Performance and psychological distress in medical undergraduate courses

Abstract

A qualitative study was conducted through semi-structured interviews with 24 students from a public university in Minas Gerais to understand medical students’ perceptions of mental health and its relationship with the daily routine of medical undergraduate courses. The thematic or categorical analysis of these interviews pointed out conceptions about mental health related to the biomedical perspective and the paradigm of psychosocial care. The main problems identified were overload, pressure for performance, competitiveness, relationships with professors, and issues related to the organization and dynamics of the course. No criticisms or discussions were presented about how these factors that generate suffering could be transformed or overcome. The persistence of elements that generate psychological distress in the daily routine of undergraduate courses and the impossibility or difficulty of thinking of other ways to deal with the demands of the educational process point to harmful elements of today’s society, characterized by the imperative valorization of performance subjectively assumed by the subjects.

Mental health; Students, medical; Medicine

Resumo

A fim de compreender a percepção de estudantes de medicina sobre a saúde mental e sua relação com o cotidiano da graduação médica, realizou-se estudo qualitativo por meio de entrevistas semiestruturadas com 24 estudantes de uma universidade pública de Minas Gerais. A análise temática ou categorial dessas entrevistas apontou concepções sobre saúde mental relacionadas à perspectiva biomédica e ao paradigma de atenção psicossocial. Os principais problemas identificados foram: sobrecarga, pressão por desempenho, competitividade, relacionamento com professores e questões relacionadas à organização e dinâmica do curso. Não foram apresentadas críticas ou discussões sobre como esses fatores geradores de sofrimento poderiam ser transformados ou superados. A persistência de elementos geradores de sofrimento psíquico no cotidiano da graduação e a impossibilidade ou dificuldade de pensar outras maneiras de lidar com as exigências do processo formativo apontam para elementos negativos da sociedade atual, caracterizada pelo valorização imperativa do desempenho assumida subjetivamente pelos sujeitos.

Saúde mental; Estudantes de medicina; Medicina

Resumen

Para comprender la percepción de los estudiantes de medicina sobre la salud mental y su relación con el día a día del grado en medicina, se realizó un estudio cualitativo por medio de entrevistas semiestructuradas con 24 estudiantes de una universidad pública de Minas Gerais. El análisis temático o categórico de estas entrevistas destacó concepciones sobre salud mental relacionadas con la perspectiva biomédica y el paradigma de atención psicosocial. Los principales problemas identificados fueron la sobrecarga, la presión por el desempeño, la competitividad, las relaciones con los docentes y cuestiones relacionadas con la organización y la dinámica del curso. No se presentaron críticas ni discusiones sobre cómo se podrían transformar o superar estos factores que generan sufrimiento. La persistencia de elementos que generan sufrimiento psíquico en la rutina académica del estudiante de medicina y la imposibilidad o dificultad de pensar otras formas de afrontar las exigencias del proceso formativo señalan elementos negativos de la sociedad actual, que se caracteriza por la valoración imperativa del desempeño asumida subjetivamente por los sujetos.

Salud mental; Estudiantes de medicina; Medicina

Brazilian medical education has undergone significant reformulations in recent decades in opposition to the Flexnerian model, which is based on the biomedical paradigm and emphasizes the biological determination of diseases. Changes in undergraduate medical courses throughout the country focused on the perspective of the social determination of health-illness processes, the need to organize and strengthen the Unified Health System (SUS), and the demands of the population and were guided by the principles of the Dawson Report ¹.

Following this perspective, the National Curriculum Guidelines (DCN) ²-⁴ for medical courses, published in 2001 and 2014, represented a significant advance in changes to medical education in the country. The DCN formalized the need for humanistic medical training focused on health care, the SUS’s principles and needs, and the population’s demands, reinforcing the commitment to defending comprehensive health and the transversality of the health-disease process ⁵.

In addition, the DCN highlighted the importance of psychosocial aspects for medical training and practices, recognizing the significant contribution of the human and social sciences ⁵. From this perspective, the mental health (MH) approach was also expanded, taking on new contours beyond the traditional approach to mental illness ⁴.

