Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives of Coping with Academic Stress among Filipino Medical Students

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248
Life on a Tightrope:
An Interpretive
Phenomenological Analysis
of Narratives of Coping
With Academic Stress
Among Filipino Medical
Students
Elizabeth Aileen Garan-Giller, M.D.1,
Dominico Carlo S. Dator, M.D.1,
Mart Blas Angelo P. Juan, M.D.1,
Genevieve Anne R. Querubin, M.D.1,
Tiphanie P. Sevilla, M.D.,
Maria Minerva P. Calimag, M.D., Ph.D.1,2,3,4
Maria Minerva P. Calimag
mpcalimag@ust.edu.ph
1 Faculty of Medicine and Surgery
2 The Graduate School
3 Research Center for the Health Sciences
4 Research Center for Social Science and Education
University of Santo Tomas, Manila, Philippines
ABSTRACT
Background Life in a medical school is stressful
for just about every medical student. Academic stress
in small doses heightens the energy and awareness,
giving one that mood most refer to as “pumped up”
or “wired”. When the incremental progression of
stress brought about by health and emotional factors
compounded by social and  nancial problems, over-
whelmingly surpasses one’s ability to cope, it leads
to feelings of being “burnt out” or “stressed out”. It
can have a negative impact on a medical student’s
cognitive and psychological functioning resulting in
poor academic performance. Each person has his
or her own unique way of dealing with it; some may
outwit pressure without a bad outcome, while others
just simply succumb to it.
Purpose A vast majority of research on academic
stress is centered on its contributing factors and how
they affect other aspects of students’ lives. Coping
mechanisms and effective ways in dealing with stress
have also been delved into, but none have dwelt on
a study of the medical students’ lived experience of
academic stress. There was no study found in litera-
ture which examined and collectively characterized
the different phases that medical students go through
in coping with academic stress, hence the impetus to
undertake this study. Anchored on the Transactional
Model of coping with stress, this study was undertaken
to answer the central question: How do Filipino med-
ical students collectively characterize the phases they
undergo in coping with the stresses in medical school?
Design The methodological underpinnings of this
study are based on phenomenology. The objective

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Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
of Interpretive Phenomenological Analysis (IPA) is to
understand how a particular phenomenon is consti-
tuted from the participant’s perspective. It offers re-
searchers the opportunity to learn from the insights
of experts – the research participants themselves.
The respondents’ insights were gathered through
narratives culled through a guided semi-structured
questionnaire patterned after social networking
sites, allowing the respondents to liberally exploit
their voices and thoughts. Narrative accounts gath-
ered focused on the medical student’s daily activi-
ties, matters that precipitate anxiety, their views on
stress, and methods of coping. Through cool and
warm analyses, the narratives were ultimately sub-
jected to phenomenological reduction.
Findings Fascinatingly, after subjecting the nar-
ratives to a thorough and comprehensive phenom-
enological analysis, six emergent themes surfaced
which collectively characterized the phases our re-
spondent medical students underwent in coping with
academic stress: Self-effacement Phase (Sensing in-
ner trepidation), Self-awareness Phase (Settling in
new surroundings), Self-weariness Phase (Struggling
through stress) Self-attentiveness Phase (Staying fo-
cused to survive), Self-equilibrium Phase (Sustaining
a state of symmetry), and Self-mastery Phase
(Striving towards sovereignty and satisfaction). The
“Tightrope” is a representation that lucidly embodies
these six themes.
Conclusion Our respondents have experienced
substantial challenges in medicine: they surmounted
their inner trepidation; settled and acclimatized to
their new surroundings; gained the courage to out-
wit stress and struggles; fought to strive, survive and
stay focused; learned to maintain a state of balance
and symmetry; and  nally lived up to a sense of
sovereignty and self-satisfaction. It is just a matter
of perspective and attitude that demarcates a victor
from a slacker.
