Lucy Marks, Independent consultant clinical psychologist

Published in JHH18.1 – Flourishing in Medical Education

Having worked in primary care as a clinical psychologist for many years I have had a lot of experience providing advice and support for GPs. I also have a long-standing interest in supporting clinicians to manage the emotional impact of their work through reflective practice. I was delighted to have the opportunity at the start of the pandemic to be involved in setting up a support programme for medical students. I think that the value of addressing the emotional lives of medical students has been seriously underestimated and we need to find ways of making sure it is not just an optional extra in the curriculum. lucymarkspsychology.com

What we have been offering, the feedback and take-up

I have been working with a team from Barts and the London Medical and Dental School for a year, since the start of the pandemic, to set up and deliver a support programme called Connecting Practice. Many students had signed up to volunteer in the NHS and we knew they could be exposed to upsetting and aversive situations very early in their careers, given the numbers of very sick patients and tough working conditions. The aim of the programme was to help the students manage the emotional impact of this work and minimise the experience of trauma. The team consisted of staff from several departments across the medical school and students including the president of the student union. We listened carefully to what the students thought was needed and how promotion of what we were offering should be done. Emails inviting students to take part in online workshops and small group discussion sessions went out from the Dean of the Medical School and the President of the Student Union. As well as focusing on the prevention of trauma, the workshops provided a confidential space to talk about and reflect on their experiences, with the focus on normal emotional responses to what they were being exposed to.

After the first wave of the pandemic, we opened up the small group discussion sessions, which we called ‘e-huddles’, to all students not just those who had been volunteering in the NHS. We offer one group a week, with two facilitators (a psychologist and member of the medical school staff) and a monthly group for year 5s. In these one-hour sessions, students are free to talk about anything that is on their mind and the facilitators enable group discussion and reflection.

…a key predictor of… more lasting trauma is the quality of relationships at the time

The rationale behind our approach

We know that when exposed to a potentially traumatic event a key predictor of whether people will go on to experience more lasting trauma is the quality of relationships at the time and the extent to which people feel heard and supported (Robinaugh, 2011).

We were aiming to provide a space to strengthen relationships between the students and the medical school so that they felt that the medical school held them in mind, and also to strengthen the connections between the students through talking about how they were feeling. Our message was that listening to and supporting each other and allowing others to listen and support them, can help them cope with challenging situations. Given that we were aware that these student are not used to talking about how they are feeling in work settings, we wanted to make it as easy as we could for them. The workshops were therefore structured with a balance of teaching and exercises that led to discussion around themes. During the ‘e-huddles’ we had themes or questions at the ready to help get a conversation started if needed, such as ‘what helps you thrive at medical school?’ or ‘what has it been like being with patients who are particularly upset?’ The feedback they have given is that they liked the questions and felt it helped them talk.

Why providing a place for medical students to reflect on the emotional impact of their work should be an essential part of their education beyond Covid-19

We know medical students have been facing particular pressures and losses due to the pandemic; however, what does not get seen is the emotional impact of the clinical work, not just during the pandemic, but in general. Patients come with their own vulnerabilities, uncertainties and fears about their health. Being a doctor always involves a relationship with a patient who needs help and learning how to manage this relationship well is key. What underpins taking a good history and enabling patients to collaborate in their care is helping patients feel understood, listened to and supported.

Medical students need a place where they can process their experience with patients and make sense of it, so that they themselves feel understood listened to and supported. Without this they will be left carrying the emotions of their patients that they may think belong to them, which can have psychological consequences and leave them questioning their abilities. For example, a student told us about taking a history from an elderly woman who said that it was her birthday but that she knew no one would mark it with her. He told her he was sorry to hear that but did not know what else to say. He thought that the response he had given was not good enough and that he felt ‘rubbish’ and wondered if he would ever be ‘any good at this’. I suggested that this feeling of not being good enough was likely to be how his patient was feeling and that made it hard for him to shake this off. This left him feeling relieved and it was a revelation to the whole group that how we feel can give us information about how our patients are feeling. When students were asked about times when they have been with upset patients they are keen to talk about it and usually say that this was the first time they had spoken about it. Without a place to process this, feelings that are to do with patients can become corrosive and build up. This can ultimately lead to lowering of confidence and/or a need to find a way to protect the self from being over[1]whelmed by becoming rigid and detached (Stokoe, 2021).

