What is missing in our clinical education?

Jonathan De Oliveira – St George’s, University of London, Final Year Medical Student

‘There’s No Such Thing as a Doctor’

Caroline Elton

This quote is intended to emphasise that nobody is ever just a ‘Doctor’, or healthcare professional, in isolation. The meaning and quality of the experiences an individual derives from their role in healthcare are intimately interconnected with, and inseparable from, the other elements of their life and psychology. The most pressing omission from clinical education, therefore, is its neglect of the holistic psychological aspects relevant to clinical work. General Medical Council (GMC) curriculum guidelines fail to include a substantial component aimed at nurturing students’ psychological growth and resilience.2,3 As educationalist Ken Robinson emphasises, everyone exists in “two worlds – the world within you… and the world around you“, and “the core purpose of education is to enable students to understand both worlds”.4 However, the curriculum I have experienced centres almost entirely around how to play the external role of doctor: on key facts, clinical skills and reasoning. This essay shall first illustrate why the relative neglect to address students’ inner psychology is detrimental. Then, it shall propose an original three-step framework, which could be incorporated into curriculum guidelines, to address the imbalance. The essay shall focus primarily on my own field of medicine, but much is likely relevant to other healthcare professions.

There are three key reasons why a curriculum’s failure to address sufficiently students’ internal psychology is problematic.

Firstly, it can result in a more inefficient learning experience. According to educational philosopher John Dewey, if educators do not consider students’ internal worlds whilst teaching external facts, it makes “the process of teaching and learning accidental”.5 A healthcare student’s inner psychology and mental state are left to chance if educational institutions fail to integrate adequate support and preparation into the curriculum. However, a student’s mental state can profoundly affect their ability to learn effectively from placement experiences. For example, stress can impair memory retrieval, make it more difficult to update memories with new information, and promote rigid, habit-based forms of learning over learning how to be cognitively flexible and problem-solve.6 Indeed, as a student, I have at times felt so psychologically underprepared for situations encountered on placement that the resulting feelings of discomfort and fear have made assimilating relevant new learning points unnecessarily challenging. These situations have included encounters with new forms of human vulnerability and objectification, medical failures, and patients’ frustrations. As Elton illustrates, such encounters are not uncommon.1 Better psychological preparation and support would allow students to learn more through these experiences.

Secondly, the lack of a substantial psychological curriculum component represents a missed opportunity to promote better resilience and mental health among healthcare professionals, and thus improve patient outcomes. A 2018 survey of UK doctors found that 31.5% had high burnout scores, and 30.7% had low compassion satisfaction, meaning they were deriving minimal pleasure from helping patients.7 Less capacity to show compassion is bad for patients. As one systematic review has demonstrated, less compassionate doctors make more medical errors, are less resilient and achieve worse patient satisfaction and patient outcomes, due to worse medication adherence, lower patient self-efficacy and a dampened placebo effect.8 In my experience, more burned out and less compassionate doctors also make poorer role models. This is significant: encounters with role models are perceived by students as highly impactful, and are crucial in promoting the development of students’ compassion towards patients.9,10 Psychological training can reduce both burnout and compassion fatigue. Mindfulness training delivered to physicians has been shown to reduce stress and burnout and increase empathy.11-13 Psychological training from an early stage could therefore greatly support healthcare workers’ resilience.

Thirdly, the lack of a substantial curriculum component focussing on students’ psychological development means students are less likely to make effective, self-aware career decisions, potentially reducing their career sustainability. Occupational psychologist Caroline Elton writes of “countless stories of mistaken career choices that doctors have recounted” to her. This led to to a great deal of unnecessary suffering, as doctors continued working in specialties to which they were poorly suited, due to underexplored priorities and past experiences.1 I have encountered similar cases on placement, including one psychiatrist who had switched specialties after years of training in hospital medicine, having realised that the work-life balance would never suit him. As Elton stresses, more student discussion and reflection around specialty choice could enhance career decision-making and sustainability.1

To combat the issues outlined above, this essay proposes a novel three-step framework – Prepare, Support, Process (PSP) – to be incorporated into GMC curriculum guidelines. This would embed institutional support for students to enhance their self-awareness and harmoniously integrate their clinical experiences into their personal psychology and narratives.

Prepare

Initially, the curriculum should Prepare students for the psychological challenges of healthcare work, particularly in earlier years. Three forms of preparation are recommended. Firstly, students should receive regular expert sessions about the mental health risks of working in healthcare, and how to utilize healthy lifestyle habits such as sleep, exercise, meditation and journaling to nurture resilience.14 Secondly, students should be prepared for experiencing situations in which they may feel uncomfortable or scared. This could involve regular discussion groups, each session centring around a different psychological challenge. Elton’s book provides pertinent examples, including transference and countertransference, clinicians’ fears of inappropriate feelings or thoughts towards patients, and encounters with particularly distressing life events.1 The pre-warning and sense of solidarity offered by such a group would have significantly improved my sense of wellbeing and the efficiency of my learning on placement. Thirdly, all students could be given regular careers workshops, where specialties’ advantages and disadvantages are honestly discussed, and students reflect on how these might interact with their past experiences and personal narratives.