The field of MH has been the focus of great interest and relevance for medical training and practice in the country for a long time. The psychiatric reform movement and the anti-asylum struggle proposed a shift from the biomedical model based on the asylum and hospital-centric logic, focused primarily on illness, to a psychosocial care model focused on defending citizenship, autonomy, and social inclusion. These important movements impacted the development of public policies and models of care in MH in Brazil, as well as discussions and changes in training models in different areas that make up the health field ⁶-⁸.

Despite the advances achieved in the field of MH, the influence of the biomedical paradigm is still strong, which can be seen in the political changes that occurred at the end of 2017, which led to significant setbacks in MH policies, strengthening the asylum logic and dismantling decades of advances in Brazilian psychiatric reform ⁶. If it is possible to observe the coexistence of the biomedical model and the psychosocial care model in practices and public policies, it can be inferred that the same occurs in medical training, including in the daily routine of undergraduate courses.

The coexistence of these models is inscribed in essential fields of tension ⁹, which involve not only different worldviews but also forms of scientific knowledge development and power relations ⁸. To understand how these tensions are situated in social relations and have repercussions on professional practices and training processes, it is vital to highlight the phenomenon of medicalization. As Zorzanelli and Cruz ¹⁰ point out, medicalization configures contemporary social relations and practices for Foucault.

According to Lemos and collaborators ¹¹, Foucault called the process of expanding medical interventions to the most diverse sectors of the social field “indefinite medicalization,” becoming part of the daily lives of all individuals. Medical practices begin to occupy all places, regardless of demand, since there is a shift in medical attention, previously focused on the pathogen, to the individual cultivation of a healthy body and health as an ideal.

From this perspective, the sufferings inherent to life begin to receive psychiatric diagnoses based on a biomedical basis, bringing psychological suffering closer to organic diseases so that they need to be corrected with drugs. Since the 1980s, with the formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM) III and DSM IV, there has been a predominance of the use of psychotropic drugs as the primary form of treatment for psychological disorders. As a result, the diagnosis takes on a distorted form, reduced to the classification and categorization of mental disorders to the detriment of a broader psychosocial approach ¹¹,¹².

Research by medical students in Brazil on MH demonstrates the predominance of identifying mental disorders based on the classifications proposed in the manuals mentioned above, which brings the notion of MH closer to, or even equates them with, that of mental illness. A review of national scientific publications from 2011 to 2021, with primarily quantitative studies ¹³-²⁶, identified the following problems among the main ones related to MH in medical students: depression; anxiety; stress ¹³-¹⁸,²⁴; burnout syndrome (BS) ¹⁹-²¹,²⁴; common mental disorder (CMD) ¹⁹,²²; sleep and eating disorders; feelings such as guilt and helplessness; suicidal ideation; and worsening of emotional issues ²⁵.

These problems represent factors associated with excessive workload ¹³,¹⁴,¹⁶,¹⁷,¹⁹,²¹,²²,²⁵; competitiveness among students ¹⁴-¹⁶,¹⁹,²³,²⁵; sleep deprivation ¹⁵,¹⁸,¹⁹,²¹-²³,²⁵; lack of physical activity and leisure time ¹⁴,¹⁵,¹⁸,¹⁹,²¹,²⁵; contact with suffering and death ¹⁵,¹⁸,²¹,²²,²⁴,²⁵; dissatisfaction with the curricular model and/or teaching methods employed ¹⁶,²⁴-²⁶; poor relationships with other students and/or professors ¹⁴,¹⁵,¹⁹,²²,²⁵; excessive social demands and self-demand ¹⁶,¹⁸,¹⁹,²⁵; poor academic performance ¹⁴,²⁰,²⁵; normalization and valorization of the suffering of medical students and physicians ¹⁶,²⁵; and stressful undergraduate environment ²³,²⁵.

