Acad Psychiatry (2015) 39:63–69 DOI 10.1007/s40596-014-0182-z
IN DEPTH ARTICLE: COMMENTARY
Developmental Life of the Medical Student: Curriculum Considerations Don R. Lipsitt
Received: 5 March 2014 / Accepted: 11 June 2014 / Published online: 8 July 2014 # Academic Psychiatry 2014
Abstract Few medical educators would dispute that the emotional development and well being of the medical student is of critical importance in the pathway to physicianhood. It has been suggested that failure to address this aspect of medical education may account for various health problems and levels of impairment during medical school and beyond. Some authors have suggested that the personal development and “professionalization” of the student occurs through modeling, the medical school “culture,” and the “hidden curriculum.” In recognition of the randomness, incompleteness, or inadequacy of this approach, a number of attempts have been made to address this important but difficult dimension of medical education. However, programs designed to foster selfreflection and appreciation of affect in the physician–patient relationship are often limited as electives or unsupported by faculty and staff and therefore fall short of their objective. The author proposes that a pedagogical framework based on an analogy of life cycle theory (a la Erikson or others) offers a schema within which to consider efforts being made in medical curricula to promote self-awareness, appreciation of affect in oneself and one’s patients, and a context in which to minimize the risk of illness and impairment. Keywords Medical student . Medical curriculum . Hidden curriculum
Human growth occurs when the vital personality weathers conflicts, inner and outer, and re-emerges from each crisis with an increased sense of inner unity, an increase in good judgment, and an increase in the capacity “to do well” according to his own standards and to the standards of those who are significant to him. —Erik Erikson [1] (p. 92) D. R. Lipsitt (*) Harvard Medical School, Cambridge, MA, USA e-mail: [email protected]
Medical education is an arduous, demanding, and stressful endeavor. Over 50 years ago, George Packer Berry, then dean of Harvard Medical School, noted: “The environment in which a medical student attains the stature of a physician is dynamic and tremendously complex. The student … must come to know himself in order to understand his patients [emphasis added]. He must have compassion and sympathy—and a high capacity for empathy. At the same time, he must achieve a detached objectivity about human behavior. Although these attributes seem mutually opposed, each must be developed without sacrifice of the others. These faculties must ripen, furthermore, under the impact of violent forces: pain, fear, hostility, death. It is a formidable task” [2]. With this brief statement, Berry succinctly captures the very essence of the enduring challenge in medical education that has preoccupied sociologists, psychiatrists, psychologists, and medical educators for decades. In the time that has passed since Berry’s remarks, much about medical education has been addressed and even altered to ensure better communication skills, accompanying compassion and empathy, and other aspects of the process referred to as “professionalization.” What may possibly have been given shorter shrift in curricular change is how the student “…must come to know himself in order to understand his patients.” It is not evident that the occasional efforts to remedy this void have been successful, admittedly perhaps the most challenging component of all. Berry’s reference to attributes that must “ripen,” and their potential conflictual existence in the medical education process, appears to acknowledge the need but not the means for the student to master specific developmental tasks essential for successful professionalization. Both Erikson and Berry allude to the “inner and outer” conflicts and “mutually opposed” attributes that appear in one’s personal life cycle.
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Others argue that failure to master the progressive steps of this “formidable task” may be at least partly responsible for later impairment (e.g., emotional disorder, suicide, drug and alcohol abuse) in both students and practicing physicians. Many studies appear to support this hypothesis [3, 4]. In this commentary, which is based on extensive teaching experience with both undergraduate students and graduate physicians, I will argue that a more dedicated curricular focus on the developmental stages of the medical student’s “life cycle,” applying a modified version of Erikson’s schema, will enhance the student’s well-being and physicianhood. Curriculum change occurs sluggishly in spite of decades of calls for more attention to the emotional health of students.
In Pursuit of the “Well-Rounded” Student Concern about the student’s professional development is not new. Many curriculum reforms have been instituted since the Flexner Report of 1910 to rectify the perceived deficiencies of education and training, with the intent—at least partly—to “produce” graduates who fulfill Berry’s description of the humanistic, well-rounded, compassionate, and empathic physician [5]. In 1986, an article in the New York Times [6], responding to critical complaints that “evolutionary technological advances threaten to obscure the more humanistic aspects of the medical field,” reported “an increasing number of medical schools are modifying their curriculums to include such subjects as art and literature in an attempt to make young doctors more sensitive to the social and psychological needs of their patients.” The focus, as described, appears largely to be on the social and psychological needs of “their patients,” not of the young doctors themselves. During my own internship, I participated in an art course, but I would question whether it enhanced my appreciation of my own capacity for introspection or psychological development.