Support

The medical curriculum should also include an explicit emphasis on sessions which Support students’ psychological growth and wellbeing whilst on placement. These could include timetabled workshops where teaching and clinical staff sit with medical students, and a neutral facilitator, to discuss potential student difficulties, and how all parties can encourage greater mutual awareness and support. Juniors and consultants could also be encouraged to discuss some of the personal challenges and joys they have experienced in medical school and more recently. The net effect of the above would be to foster a more compassionate, open and communicative culture in healthcare education, helping clinicians to be more positive role models and creating more psychologically protective spaces in which students can grow and develop. These are certainly the effects I feel whenever I experience an all-too-uncommon discussion with a clinician about vulnerabilities.

Process

Finally, the curriculum should nurture students’ ability to Process productively past challenging experiences, to improve resilience and maximise the extraction of learning points. This could include offering regular Balint group sessions for all students. I have never attended one, but a fellow medical student emphasised to me the tremendous therapeutic value he derived from its unique format, where participants each bring a clinical situation which made them feel uncomfortable, and the group discusses it non-judgementally. Moreover, research suggests that Balint groups can improve students’ empathy and intellectual interest.15 The curriculum could also include regular workshops where students learn and practice reflection with facilitators trained in reflective practice. Research indicates that reflective skills can be taught and improved with practice, and that through reflection “students may become more self-aware, which could increase self-care and decrease stress”, among other benefits.16 During my studies, my direct exposure to teaching and meaningful feedback from staff trained in reflective practice has been minimal. Educational institutions must do more to nurture students’ abilities to effectively process their experiences.

In conclusion, our clinical education is missing an emphasis on nurturing students’ internal psychological resilience and growth, as they integrate their new roles in healthcare systems with the rest of their personality, preferences, and past experiences. This deficit makes the learning process less efficient, deprives doctors of psychological tools which could significantly boost their resilience and help prevent burnout, and results in less effective career decision-making. The net effect is a significant missed opportunity to curtail unnecessary suffering, and promote empathy, compassion and thriving, among healthcare professionals. This essay has proposed the incorporation of a simple three-step framework – Prepare, Support, Process – into GMC curriculum guidelines, to address this deficit and create a more holistic educational experience for students, during which they learn not just about their external role, but also how to attend to their inner world and the relationship between the two. In the words of acclaimed spiritual teacher Eckhart Tolle, “If you get the inside right, the outside will fall into place”.17

References:

1. Elton C. Also human. London: Windmill Books; 2019.

2. Promoting excellence: standards for medical education and training [Internet]. General Medical Council; 2022 [cited 26 July 2022]. Available from: https://www.gmc-uk.org/-/media/documents/promoting-excellence-standards-for-medical-education-and-training-2109_pdf-61939165.pdf#page=9

3. Outcomes for graduates 2018 [Internet]. General Medical Council; 2022 [cited 26 July 2022]. Available from: https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-2020_pdf-84622587.pdf?la=en&hash=35E569DEB208E71D666BA91CE58E5337CD569945.

4. Robinson K, Robinson K. Imagine If .. New York: Penguin Publishing Group; 2022.

5. Dewey J. Experience & education. Kappa Delta Pi; 1938.

6. Vogel, S and Schwabe, L. Learning and memory under stress: implications for the classroom. Npj Science of Learning. 2016;1(1).

7. McKinley N, McCain R, Convie L, Clarke M, Dempster M, Campbell W et al. Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study. BMJ Open. 2020;10(1):e031765.

8. Trzeciak S, Mazzarelli A. Compassionomics. Pensacola: Studer Group; 2019.

9. Murinson B, Klick B, Haythornthwaite J, Shochet R, Levine R, Wright S. Formative Experiences of Emerging Physicians: Gauging the Impact of Events That Occur During Medical School. Academic Medicine. 2010;85(8):1331-1337.

10. Pohontsch N, Stark A, Ehrhardt M, Kötter T, Scherer M. Influences on students’ empathy in medical education: an exploratory interview study with medical students in their third and last year. BMC Medical Education. 2018;18(1).

11. Krasner MS. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009 Sep 23;302(12):1284

12. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study. The Annals of Family Medicine. 2013;11(5):412-420.

13. van Wietmarschen H, Tjaden B, van Vliet M, Battjes-Fries M, Jong M. Effects of mindfulness training on perceived stress, self-compassion, and self-reflection of primary care physicians: a mixed-methods study. BJGP Open. 2018;2(4):bjgpopen18X101621.

14. Mental Health and Stress Reduction – British Society of Lifestyle Medicine [Internet]. British Society of Lifestyle Medicine. 2022 [cited 26 July 2022]. Available from: https://bslm.org.uk/mental-health-and-stress-reduction/.

15. Monk A, Hind D, Crimlisk H. Balint groups in undergraduate medical education: a systematic review. Psychoanalytic Psychotherapy. 2017;32(1):61-86.

16. Uygur J, Stuart E, De Paor M, Wallace E, Duffy S, O’Shea M et al. A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51. Medical Teacher. 2019;41(1):3-16.

17. Tolle E. The Power of Now. Novato: New World Library; 2001.