Common issues and themes

Some of the issues that students brought to the sessions included worrying they were not being useful and feeling like a ‘spare part’ on the wards, finding it difficult when they were uncertain but feeling too awkward to ask for help. They also described wondering if something they had done or said had been wrong. A particularly poignant example of this was their worries about how they had handled sensitive conversations with relatives about picking up belongings after a loved one had died. In fact, their ability to handle such a difficult task with empathy and kindness was impressive despite the lack of input or advice. This feedback was a great relief to them and left them feeling that they were competent. Another theme that has come up was about their placements. Year 3s, who had no placements in the first term, struggled with a sole focus on online teaching and many found this demotivating and left them feeling somewhat purposeless. When placements do not go well and students feel that the doctors teaching them are not interested in them and their learning needs, it can be upsetting and frustrating. However, when students feel that their tutors on placement keep them in mind and take time to make sure they are learning as much as possible, this makes such a positive difference and can help them deal with some difficult changes and losses they have had to face due to the pandemic.

Medical students need a place where they can process their experience with patients

Feedback and what we have learned

We gathered feedback verbally at the end of sessions and through feedback forms and their responses have been overwhelmingly positive.

‘Really useful to reflect upon the stress of working on a Covid-19 ward. It was helpful to learn about trauma and talk through our hopes and fears. It was really useful to spend some time thinking about how to take care of my colleagues too.’

‘I really enjoyed it, I hadn’t really taken the time to think about what I had been going through because it’s been so fast paced. It made me realise the importance of listening and communication skills.’

‘I’d love for this to be a regular thing for students during term time! Regardless of the pandemic, students experience a lot of difficult situations, and I strongly feel these workshops would help. Even just once a term. It would improve the mental wellbeing of many, and also make the students feel more connected to the medical school. Sometimes it’s easy to feel like no-one cares. But when we build relationships with teachers, it helps a lot for our wellbeing.’

‘This is the first time I have felt that the medical school cared about me.’

We are also carrying out qualitative interviews to evaluate this work more fully.

The first piece of feedback they usually give is that it is a great relief when they talk about their experiences and preoccupations and find that these are shared. Many have said that they did not realise they needed to talk until they started talking and that other than this, they never have any time to talk together about their experiences because all their teaching sessions are timetabled and structured. They have said that it can be hard to talk to their friends and family about their experiences for several reasons, including because they have been seen as ‘heroes’. Students have said they found it really useful and many have said that this needs to be part of the curriculum. The medical school team also recognised that Connecting Practice should not stop at the end of the pandemic but that we should find a way to integrate it into the curriculum. Despite this endorsement only a relatively small but steady stream of students do actually come. This is consistent with the literature that documents the low take-up by medical students of interventions that address their wellbeing, which is concerning (Chew-Graham, 2003).

Feedback from students and the issues they bring give us clues about their reluctance to engage

What the students told us when we were setting up Connecting Practice was that if we said this was something to help them they probably would not come, and the best way to frame it was in terms of an opportunity to learn how to support their fellow students. This was helpful advice but feeling unable to attend something for themselves is a problem. To have emotional needs and vulnerabilities appears to be unacceptable, leaving them only able to attend to others’ needs and not their own. However, it is part of healthy human development to be able to acknowledge our need for others and to take up help. Difficulties experienced by qualified doctors acknowledging their need for help has been richly documented by Caroline Elton in her book Also Human: The Inner Lives of Doctors (2018). It appears that medical students have been quickly acculturated into this state of mind. Thankfully there are doctors providing placements who do give the message that expressing vulnerability is to be welcomed, but it is damaging when they receive the unspoken message that their needs can be dismissed.

We know that medical school is a highly competitive environment, and the academic workload is heavy. The pressure to get good results is particularly intense given the decile system that ranks each student and is part of what will determine their place of employment once qualified. In this climate, fear of being exposed for not knowing something, or the horror of failing an exam, are dreaded. The worry that someone will find out that a medical student felt uncertain about something is also part of the same picture of needing to present a confident exterior at all times. I suggest that a vicious cycle is created when these preoccupations are added to the corrosiveness of unprocessed experiences resulting from encounters with patients.

This is a perfect storm that makes it practically impossible to come to a session that is designed to provide them with support. Ultimately this also creates the conditions for being seriously harmed when faced with a ‘burnout’-inducing culture. We know that even before the pandemic the number of doctors leaving the profession in the first two years after qualifying was alarmingly high, with high levels of burnout. The GMC has recognised this and is clear that medical school wellbeing is a priority and has developed a wellbeing charter (BMA, 2021). This is a welcome step, and Connecting Practice is a mechanism for achieving some of the goals of the charter. However, to progress this the cultural barriers need to be actively addressed so that students are able to attend sessions designed to help them address their emotional needs.