Keywords: Medical students, Stress, Coping,
Filipino
“All that a man does outwardly is but the expression
and completion of his inward thought. To work ef-
fectually, he must think clearly; to act nobly, he must
think nobly. Intellectual force is a principal element
of the soul’s life, and should be proposed by every
man as the principal end of his being.” Channing
In the words of Sadock et al. (2007), stress can be
described as a circumstance that disturbs or is likely
to disturb the normal physiological and psychologi-
cal functioning of a person [1]. Asterita (1985) de-
 ned stress as a “perceived threat,” the term incor-
porating both the stimulus (stressor) and the response
(coping) [2]. Bisht (1980) has de ned academic
stress as a demand related to academic frustration,
academic con ict, academic pressure and academ-
ic anxiety that taxes or exceeds the available inter-
nal or external resources as cognitively appreciated
by the student involved [3]. Lal (2014) described
academic stress as mental distress linked to some
anticipated frustration brought about by academic
failure or even an unawareness to the possibility of
such a failure [4].
In small doses, academic stress heightens the en-
ergy and awareness; alerting the senses to be able
to focus on the important things at hand. People re-
fer to the experience of this type of stress as feeling
“pumped” or “wired.” Incremental progression of
overwhelming stress, however, can surpass our ability
to cope with it in a positive way. People often describe
the feeling as being “burned out” or “stressed out”. It
is therefore important to  nd means to shift to positive
and productive ways when dealing with stress.
Globally, studies have shown that medical students
experience a high incidence of personal distress dur-
ing their undergraduate medical education [5-44].
Many studies have shown that medical students are
vulnerable to stress and anxiety because of academ-
ic challenges that are unique to the discipline such
as stress over struggling to meet academic stand-
ards, time management worries, and concerns over
grades. Additionally, dealing with illness, disease
and dying can impose emotional burdens, while cur-
ricular demands can tax the physical and physiolog-
ical stamina of the medical student, often leading to
depression [18, 22-23, 29-30] and substance abuse
[39]. Along with this awareness had come the cor-
responding recognition that such stress may lead to
a high incidence of impairment, particularly in their
mastery of the academic curriculum. This can lead
to mental distress and have a negative impact on
cognitive functioning and learning [6]. In most med-
ical schools, the prevailing environment is one of an
authoritarian and rigid system that encourages com-
petition rather than cooperation between students.
Studies suggest that poor mental health among stu-
dents during medical school usually persists through-

250 Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
out training. When stress becomes overwhelming,
then it affects the physical and mental functioning,
and consequently undermines performance.
Life in medicine is stressful for just about every
medical student [19, 22, 25]. The transition from col-
lege to postgraduate studies brings about a number
of adjustment problems to aspiring doctors. Every-
one reacts to stress differently and have their own
unique way of dealing with it. Some may handle
pressure and anxiety and outwit it without a bad out-
come, while others just simply succumb to it [18-23].
Every day, medical students come face-to-face with
lectures, small group discussions, practical exams,
quizzes and other school activities. Stress is appar-
ently caused by many factors, and it is inevitable in
the lives of students, whether they are in the  rst year
medical proper or in clerkship [32, 37-38, 40-41].
Only the students themselves can assess their level
of tolerance to stressful situations. There are various
ways of coping with and treating stress, but the best
treatment is to prevent getting into situations that are
likely to depress your ability to cope. It may not be
possible most of the time, and may generally be out
of control.
This study construes the stressful experiences as
person-environment transactions and herein utilizes
the Transactional Model of Stress and Coping as
the lens for examining the phenomenon of coping
with stress in medical school. These transactions de-
pend on the impact of the external stressor, mediat-
ed by the person’s appraisal of the stressor and the
social and cultural resources at his or her disposal
[45-47].
Studies have only addressed the physiological
and psychological dimensions of stress in the school
setting, centered mostly on contributory factors af-
fecting other aspects of the students’ lives. No study
was found in literature which examined and collec-
tively characterized the different phases that medical
students go through in coping with academic stress
and while academic stress in medical school has
been studied globally, none has been done among
Filipino medical students. To address this gap, the
present study was undertaken to answer the central
question: How do medical students collectively char-
acterize the phases they undergo in coping with the
stresses in medical school? Against this backdrop,
it is, therefore, the overarching goal of this study to
capture the essence or the “Lebenswelt” of the phe-
nomenon of coping with academic stress among Fil-
ipino medical students.