A single qualitative study ²⁷identified feelings such as insecurity, inferiority, frustration, not belonging, guilt and uselessness, self-demand, exacerbated stress, overload, and damage to affective and social relationships. The factors associated with psychological suffering were individualism, living far from family, extensive workload, lack of preparation of professors to deal with students’ anxieties and demands regarding performance, overload of knowledge to be assimilated, need to deal with suffering, illness and death; competitiveness among students; excessive extracurricular activities; lack of time for physical activities and leisure; lack of contact with people outside the medical course; fear of making mistakes; pressures and expectations; trivialization of illnesses presented by the students themselves; and naturalization of suffering related to the medical training process.

Considering the relevance of studies that allow for a broader understanding of the elements that make up and interfere in the MH of medical students and seeking to go beyond the identification of problems related to their psychological suffering, this study sought to understand the perception of medical students about what MH is and the relationship between MH and the daily life of medical undergraduate studies.

Method

This qualitative exploratory study is relevant to the health field because knowledge that goes beyond quantifying phenomena’ characteristics must be built and can contribute to analyzing their constituent qualities ²⁸,²⁹.

To collect data, individual semi-structured interviews were conducted using a script developed by the researchers based on the objectives defined for the investigation and the literature review carried out so that the information collected would allow a broader understanding of the reality investigated ²⁸,²⁹.

To define the sample, we sought to include individuals who shared experiences related to the issues intended to be investigated. Therefore, to ensure that the complexity of the relationship between MH and the daily medical training routine was addressed, the sample should include students from different stages of the medical course of both sexes. In addition, sufficient participants were required to address different perceptions to cover the diverse realities of the students ²⁸,²⁹.

In this sense, four students from each year of the medical course (first to sixth), two men and two women, were randomly selected from the Federal University of São João del-Rei, central-west campus (UFSJ-CCO), in Divinópolis/MG. At the time of the interviews, 352 students were enrolled in the medical course, and all 24 students agreed to participate in the study.

The interviews were conducted remotely from January to March 2023 using the Google Meet platform, according to the guidelines established in the legislation for procedures for conducting research in a virtual environment ³⁰. The participants signed the informed consent form (ICF) on a digital form and, after formalizing their acceptance to participate, completed a sociodemographic questionnaire with information about gender, ethnicity, marital status, age, place of birth, and housing characteristics.

The interviews were recorded, transcribed, and analyzed using the thematic or categorical analysis framework proposed by Bardin ³¹. Three categories emerged from this analysis: 1) students’ perceptions of MH; 2) impacts of the daily life of undergraduate studies on MH; and 3) strategies for seeking and maintaining MH.

To preserve the confidentiality of the interviewees, an alphanumeric coding system was used that initially contained the interviewee’s number—I1 to I24—followed by the coding related to the year of the course they were in at the time of the interview, ranging from Y1 to Y6. Finally, letters F were added for female and M for male interviewees.

Results and discussion

Half of the 24 students interviewed were female, and half were male. Most of the students were white, single, young, from the state of Minas Gerais, and lived with family members, students, or a partner. The characteristics of the participants can be seen in Chart 1.

Chart 1
Characterization of the participants

Identification	Sex	Age	Color	Marital Status	Place of Birth	With whom you live
I1	Female	21	White	Single	Belo Horizonte/MG	Alone
I2	Male	21	Black	Single	MG countryside	In a shared house
I3	Female	26	Black	Single	Belo Horizonte/MG	In a shared house
I4	Male	21	White	Single	Belo Horizonte/MG	Alone
I5	Female	21	Brown	Single	Divinópolis/MG	With family
I6	Female	34	Brown	Single	MG countryside	In a shared house
I7	Male	21	Brown	Single	MG countryside	Alone
I8	Male	20	White	Single	MG countryside	Alone
I9	Female	24	White	Single	Belo Horizonte/MG	In a shared house
I10	Male	28	White	Single	Divinópolis/MG	With family
I11	Male	36	White	Married	SP countryside	With family/in a shared house
I12	Female	23	White	Single	Divinópolis/MG	With family
I13	Male	39	Brown	Married	São Paulo/SP	With partner
I14	Female	23	Brown	Single	Belo Horizonte/MG	In a shared house
I15	Female	21	White	Single	Belo Horizonte/MG	Alone
I16	Male	23	White	Single	MG countryside	With partner
I17	Male	24	White	Single	MG countryside	Alone
I18	Male	28	White	Single	MG countryside	Alone
I19	Female	25	Brown	Single	Belo Horizonte/MG	With partner
I20	Female	35	White	Divorced	MG countryside	Alone
I21	Male	24	White	Single	SP countryside	In a shared house
I22	Male	26	White	Single	São Paulo/SP	In a shared house
I23	Female	26	White	Single	Belo Horizonte/MG	Alone
I24	Female	24	White	Single	MG countryside	In a shared house

