Earlier this month I was facilitating Reflective Rounds for 3rd year medical students at the George Washington University School of Medicine and Health Sciences. Reflective rounds is a discussion group where medical students just entering the clinical world can reflect on their experiences. I used a prompt to start the discussion: reflect on a moment when you learned something new about yourself – whether through a clinical interaction with a patient or through interactions with your team of attendings, fellows and residents.
One of the medical students shared an incident from her on-call shift in the psychiatric ER. She described evaluating a middle-aged man who was profoundly depressed and suicidal after just being released from several years in prison. In our rounds, the medical student voiced frustration with the clinical assessment. She felt that the doctors did not express an appropriate level of empathy with this gentleman who was so clearly in existential crisis. Instead, the resident took down the patient's list of symptoms, and attempted to pin down a psychiatric diagnosis. This particular medical student was able to confidently voice her feedback during team rounds - and, it sounds like it was received positively. This was brave, given that medicine is still a hierarchy where students and residents are taught to follow orders, and ask questions later.
Each time I lead Reflective Rounds I'm reminded of my own medical education at Sidney Kimmel Medical College of Thomas Jefferson University. As a third year medical student, I rotated through various medical specialities - internal medicine, OB GYN, pediatrics - just as these students are doing. I felt comfortable in psychiatry in a way that I never did in other areas of medicine. Looking back, I see what drew me into psychiatry: the opportunity to give voice to the suffering, disappointment, and fear that lived inside the hospitalized patients I rounded on every morning.
There is more and more evidence for the value of teaching and modeling empathy to doctors in training. Humanism in medicine is a hot topic these days. I use the word a lot myself, and this particular interaction with our budding physicians had me think about it more deeply. Medical training is the process of developing personal identity as a physician. It is the time to struggle with the internal conflicts that inherently arise when developing into a good physician. In a 2015 article, Dr. Hedy S. Wald PhD, Clinical Professor of Family Medicine at the Warren Alpert Medical School of Brown University, discusses the intricacies of constructing a professional identity as a physician. Wald writes:
“Key drivers of professional identity formation include experiential and reflective processes, guided reflection, formative feedback, use of personal narratives, integral role of relationships and role models, and candid discussion within a safe community of learners (an “authentic community”)."
It’s easy to see the competing demands we put on physicians. On one hand – we are taught to excel in linear, goal oriented thinking – such as reading an EKG, or safely dosing lithium in a manic patient. Managed care is constantly squeezing more and more productivity: more patients! Faster documentation! Counter-intuitively, in the face of this pressure, physicians need to push back and call for development of a different skill set. Wald describes a continuous process of practicing reflection, relationship, resilience, and reciprocity. In other words, a feelings based, connected approach. This is quite different from the fast pace, quick decision medical environment we live in.
Wald uses the metaphor of a growing tree. Meaningful mentor relationships and reflective, creative work are akin to fertilizer, nurturing the underground roots and providing a strong base. The growing tree branches symbolize the tangible outcomes we need to do the work of doctoring - medical knowledge and patient care. I often use a similar metaphor when practicing psychotherapy: the branches represent how we engage in the physical world, and the roots illustrate our vast internal world of feelings and thoughts. The key here is that these intangibles are the groundwork that the entire tree is built upon. Each external action has a hidden precursor full of meaning.
I’d like to wrap this all up in a nice bow, and present you with a hopeful statement about physician identity. But, I can’t seem to find the words for that solution – yet. This is more of an open-ended reflection on my own experience. Part of my own fertilizer, I suppose…
Wald, Hedy S. "Professional identity (trans) formation in medical education: reflection, relationship, resilience." Academic Medicine90, no. 6 (2015): 701-706.
Cohen, Libby Gordon, and Youmna Ashraf Sherif. "Twelve tips on teaching and learning humanism in medical education." Medical Teacher 36, no. 8 (2014): 680-684.
Holden, Mark, Era Buck, Mark Clark, Karen Szauter, and Julie Trumble. "Professional identity formation in medical education: the convergence of multiple domains." In HEC forum, vol. 24, no. 4, pp. 245-255. Springer Netherlands, 2012.
Rabow, Michael W., Rachel N. Remen, Dean X. Parmelee, and Thomas S. Inui. "Professional formation: extending medicine's lineage of service into the next century." Academic Medicine 85, no. 2 (2010): 310-317.