METHODS
Design
In this qualitative study, a narrative framework was
used to explore how medical students characterize
the phases they undergo in coping with the phenom-
enon of academic stress. As human beings, we in-
teract socially through the stories that we tell about
ourselves and others. Thus, the context of the study
of this narrative is about how humans make sense of
the world through their experiences. The participants
are storytellers and characters in their own and oth-
er’s stories. The narrative is a way of characterizing
the human experience of a phenomenon. Stories are
constructed to make sense of our lived experience
through the organization of disparate elements into
meaningful wholes. Narratives call the subject into
being and serve to situate its experience in time. The
central task is evident when it is grasped that the
participants are both living their stories in an ongo-
ing experiential text and telling their re ective stories
in words. The participants are, at once, engaged in
living, telling, retelling, and reliving stories [48].
The methodological underpinnings of this study
are based on interpretive phenomenology. Partici-
pants’ narratives were analyzed using Interpretive
Phenomenological Analysis (IPA), which is particu-
larly appropriate to address meanings and perspec-
tives of research participants. The major concern
of interpretive phenomenological analysis is to un-
derstand “how the everyday, inter-subjective world
is constituted” from the participants’ perspective
[49-52]. Hence it offers researchers the opportunity
to learn from the insights of experts – the research
participants themselves. Husserl’s [53] statements
explain the basic philosophical assumption under-
lying this inquiry when he said, and I quote “we
can only know what we experience.” In the words
of Rossman and Rallis [54], phenomenology is a
tradition in German philosophy with a focus on the
essence of the lived experience. Heidegger [55]
further re ned Husserl’s thought into existential phi-
losophy and hermeneutics. In hermeneutics (derived
from the name of the Greek god Hermes, which
means ‘to interpret’ or ‘to make clear’), the IPA
researcher engages in a dynamic process of com-

251
Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
prehending the mindset of the respondents, putting
himself in their shoes, and through an interpretative
meaning-making activity translates the experience
into something that is readily comprehensible. In the
present study, the researchers themselves are med-
ical students and are researching the phenomenon
from an emic perspective. Member checking or par-
ticipant feedback procedure were done to validate
the  ndings.
Those engaged in phenomenological research fo-
cus in-depth on the meaning of a particular aspect
of experience assuming that through dialogue and
re ection, the quintessential meaning of the expe-
rience will be revealed. Language is viewed as the
primary symbol system through which meaning is
both constructed and conveyed [56]. The purposes
of phenomenological inquiry are to describe, inter-
pret, and critically engage in self-re ection into the
“world as a world” [57]. The major data source for
this inner perspective was interviewing. Patton [58]
stated the purpose of interviewing speci cally as “to
 nd out what is in and on someone else’s mind”,
and that is exactly what the target of this phenome-
nological study focuses on, ie, how Filipino medical
students characterize the phases they go through in
coping with academic stress.
Selection
A purposive sample of 75 full-time medical students
in the three didactic levels of medical school in a
comprehensive Philippine University was recruited.
The sampling frame used was an up-to-date list of
of cially registered medical students obtained from
the Dean’s of ce.
Research Instrumentation
Data were collected using written narrative respons-
es guided by semi-structured interview questions
designed to inquire about a medical student’s daily
activities, matters that precipitate anxiety and their
views on academic stress. The questionnaires were
prepared in a manner that simulated social networks
and blogs, thus allowing the respondents to liberally
exploit their voices and thoughts. The narratives of
stories collected from the informants and observation
reports made by researchers themselves constitute
the ‘data’ for this particular research study. Explicitly
and avowedly narrative accounts emphasize subjec-
tivities and contextual circumstances and the way in
which events are causally linked and given meaning
by their connections.
This is where the noetic and noematic structure of
consciousness takes into account – “the conscious-
ness of something”. All consciousness has two as-
pects: the process of experiencing or noesis, and the
stable something which is experienced or noema.
We may have certain accounts of knowledge about
the phenomenon; however, these are just precon-
ceptual knowledge, and we have yet to experience
it. There is an experience of astonishment in which it
is possible for us to come to the world with no knowl-
edge or preconceptions in contrast to our everyday
theoretical knowledge.
