Emote Control: “Inside Out” for Prehealth and Professional Development

The 2024 summer blockbuster film Inside Out 2 explores the complex emotions that first hit teenagers during puberty. Briefly, the five original emotions (from the first movie in 2015) that define the behavior of childhood Riley – Joy, Anger, Fear, Sadness, and Disgust – meet new emotions that allow Riley to grow further toward young adulthood. Unfortunately, the new emotions – Anxiety, Envy, Embarrassment, and Ennui – threaten to ruin long-standing friendships and make Riley more vulnerable to losing her sense of identity. As prehealth applicants, you likely have had to control these new emotions in preparing to become a student doctor. As health professions students, you probably experienced similar emotions when trying to impress others during your clinical rotations.

We will consider how the newer emotions contribute to your experience as a health professions student. I apologize for some plot spoilers. Throughout the article, “medical” school is meant to include other health professional education programs.

Anxiety

Taking control of Riley’s behavior, Anxiety helps Riley to make decisions that benefit her to avoid being a social outcast. In many cases, the decisions help her grow out of her comfort zone. However, Riley’s naive belief system (“I am a good person, I want to help people.”) becomes replaced by a belief of inadequacy (“I’ll never be good enough.”), and, at the climax, Riley experiences a panic attack that paralyzes her and endangers her health.

I’m admittedly understating the fact that anxiety dominates the mindset of most pre-health applicants (“premed syndrome”). For years, students dread being rejected from their desired career path, and they fret about not getting the right professors for the right classes or missing out on extracurricular opportunities. They can become consumed with getting into medical school. As a result, anxiety drives students to develop a comprehensive checklist for success, anticipate every contingency for every unanticipated disaster, and look for ulterior motives in every optional secondary essay prompt.

Social concerns amplify the anxiety further: How can you fit into the culture of their new school, make the “right” friends, or get along with roommates? Can you leave positive impressions with faculty or other administrators and still be “cool” to your peers? Do people like you enough to get elected to a leadership position in a club or across your campus? Can I get into this selective organization (such as a Greek organization) despite all the initiation hoops I must jump through? Do I emulate “effortless perfection?” Can I find a date for the next formal? Am I exercising or meditating enough to stay calm (asked with irony)? If not, am I doomed to an eternity of regrets and failure?

Just wait until medical school; if anything, the questions get more intense around making sure you pass your classes and avoid a remediation semester, find the “right” opportunity for a productive research record, or receive strong enough clerkship evaluations despite the brief exposure time to set up an application to a highly selective residency program (and thus get higher lifetime earnings). Other health professional programs share similar concerns as students seek employment or a post-graduate residency after graduation. First-generation health professions students or those from underrepresented communities may also bear the additional burden of wanting to succeed to represent and benefit their families or communities. Medical school is a crucible of stress that can transform or destroy you. Finally, there’s the dark cloud of student debt.

Pervasive among medical students around the world (Mirza et al., 2021, Quek et al., 2019, Sherif et al., 2023), anxiety often develops into depression, especially among vulnerable populations. Social isolation, like during the COVID-19 global pandemic lockdowns, further exacerbates feelings of isolation, anxiety, and depression (Alshehri et. al, 2023). Students should take advantage of proactive strategies employed by schools, clinics, and hospitals to manage and mitigate the health challenges that could result from uncontrolled anxiety.

Envy

The adage “comparison is the thief of joy” summarizes the power of envy. Most who want to be doctors admire the mix of personal or community impact with altruism and selflessness shown by role models and mentors. Successful professionals lecture or mentor students, including significant benefactors who endow scholarships or new research facilities. Placing peers on pedestals for their outstanding grades, achievements, attractiveness, financial security, or offers of admission to brand/top-20 graduate programs may be additional fuel for motivation during the application process and health professions education.

But envy turns the admiration for the recognition of peers into an unhealthy obsession to place one’s needs or desire for acknowledgment above others. Sometimes, one may find satisfaction in seeing their peers fail (known as schadenfreude). Empathy, compassion, and gratitude become victims to envy, and patient-centered care is replaced by provider/physician-centered ambition that sacrifices interprofessional teamwork and the patient’s welfare. Redelmeier et al., 2023, lists some ways envy contributes to making decisions that are less professionally appropriate or contribute to burnout. 

Embarrassment, the Precursor to Shame

Closely associated with “imposter syndrome” is embarrassment. Whether one is placed on the spot during a “pimping” session or misgendering a patient or peer, embarrassment humbles an individual who is exposed to making a mistake or showing their lack of complete preparation (Barry et al., 2022). Embarrassment may result when someone is reminded of more humble beginnings, as if they do not deserve the privilege of being a healthcare professional, so they suppress their connections to their home communities to “fit in” and be a perceived professional.

