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ss nucleus - summer 1999,  Stressbusters


How can we combat stress in exam periods? Jim Paul, registrar in Palliative Medicine and former CMF Student Staffworker, offers some practical advice.

I find travelling by aeroplane stressful, even in a 747 belonging to the ‘world’s favourite airline’. But this time I was in a small twin-propeller plane flown by a company known as ‘prayers in the air’. I was soon to discover why! During my elective, what I thought would be one quick flight had turned into four hops across uninhabited rocky desert. As we taxied down the third runway my hyperalert senses detected that the engine had not quite reached the hum required to get airborne. It came as no surprise when the captain announced he was aborting takeoff. The next day an engineer arrived and fixed the engine using a tool box that looked like it had been made by Fisher Price. As we took off I think I was justified in feeling just a little stressed.

So when it came to final MB at least I could say ‘I’ve been more stressed than this.’ Well, a bit more. But next to my aviation experience, exams rank as some of the most stressful events in my life. I’m sure that many Nucleus readers would agree with me.

Exams. The average medic does between 80-100 of them in their lifetime: school exams, GCSE’s, A-Levels, pre-clinical, BSc, end of clinical blocks, final MB, and then postgraduate qualifications. For medics, exams are an ever present feature of life. And yet for me, as I’m sure you too have found, they don’t get any less stressful.

Is there anything we can do about this? I’ve tried to put together some advice, based on personal experience and biblical wisdom, that I have found a help. I hope it is useful for you too.

1. Plan your revision

Whilst at junior school I had a brief encounter with rugby in the 3rd XV. We won 4 of our 6 matches, due more to youthful energy and enthusiasm than sound tactics. I remember being amazed by one of the teams we lost to. We played as 15 individuals but they played as one team. We took chances that came our way but they played with a strategy in mind. At each set-piece the whole team knew what they were going to do. They had a game plan. And they won because of it.

When it comes to exam revision most of us are a bit like my rugby team was - we tend to leave things to chance. We might work hard but rarely do we plan ahead and if we do, we make an unrealistic timetable that a ‘Brain of Britain’ would find it hard to keep. If we want to succeed we need to have a revision game plan. But what does that game plan need to take into account?

a) Relative weighting of the different subjects

Our revision plan needs to start in time to allow us to cover all necessary subjects. But the time we allocate to each subject needs to be relative to the importance of that subject. A large subject such as surgery might need three weeks, a smaller subject such as rheumatology only a few days.

b) Anticipated topics

Examiners have favourite topics which they use to test the candidates’ knowledge of the basic sciences and their application to medical conditions. Porphyria and congenital adrenal hyperplasia may be rare in real life but not so in exams. If possible (and legal!) take a look at old exam papers to get an idea of the questions asked, and focus on revising for those that keep coming up.

c) Types of questions

Give thought to the form of response that the exam demands. If you have to write essays then prepare sketched outlines for anticipated topics. If the questions require short answers then it’s best to learn lists. The dreaded MCQ is hardest to prepare for. The best way I have found is to do as many past questions as you can get your hands on. Look up in a textbook any answers you don’t know.

d) Know your own personality

Knowing the way that you personally work best will help you plan your revision. Are you a ‘night owl’? If so you need to keep evenings free for revision. If you are a ‘morning motivator’, rising early to do an hour before college and using weekend mornings may help you use your time most efficiently.

2. Plan rest periods

‘All work and no play makes Jack a dull boy’. And a stressed one! Why? Because we were made that way.

‘Remember the Sabbath day by keeping it holy. Six days you shall labour and do all your work, but the seventh day is a Sabbath to the Lord your God. On it you shall not do any work.’ (Ex 20:8)

When God made us he didn’t make us to work seven days a week. He made us as finite beings so that we would need to take at least one day a week to rest and remember our relationship with him. What wonderful news! God wants us to take sufficient time to rest. He doesn’t want us to wear ourselves out working all hours of the day and night. And when we go against this principle we go against the way we were made to be. We become over-tired, short-tempered and argumentative. We spoil relationships with those around us, as we do whenever we break any of God’s commands. His decrees are not there as a burden but to help us live in right relationship to him and to each other.

In the 1st century AD the Roman authorities viewed Christian slaves as lazy because they would ask for one day’s rest a week. Many were beaten back to work by their masters. But the Romans soon noticed that if they allowed their slaves one day off, their work became more efficient in the remaining six. They got more work done in six days than they used to in seven.

In the same way, if we take proper rest periods we will find that our work efficiency increases rather than reduces. If we allow ourselves time to exercise and relax, space to think and to enjoy relationships, then we will be more motivated to keep to our revision plan when it’s time to work. We end up being able to do more work rather than less.

Even Jesus needed rest periods. He understood what it was like to work hard and be stressed. But he also knew what to do about it. In the Gospels we often read of Jesus going off alone to a quiet and secluded place to rest, to pray and to recuperate (Mt 14:23, 26:36, Mk 1:35, Lk 6:12). As important as his mission was he knew that to do his work effectively he also had to have time to rest. If Jesus, the God and Creator of the whole Universe, took time to rest then surely we should do the same.