Reliance on the Hidden Curriculum As one way of addressing the need to make the “hidden curriculum” less hidden, several medical schools in the 1980s introduced curriculum change. Harvard’s New Pathway, for example, instituted small group discussion in the “Patient–Doctor” sequence, an obligatory course during the first 3 years to foster greater appreciation of the emotional, psychological, ethical, and cultural aspects of human behavior as they influenced patient–doctor relationships, reported to show improvement in “humanistic” aspects of medicine [7].
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Most such reforms focus on the need to retain compassion, humanism, and caring values, heretofore almost invisible in the “hidden curriculum.” Only rarely, in the past, has a specific recommendation been made to include the study of one’s personal life, the emotional vicissitudes of becoming a physician, the individualistic impact of stress on the student and physician; even interviewing and communication courses emphasize the interpersonal rather than intrapersonal aspects of one’s interactions. Attention, more recently, is being directed to the important affective ingredient in the experience of medical education. While much is made of the importance of the doctor– patient relationship, relatively little time is devoted to exploring the complexity of the interactive behaviors implied in this simplistic expression. Understandably, even delicate efforts to address personal aspects of a student’s experience are generally steadfastly resisted by both student and teacher, with understandable reluctance. Bloom [8], an astute long-time observer of changes in medical education, states that “…medical students are startled by the mirror-like familiarity of 30-year old accounts of medical student life” [8] (p. 229). Bloom adds, “Even when conventional curriculum models are replaced, the teaching/learning experience of medical students remains much the same as it has been for 50 years” [8] (p. 232) (clearly, this was before the advent of computer-based learning technologies).
Old Wine in New Bottles? Curriculum reforms of one kind or another, while slow to change, have been a constant accompaniment of medical education. The waggish remark that “it is easier to move a cemetery than to change a curriculum” comes to mind. Indeed, Phillipe Pinel, in an essay on the clinical training of doctors [9], wrote in 1793 that the ideal medical education was ensured through “informal groups that meet without the paraphernalia of pedantry and where burgeoning talent is given free play…. The Professor [sic] can enjoy the moving experience of watching passionate and well-motivated young men [note: this was before the days of women students] make rapid progress, unrestricted by sterile efforts at memorization” [9] (p. 91). Pinel’s advocacy for more leisure, small groups, fewer lectures, and less memorization has been incorporated, more than 300 years later, by contemporary curricula, as in Harvard’s New Pathway and others. Almost 200 years after Pinel, the General Professional Education of the Physician (GPEP) Report [10] of 1984 lamented the lack of progress, stating, “Despite frequent assertions that the general professional education of medical students is the basic mission of medical schools, it often occupies last place in the competition for faculty time and attention” [10] (p. 60). And the report was forecasting changes for the twenty-first century!
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The impediments to change, the Report seems to claim, are systemic and institutional rather than personal. But it is important that faculty look beyond acquisition of skills, knowledge, values, and performance that are part of learning to become a good physician and look as well to the internal characterological changes that are incurred in the process. Unquestionably, much has changed and even improved in the decades since GPEP, but current literature on the emotional status of medical students suggests that this ingredient remains in need of greater attention [11]. More recently, in a call for “a renewed sense of professionalism,” meetings were jointly convened of the American College of Physicians–American Society of Internal Medicine (ACP-ASIM), the European Federation of Internal Medicine, and the American Board of Internal Medicine (ABIM). The ultimate product of their deliberations was “A Physician Charter on Medical Professionalism in the New Millennium” [12]. A summary statement of the charter’s content lists “Three Fundamental Principles” at the “heart of the charter”: (1) principle of primacy of patient welfare, (2) principle of patient autonomy, and (3) principle of social justice. Again, as of 2002, we see no reference to a “principle of student well-being,” in spite of acknowledgement that “physicians today are experiencing frustration as changes in the healthcare delivery system…threaten the very nature and values of medical professionalism.” Setting out a laudable “set of professional responsibilities,” the document does not allude to the responsibility medical students and future physicians have to themselves to ensure self-awareness and emotional competence. There is a hint that “physicians [note: not medical students] …as members of a profession…should participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards” [12]. But the likely causes of those failures, beginning in medical school, are not addressed. This, in spite of an extensive literature on the mental health problems of medical students.
