among final-year medical students.Rev Assoc Med Bras 2011;57 (4):379–86.

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9 Shapiro SL, Astin JA, Bishop SR,Cordova M. Mindfulness-basedstress reduction for health careprofessionals: results from arandomised trial. Int J Stress Manag2005;12 (2):164–76.

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13 Dobkin PL, Hutchinson TA.Teaching mindfulness in medicalschool: where are we now andwhere are we going? Med Educ2013;47:768–79.

14 Hutchinson TA. Whole PersonCare: A New Paradigm for the 21stCentury. New York, NY: Springer2011.

15 Hutchinson TA, Hutchinson N,Arnaert A. Whole person care:encompassing the two faces ofmedicine. CMAJ 2009;180 (8):845–6.

Medical student resilience, educational context andincandescent fairy talesGabrielle M Finn1 & Frederic W Hafferty2

In their paper, Mavor and colleagues1

set out a well-reasoned and theoret-ically distinctive resistance-to-stressmodel of resilience. Within thismodel, the authors conceptualisemedical student well-being, burn-out and stress as being shaped by atripartite set of variables: (i) self-complexity; (ii) identity, and (iii)reference group norms. The pro-posed model is quite useful in high-lighting the complexities of contextand coping, and we agree with theauthors1 that social psychologicalfactors make appreciable contribu-tions to the complex issues sur-rounding well-being and medicaleducation. We also support theauthors’ effort to move beyond a

prevalence model of stress and well-being. Nonetheless, we feel thereare a number of unsecured threadsat the edges of their arguments thatwarrant additional scrutiny, two ofwhich we explore here: (i) theseductive tug some might feel toimplement such a model withinmedical school admissions, and (ii)the siren call to deploy such amodel to curb the more excessiveelements of stress without ensuringthe preservation of the lower-levelstress identified by Mavor et al.1 asnecessary to promote both knowl-edge acquisition and professionalformation. We explore thesethreads by drawing upon two well-known fairy tales: Snow White andthe Seven Dwarves, and Goldilocksand the Three Bears.

The proposed model is quite useful inhighlighting the complexities of context

and coping

The fairytale of Snow White andthe Seven Dwarves reflects anumber of the issues raisedwithin this article,1 includingthose of resilience, medical stu-dent selection, and remedialinterventions. The dwarves are adiverse cohort, a combination ofpeers and allies of Snow White.Each has his relative strengthsand weaknesses, but collectivelythey demonstrate the functionalnecessity of heterogeneity. SnowWhite is a somewhat conflatedindividual known for her human-ist values and joyous acceptanceof each of her peers, but she isalso vulnerable to poisonous ele-ments and to the necessity of res-cue by a charming other. Like allmedical students, Snow Whiteexperiences multiple vectors ofstress, the primary source ofwhich is the poisoned apple.Snow White’s rescuer is an out-side agent, Prince Charming, whomight well represent the medicalschool and its faculty.

1Heslington, York, UK2Rochester, Minnesota, USA

Correspondence: Dr Gabrielle M Finn, HullYork Medical School, University of York,Heslington, York YO10 5DD, UK.Tel: + 44 191 334 0737; E-mail: gabrielle.finn@hyms.ac.uk

doi: 10.1111/medu.12415

342 ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 340–348

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Each (dwarf) has his relative strengthsand weaknesses, but collectively theydemonstrate the functional necessity of

heterogeneity

Although Mavor et al.1 note thattheir main goal in this modellingeffort is to ‘inform medical edu-cators as to the students whomay be most vulnerable to theeffects of stress, and the potentialinterventions from which theymay benefit’,1 we could not helpbut imagine how this same modelmight prove irresistibly seductiveto medical educators, particularlythose on admissions committees,who may desire to better screentheir applicants for those whowill be least vulnerable to theeffects of stress, or those who willbe least likely to consume scarceremedial resources during train-ing. Similarly, we found ourselvestrying to imagine a class of medi-cal students awash with high-achieving, competitive and stress-resistant matriculates, and we didso with some measure of disqui-etude. What would it be like towork with such a group? Whatwould educational life look likein this land of the immunologi-cally advantaged? Who amongour forest residents would makethe grade? In a medical culturestill marked by hierarchy andpower, who would win a starringrole by virtue of their resilienceand who would be marginalisedto the periphery of whateversocial network might emerge?

We found ourselves trying to imagine aclass of medical students awash with

high-achieving, competitive andstress-resistant matriculates.

In a sentence that almost escapesnotice, Mavor et al.1 acknowledgethat stress (at lower levels) is func-

tional for learning. This bio-cogni-tive fact brings us to a complicatingboundary issue that is notaddressed in the paper. What hap-pens when a ‘just-the-right-amount’level of stress (however this isdetermined) begins to percolateand thus breaches (for whateverreason) the threshold between‘good’ and ‘bad’ levels of stress sothat this new (and still possiblylow) level of stress is now consid-ered to be dysfunctional for medi-cal student well-being? How are weto think about these dynamics,particularly in light of a model inwhich such dynamics are not partof the authors’ discussion?

