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Prophylaxis for Burnout: The Sabbath- Can Med Students Take a Day Off?

Nov 24, 2020

Written by Elli Izrailov

Elli is a final year postgraduate Monash medical student, with a love for general practice, rural health, mental health, and memes.

Burnout is as common in medical students as perfectionism is to… well medical students. While a multitude of suggestions have been offered as a cure of this all-consuming plague, perhaps this new addition, or rather archaic one, will make all the difference - The Sabbath.

It’s 11:30pm and I’m lying in bed, exhausted after a long day’s study. As I’m drifting away I hear a gentle rap at my door. I let out a non-commital grunt, acknowledging that while I’m not asleep, I still wish I was. Regardless, it’s a sound which permits my younger sister, because who else would it be, to enter my room. She sits by my bed. I open my eyes and turn to face her. She looks very distressed. 

She doesn’t know what to do. She has several essays to memorise for some school assessments which she has to do tomorrow, but it’s already incredibly late and she’s super tired. 

This is classic behaviour on my sister’s part. She’s always been very brilliant, so she’s never had to study too much. However, as she’s been getting into her final year of school, she has begun to feel woefully underprepared. So she does what she does best, crams last minute, and still manages to pull off amazing grades for her classes. I wish I had half of her brain. But then again, she puts herself in these situations a fair bit because she has that brain. So maybe I don’t want it. Regardless, I tell her what I’ve been telling Year 12 students since I was in first year uni, from my incredible breadth of experience.

“Go to bed now. If you stay up all night, and do everything you’ve been wanting to do, you’ll finish at what, 3am? Then you won’t get enough sleep and when you wake up you'll feel like an anxious wreck, do sloppy work, and then stay up the next night trying to catch up on the poor work you’ve been doing all of that day. 

Just go to sleep now, feel refreshed, and your work efficiency will significantly improve by the next day and you’ll avoid tumbling down this little rabbit hole you’ve stumbled into.” 

But alas she stays up. Granted, she goes to bed at 1am, which is a lot better than usual, but she still feels anxious the next day and the cycle repeats. Regardless, she is still successful and the habit is reinforced. Because why shouldn’t it? It works after all. 

I sigh and think how silly she is, how could anyone possibly get in her position. The solution to her problems is so obvious, and the path she’s walking ultimately arrives at unsustaina-ville. As I drift off to sleep I laugh and realise that I am a hypocrite. 

The medical student fallacy

Medical students are an interesting breed. We have a culture of studying 24 hours, seven days a week, and if we’re not studying then we’re either participating in extra-curricular activities, researching, and doing whatever else is necessary to sow the seeds of the career we will one day reap. If we’ve done all our chores and then some, only then can we think about getting some social time in. 

2020 was a year of many insights and epiphanies, as challenging times often prove to be. For me, seven months of lockdown, four of those in Melbourne’s hard lockdown, made me rethink how I spend my time, and more importantly the time I spend stressing, well about everything. 

Unfortunately stress does not dissipate easily, not even after rewatching Avatar the Last Airbender for the third time. I’ve studied to the point of exhaustion, dulled my eyes with flashcards to the point where my vision blurs, and grilled myself till I lack the energy to learn one more paediatric sepsis management pathway, or revise the management of shoulder dystocia. I am burnt out. 

Burnout is almost synonymous with perfectionism, and perfectionism is almost synonymous with med students. Sadly, but not surprisingly, studies show that the cumulative stress and exhaustion associated with studying all day every day to aim for excellence in a field that calls for nothing less, has poor physical and mental health outcomes, and medical students are disproportionately represented.

But what’s being done to prevent burnout in medical school? From my experience, universities do have some measures to address the poor mental health outcomes among medical students through a multitude of means. Yes they are incorporating mindfulness into the curriculum, and implementing a less than 100% attendance rate in order to accommodate for student sick and mental health leave. But the results are mixed and at times anecdotally hypocritical. Universities say look after the mental health of medical students but at the same time institute policies which are counterproductive to said point.

Having said that I must give credit where credit is due. The university I attend emphasised during the first weeks of pre-clin the importance of self-care, debriefing, and group-care to prevent burnout, especially through the comradery in our peers. And the importance of that comradery and peer support is one of the best changes to improve cohort mental health.

But what this year, and particularly lockdown, has taught me is that if my sister and I are to break these destructive study habits, maybe we should draw on some practices we were brought up with - enter the Sabbath.

What if I reframe the conversation with myself? Get rid of the guilt and embrace the break. I decided that the best way to do that is change my outlook from med-school to old-school, and to revisit my roots. To indulge in the Sabbath.

- Elli Izrailov  

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The Sabbath

Reflecting on the hypocritical advice I gave to my sister, I thought what would be the best way to build in breaks to my study schedule? I wanted something sustainable, something to avoid repeating the pattern of ‘working to exhaustion and then work ineffectively’. It’s not that I hadn’t taken breaks before, I did end up taking one or two days within a week for myself, but everytime I took one of those days off, I would feel guilty. 