The questionnaire focused on the students’ lived
experience as they underwent coping with the stress-
es. There were other factors considered that focused
on the culture in medical school that either increased
or attenuated their burden. Probing questions were
asked so that the students can elaborate on their feel-
ings or the necessary constituents of these feelings
or experiences. Additionally, it centered on what the
existence of these feelings or experiences indicates
concerning their very nature as medical students.
This phenomenological inquiry attempted to identify,
isolate, formalize and produce an analysis of narra-
tives regarding the phenomenon of academic stress
in medical school.
Mode of Analysis
Polkinghorne’s schema was utilized whereby analy-
sis of narratives refers to storytelling projects that are
grounded on pragmatic reasoning [59-60]. These
projects treat stories as ‘data’ and use ‘analysis’
to arrive at themes that hold across stories or on
delineating types of stories and/or storylines. The
study made use of phenomenological reduction after
reading and rereading the text, drawing and listing
the concepts or memoing and coding, followed by
categorizing (cool analysis) and thematizing (warm
analysis) in an af nity diagram.
When stories are used as data in research, the
object of study is the text itself. The researcher looks
at the text in search of various themes (either pre-
determined themes or themes drawn from the data
itself). The researcher is typically an objective (or

252 Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
subjective) outsider, looking in on the text and ana-
lyzing it for themes akin to making generalizations
in quantitative research.
Memoing and Coding
The researchers applied memoing by recording or
listing re ective notes with regard to the collected
data that is relevant to answering the study’s re-
search question. Researchers transcribed the notes
and grouped them into meaningful analytical units.
These meaningful analytical units of data were then
coded with symbols or descriptive words. These pro-
cesses of coding, in a reductionist manner, aided in
the ease of review.
Categorization: Cool Analysis
After memoing and coding, the data were summa-
rized and organized creating a master list of cat-
egories. This involved the process of enumeration
and searching relationships in the data. The different
codes were organized in such a way that different
hierarchical levels and category systems were cre-
ated and given names. Category names emerged
from the researcher, participants or literature. These
categories were mutually exclusive, sensitive to what
are in the data and in effect, the answers to the re-
search questions. The categories were then linked
together in a meaningful way with the use of an
af nity diagram to reduce the data and facilitate
this process. An af nity diagram allows for the or-
ganization of large amounts of narrative data and
to create categories based on the natural relation-
ship between topics. Memos with similar ideas were
posted together and at a distance from dissimilar
ideas.
Thematization: Warm Analysis
Upon reviewing the categories, a series of themes
emerged. Emerging themes were organized into an
af nity diagram, analyzed and their discourse dis-
sected, thus determining how the participants var-
iedly interpreted the phrase “coping with stresses in
medicine” in their context.
For the purpose of this study, either abstract or
conceptual categorization scheme was used. Data,
such as metaphors among different student narra-
tives were broken into segments and classi ed under
a certain category that allowed ef cient compari-
son. Comparison of similarities and dissimilarities
allowed the interpretation of depth and meaning
and type of phenomena re ected among the written
metaphors or narratives.
Results were interpreted through the method of
analyzing short re ected and written narratives
made by the students on their perception of stress
and their life as a medical student. Since this study of
narrative seems to promise change, forcing sciences
to develop new theories and new methods, particu-
larly ways of talking about life and self in medicine
as perceived by the very unit that makes a medical
student body in the university [61].
The narrative framework in research as described
by Nygren & Blom [62] is an approach where in-
terviewees are asked to re ect and then write down
(short) narratives instead of telling them orally, which
is a signi cantly different but complementary meth-
od. In the present study, the respondents were asked
to write down their story of academic stress and then
make an initial interpretation of what they have writ-
ten. The researchers assumed that the respondents’
written narratives constitute an interpretative step
that impacts the quality of data for the analyst in a
positive way. Written narratives produced by a ho-
mogenous group (as in this case) provided a more
direct focus on the respondents’ way of de ning and
understanding a phenomenon.
