Hester Toovey Medical student, Barts and The London School of Medicine and Dentistry

Published in JHH18.1 – Flourishing in Medical Education

I have been at medical school for five years now and for many years I felt like my voice wasn’t important. It was only when I learnt about qualitative research during my medical education intercalated degree (IBSc) that I realised that there was a whole branch of research devoted to exploring people’s lived experiences. I had done a creative enquiry component in my first year which is when I first encountered the idea of flourishing. This had a significant influence on me choosing to research flourishing in medical education in my IBSc, so I could honour the experiences of my peers, exploring when they flourished and when they did not.

Introduction

When I approached flourishing I was initially slightly hesitant. Was it a fluffy word used to show that educators cared about their students, or was it, like resilience, another standard by which medical students can be measured or judged? Perhaps this was rather cynical of me, but I was three years into medical school at the time of conducting this research (early 2020) and much of my experience was dominated by comparison with my fellow students. Much to my relief I found it was neither.

Flourishing for me is grounded in Aristotle’s eudaimonia where it describes living your life ethically to meet a purpose – doing what is right for others helps you to flourish (Toone, 2014). This outward looking element of flourishing helped to diminish the idea of flourishing as a new way to measure student performance. Toone’s A Flourishing Practice helped me to understand the importance of flourishing in healthcare and made me more curious about how flourishing practices are fostered in medical school. Another area I explored to help inform my understanding of flourishing was the positive psychology movement where flourishing is recognised as part of wellbeing.

Anecdotally and personally it was clear to me that medical school has a significant impact on people’s wellbeing. However, on researching it, the evidence was stark with large numbers of students in the UK and across the globe suffering from issues with their mental health and emotional wellbeing (Puthran et al, 2016; British Medical Association 2019). This is particularly poignant at the moment due to the impact of Covid-19 on medical students. Chinese medical schools, which have been coping with the virus longer than the UK, have found that 25% of students have self-reported anxiety after the pandemic (Chandrate, 2020). From personal experience it was extremely difficult writing about flourishing in the midst of the pandemic. At this time, as a medical student, I felt I was not flourishing but flailing, trying to stay afloat in a time where everything was so uncertain. In my experience, environments have a significant impact on my ability to flourish in my medical education. This made me wonder whether it was not only medical students that were sick but the environments they were placed in (Bynum, 2021). I therefore felt it was important to contextualise students’ experiences and ask about their experience of medical education: when they felt they flourished and when they did not.

Methods

In this research I interviewed six medical students at Barts and The London using the biographic narrative interpretive method (BNIM). This method focuses on the stories and lived experiences of students. I paid close attention, not only to the stories that they told, but also their intonation and choice of words. I chose this method as I felt creating an environment for meaning making and reflection was an opportunity to honour student’s unique voices and experiences. When I asked students to tell me about their medical education journey many found it strange and in some cases overwhelming. As a student myself, I feel it reflects the rarity of educators asking students about their experiences in a non-transactional way: asking students for the sake of asking rather than for feedback.

It is important to note that these interviews occurred in the weeks before and two weeks into our first national lockdown in February and March 2020. Although many of the findings of this research are transferrable, students are now faced with new barriers to flourishing in their personal and professional lives which are yet to be fully explored.

 Results and discussion

In my interviews I had long conversations with students where they shared poignant stories from their medical education candidly. I have tried to portray some of the experiences most important to them in short vignettes (names are pseudonyms). From the stories they shared with me there seemed to be three main themes: flourishing and work-based learning, flourishing and exams, and flourishing and peer support. I will explore each theme below using quotes directly from the students.

Sadia

Sadia’s experience of medical school was impacted by her mental health but she was now starting to feel more ‘mentally stable’. She attributed this change to formal support for her emotional wellbeing. She described feeling reluctant to seek help for fear she would be ‘chucked out’ of medical school.

After failing a first-year examination she described having a change in priorities and focused more on personal growth, such as learning new skills, than exam attainment. Her accounts of flourishing reflect this.

Sadia described power imbalances between herself and doctors. They seemed to undermine her knowledge and motivation for pursuing medicine which caused emotional distress.