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Curriculum modifications of recent years have been made to strengthen the student’s appreciation and expression of the “humanistic side of medicine.” Nevertheless, according to Ludmerer [14], empirical evidence is lacking that instruction in the medical humanities produces caring physicians; indeed, the years after 1970 saw increased public charges that doctors were impersonal, self-serving, greedy, and dishonest, despite greater amounts of time devoted to teaching medical humanities in the curriculum. In view of the questionable results of many curriculum reforms designed to address the risk of student and physician impairment, it is surprising that educators have not turned their gaze and reformist motives more toward internal, rather than external, factors concerning the professionalization process. The missing link in past efforts may be the developmental “life cycle” of the medical student, the process, in Eriksonian terms, that each student goes through in making the crucial transition from postadolescent to mature adult physician.
Mental Health of Medical Students Although statistics are difficult to come by because of confidentiality and other factors, at least one report claims that “studies suggest that mental health worsens after students begin medical school and remains poor throughout training” [15]. Additionally, it is reported that unresolved reaction to stress bears both a personal risk of substance abuse, impaired relationships, suicide, and professional attrition as well as a professional risk in the care of patients, interaction with faculty, and the development of a mature professional identity. One study reports that 90 % of over 1,000 students at nine medical schools confidentially acknowledged “needing care for various health concerns” (including 47 % with at least one mental health or substance-related health issue) [15].
Erikson’s Life Cycle A Missing Ingredient? Less-than-ideal results of modified educational endeavors continue to be noted in the professional and lay press. In 1955, Eron [13] observed that freshmen medical students entered medical school as compassionate, caring, humanistic individuals and graduated as cold, cynical, dehumanized physicians after 4 years. There have since been many attempts to understand and to alter this discouraging situation [11]. Most efforts to address what is in all likelihood a complex phenomenon, have focused, again, largely on institutional changes in the belief that it is exposure to the curriculum structure and the medical school culture that accounts for the developmental impediments of the student.
Erikson’s [1] conception of the human life cycle posits a series of developmental stages, each of which must be encountered and mastered, from the basic trust of childhood to the stage of generativity of later years, before successfully transitioning to the next level of psychosocial maturity. According to Erikson, the psychological work of each stage presents a kind of “crisis” because of the sense of vulnerability that accompanies each shift in “instinctual energy” [1] (p. 95). The crisis for the adolescent is the sometimes “stormy” effort to establish an identity for oneself. Failure to achieve this can result in identity confusion, ego flaws, psychopathological behavior, and developmental arrest. Erikson states, “…it is the ideological potential of a society which speaks most clearly to the adolescent who is so eager to be affirmed by peers, to be confirmed by teachers, and to be inspired by
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worthwhile ‘ways of life’” [1] (p. 130) that will have the greatest developmental impact on him or her. If that society to which the medical student is exposed is medical school, then exposure to its new ideas, ideals, fears and threats, expectations and disappointments, behaviors, and techniques may result in considerable emotional turmoil and confusion for the aspiring student–physician.
The Medical Student’s “Life Cycle” The postadolescent student, often still in the midst of exploring identity issues, on admission to medical school may experience a developmental clash, with cataclysmic emotional repercussions, as in a first encounter with a cadaver [16]. Anxiety may accompany initial elation and excitement over acceptance itself to medical school. In anticipation of the challenge awaiting them, some students have even joked that it would be enough of an accomplishment merely to be accepted without having to go. Arriving at the threshold of medical school with already a high level of developmental maturity, students confront head-on aspects of medical education that threaten to derail—or at least to re-track—a process that is already part of the individual’s identity. With premature closure or inadequate mastery of tasks, students are confronted with a kind of life cycle asynchrony, fueled by doubt, identity confusion, inferiority, mistrust, and isolation. This collision of the normal life cycle with the unique demands of professionalization promotes the beginning of defensive adaptations to the realities of medical life that feels to the student like “dehumanization.” Such alien feelings arouse shame because they so abruptly clash with the idealization of medicine held before medical school admission. Strongly held values must be reassessed, socially endorsed taboos about looking at and touching the human body are reversed, and professional identity merges imperfectly with personal identity. Ideological commitments previously thought to be well stabilized may be stirred into a new sense of chaos, frequently reflected in remarks like “I don’t like what I see when I see how doctors treat patients” or “I wonder if this really is the right field for me” or “Medical education will never change me into a cold, cynical doctor,” and so on. Task accomplishments thought to be essentially closed matters before medical school admission may have to be reopened, and developmental processes still in a state of openness may experience a defensive premature closure, unless there is readiness and sensitivity of faculty to help modify such events. Studies have shown and observations confirm that some students between their first and fourth years come to resemble the very models of “good physicians” they had previously criticized as heartless and inconsistent with their own ideals; professional ambiguity and uncertainty engenders a sense of vulnerability as students embark on their professional adventure.