Since this address to a narrative aimed to extend
analyses to research regarding students and their
experiences in medicine, not only did it bring struc-
tures of language to possibilities of behavioral anal-
ysis but extended or rather focused on the context
of every individual phrase, accounts and re ections
of medical students perceiving life in medicine as a
unit.
Ethical Consideration
This study received approval of the university’s in-
stitutional review board. An informed consent let-
ter was made inviting participants to take part in
this study and be noti ed that their participation is
completely voluntary. Further appraisal was done re-
garding the purpose, procedure, bene ts, and risks
of the research study with great emphasis on the vol-
untary nature of research participation where they
are free to terminate their involvement in the study at
any point. Participants were likewise informed that
their responses will be strictly con dential and the
data will be reported only in the aggregate.

253
Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
FINDINGS
After subjecting the narratives to a thorough and
comprehensive IPA, six emergent themes surfaced
which collectively characterized the phases our
respondents underwent in coping with academic
stress in medical school. Interestingly, we found the
“Tightrope” as a symbolic representation which apt-
ly embodies these six themes.
Self-effacement Phase: Sensing Inner Strife
The participants invariably started their narratives
by recalling one of the momentous events in their
lives, which is the decision-making process of wheth-
er or not to go into medical school. They expressed
incoherent thoughts of raging emotional excitement
against a backdrop of uncertainty and apprehen-
sion. They verbalized fear about what lies ahead
thinking that they might not be able to measure up
to expectations.
“At fi rst I’m kind of doubtful if this is the
one for me.”
“Sometimes I don’t know what my goal in
life is. What happens next? I just let it be.”
“I know it is not easy, but I think I can
handle it very well”
“I really want to be a doctor someday.
You know that sweet taste of reward after
paddling through all the hardships”
“Coupled with prayer, I believe that I can
outwit all the hardship medicine brings.
So, bring it on!”
Self-awareness Phase: Settling in New Sur-
roundings
After conquering the hurdle of decision-making, our
respondents  nally moved on to a phase that marked
the start of their career. At this point in time, everything
was de ned by novelty: a different institution, refresh-
ing milieu and fresh new faces. The students became
aware of how to regulate their bodily responses to
the slightest peculiarities of their environment, de n-
ing what they called as the “adjustment phase,” a
phase characterized by striking shifts in responsibili-
ties that affect all other aspects in their lives.
“It was tough, especially the fi rst few
weeks, because we were still in the period
of adjustment”
“I have minimal social life now. I choose
sleeping over going out with friends.
My life mainly consists of school and
academics.”
“Everyday is a new struggle for me.”
“I wasn’t accustomed to sleeping very late
everyday. But I’m starting to adjust now.”
“I haven’t completely adjusted to my
classmates. Coming from a different
school for pre-med, with a totally different
atmosphere and culture, it’s tough to go
about around these people”
Self-weariness Phase: Struggling Through the
Stressors
The experience of medical students likewise resonat-
ed with feelings of overwhelming stress and constant
struggle. Stress is precipitated by various factors: in-
ner struggles, family expectations, workload, and
other responsibilities.
“It’s diffi cult and scary in such a way that
I’ve been pressuring myself to get good,
high grades in order to maintain my
scholarship. Being the only doctor in the
whole clan, I fear of getting disappointed
if I don’t become successful as what my
relatives expect me to be.”
“It’s quite stressful when I study so hard
only to get a low grade; Sometimes, no
matter how much effort you give into a
particular goal, it’s not just good enough”
“It is stressful when people don’t do
their jobs in group-related activities like
reporting”
“Life as a student in medicine is busy,
hard, long and tiring. Some things just
couldn’t fi t in a day, so other things must
be sacrifi ced. But really, the studying part
is easy, only if we had ample of time”

254 Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
“My family can be very demanding of
bonding time even when there’s just no
non-academic time to spare”
Self-attentiveness Phase: Staying Focused to
Survive
Life in medicine is guarded by a few rules: never
look back, never look down and never get ahead of
yourself, similar to walking the tightrope. Yesterday
is history and it can no longer be undone, tomorrow
lies in the future and it is yet to unravel, what is most
important is to pay attention to the present and make
the most out of it. Staying focused is an inner battle
that one needs to live out, but it can also be promot-
ed or deterred by external factors.