Mia

Mia felt her experience of medical education was negatively impacted by the competitive environment of medical school. She felt constantly compared to other students which created pressures to succeed academically. She described flourishing as being linked to exam attainment.

She found peer working was the best way for her to learn. She felt that this was discouraged by the competitive atmosphere of the university.

In pre-clinical years she felt she had to suppress her patient centred mindset and focus more on the biochemical aspects of medicine.

In her clinical years Mia felt she could prove she was good enough to be in medical school.

Ellie

Ellie spoke about scenarios related to assessment. She felt that exams often acted as a barrier to flourishing for her as she was dyslexic.

Assessment was also linked to emotional distress as she experienced burnout during her first-year final examinations.

She felt she flourished when motivated by her own personal interest. Verbal praise she received from teachers she admired helped her to feel as if she was succeeding without the need for a formal exam grade.

 André

André’s experience of medical education was enriched when educators took time to explain things to him and help him improve. When this did not happen, it would make him anxious about how he would be able to treat patients safely.

He often revised with peers and felt this camaraderie was beneficial to his academic achievement and his wellbeing.

André had failed some of his exams and wished that there was more contact between academic tutors and students for support and guidance.

Oliver

Oliver spoke in depth about different educational techniques. He found work-based learning activities in which he independently performed tasks and then received constructive feedback made him feel as if he was flourishing. Having clinical mentors invested and engaged in his learning made him feel valued as part of the team. He felt good role models helped him to learn and spoke at length about a consultant who had inspired him through his good patient manner.

Oliver said his experience on a nine-week placement made him feel isolated. He felt it was unclear who to go to for support with any academic or pastoral issues. Being separated from the support of friends was hard.

Yousuf

Yousuf commuted to university. He felt that this made getting to know people and integrating into the ‘Barts bubble’ more difficult. He integrated more into the student body through extracurricular activities and had a strong friendship group who were all mostly commuters as well.

He valued independence on work-based placements and found new experiences in clinical environments enriched his experience of medical education.

He felt that his experience of flourishing depended on the outcome of his exams.

Flourishing and work-based learning

Role modelling of ethical behaviours by educators had a positive impact on the professional development of students. Oliver felt that:

You learn a lot from the doctors that are really really good. And you’re like, wow I wish I could have that kind of manner.

It was evident that the opposite was also true. Some students reported observing practices that conflicted with their personal values. Sadia describes:

I got there and it felt so checklisty like it was literally like ward round where they go to each patient’s bed and be like have you done this, have you done this, have you done this, no one talked to the patient. No one really cared, it didn’t seem like they cared and I just had this moment of like ‘is this what doctoring is because this isn’t what I came here for’… it was so not human and I was there for the human and I didn’t find it.’

Although it is important to acknowledge the impact this encounter had on Sadia, it seems to be an extreme case formulation. It is unlikely that ‘no one’ cared about the patient, however, as a rhetorical strategy it draws attention to her experience of a perceived deficit in relational aspects of medicine. In addition, the dehumanisation of patients challenged Sadia’s personal values.

The experiences of our students also suggested that hierarchy in medical environments had a significant impact on their ability to flourish. Oliver spoke about a consultant who:

…treated everyone equally, he didn’t like speak down to us, he just, he’d speak to us as if, you know, we’re just part of the team.. a lot of consultants, you know, it feels like they’re almost belittling you.’

Integrating Oliver into the team seemed to neutralise the power dynamic between them and create a safe and welcoming working environment. This is a notable example, as Oliver felt that often there was ‘this kind of like embarrassment’ that is ‘almost built into the system’ of clinical placements. This was echoed in the narratives of other students where some described feeling voiceless and crying after encounters with doctors. Sadia made the following comment on an exchange with a doctor on an assessed piece of work:

I said, “Patients can be called in to have their injections…” …the person who marked me said: “How do you believe that we even have time to do things like that?” like, “How can you even say that?”. And I was like “oh because I saw it in real life” but I didn’t say anything to her, I just.. when I left I cried.

Flourishing and exams

Many students also linked the experience of flourishing in medical education to exam attainment where success in assessment was perceived as flourishing. In UK medical education, exams feed out into a system of deciles used to discriminate student achievement. Students felt this fostered a competitive working environment. Mia commented that:

Something about getting a number [decile ranking], isn’t it, that makes you feel like you have to fight and obviously everyone deserves a place if you know, if you’re going through the years and you’re working hard and you’re being a good person and you’re working towards the things that will make you a good doctor, everybody kind of has the right to be there but it kind of made me feel like you didn’t if you were struggling along.