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They also may endure a sense of frustration at the possibility of losing out on the broader social aspects of personal development missed because of the intensity of the work demands that lies before them. The result might be to delay the stage of intimacy, to compromise one’s autonomy, to revive doubts and distrust in oneself and in the “system,” and to once again bring into conscious awareness preoccupation with identity issues like “Just who am I, anyway?” [17]. This latter concern is most dramatically illustrated in the student’s first contact with a live patient, when he or she does not know how to, is awkward at, or feels deceitful in the attempt to introduce himself or herself to a patient as a “physician in training,” with a sense of exploiting rather than helping the patient. Students at the beginning of their second year have expressed to me the feeling that “there doesn’t seem to be any way for me to be comforting to the patient and to learn a technique.” One student said that he had come to regard the “exploitation” of patients as “a necessary evil; I need to learn the skills.” Another felt “It’s a game—you just have to get through it.” The emotional states experienced in these encounters generate feelings of fraudulence that are strongly defended against unless brought to the surface for exploration and clarification. To counteract discomfiting feelings during first interviews, students almost invariably have a tendency to “socialize” the encounters with patients to compensate for feelings of incompetence or lack of professional identity. Lacking the skills and knowledge at this emotionally charged stage of development, students defend against affect by focusing on operational skills, eagerness to use technology, retreat into knowledge for its own sake with dependency on computers and other electronic devices (and thus away from patients), and the high valence put on competence and knowledge as the most expedient solution to disquieting feelings of uncertainty. The comfort achieved through mastery of technique runs the risk of neglecting identification of those emotions in oneself and one’s patient so essential for an empathic response. Medical education trains students to deny or suppress affect [18]. There is little openness, enthusiasm, or encouragement for self-examination attending the student’s affective experience. It is as though “receptor sites” (Dr. Randall Paulsen, Harvard Medical School) for assimilation of such experience have been ablated or not yet developed. Nor are all faculties attuned to the developmental, life cycle, and identity issues that must first be recognized before they can be addressed. When preceptors, in their modeling roles, show a tendency to minimize or denigrate the importance of emotions, or to suggest that attention to that side of life and experience hampers the “real” purpose of medical encounters, then students are likely to believe that looking at their own emotions is a deterrent to progress toward their goal of becoming a physician. Some physicians, for example, observing that patients may cry during a psychiatric
Acad Psychiatry (2015) 39:63–69 Table 1 Addressing affect through life cycle • Require preadmission course in developmental psychology • Role play various stages of life • Continuity of mentoring by knowledgeable faculty member • Training of house staff in life cycle concept • Balint groups for case discussion and reflection • Workshop or focus group on curriculum building for students • Include assessment of self-knowledge in qualifying exams • Integrate life cycle concept throughout curriculum • Include developmental psychology and life cycle literature in psychiatric training
consultation, condemn the psychiatrist for “upsetting” the patient rather than acknowledging the potential value of helping patients express their emotion. Some physicians are experienced as abusive in their “teaching techniques.” Such reaction has a powerful influence over novice medical students looking for acceptable role models. Some physicians, noting students’ interest in psychiatry, have told them, not entirely jokingly, “You’re too smart to go into psychiatry.” Increased attention to the role of affect in medical education can be achieved through techniques listed in Table 1.
Where to From Here? It should be apparent by now, after decades of curriculum experimentation and modification, that the answer to more effective physician education is not likely to be found in environmental or “cultural” alterations of the curriculum, the structural surround, or the social environment. It is at least as (if not more) important to look at how medical students internalize their educational experience and deal with the affect that it generates. Efforts in this direction have been made with a focus on the use of “narrative,” “critical incident,”
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or “portfolio” review to encourage and promote selfreflection. Courses in literature, poetry, and art that focus on the humanistic aspects of life are often taught by nonphysician professionals rather than physicians “in the trenches,” perhaps unwittingly implying that these aspects of professionalization lie outside of medicine’s realm.
The “Doctor Tree” That early experience influences development, and later behavior is well established. All developmental psychologies posit that maturation evolves through stages, whether Freud’s psychosexual development, Erikson’s life cycle, or others. Such theories offer an analogy to the developmental tasks of the student and a basis for meaningful discussion. A thoughtful approach to such matters that addresses the complexity of the medical student’s developmental experience is found in the underappreciated book “The Doctor Tree,” by Zabarenko and Zabarenko [19]. The authors suggest that “one good way to think about physicians’ development” is to consider the manner in which five essential stages are addressed (Table 2). “Professionalization” is a complex process of multiple tasks that the student cannot accomplish alone or only through a “hidden curriculum” [20]. Monitoring and facilitating these tracks is the responsibility of faculty and mentors. Faculty and curriculum modifications that do not attend openly and overtly to these intrinsic tasks, no matter how innovative, will likely perpetuate many of the detrimental outcomes of medical education if they do not make personal development part of the process. This process cannot be postponed to postgraduate training. Changing attitudes and behavior is a notoriously difficult challenge [21]. Selective implications for educators have been found helpful (see list after “Conclusion”).