“Being a medical student requires a lot of
perseverance and hard work. One cannot
be lazy or else you suffer and fail”
“I think positive and pray. I don’t like
getting stressed over something that has
happened already. I can’t do anything
about it anymore”
“There are times when I feel motivated to
study, but there are also instances when it is
diffi cult to start studying especially during
weekends. What keeps me to continue
studying are my parents who sacrifi ced a
lot, my classmates who make me happy
most of the time, and my future in this fi eld”
“With my focus and passion in
accomplishing things, I know I can achieve
greater heights”
Self-equilibrium Phase: Sustaining a State of
Symmetry
One must  nd his center of gravity. A good play of
balance is the key to coping with the struggles in
medicine.
“When I’m stressed, I eat. I buy junk foods
like “Chippy” and coke zero, go home,
and watch TV. I even date myself in the
movie house, of course with my burger
(from Burger King) and coke zero; window
shopping with family and friends, dancing,
singing, facebooking, and sleeping”
“Being able to balance academics with
extracurricular activities is just a matter of
time management”
“I take the time off, even for just an hour
or two, not worrying about school-related
stuff”
“What matters most is the balance
between medicine and other aspects
of life. I escape from all the stresses by
spending time out of Manila. I watch TV,
listen to music, eat good food, read a
good book, and spend time with friends”
“I make sure I get enough sleep in order to
be functional the next day”
Self-mastery Phase: Striving Towards Sover-
eignty and Satisfaction
Our respondents pride themselves with their ability
to master the art of multitasking. Self-mastery brings
about a sense of self-satisfaction. It is the integration
of 3 entities - balance, rhythm and focus: balanc-
ing work and rest, timely rhythm of accomplishing
one’s errands and the depth of concentration one
submits in executing a task. One acquires that feel-
ing of self-satisfaction in knowing that one is able to
conquer new objectives with skillful execution and
humble acceptance of failures.
“It’s like a roller coaster! Sometimes you’re
up, sometimes you’re down. Don’t let it get
to you. Remember that you are the master
of your fate”
“If you come to think of it, medicine really
is overwhelming. But it is how you view
stress that defi nes you and demarcates
you from the rest”
“I seldom let bad vibes and stresses get
the best of me. If I fall, I get sad; I shrug it
off and get up again”
“In order to appreciate and enjoy
medicine, you need to see it in a different
light”
“I love to learn new stuff, especially if I
get to apply it in experience and practice.
Practice makes perfect.”

255
Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
DISCUSSION
Self-effacement Phase
Our respondents were once in
a phase where they felt alone
and utterly clueless about how,
when, or where to start. Life
in Medicine is like walking a
tightrope. Making a strenuous
climb to the summit is but  rst
of the many series of chronological events leading
to their goal. This is the point where they go into qui-
et introspection, dissecting their thoughts and inner
desires, and asking themselves, “Am I ready to con-
quer my fear?” According to a case study by Levine
[63], medical students often experience uncertain-
ty and apprehension around career planning, and
many seek advice during the process. The medical
student is at crossroads and wondering, “Is medi-
cine right for me, and am I right for medicine?” A
student’s  nal decision represents a complex cogni-
tive and emotional process that takes into account
multiple contributing factors. The climb is not the
starting point. It is merely an obstacle set to surmount
the “inner trepidation” before actually reaching the
summit, the of cial START. Before stepping into a
medical institution, the students get overwhelmed by
mixed emotions. There’s that irrational unbridled joy,
a thrilled feeling which sprang from a strong desire
to  nally become a medical student, or a feeling
clouded with doubt and fear. “Is this as good as it is
ever going to get? Am I ready to become a medical
student? Is this what I really want?” These are the
various environmental  lters that the medical student
needs to focus on. Medical students who are on their
way to becoming the  rst physicians in the family
face the fear of the unknown. The biggest hurdles
for them are their fear of the unknown, and of being
alone with no one to fall back on. Medical students
who have physician parents felt the need to measure
up to parents who are successful physicians.
Self-awareness Phase
A sudden strike of awareness
reels them from their reveries.