So I thought, what if I reframe the conversation with myself? Get rid of the guilt and embrace the break. I decided that the best way to do that is change my outlook from med-school to old-school, and to revisit my roots. To indulge in the Sabbath. But for my fellow gentiles who aren’t familiar with the Sabbath, allow me to explain. 

The Sabbath or in Hebrew ‘שַׁבָּת‎’ (Shabbat) can be translated as ‘rest’, ‘cessation’, or simply to ‘sit’. When I was but a wee lad I was taught that the Sabbath was a day of rest. 

But to fully observe the Sabbath meant going to Synagogue on a Saturday, praying, having a meal hosted by the Rabbi, and in between from Friday sunset to Saturday sunset, not using electricity. That meant no GameBoy, no television, no video-games, so all in all, none of my favourite things. That didn’t mean I didn’t do all those things, I did, but to me the Sabbath sounded like a chore more than anything. There was nothing about it to look forward to. 

Getting older and going to a Jewish day school I learnt more about the Sabbath. Jews like to flex that we had the first mandated weekend and the reason we should observe this holy day is that even God rested after creating the world in six days. Are we to think we are greater than God? 

Later on, I was taught that the reason why we don’t use electricity over the Sabbath is because electricity is control. The idea of the Sabbath is to rest, and to properly rest one must cede control; so no electricity, no phones or telly, no exchanging money either (can’t make any transactions), no writing, and no driving or even using a bicycle! (Interestingly, scooters are allowed. Don’t ask me why, the Rabbis made an argument that using a scooter isn’t really doing work, I think it has something to do with gears.) 

When I got to the tail end of my schooling there was a ‘final’ lesson about the Sabbath. That being, the reason we cede control is so that we can fully introspect into the week that was, to examine it, to grok it, to let go of it, and to grow. It’s a day of necessary rejuvenation. 

Which is why I think the Sabbath is the best thing that I can do, and medical students and junior doctors can do for themselves to prevent burnout. A mandatory day off. A day which is strictly no study, so that you can disconnect and recharge your batteries. I think if medical students can get onto this, they won’t feel so fatigued from studying all the time, and they can properly split work from play.

It’s like sleep hygiene; your bed is just for sleeping and if you transgress, overtime, you won’t be able to sleep as well, and even if you do, you will be less rested. Comparatively, the Sabbath is just for rest; you’re not supposed to work on the Sabbath because otherwise you can’t properly rest and if you do, it just won’t be the same. 

Now it’s very easy to talk about finding a day off in a week as an unemployed medical student living at home with no monetary stresses. A fair chunk of medical students are living out of home working and trying to balance the strains and stressors of balancing that work with, you know, being a medical student which is in itself a full-time job. 

People who are working to support themselves through medical school may not necessarily have the time to take a full day off every week. That full day is time where they are working or where they are studying to make up for the time they’ve spent working. It’s simply not feasible in their situations to take that time off.  

The only advice that I have for these medical students is to make some time for themselves during the week. Whether that’s an evening off during the week for introspection or self-care, or maybe a few hours. Because the best thing for time management isn’t really time management but time prioritisation. And you have to prioritise time for yourself. 

My Sabbath Experiment

It’s been three weeks since I started implementing this social experiment of observing the Sabbath and to be honest the results are full of confounding variables. 

Every Saturday I have done no work whatsoever. 

None at all. 

Which is particularly distressing because on top of the ever-present nagging in my mind of ‘you should be studying’ and ‘why aren’t you studying’ I am in the midst of my exam season. So every Saturday that has come, half of me is thinking ‘why are you so stupid, every second going by is time you could be studying. I’m also embracing the fact that by making the time for myself today, I will be better equipped to handle the rest of the week. I will escape my exhausting cycles of burnout, which are unsustainable and miserable. So it’s essentially like taking the medicine I offered to my sister in what feels like so long ago. 

So I don’t study, and nowadays with Melbourne’s restrictions eased, I can actually socialise with friends *gasp*. I also make a point to be more mindful and to really be in the present as I maximise my enjoyment of the day. Now my social experiment has coincided with the easing of lockdown—a confounding variable — which means I can go to restaurants and bars for the first time since February. And as you can probably tell, this has done wonders for my mental health.  

While I wish I could firmly say that keeping the Sabbath as a day off is doing miracles for my mental health and my schooling in terms of how much more efficient I’m studying and how much better I’m doing, I can’t make those claims with a p-value of <0.05. 

All I can say is that I’m doing much better now than I was back when there seemed to be no end to lockdown. 

Keeping Saturday’s to myself has allowed me to push my study periods for longer because I can rationalise to myself that on Saturday I will get an entire day off. I have a more diverse routine now and I can separate work from play. I now have something to look forward to and I am so much the more thankful for it. 

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