Chart 2 presents the categories that emerged after the content analysis and their core meanings.

Chart 2
Categories and core meanings from the analysis of the interviews

Categories	Core meanings
Students’ perception of MH	MH as an ideal MH in a complex and dynamic perspective
Impacts of daily undergraduate studies on MH	Overload Pressure for performance Competitiveness Relationship with professors and the dynamic organization of the course
Strategies for seeking and maintaining MH	Social and family support Enjoyable and self-care activities

• MH: mental health

Students’ perceptions of mental health

Students’ perceptions of what MH would be were linked to the most idealized perspectives, such as a situation of balance and harmony, and the most complex and dynamic perceptions of MH, related to the need to reconcile life challenges, suffering, problems, and difficulties. The perspective of MH as an idealized state or condition appeared as the possibility of living and being well with oneself, without any problems in relationships or studies and without financial worries, as can be seen in the students’ statements:

“Mental health is being well both psychologically, in terms of your day-to-day life, with everything you are doing, and with your relationships with people. I think it is a bit of a mix of being healthy with yourself and with the relationships around you” (I8Y2M).

“A state in which you can get your brain, mind, and body to be in harmony with the environment, with reality, with relationships” (I13Y4M).

The most complex and dynamic perceptions about MH appeared with greater intensity among the students, with MH being discussed based on the interaction of several factors in life. It represents a search that includes daily tensions and challenges, as well as a process of reconciling competing aspects.

From this perspective, the understanding of MH was outlined based on different degrees of concern and/or suffering, not on the absence of these aspects. In addition, MH appeared as the ability to perform tasks and reconcile daily demands with things considered good and pleasurable, such as leisure, spending time with family and friends, and taking care of oneself. Some of these issues are expressed in the following statements:

“Obviously, good mental health is not ‘my life is perfect, I won’t complain about anything and so on,’ but I think it has a lot to do with disposition, you know? When you wake up feeling ready, wanting to do something, when you set a goal” (I4Y1M).

“When we don’t have any excessive concerns about the future or the past” (I14Y4F).

“Mental health, for me, is being at peace with yourself, with the context in which you live. Knowing how to face life’s adversities without too much suffering” (I15Y4F).

“We have to consider that it is a state in which there is no right or wrong. It is created by a multiplicity. Several factors concerning the psyche involve how the individual interacts with the world. So, for example, it would be how people deal with things, with physical things, with their behavior, with the behavior of others” (I16Y4M).

In general, the students did not mention specific diagnoses that they had received from a doctor to name or characterize problems or suffering related to their MH, except for a single participant, who mentioned using medication for anxiety and depression. A few students mentioned that they felt or had felt anxious.

It is possible to verify that diverse perceptions about MH coexist. On the one hand, some follow the biomedical model, anchored in the idea of health and illness as opposites, with the notion that faced with psychological problems, the individual would not have any well-being or MH ³²,³³. On the other hand, some conceptions understand MH as the absence of psychological disturbance or suffering and as the result of interactions between biological, psychological, and social factors. From this perspective, MH is configured as a state where the individual can deal with daily stresses and still engage appropriately in productive activities, leisure activities, care, relationships, and affections ³⁴-³⁷.

In contrast to the biomedical model, the psychosocial care model brings the complexity and scope of MH as a social production ³⁵,³⁷, indicating that it should not be reduced to disease ³⁶. This is because it can only be understood in the set of dynamic elements present in individuals’ daily lives, including social changes, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyles, violence, and violation of rights ³⁸.