Table 2 The “Doctor Tree” Phase
Developmental stage
Tasks
I
Balancing objectivity and empathy
II
Managing nurturance and executive necessities
III
Regulating control of omnipotence and tolerating uncertainty
IV
Forming a professional ego ideal
V
Consolidating a professional identity
Maintain flexibility between attention to facts (“science”) and feelings (“empathy”) Begin developing confidence Distinguish between “giving” and “getting” Learn to assume responsibility, “take action” Relinquish childhood fantasies of omnipotence Learn use of control in oneself and others Appreciate the “real world” Identify with role models and realign values Reaffirm commitment to standards and industry Integrate all “bits and pieces” of educational process Accept entrance into “physicianhood” and identity as physician
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The Challenge Integrating “humanizing” experiences is an especially challenging objective. If a student’s acceptance of emotionality in himself or herself is not reinforced or at least accepted in various stages of the educational process, greater conflict and confusion may occur. For example, an especially talented and empathic student in an early course on patient–doctor relations confessed to me during her first residency year that she was frustrated, guilty, and ashamed not to be able to make use of what she had learned because it was not supported by her ward staff. And the pressures of time made her find ways to avoid “meaningful time” with patients or to engage family members of her patients. Such problems will continue with the increased pressures and time constraints of health-care delivery and scarcity of role models who value behaviors and attitudes respected in emerging physicians.
Conclusion In medical education, it is easier to be a critic than an innovator. Curriculum reforms have been tried for centuries; modifications will always be necessary as times, needs, and progress change. Evaluation of these many changes is beyond the scope of this paper. Although this commentary reflects a selective interpretation of the literature, it is my opinion that the matter of the medical student’s personal development has been relatively neglected. In an educational experience that becomes more burdened with technology, burgeoning knowledge, and stressful pressures (e.g., managed care, health-care rationing, bioethics), such neglect can escalate. Unless special concern is expressed by those who serve on faculties and on admissions and curriculum committees, this dimension of physicianhood will be at risk to continue to be obscured by other more dazzling aspects of medicine. Francis Peabody, in 1927, warned of the pitfalls of “medical progress” [23]. He wrote, “When one considers the amazing progress of science … it is not surprising that the schools have tended to concern themselves more and more with this phase of the education problem,” to the detriment of the personal and humanistic sides of medicine. This, more than 85 years ago! If Peabody fretted over the affront of scientific progress to humanism in his day, what would he think of the hazards of today’s dramatic advances in neuroscience, genomics, and pharmacology? We must guard against losing the student in the welter of demands made upon him and her. Words like humanism, compassion, empathy, and so on must not become mere buzzwords or shibboleth, obscuring real deficiencies and diverting attention from an energetic pursuit of new resolutions for old problems. In the face of expressions of growing dissatisfaction with medical practice, it is heartening to observe increased
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attention in some instances to the personal psychosocial development of the medical student, the emotions that accompany transitions in the professionalization process, and the nodal points of vulnerability throughout the 4-year journey and beyond. With this, we may see an escape from the “collateral damage” to our future physicians. “Weathering inner and outer conflicts” is a perpetual challenge of the medical education process. It is, indeed, as Dean Berry stated, “a formidable task.” Implications for Educators • The sharing of “critical events” in student groups has been a useful technique for observing and acknowledging feelings. • Balint groups, used successfully with practicing physicians to learn about one’s own influence on patient behavior and illness outcome, can be applied to students as well, but the curriculum must make time and skilled faculty available for it. • Faculty who encourage and protect open interaction with students as well as with patients can have a salutary effect. • The experience of transference and countertransference is seen in all aspects of the physician–patient relationship, not only in psychiatry, and should not be dismissed by faculty as some archaic Freudian concept. • It is useful to include in the curriculum conversation about vulnerability, shame, resilience, confidence, and uncertainty. • Curriculum committees that provide “equal opportunity” for matters of the mind as well as matters of the body will be rewarded with improved attitudes in students toward emotional life—their own as well as their patients. • The screening of applicants for interest in subjects like psychology and sociology as well as chemistry and physics may start students off with a scaffold on which to build interest in their own emotional life. Jordan Cohen, president emeritus of the Association of American Medical Colleges, has stated, “The first and most obvious implication for medical education of the link between professionalism and humanism centers on the admission process” [22] (p. 1029). A major challenge for admission committees, according to Cohen, is “to identify candidates who, in addition to the requisite academic background and scholarly achievements, also possess the character traits indicative of success as humanistic physicians” [22] (p. 1030). • Obligatory courses in medical school on developmental and interpersonal psychology and life cycles can provide students with skills to learn as much about a patient as might be gleaned, for example, from yet another CT scan. • Obligatory training for faculty in the recognition and management of emotional life in students and life cycle theory (Erikson or others) may be of some help. • Assign “personal mentors or advisors” for each student throughout the medical school experience, without abruptly having to confront stigma or fear, when dealing with stress, anxiety, depression, and burnout. Many precursors of mental health problems can be ameliorated before they become “urgent,” but the cultural context must be one of understanding, acceptance, and support. • Students should be encouraged to report “abuse” by faculty to their dean.