However, there are several things to note about rest periods.

a) Have one longer rest period each week

Half a day is good, a whole day ideal. It’s hard to relax properly during short breaks. Taking a large rest period means that you really unwind. Knowing that you have a day off helps you to work harder in the rest of the week. I have found Sundays a natural day to take as a rest day and a day to spend some time with the Lord and his people. It’s hard to take the whole day off, especially when feeling pressurised, but I have always found the Lord to be faithful in the peace that he gives and the energy to work harder in the coming week.

b) Have more regular but shorter rest times as rewards for work done

‘Discipline is delayed gratification - not no gratification’. I find it useful to take a 15 minute break for every hour worked. Use rest periods as a reward for work well done, and as time to unwind. Go for a walk, play a musical instrument, read a few pages of a good novel.

c) Keep proper boundaries to your rest time

Don’t let work eat into your rest time. It’s easy to keep working especially if you haven’t quite finished a topic you had hoped to have covered by now. But it’s better to put it down and come back to it later when refreshed. Don’t let panic stop you having proper rest times. Without them inefficiency increases. A good illustration of this is to think of Starling’s Curve. As the cardiac muscle fibre stretches so does the force with which it contracts (ie the work it does). But above a certain level of stretch the muscle starts to become less efficient and more stress reduces its work capacity rather than increasing it. In the same way, when we start to panic about our exams we are tempted to work longer hours and take less rest. But the longer we work the more tired we get, the more stressed we feel and lower the quality of the work we do. If you find yourself having stared blankly at the same page for the last 15 minutes it’s definitely time to take a rest!

d) Make sure your rest time is rest time

During stressful times like exams it’s important to make sure that your rest time is really rest. Don’t use it to do other stressful tasks. For example, don’t use your few hours off to prepare a Sunday school lesson or to lead a hall group Bible study. If you have responsibilities like these ask others if they could cover you for the time around exams. Instead do whatever helps you to relax and recuperate. If it’s being alone then be alone, if it’s playing sport then play sport, if it’s being with a group of friends then be with them.

e) Don’t let rest time become all your time

It’s easy to procrastinate and never to get around to revision. ‘I went past the field of the sluggard, past the vineyard of the man who lacks judgement; thorns had come up everywhere, the ground was covered with weeds, and the stone wall was in ruins. I applied my heart to what I observed and learned a lesson from what I saw: A little sleep, a little slumber, a little folding of the hands to rest - and poverty will come on you like a bandit and scarcity like an armed man.’ (Pr 24:30-34.)

3. Choose your friends

The Book of Proverbs warns us that friends can be worse than enemies (Pr 22:24).

Therefore, beware the friends who increase your stress levels by testing your knowledge on a topic that they have just revised! Avoid friends who waste your time by complaining how stressed they are or who encourage you in fruitless activity and procrastination.

Instead look for a friend who will revise with you and encourage you to keep going. Someone of the same academic ability, who is determined to pass their exams and has a strategy to do so makes an ideal work companion. It’s also good if you can take breaks together. My workmate and I found it easier to do a good day’s work if we had a game of squash and a pint in the pub together to look forward to at the end of the day. Having a friend who is outside medicine to relax with means that you aren’t tempted to ‘talk shop’.

One excellent friend who is ‘outside medicine’ is Jesus. Although he is both Lord and God he promised those who follow him that he will be with them in a very personal way (Jn 14:23, 15:13-15). He longs for each of us to enter into an open, honest and obedient relationship with him. He is ready to listen as we speak about our struggles and stresses (Rom 8:26-27). He understands our situation because when he walked on this earth he was tempted to put his feet up and give up the stresses of his life’s mission (Mt 4:1-11). But he has also promised us help in times of stress. He said that he will send to each person who loves him his Spirit who will help restore our peace by reminding us that he is the true Lord of our lives (Jn 14:25-27), including our exams.

4. Keep things in perspective

When your mind is focused on exams it’s easy to get life out of perspective. Passing or failing the exam becomes our whole world and revision a never-ending state of limbo. Failing exams becomes the worst event we can imagine and this fear multiplies our stress levels until they become a panic.

Before my finals I was heading for just such a state. Then I decided to read ‘An Evil Cradling’, an account by Brian Keenan of his years as a hostage in Beirut. Much of it was in solitary confinement, often chained and blindfolded in cramped conditions, fed rotten food and physically abused. As I looked up from the book I realised there were worse things than exams, that actually my life was pretty comfortable. I could look out the window and see the sky and the sun. I could make a cup of coffee when I wanted to. I could go to the movies that night. Life wasn’t that bad after all. I had regained perspective and was able to give thanks to God for the everyday good things in my life.

Despite what our professors teach us, medicine is not the be all and end all of life. I don’t think that it’s God’s number one priority either. There are more important things! Our relationships with other people and above all with our heavenly Father should have more priority than our careers (Mt 6:33).

In the Sermon on the Mount Jesus tells us what it means to have a kingdom perspective rather than a worldly one. Our view is to be eternal not simply earth -bound. We should focus on things that last rather than that which perishes (Mt 6:19-20), on serving God rather than career or the accumulation of possessions (Mt 6:24). It is Jesus who is ultimately in control of all history and of our lives and trusting him with the future will provide us with the peace necessary to live for him in the present (Mt 6:25-34).

Exams are stressful but we can reduce this by planning ahead, taking adequate rest, choosing our friends and keeping things in perspective.

Above all we need to keep everything we do in the perspective of the one future exam that every person will have to face. It has only one question, and only one right answer. It’s a test that most people ignore. But it’s also one for which we can be fully prepared because Jesus has told us the answer. In fact, he is the answer.

‘For God so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life. For God did not send his Son into the world to condemn the world, but to save the world through him. Whoever believes in him is not condemned, but whoever does not believe stands condemned already because he has not believed in the name of God’s one and only Son. This is the verdict: Light has come into the world, but men loved darkness instead of light because their deeds were evil. Everyone who does evil hates the light, and will not come into the light for fear that his deeds will be exposed. But whoever lives by the truth comes into the light, so that it may be seen plainly that what he has done has been done through God.’ (Jn 3:16-21)

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