It is possible to assume that students with a more comprehensive and complex view of MH have greater possibilities of critically analyzing the elements that make up their life trajectories, educational paths, and daily training, which impact their MH. In addition, they could establish more effective forms of dialogue, understanding, resistance, and confrontation concerning the elements of daily undergraduate studies linked to suffering. Thus, they would go beyond announcing suffering in the forms previously defined in the manuals for classifying mental disorders.

Impacts of daily undergraduate studies on mental health

The students identified that the main factors present in the undergraduate course’s daily routine that impact the MH are overload, pressure for performance, competitiveness, relationships with professors, and organization and dynamics of the course. They did not question or problematize the reasons that sustain such overload or prevent them from countering the pressure for performance.

A few students pointed out that medical students are expected to give their best and always be the best due to the responsibility that the profession entails. Two interviewees pointed to the residency process as a source of pressure for performance, generating comparisons with other students and, consequently, competition in the undergraduate context.

There was no discussion about the possibilities of conducting the undergraduate course in ways other than related to the elements that make up the bases they identified as causing suffering, despite expressing concerns and disapproval with the undergraduate context. Some even mentioned that pressure for performance should occur despite recognizing that the current form of undergraduate courses generates suffering. Together, these problems were related to loss of quality of life, anxiety, frustration, illness, suffering, and deprivation of sleep, food, and time to rest.

Students from all years of the course mentioned overload as the main problem. This was related to the extensive workload of academic activities, a lot of content to study, the need to spend the whole day at college, and having to give up opportunities offered by the educational institution itself due to the lack of conditions to reconcile demands and interests.

“The main factor that has impacted me so far was the workload during the period I spent there. It is very extensive and ends up causing anxiety because you spend the whole day at college and have to get home and study a lot of material that seems like there will be no time, that the material will swallow you up, that you will not be able to do it. Anyway, you have to start choosing, either you study, sleep, exercise or cook your food” (I1Y1F).

“I think that the daily routine for medical school is hectic and demands too much of the person, mainly because the course ignores that you are training a person and that they need to have this time to rest. They need to have a moment there to relax because it’s kind of a convention of the course that you have to put up with all of this; it’s kind of like it’s a profession requirement” (I8Y2M).

“Medical school is very exhausting, like, I’ve been through periods that, man, seriously, there’s no explanation, how much it is, like, it feels like it’s going to suck your soul out” (I19Y5F).

Students from all years of the course mentioned that the pressure for academic performance comes from training activities, professors and colleagues, social expectations about the profession, and self-demand due to the residency test at the end of the course, and is also related to the professional future. Aspects such as concern about achieving high-performance levels, the fact that they can’t make mistakes, having always to do their best, feeling that they have not studied enough, and the fear of not knowing enough or not being good enough marked the students’ statements:

“I felt desperate because there was so much new material and knowledge, those tests, and it seemed you couldn’t make mistakes. I had this feeling that you can’t make mistakes; you have to make it work” (I3Y1F).

“I think, if we continue at this pace, what will become of us throughout this course? I think it’s dangerous, very dangerous, to almost become a psychopath in the course, you know? I found it problematic, and I don’t want that for myself. I felt a little bit about my mental health and my body; I felt that it’s not a good path; you end up terribly. So, medical training made me feel desperate, but I feel that there are paths I can take to maintain my mental health in balance, but I need to be careful because the academic style, as a hostile environment, can lead me down dangerous paths” (I3Y1F).

“I wasn’t counting how many points I was gaining or losing as if the goal was 100, right? But the main problem, I think, is that nothing is perfect, right? I think that’s the problem with perfectionism. So, if you get 90, you want 95. If you get 95, you want 100, and you get to 100, it doesn’t seem like it’s enough, you know? It seems like you start to doubt whether that brought you any benefit or whether you needed to do more, you know?” (I16Y4M).

“The environment and culture that exist in college, for example, is that you need to be vigilant so you don’t lose your balance. There is something hidden, of a demand, of a requirement. That really affects me there” (I13Y4M).