Disclosures The author states that there is no conflict of interest.
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References 1. Erikson E. Identity: youth and crisis. New York: WW Norton; 1968. 2. Berry GP. Fifth Teaching Institute of the Association of American Medical Colleges. 68th Annual Meeting, October 18–19. Atlantic City: Association of American Medical Colleges; 1957. 3. Roberts LW, Warner TD, Rogers M, et al. Medical student illness and impairment: a vignette-based survey study involving 955 students at 9 medical schools. Compr Psychiatry. 2005;46:229–37. 4. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80:1613–22. 5. Putnam C. Reform and innovation: a repeating pattern during a half century of medical education in the USA. Med Educ. 2006;40: 227–34. 6. Moore G, Block SD, Style CB, et al. The influence of the New Pathway curriculum on Harvard medical students. Acad Med. 1994;69:983–9. 7. New York Times: Effort grows to create sensitive doctors. April 8, 1986. 8. Bloom SW. The medical school as a social organization: the sources of resistance to change. Med Ed. 1989;23:228–41. 9. Weiner DB. Philippe Pinel: The clinical training of doctors. An essay of 1793. Baltimore: Johns Hopkins University Press; 1980. 10. Report of the panel on the general professional education of the physician (GPEP) and college preparation for medicine. Physicians for the Twenty-first Century. Washington, DC: Association of American Medical Colleges; 1984. 11. Newton BW, Barber L, Clardy J, Cleveland E, et al. Is there hardening of the heart during medical school? Acad Med. 2008;83:244–9.
69 12. Project of ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136: 243–6. 13. Eron LD. Effect of medical education on medical students’ attitudes. J Med Ed. 1955;30:559–66. 14. Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. 15. Roberts LW, Warner TD, Lyketsos C, et al. Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Health. Compr Psychiatry. 2001;42:1–15. 16. Madill A, Latchford G. Identity change and the human dissection experience over the first year of medical training. Soc Sci Med. 2005;60:1637–47. 17. Reis DC. Who am I and why am I here? Professionalism research through the eyes of a medical student. Acad Med. 2008;83(10 Suppl): S111–2. 18. Daniels MJ. Affect and its control in the medical intern. Am J Sociol. 1960;16:259–61. 19. Zabarenko RN, Zabarenko LM. The doctor tree. Pittsburgh: University of Pittsburgh Press; 1978. 20. Gabbard GO, Roberts LW, Crisp-Han H. Professionalism in psychiatry. Washington, DC: American Psychiatric Publishing; 2012. 21. Murinson BB, Klick B, Haythornthwaite JA, et al. Formative experiences of emerging physicians: gauging the impact of events that occur during medical school. Acad Med. 2010;85:1331–7. 22. Cohen J. Linking professionalism to humanism: what it means, why it matters. Acad Med. 2007;82:1029–32. 23. Peabody FW. The care of the patient. JAMA. 1927;88:877–82.