In this statement, Mia juxtaposes feeling the need to ‘fight’ because of getting a number, with the values of hard work and ‘being a good person’, which she feels makes a good doctor. This suggests her professional values seem to conflict with what she feels is valued by the university, with academic achievement being rewarded over other aspects of medical practice. As assessment drives learning, this account suggests the assessment structure at some medical schools may encourage learning which does not align with the qualities Mia implies are integral to being a good doctor (Elton, 2006).

The pressure of academic attainment caused distress to students. Ellie described a time when she experienced burnout:

I then felt like I was a failure because I’m not going to get good grades and I’m not gonna pass… It just felt suddenly really overwhelming and really like, like all the rest of my life could kind of hinge on this one pass or fail mark.

Her concern was seemingly solely for the attainment of good grades instead of her own personal wellbeing. Her exam anxiety was marked. Sadia also struggled with exam anxiety. She said:

So normally a month before exams I start losing it, I start crying most days.

The normality associated with emotional distress around exams was troubling and could reflect a wider acceptance of poor wellbeing in medical students around times of assessment.

Flourishing and peer support

Students spoke about the importance of peer support, both emotionally and academically. Andre commented:

We still form small study groups and try to teach each other everything because we, we’re all in the same boat, so we might as well suffer together [laughs] than suffer alone.’

This suggests a camaraderie between students approaching assessment and support of each other while they suffered. Group working and sharing knowledge was important to many students’ experiences at medical school. However, this aspect of student experiences was impacted by a competitive culture at medical school. Ellie recalled:

So after I did the objective structured clinical examination I just like, everyone stopped talking to each other and everyone kind of hid in their rooms because they’re like, why do I need these people anymore.’

It seems that Ellie felt her friendships were being exploited for academic gain. This could reflect a fragmented student community.

Students were also supported by their peers emotionally. Sadia recalled a time when:

I was just in a really bad mood all the time until my flatmate sort of exploded one night “You’ve got to do something about this”…. saying “okay I’m coming with you to get help tomorrow…” and I was just like “okay fine” so we met up and went to counselling for the first time’.

In having the emotional support of friends Sadia was able to seek the formal support she needed. This emphasises the importance of relationships in fostering wellbeing and helping students to flourish. This section is particularly poignant in the current time of Covid-19 as students have less opportunities to connect with others in person.

Conclusion

In summary, the narratives students shared highlight how students’ medical education has a significant impact on their ability to flourish. Educators influence the development of flourishing practices in students through role modelling in their clinical work. Additionally, the environments created by medical school curricula can negatively impact on student wellbeing and therefore their ability to flourish. From this research, it seems evident that in order to make student flourishing a priority in medical education, evaluation of educational practices and structural change is required. These students’ experiences demonstrate the importance of role modelling ethical, professional behaviours because students internalise the values they see in the workplace. This can impact how they cultivate flourishing practices in their own careers. Assessment reforms are also important to ensure that assessment encourages and values the cultivation of flourishing practices. By reducing the culture of competition, it could encourage students to foster supportive flourishing relationships with each other. To conclude, in rooting their experiences in educational landscapes that support student flourishing, it enables medical students to grow flourishing practices.

References

• British Medical Association (2019) Caring for the mental health of the medical workforce. British Medical Association.
• Bynum WE, Varpio L & Teunissen P (2021) Why impaired wellness may be inevitable in medicine, and why that may not be a bad thing. Medical Education, 55(1), 16– 22
• Chandrate, S (2020) Medical students an COVID19: Challenges and supportive strategies. The Journal of Medical Education and Curricular Development, 7, 1–2.
• Elton L (2006) Student motivation and achievement. Studies in Higher Education, 13(2) 215– 221.
• Puthran R, Zhang M, Tam W & Ho R (2016) Prevalence of depression amongst medical students: a meta-analysis. Medical Education, 50(4), 456–468.
• Toone P (2014) A flourishing practice? London: Royal College of General Practitioners.