What happens when a ‘just-the-right-amount’ level of stress breaches thethreshold between ‘good’ and ‘bad’

levels of stress

Because of this conceptual void,we began to imagine a ‘hedgedbet’ or Goldilocks-based (not toohot, not too cold) model of stressresistance in which self-complexity,identity and reference group normsremain functionally muted duringperiods of ‘appropriately low’stress (all of which facilitate learn-ing), but in which these sameindependent variables kick in whenstress levels rise, cross our imag-ined threshold and thereuponbecome dysfunctional for learning.At this point, and in keeping withthe model outlined by Mavoret al.,1 students would now requirea ‘danger zone’ immunologicalboost, but a boost that nonethelessmust be temporary in its efficacybecause the hedged-bet framing ofstress (good at low, but bad athigh levels) advanced in this paperrequires that students in the dan-ger zone receive only a short-act-ing form of stress reduction inorder not to neutralise the func-tionally beneficial lower levels ofstress. Anything longer lasting,

almost by definition, might alsowash away lower-level stress so thatit would no longer be able to workits ‘learning magic’. Goldilocksassuaged her hunger because shefound a third ‘just-right’ bowl ofporridge. Should we assume thatthe same is true for self-complex-ity, identity and reference groupnorms?

The hedged-bet framing of stress requiresthat students in the danger zone receiveonly a short-acting stress reduction inorder not to neutralise beneficial lower

levels of stress

As a result of the ever-increasingcompetition for places, medicalschools are resorting to increas-ingly refined (and complicated)selection measures. For example,applicants now face multiple mini-interviews,2 complete cognitiveand non-cognitive selection tests3

and meet ever more stringent aca-demic standards. Adding resilienceto stress to the mix has the poten-tial to result in future cohorts ofmedical students who are moreclone-like than authentic, who maylack Snow White’s humanitarianvalues and her embrace of thosewho appear (at face value) to bequite unlike herself, and who thusbecome increasingly distant from,and unable to relate to, theirpatients. Losing the diversitywithin a cohort prevents studentsfrom learning from one another.A cohort consisting of only Bash-fuls or Docs, with no alternativeothers, would create a dysfunc-tional learning environment andone that would not meet theneeds of a diverse society. Weneed to strike a balance. We needto enrol individuals who are capa-ble of meeting the academic andpsychological demands of the pro-fession without losing the rich edu-cational landscape created bydiversity, while adhering to

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343ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 340–348

selection processes that are defen-sible, robust and fair. McManuset al.3 determined that around35% of first-year medical schoolperformance is not accounted forby academic achievement, postulat-ing that personality and attitudinaldifferences may account for atleast some of the remaining ‘darkvariance’. Although some variancewithin student performance proba-bly relates to factors that areunpredictable at selection, such asillness or other life events, someassociation with factors such aspersonality, motivation and studyskills may exist.3 The dark side isoften more interesting: what woulda fairytale be without the occa-sional dark twist or element of theunknown?

We need to enrol individuals who arecapable of meeting the psychologicaldemands of the profession without

losing the rich educational landscapecreated by diversity

Resilience is the capacity to with-stand stress. However, being resil-ient to stress does not mean goingthrough medical school withoutexperiencing any stress whatsoever.Resilience results from managingstresses, learning from experienceand developing as an individual.That said, links have been shownbetween personality traits, jobstress, depression and anxietyamongst junior doctors.4 Neuroti-cism has been found to predictstress, while extroversion protectsagainst depression. The selectionof homogeneous cohorts of super-resistant students would indeedmake medical education easier for,after all, heterogeneity is challeng-ing. Wouldn’t it be great if every-one liked the same porridge?

Instead of succumbing to theseductive promise of selectingresilient students, we need to putin place interventions to help stu-dents differentially manage stress.A resilient and thus capable clini-cian will develop in the context ofsupportive relationships with peersand educators, in a positive work-place culture, and through thedevelopment of self-managementstrategies and the development ofpositive personal and professionalidentities.

Resilience results from managing stresses,learning from experience and developing

as an individual

The happy-ever-after ending to themedical school fairytale is studentwell-being. However, well-being isa trajectory, based within both thepresent and the future. A modelof stress reduction is one way ofworking towards that goal.Although we do not imply thatMavor et al.1 argue otherwise, weurge that caution be exercisedagainst a model of stress reductionthat targets individuals – particu-larly individuals who occupy anessentially low-status positionwithin the landscape in question –to the exclusion of analysing thebroader learning environment.Calling for resiliency as a desiredskill set for trainees is a short stepfrom advocating that resiliencytraining is the preferred remedialaction. When Mavor et al.1 talkabout the ‘risk of suffering fromstress and associated problems’,1

they are talking about the risk toindividuals (medical students)rather than the potential toxicityor riskiness of learning environ-ments as the ‘caldron of cause’.Medicine, for a number of histori-

cal reasons, has tended to focus itsremedial and restorative efforts onindividuals rather than on environ-mental or public health factors.We feel it would be a mistake,however, to carry over argumentsthat are based on factors medicaleducators cannot influence, suchas disease, to the issue of medicalstudent stress and well-being giventhat medical schools are ultimatelyresponsible for – and in control of –their learning environments. Justas the authors of fairy tales selectcharacters who will advance theirstory line, so do medical schoolsselect students who are able tomeet the demands of the medicaleducation journey. Nonetheless, itis of paramount importance thatthey select those who will be goodfor society and beyond the needsof the proximate educationalsetting.

REFERENCES

1 Mavor KI, McNeill KG, Anderson K,Kerr A, O’Reilly E, Platow MJ.Beyond prevalence to process: therole of self and identity in medicalstudent well-being.Med Educ 2014;48:351–60.

2 Eva KW, Rosenfeld J, Reiter HI,Norman GR. An admissions OSCE:the multiple mini-interview. MedEduc 2004;38:314–26.

3 McManus I, Dewberry C, NicholsonS, Dowell J, Woolf K, Potts H.Construct-level predictive validity ofeducational attainment andintellectual aptitude tests inmedical student selection: meta-regression of six UK longitudinalstudies. BMC Med 2013;11:243.

4 Gramstad T, Gjestad R, Haver B.Personality traits predict job stress,depression and anxiety amongjunior physicians. BMC Med Educ2013;13:150.

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