“When it comes to medical education for medical students, people put us on a pedestal, right? And then people end up saying: ‘Medical students have to know everything, they can’t make mistakes, they have to know everything at all times and be the owner of the truth.’ So I think it’s this cultural issue of how people see medicine, see doctors and so on, that ends up weighing heavily against us” (I15Y4F).

“(…) as the course progresses, we feel more and more the responsibility we have, of the things we have to know, of the things we have to do, of the things we shouldn’t do. We get to the end of the course and start thinking about how many things I should already know that I don’t, how many things I still have to know and don’t know how to do in practice” (I15Y4F).

Competitiveness among colleagues was identified in the daily training, in situations such as presenting work, grades, and internships, which created problems for the MH and an environment of hostility.

“We end up living in a place of comparison, right? We always compare ourselves a lot with others: ‘Oh, so-and-so is doing this, and I’m not doing it,’ so I think the internal pressure is very great and the external pressure too” (I12Y3F).

“And there is a lot of comparison in medical school; you are always comparing yourself like this: ‘Oh, my friend has already read the whole Guyton; if I don’t read it too, I will fall behind,’ but that is not how it works. But we end up having this impression and, unconsciously, sometimes we want to fulfill this thing of being better than the other, having more knowledge, knowing more names of medications, etc., and we end up taking ourselves to the extreme and not prioritizing our mental health” (I14Y4F).

“You are constantly reminded that you have to compete, whether for a place in the residency or a workgroup, a place in the internship, to get good grades on the semester; you always have to be better than the others” (I21Y6M).

“In addition, the hypercompetitiveness of our course affects me and is something that really affects my mental health” (I22Y6M).

Students reported difficulties in their relationships with professors and hostile ways of communicating with students, leading to insecurity, demotivation, and stress. They also mentioned problems related to the organization and dynamics of the course, such as the group work methodology, problems in organizing timetables, canceling classes, and a lack of planning for activities and assessments.

“The professors are not flexible at all. They do whatever they can to make things difficult. If we need help in a specific situation, they are not flexible at all; they don’t try to understand, they don’t try to help” (I15Y4F).

“Discussions with professors harm my mental health because it is not an equal situation to discuss. Whether we like it or not, we enter the discussion already losing, even if we are right. Not being well received in some internship fields is a complicated situation and a question of double standards. For example, if a professor didn’t like you, they would give you a lower grade on a test than another colleague they liked” (I24Y6F).

“Not only the timetable but also, I think there is a great lack of commitment, right? Because the professors schedule the class and simply don’t show up, they let us know at the last minute, and this has happened to us several times” (I14Y4F).

The results of this research follow the trend of the set of problems found in the specific literature of the area. The suffering related to excessive workload and overload harms not only sleep but also the quality of life in general and the possibility of individuals seeking help for the problems faced due to lack of time ¹⁴,¹⁵,¹⁷,¹⁸,²⁰-²³,²⁷. Likewise, suffering related to the demands of high academic performance from the initial periods of the course ¹³, competitiveness and hostility in the academic environment ¹⁴,¹⁶-¹⁸,²⁰,²⁷, difficulties in relationships with professors ¹⁴,¹⁶,¹⁸,²¹,²⁷, and problems with the organization and dynamics of the course ¹⁷,²³,²⁷.

A review study ²⁷ indicated that the academic environment is understood by students as a preparatory environment for their future professional life, incorporating elements that make up the medical culture in Brazil and that value this entire reality of hierarchy, competition, comparison, and even embarrassment as a teaching method. If the results indicated so far cannot be considered new but rather long-standing trends, it is worth discussing the persistence of elements that are repeated and that are related to psychological distress in the medical undergraduate studies process. In this sense, it is essential to remember that both the dynamics that constitute the undergraduate studies and the professional dynamics reflect essential elements that make up today’s society and that the psychological distress of medical students is not just theirs – it concerns all social actors and institutions that participate in the training process.