IN DEPTH ARTICLE: COMMENTARY
Developmental Life of the Medical Student: Curriculum Considerations Don R. Lipsitt
Received: 5 March 2014 / Accepted: 11 June 2014 / Published online: 8 July 2014 # Academic Psychiatry 2014
Abstract Few medical educators would dispute that the emotional development and well being of the medical student is of critical importance in the pathway to physicianhood. It has been suggested that failure to address this aspect of medical education may account for various health problems and levels of impairment during medical school and beyond. Some authors have suggested that the personal development and “professionalization” of the student occurs through modeling, the medical school “culture,” and the “hidden curriculum.” In recognition of the randomness, incompleteness, or inadequacy of this approach, a number of attempts have been made to address this important but difficult dimension of medical education. However, programs designed to foster selfreflection and appreciation of affect in the physician–patient relationship are often limited as electives or unsupported by faculty and staff and therefore fall short of their objective. The author proposes that a pedagogical framework based on an analogy of life cycle theory (a la Erikson or others) offers a schema within which to consider efforts being made in medical curricula to promote self-awareness, appreciation of affect in oneself and one’s patients, and a context in which to minimize the risk of illness and impairment. Keywords Medical student . Medical curriculum . Hidden curriculum
Human growth occurs when the vital personality weathers conflicts, inner and outer, and re-emerges from each crisis with an increased sense of inner unity, an increase in good judgment, and an increase in the capacity “to do well” according to his own standards and to the standards of those who are significant to him. —Erik Erikson [1] (p. 92) D. R. Lipsitt (*) Harvard Medical School, Cambridge, MA, USA e-mail: [email protected]
Medical education is an arduous, demanding, and stressful endeavor. Over 50 years ago, George Packer Berry, then dean of Harvard Medical School, noted: “The environment in which a medical student attains the stature of a physician is dynamic and tremendously complex. The student … must come to know himself in order to understand his patients [emphasis added]. He must have compassion and sympathy—and a high capacity for empathy. At the same time, he must achieve a detached objectivity about human behavior. Although these attributes seem mutually opposed, each must be developed without sacrifice of the others. These faculties must ripen, furthermore, under the impact of violent forces: pain, fear, hostility, death. It is a formidable task” [2]. With this brief statement, Berry succinctly captures the very essence of the enduring challenge in medical education that has preoccupied sociologists, psychiatrists, psychologists, and medical educators for decades. In the time that has passed since Berry’s remarks, much about medical education has been addressed and even altered to ensure better communication skills, accompanying compassion and empathy, and other aspects of the process referred to as “professionalization.” What may possibly have been given shorter shrift in curricular change is how the student “…must come to know himself in order to understand his patients.” It is not evident that the occasional efforts to remedy this void have been successful, admittedly perhaps the most challenging component of all. Berry’s reference to attributes that must “ripen,” and their potential conflictual existence in the medical education process, appears to acknowledge the need but not the means for the student to master specific developmental tasks essential for successful professionalization. Both Erikson and Berry allude to the “inner and outer” conflicts and “mutually opposed” attributes that appear in one’s personal life cycle.
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Others argue that failure to master the progressive steps of this “formidable task” may be at least partly responsible for later impairment (e.g., emotional disorder, suicide, drug and alcohol abuse) in both students and practicing physicians. Many studies appear to support this hypothesis [3, 4]. In this commentary, which is based on extensive teaching experience with both undergraduate students and graduate physicians, I will argue that a more dedicated curricular focus on the developmental stages of the medical student’s “life cycle,” applying a modified version of Erikson’s schema, will enhance the student’s well-being and physicianhood. Curriculum change occurs sluggishly in spite of decades of calls for more attention to the emotional health of students.
In Pursuit of the “Well-Rounded” Student Concern about the student’s professional development is not new. Many curriculum reforms have been instituted since the Flexner Report of 1910 to rectify the perceived deficiencies of education and training, with the intent—at least partly—to “produce” graduates who fulfill Berry’s description of the humanistic, well-rounded, compassionate, and empathic physician [5]. In 1986, an article in the New York Times [6], responding to critical complaints that “evolutionary technological advances threaten to obscure the more humanistic aspects of the medical field,” reported “an increasing number of medical schools are modifying their curriculums to include such subjects as art and literature in an attempt to make young doctors more sensitive to the social and psychological needs of their patients.” The focus, as described, appears largely to be on the social and psychological needs of “their patients,” not of the young doctors themselves. During my own internship, I participated in an art course, but I would question whether it enhanced my appreciation of my own capacity for introspection or psychological development.
Reliance on the Hidden Curriculum As one way of addressing the need to make the “hidden curriculum” less hidden, several medical schools in the 1980s introduced curriculum change. Harvard’s New Pathway, for example, instituted small group discussion in the “Patient–Doctor” sequence, an obligatory course during the first 3 years to foster greater appreciation of the emotional, psychological, ethical, and cultural aspects of human behavior as they influenced patient–doctor relationships, reported to show improvement in “humanistic” aspects of medicine [7].