Keeping information private or confidential is also important in controlling embarrassment. Most do not want it known that they need or receive help because of the appearance of being impotent. One example is remediation due to failing an exam or a class; students can feel shame for having to be remediated, often something they have not experienced in their lives, and they may feel that their flaws are immutable (Whelan et al., 2021). Those who feel such shame risk burnout or dropping out of school.

A culture rooted in dignity for others and self-care can be used to fight embarrassment (James 2018). Finding constructive ways to discuss errors and correct mistakes can relieve providers’ self-doubt and build resilience and wisdom as part of their professional identity. By acknowledging that one does play a meaningful role in others’ lives and the performance of their team, students, residents, and providers can respectfully manage challenges and maintain appropriate care for their patients. 

Ennui, or “the Boredom”

After the excitement of orientation wears off, first-year students become mentally exhausted with the day-to-day grind. University professors are used to seeing bored students who attend their lectures only to scroll through their phones or laptops disengaged from the class, no matter how exciting the material is (or is not). Most pre-health students are used to “showing up,” “checking the boxes,” and “tapping out” to search for things they otherwise find more interesting. Tedium with experiments and data analysis often causes graduate students to question whether the Ph.D. is worth it.

Discussion of boredom in school has been ongoing for decades (DeLeon 1958, SDN 2004). Personal hobbies and habits are generally recognized as ways to fight against medical school malaise, and student affairs and organizations run programming to allow students to occasionally decompress so that their lives are not solely defined by the number of hours studying alone with flash cards. When it comes to studying things that one is not passionate about, mustering enough interest to fight ennui is challenging. Ennui comes from skepticism about the entirety of medicine and whether one truly has “the passion” to fulfill society’s call (Shatz). You can enter a state of ennui when your are exhausted from processing the emotions of anxiety, envy, and embarrassment, resigning to futility and nihilism as nothing you do seems worth the effort.

Changing routines, shifting focus, or taking an extended holiday away from the daily stress of healthcare can lessen burnout and ennui. By reconnecting with a belief system combining self and purpose, one can appreciate the importance of living and engaging in the moment (mindfulness), especially with a caring community. These techniques help build your resilience and curiosity which will benefit your professional and personal growth.

Bringing Back Joy

As the mental health crisis has worsened, more schools are welcoming open discussions of these emotions to combat moral distress (Dudzinski 2016). When it comes to applications to medical school, disclosure of effectively managed mental health conditions (to demonstrate resiliency or overcome adversity) does not harm an applicant’s chances for a fair file review (Abraham 2022).

More physicians and administrators recognize that the health care and medical education systems drain a sense of joy from those who work long enough. With increasing concern about provider burnout since the COVID-19 pandemic, everyone wants to find ways to bring joy back into medicine/health care (Okwerekwu 2016). Instead of rewarding health professionals for practicing kenosis (“an emptying of the self”), leaders must offer safe spaces and opportunities to discuss experiences that cause moral distress and disengagement. Patients and the public expect our healthcare providers to be more than just a computer AI chatbot with hands and some therapeutics to cure our ills; they expect and deserve affirmations of empathy and dignity within the natural human connection we share.

At the movie’s end, Riley finds a way to find the joy she lost. She expands her circle of friends and gains confidence that despite her mistakes, she knows her family and friends will still love and care for her. The story may not be as happy or simple for everyone, but being more aware of these complex emotions during your growth as a future professional may strengthen your resolve to achieve your goals.

Good luck to all the first-year students. May you find new ways to nurture joy and your belief in your personal and professional self.

Image courtesy of Disney Pixar.

Appendix

Pixar Studios website

https://www.pixar.com/inside-out-2. Accessed June 20, 2024.

Reading more: the neuroscience/psychology of “Inside Out.”

• What ‘Inside Out,’ a film about feelings, gets right about the brain – The Washington Post 
• The Real Science Behind the Animated Emotions of Inside Out 2 – Time Magazine 

Works Cited

Abraham, A. E., Busch, C. A., Brownell, S. E., & Cooper, K. M. (2022). Should I write about mental health on my med school app? Examining medical school admissions committee members’ biases regarding mental health conditions. Advances in Physiology Education. https://doi.org/ADV-00094-2022. Committee members highlighted that revealing a mental health condition to demonstrate resiliency could be beneficial, but if the reference is vague or the condition is not being managed, it could be detrimental to a student’s application. This work indicates that medical school admissions committee members do not exhibit a bias against mental health conditions and provides recommendations on how to discuss mental illness on medical school applications. 

Alshehri, A., Alshehri, B., Alghadir, O. et al. (2023). The prevalence of depressive and anxiety symptoms among first-year and fifth-year medical students during the COVID-19 pandemic: a cross-sectional study. BMC Med Educ 23, 411. https://doi.org/10.1186/s12909-023-04387-x 

Barry K, Schiffman FJ, Collins BJ. (2022). Assessing Medical Student Fear and Shame as Barriers to Active Participation on the Wards. Brown Hospital Medicine. 2(1). doi:10.56305/001c.40087 

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