Some discussions on the “performance society” developed by Byung-Chul Han are considered to increase our understanding of the broader scenario of current reality and to problematize the vital link between psychological distress and everyday undergraduate life ³⁹. The problematization that the author proposes is of particular importance for this analysis of the relationships between society and psychological distress in today’s society. The author named the configuration of today’s society “performance society,” representing a paradigmatic change concerning what Foucault had named a disciplinary society, without, however, representing a rupture or contradiction. On the contrary, it represents a continuity concerning the forms of control of the productive system, which, at the time of Foucault’s analysis, operated through external instances of control. Now, according to Han’s proposal, this control, as an imperative of performance, is subjectively assumed by the subjects, becoming self-exploration. In today’s society, there is a new subjective constitution in which the false perspective of freedom presents itself to each individual as an imperative of achievements, of being an entrepreneur of oneself, of having no limits to what one does, of flexibility, multitasking, of constant speed and overcoming, of the inability to deny, standardization and surveillance over oneself ³⁹-⁴¹.

The performance society is poor in negativity, i.e., in contradictions, oppositions, and resistances, leading to the suppression of otherness. On the contrary, it is characterized by an excess of positivity—everything is the same, and there is an excess of stimuli, information, and impulses that indicate that it is possible to do everything and a lot, but always the same. Subjects find fewer and fewer possibilities to resist and oppose the stimuli indicative of the imperative of performance and productivity. This social configuration, based on what the author describes as a paradoxical logic of coercive freedom, produces states of mental exhaustion that isolate individuals and are common in contemporary society in the form of depression, hyperactivity, and burnout syndrome³⁹-⁴¹.

In this social configuration, arguments in defense of cognitive enhancement gain relevance and strengthen the use of psychotropic drugs for individuals who, in search of social success, constantly need to improve themselves and seek well-being. Furthermore, since the subject of performance has no time for sleep, rest, or to engage in processes that seek to understand psychological conflicts and the suffering resulting from them, the therapeutic resource is also reduced to psychiatric medication ³⁹-⁴¹.

From this, it is possible to infer that the statements of the students interviewed are complete of elements that show that the pressure for adequate performance in the undergraduate situation and the future profession is subjectively assumed as an imperative that is difficult or impossible to counter. Individually and in isolation, they announce their suffering as a set of deficiencies to be overcome since they prevent them from achieving the expected and adequate performance throughout their undergraduate studies. Furthermore, despite demonstrating more complex understandings about MH, compatible with the psychosocial care model, as perceived in category 1, this complexity, which is perhaps more linked to the conceptual field, seems to encounter limitations when thinking about the concrete reality of their suffering concerning the demands of everyday undergraduate studies.

Searching for and maintaining mental health

When asked how they used to seek and maintain MH, the students mentioned the importance of reconciling various aspects of life, which involved a set of negotiations related to academic activities and the interpersonal relationships in which they are involved, in addition to other areas of interest. They identified the importance of social and family support, engaging in pleasurable activities and seeking to have good conditions for sleep, food, rest, and vacations, the search for therapy and self-knowledge, and the importance of the support received from classmates. Two students mentioned their pleasure in academic activities and choosing a profession related to MH despite their efforts and suffering. Some of these issues can be exemplified in the following statements:

“I consider my parents to be understanding, in the sense that they say, ‘Look, we know it’s hard; what can we do to help you?’. And I think that the financial support I have from them is just as important, right? I think that if I didn’t have that, maybe… if I had to be working and worrying about these other things, my mental health would be worse, right?” (I16Y4M).

“Now, one positive point that I think is the care that my classmates have, although sometimes it seems that everyone is trying to ‘do their own thing.’ But I realize that it is solidarity, people’s attention, and trying to help, and every time you talk and express yourself, there is someone who gives you support. So I think that this network of classmates has something positive in this regard” (I13Y4M).

“Getting the necessary amount of sleep is essential for me to maintain my mental health. If this is compromised, the first thing that goes away is my mood, and other functions, such as attention and memory, are also compromised. So, if the routine is too busy, I end up sleeping less, in addition to feeling tired, and this ends up having a big impact” (I11Y3M).

“I feel a lot better when I practice meditation or do some kind of work to feel the spiritual side” (I13Y4M).