This is the point of realization
that there has got to be more
to life than what they origi-
nally thought. Swallowing
their fears, they climb towards the summit, one hand
over the other, one step at a time, and  nally con-
quering it! They are freshmen off to a starting point
in medicine life.
One must try to become accustomed to the new
surroundings. Now, how to start? “Tightrope walk-
ers live by a few rules. Never look down. Hold your
arms out for balance. Do not wait for the rope to
stop wobbling before you take another step. And
then there is this one: Practice standing at fi rst.
When you are able to do so without wobbling too
much, take a step, stand again, take a step, stand
again, until you reach the end of the rope.” [64] In
a wire act, the rope is slightly springy and taut so
that it can launch funambulists (tightrope walkers)
into the air to perform balancing acts. The tightrope
must have the right amount of tension, meaning it
cannot be too slack to cause too much wobbling or
too taut to allow it to break. Now it all depends on
how the respondents cross the tightrope. Suspended
in the air like a funambulist, one must start with one
foot forward, adjusting to the slightest bobbing of
the rope, and then takes a second step, and stand-
still. This is the period of adjustment when our re-
spondents become aware of how to regulate their
bodily responses to the slightest peculiarities of their
environment. Some would claim that they were not
accustomed to the sudden change in sleeping hab-
its or an unexpected plummet in their social lives.
These imposing shifts of responsibilities now mainly
consist of school and academics. It is only a matter
of time that one gets acquainted with the change in
environment and gradually progresses further to an
established level.
Self-weariness Phase
Medical students become mindful over their balance
that, like a funambulist, they hastily look down at
their feet and become daunted by the altitude.
Inadvertently, they gaze upon the crowd of

256 Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
spectators cheering their name. These spectators
are their family and friends. They are the ones en-
couraging them to conquer medicine’s daily battles,
giving that burst of motivation to cheer them on.
Social support and attention to interpersonal rela-
tionships are important in buffering the impact of
stress. These cheers prod them forward and give
them the drive to exert strenuous efforts toward their
goal.
The reverberating cheers
grow louder and louder, turn-
ing into a distraction, a noise
that persistently blares in the
background. All of a sudden,
it becomes crowded, hectic,
and frenzy. In the Transac-
tional Model of coping with stress, this phase in-
volves the primary appraisal of one’s situation, that
is, whether to consider the stressors as irrelevant, as
dangerous, or in a positive light so as to overcome
the stressors. A qualitative study by Jaykaran [33]
summed that “An important issue was over expec-
tation from themselves and parental pressure to per-
form better. The competition becomes tough. When
a student cannot get good marks or high ranks, it
becomes a source of stress.” Low scores and failing
grades evoke negative thoughts and feelings that
can precipitate stress. In a multi-institutional study
done by Dyrbye [31], approximately 11% of stu-
dents have serious thoughts of dropping out of med-
ical school each year. Burnout seems to be associat-
ed with an increased likelihood of serious thoughts
of dropping out even in the absence of depression.
On the basis of their responses, medical students
likewise conveyed their feelings on the overwhelm-
ing workload: “Life as a student in medicine is busy,
hard, long and tiring. Some things just couldn’t fi t in
a day, so other things must be sacrifi ced. But really,
the studying part is easy, only if we had ample of
time”.
Self-attentiveness Phase
Like a tightrope, life in medi-
cine is also guarded by a few
rules: never look back, never
look down and never get
ahead of yourself. Most of
our respondents tend to look
back and regret over yesterday’s mistakes, like pon-
dering on the answers they changed on a previous
quiz which turned out right. Seldom do they realize
that dwelling on the past would get them nowhere
but slacking in stagnant waters. They tend to prod
themselves too hard trying to get ahead of time, and
then end up in a state of unnecessary anxiety over
tomorrow’s problems. They get fretful of tomorrow’s
reports, or the quizzes set the next day, and even
the papers due next week. They fail to realize that
what’s most important is to slowly tackle it one step
at a time. Yesterday is history and it can no longer
be undone, tomorrow lies in the future and it is yet
to unravel, what is most important is to pay atten-
tion to the present and make the most out of it. In
the Transactional Model of coping with stress, the
Self-attentiveness Phase is the secondary apprais-
al phase whereby medical students muster all their
competencies to cope with their life goal to  nish
medicine. Focus is the key.