What can be done to start to address the cultural barriers and enable this work to thrive

• A strategy to address the culture of medical schools is needed so that the emotional lives of students can be actively integrated into the curriculum. This is complex and is beyond the scope of this paper, but the production of this journal issue is part of this effort.
• Medical students need to receive the message from the medical school that there is genuine interest in their emotional life, and that processing and acknowledging feelings provides essential information, and that this approach can be integrated into how communication and clinical skills are taught.
• Quality of placements makes all the difference to both students’ learning and their confidence and motivation to become a doctor. We need better mechanisms to create systematic feedback from placements so that difficulties can be addressed, and a positive learning environment becomes standard practice.
• Supervision and teaching needs to be carried out in a way that encourages students to talk about uncertainty, not hide it. The myth that eventually as a clinician you will no longer experience moments of profound uncertainty or anxiety needs to be expelled. Students have said that they really appreciate it when teaching staff model talking about their own normal everyday vulnerabilities.
• Students need to be fully involved in the design of what is offered to address their emotional lives. At Barts and the London Medical School they are part of the team and a small group have attended our away days and are central to our decision-making. They also lead on promoting the sessions.
• Listening to the students’ concerns and preoccupations provides very useful information that needs to be fed back to the right place in the medical school. For example, we have heard how hard it has been for some first-years who moved here from abroad and are very isolated as well as the perspective from third-years on how difficult it has been for them not having placements in their first term. We let the students know that what they say individually is confidential but that we will feed back themes that come up so that steps can be taken to resolve issues. This process of feeding back gives the medical school information about what is working and what some of the challenges are and creates opportunities for action to help the students. It is also a way of raising the profile of the work.
• We need to focus on the quality of the support sessions that the students are offered. We want feed[1]back from the students to be consistently positive so that others are encouraged to attend. To achieve high-quality work, staff running sessions need to be trained and there needs to be a common understanding of the task and how to do it safely. There will be an emotional impact on the staff running these groups and they need supervision to enable them to perform their facilitator role well. One of the factors that has enabled our programme to thrive are our regular team meetings which provides a place where successes and concerns can be discussed, as well as ideas to progress this work.

All medical students need to have a place to regularly talk about and reflect on the emotional impact of their work, including their contact with patients, so that they can process this and learn from it. This can be in the form of ‘e-huddles’ or reflective practice supervision, or Balint groups. Reflection becomes ordinary when everyone is involved and avoids the stigma attached for those who most need it but may be most reluctant to come. It is not just about improving wellbeing but learning how to be a good clinician. This involves making compassionate connections with our patients which is underpinned by being able to tolerate our own uncertainty and vulnerability. But we cannot give what we do not have and students need to feel understood, heard and kept in mind in order to do this for their patients. They need to be in a state of mind where they can feel curious. The moment high levels of anxiety arise we all move into judgement mode which kills our capacity for curiosity. To regain this capacity quickly, regular reflection and supervision is needed and should be seen as an essential part of medical education not an optional extra. In this way a new generation of doctors will develop who will be more likely to have healthy emotional lives themselves and be able to strengthen the culture of compassion whereever they work.

I would like to acknowledge the input of the Connecting Practice Team in the development of this work, including Megan Annetts, Dr Siobhan Cooke, Dr Riya George, Dr Danë Goodsman, Dr Esther Murray, Mat Robathan and Harvey Wells

References

• BMA (2021). Improving the mental wellbeing of doctors and medical students. www.bma.org.uk/advice-and-support/nhs-delivery-and-work[1]force/mental-health-of-doctors-and-medical-students/improving-the[1]mental-wellbeing-of-doctors-and-medical-students (accessed 8 March 2021).
• Chew-Graham C (2003) ‘I wouldn’t want it on my CV or their records’: medical students’ experience of help-seeking for mental health problems. Medical Education, 37, 873–880.
• Elton C (2018) Also human: The inner lives of doctors. Penguin Random House (UK) and Basic Books (US).
• Robinaugh D, Marques L, Traeger L, Marks E, Sung S, Gayle Beck J, Pollack M & Simon M (2011) Understanding the relationship of perceived social support to post-trauma cognitions and posttraumatic stress disorder. J. Anxiety Disord., 25(8) 1072–1078.
• Stokoe, P (2021) The curiosity drive. Our need for inquisitive thinking. Phoenix Publishing House.