“Having some leisure time, doing something I like during the week, going out to eat, going out for drinks with my friends, with my girlfriend. Always having my leisure time guaranteed” (I19Y5F).

“I think the medical course gave me as much as it took away from me. It gave me a lot of self-confidence and the power to help others, which is something that I think is wonderful, and every time I feel that I am helping, it brings me a lot of happiness. The medical course brings me daily happiness, including fulfilling purpose, which is one of the things I mentioned that gives mental health. What it takes away is dedication and effort. It is the time of your life that you give to the profession, which I really feel is a little disproportionate and that it is not a momentary thing” (I24Y6F).

Strategies for seeking and maintaining MH related to the group of medical students were not mentioned, just as no ways of seeking and maintaining MH were mentioned that related to proposals for dialogue with professors and educational institutions or ways of thinking and discussing the curricular organization and the dynamics of the undergraduate course to minimize the elements of the undergraduate course related to suffering.

Studies on medical students’ MH indicate a set of strategies to deal with problems related to psychological distress, such as physical activity, leisure activities, diet, good quality sleep, and seeking psychological assistance. Other essential aspects of MH identified in these studies involved family and social support, time management, religious interests, extracurricular activities other than those directly linked to medical training, and a new dimensioning of the importance of undergraduate studies ⁴²-⁴⁶. It is essential to highlight that medical students who participated in some of these studies indicated the use of psychotropic drugs as a way of coping with problems identified in the daily routine of undergraduate studies that affect MH, as it is a strategy that requires less effort and time ⁴⁶,⁴⁷.

A single study ⁴⁸ presented collective strategies to create spaces for reflection, self-assessment, and ongoing guidance/tutoring to improve students’ involvement and reflection on their course, generate relief from sources of distress, and help them perceive their education as a rewarding activity. The need to include disciplines focused on medical psychology, professor training, and psychoeducational and emotional support was also mentioned. Two studies indicated the need to change the course’s political-pedagogical project, workload, and teaching methodology to alleviate psychological distress ⁴⁸,⁴⁹.

The statements of the interviewees and most of the studies listed here point primarily to adopting individualized strategies to seek and maintain MH, which indicates an individualized, less complex, and fragmented reading of the issue. Returning to the analyses of the current performance society and its presentation as a society of fatigue, it is possible to consider that, despite perceiving that there is social pressure for maximum performance, overburdened and exhausted, students are unable to consider that the problems they identified as associated with psychological distress can and should be faced in the daily life of undergraduate studies. In this sense, they are unable to consider that the solution to psychological distress has a collective dimension and does not depend only on changes in individual behaviors and lifestyles but also on the group of professors, educational institutions, and trained professionals who sustain these pressures in the educational process ³⁹-⁴¹.

Final considerations

The medicalization process insists on the understanding that psychological distress concerns exclusively an individual dimension that is subject to intervention. It would not be related to other elements that constitute reality, especially those related to productivity and performance expectations on individuals in the most diverse social fields.

Dealing with psychological distress in the daily lives of medical students in undergraduate courses requires considering that the reality of the training process can be modified and that MH is more complex than the diagnostic classifications so abundant in studies on the subject. Changes depend on the possibility of opposing the logic of the imperative for performance and the psychological states of exhaustion that it entails instead of naturalizing them.

Pushed toward the imperative of maximum performance, students find it challenging to understand that suffering and illness are not exclusively individual issues. However, this does not only happen to them since others involved in the training process also need to come out of isolation to understand that MH is a complex socio-historical issue, for which it is not enough to conduct research that identifies the number of students who respond to each of the current diagnostic classifications.

So, if studies identify that medical students in Brazil experience the same problems, it is time to intensify questions about why the daily training routine maintains so many elements linked to suffering and what can be done, collectively, to change this reality.

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• Approval:
  IEC/IRB-UFSJ-CCO 57943522.2.0000.5545

Publication Dates

• Publication in this collection
  13 Jan 2025
• Date of issue
  2024

History

• Received
  27 May 2024
• Reviewed
  21 Aug 2024
• Accepted
  3 Sept 2024