Self-equilibrium Phase
Medicine life must have
a good play of balance.
Funambulists think of certain
strategies that would help
ease out the tension when
crossing. They use a balanc-
ing pole to attain that speci c degree of symmetry.
The pole helps to balance by lowering his or her
center of gravity. A study by Schuster and associates
[65] mentioned that certain methods to reduce stress
by students often include effective time management,
social support, positive reappraisal and engage-
ment in leisure pursuits. Shaikh and colleagues [15]
summed that the “prevalence of perceived stress
seems to be high among medical students, which
tends to affect not only their academic performances
but also all aspects of their health. Review of aca-
demics and exam schedules, more leisure time ac-
tivities, better interaction with the faculty and proper
guidance, advisory services and peer counseling at
the campus could do a lot to reduce the stress.” It
is important that one must  nd his center of gravi-
ty. Balance is the key to coping with the struggles
in medicine. One must get the right amount of
everything: sleep, fun, social, spiritual, and work, in
order to function effectively.

257
Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
Self-mastery Phase
Once you get the hang of it, everything becomes
easier and lighter. Medical students pride them-
selves with the ability to deftly multitask. They are ef-
 cient enough to deal and juggle with the overload
of duties they are faced with. One does not need a
dozen hands to do multitasking. One just needs two
hands and a skill that is developed through constant
and persistent practice. In the study by Melaku et
al. [42], it was shown that as medical students pro-
gress in their year of study, the prevalence of stress
decreases, possibly due to gradual adjustment to the
learning environment and the usually declining fail-
ure rates in the later years of the course [5, 22, 32,
38, 40-41]. The highest prevalence of stress was
observed among  rst-year students as they adapt to
a new life, in a new environment, away from their
family. Senior students, on the other hand, have de-
veloped their multitasking skills and are therefore
better able to manage their studies and therefore
better able to cope with stress than their younger
counterparts.
Multitasking is, like almost anything else, an
art that can be improved with practice. Balance,
rhythm and focus are the key. The coordination of
these three components molds a skillful juggler. This
aptly applies to medical students: balancing work
and rest, the timely rhythm of accomplishing one’s
errands and the depth of concentration one submits
in executing a task [41]. Coping with stress in the
Transactional Model can either be problem-focused
or emotion-focused. The medical student can multi-
task, either to change the situation or change the
way they react to the stress-inducing situation.
Similar to scaling the tightrope, juggling tasks in
medical school adds strain to the whole process;
but as soon as one gets the hang of it, one can see
medicine in a different light.
SUMMARY
Often when people are faced with dif cult or stressful
situations, whether it be in medicine or other  elds,
they are almost always left wondering how to deal
with them. From the words of an anonymous writ-
er, “listen not to the voice without, but to the voice
within, for here, recessed in your own mind, lies the
answer to your future.” The success and failure in
dealing with academic stress depends upon the way
we think or on the pattern of our thought. Stressors in
medical school can evoke negative emotions which
would sometimes feel overwhelming and where solu-
tions seem elusive. However, the challenging situa-
tions in life are often the ones that offer the greatest
opportunity for personal growth. Overcoming the
challenges that life brings is never easy, but taking
a long and honest look at the situations, experienc-
ing and coping with the emotions they bring up and
searching within oneself for the answers often brings
surprising positive outcomes. Our respondents have
experienced substantial challenges in medicine: they
surmounted their inner trepidation; settled and accli-
matized to their new surroundings; gained the cour-
age to outwit stress and struggles; fought to strive,
survive and stay focused; learned to maintain a state
of balance and symmetry; and  nally lived up to a
sense of sovereignty and self-satisfaction. It is just a
matter of perspective and attitude that demarcates a
victor from a slacker.
The The world idly waits at their fi ngertips.
They will someday heal the sick. For now, they are
but few of the chosen ones to walk the tightrope in
the clouds.
Paraphrasing “On a Tightrope” (2007)

258 Life on a Tightrope: An Interpretive Phenomenological Analysis of Narratives
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