes in your body or mind.

Having identified your thoughts, you can evaluate the validity of your thinking. Do a reality check, and recall past experiences. When you find your interpretation of a situation is erroneous and correct it, you probably discover that your mood improves, you behave more functionally, and your physiological arousal decreases. This is about thinking realistically.

Look for these common errors in your thinking:

1. All-or-nothing, black-or-white thinking. “I have to do a great job on everything.” “I’m terrible at anything involving math.”

2. Catastrophizing. “If I can’t ace this class, I might as well give up.”

3. Disqualifying or discounting the positive. “I just got lucky. My past successes don’t count.”

4. Emotional reasoning – believing something must be true because it feels true. “I’m incompetent. I feel like a failure.”

5. Labeling. You put fixed labels on yourself or others without considering the evidence. “I’m a loser.” “They’re a natural.”

6. Magnification/minimization – unreasonably magnifying the negative and minimizing the positive. “I got nine out of a hundred questions wrong – I screwed up.”

7. Mental filter (selective abstraction) – you pay attention only to the negative aspects of any situation.

8. Mind reading – you are sure that you know what others are thinking, particularly when it comes to you.

9. Overgeneralization – drawing a general conclusion based on a small amount of evidence. “I do everything wrong.”

10. Personalization. This means taking the actions of others personally, when in reality, they have other, or no, intentions.

11. Imperatives – you have an unreasonably rigid idea about how you or others must behave.

Any of these thought distortions can lead to increased stress, but we seldom stop to examine them for what they are. By examining thought distortions and looking at the evidence before us, we can adjust our REACTION – hopefully to a far less stressful and more productive one.

Cognitive techniques are just one of several aspects of stress-management coping techniques we teach students. We also share relaxation and mindfulness pointers with our students in this second workshop and find them highly worthwhile for stress management in at the graduate level.

When self-care goes wrong

We are always careful to remind students of certain dangers, and we can all take a lesson from these moments when we think we are helping ourselves but only making things worse. Examples of maladaptive self-care include:

• Self-medicating with alcohol or drugs.

• Highly critical self-talk to “motivate” yourself.

• Engaging in workaholic behavior (e.g., skipping breaks, working longer hours, etc.)

• Avoidance/procrastination.

These solutions may feel rewarding or motivating in the short term, but they’re highly counterproductive – and most of us realize that after the fact!

Conclusion

Stress affects us all, and to a point, that’s a good thing. We want to see the line beyond which pressure begins to hurt us more than it motivates us in the right direction. Graduate medical students are particularly susceptible to stress, which can negatively affect their lives. By teaching students essential stress management awareness and coping techniques, I believe we can improve their experience immensely during their graduate studies and future careers.

Please join me again for my following newsletter for more discussion of topics relevant to the PA School administrator and the students and faculty for whom we are responsible.