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Most such reforms focus on the need to retain compassion, humanism, and caring values, heretofore almost invisible in the “hidden curriculum.” Only rarely, in the past, has a specific recommendation been made to include the study of one’s personal life, the emotional vicissitudes of becoming a physician, the individualistic impact of stress on the student and physician; even interviewing and communication courses emphasize the interpersonal rather than intrapersonal aspects of one’s interactions. Attention, more recently, is being directed to the important affective ingredient in the experience of medical education. While much is made of the importance of the doctor– patient relationship, relatively little time is devoted to exploring the complexity of the interactive behaviors implied in this simplistic expression. Understandably, even delicate efforts to address personal aspects of a student’s experience are generally steadfastly resisted by both student and teacher, with understandable reluctance. Bloom [8], an astute long-time observer of changes in medical education, states that “…medical students are startled by the mirror-like familiarity of 30-year old accounts of medical student life” [8] (p. 229). Bloom adds, “Even when conventional curriculum models are replaced, the teaching/learning experience of medical students remains much the same as it has been for 50 years” [8] (p. 232) (clearly, this was before the advent of computer-based learning technologies).
Old Wine in New Bottles? Curriculum reforms of one kind or another, while slow to change, have been a constant accompaniment of medical education. The waggish remark that “it is easier to move a cemetery than to change a curriculum” comes to mind. Indeed, Phillipe Pinel, in an essay on the clinical training of doctors [9], wrote in 1793 that the ideal medical education was ensured through “informal groups that meet without the paraphernalia of pedantry and where burgeoning talent is given free play…. The Professor [sic] can enjoy the moving experience of watching passionate and well-motivated young men [note: this was before the days of women students] make rapid progress, unrestricted by sterile efforts at memorization” [9] (p. 91). Pinel’s advocacy for more leisure, small groups, fewer lectures, and less memorization has been incorporated, more than 300 years later, by contemporary curricula, as in Harvard’s New Pathway and others. Almost 200 years after Pinel, the General Professional Education of the Physician (GPEP) Report [10] of 1984 lamented the lack of progress, stating, “Despite frequent assertions that the general professional education of medical students is the basic mission of medical schools, it often occupies last place in the competition for faculty time and attention” [10] (p. 60). And the report was forecasting changes for the twenty-first century!
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The impediments to change, the Report seems to claim, are systemic and institutional rather than personal. But it is important that faculty look beyond acquisition of skills, knowledge, values, and performance that are part of learning to become a good physician and look as well to the internal characterological changes that are incurred in the process. Unquestionably, much has changed and even improved in the decades since GPEP, but current literature on the emotional status of medical students suggests that this ingredient remains in need of greater attention [11]. More recently, in a call for “a renewed sense of professionalism,” meetings were jointly convened of the American College of Physicians–American Society of Internal Medicine (ACP-ASIM), the European Federation of Internal Medicine, and the American Board of Internal Medicine (ABIM). The ultimate product of their deliberations was “A Physician Charter on Medical Professionalism in the New Millennium” [12]. A summary statement of the charter’s content lists “Three Fundamental Principles” at the “heart of the charter”: (1) principle of primacy of patient welfare, (2) principle of patient autonomy, and (3) principle of social justice. Again, as of 2002, we see no reference to a “principle of student well-being,” in spite of acknowledgement that “physicians today are experiencing frustration as changes in the healthcare delivery system…threaten the very nature and values of medical professionalism.” Setting out a laudable “set of professional responsibilities,” the document does not allude to the responsibility medical students and future physicians have to themselves to ensure self-awareness and emotional competence. There is a hint that “physicians [note: not medical students] …as members of a profession…should participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards” [12]. But the likely causes of those failures, beginning in medical school, are not addressed. This, in spite of an extensive literature on the mental health problems of medical students.
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Curriculum modifications of recent years have been made to strengthen the student’s appreciation and expression of the “humanistic side of medicine.” Nevertheless, according to Ludmerer [14], empirical evidence is lacking that instruction in the medical humanities produces caring physicians; indeed, the years after 1970 saw increased public charges that doctors were impersonal, self-serving, greedy, and dishonest, despite greater amounts of time devoted to teaching medical humanities in the curriculum. In view of the questionable results of many curriculum reforms designed to address the risk of student and physician impairment, it is surprising that educators have not turned their gaze and reformist motives more toward internal, rather than external, factors concerning the professionalization process. The missing link in past efforts may be the developmental “life cycle” of the medical student, the process, in Eriksonian terms, that each student goes through in making the crucial transition from postadolescent to mature adult physician.
Mental Health of Medical Students Although statistics are difficult to come by because of confidentiality and other factors, at least one report claims that “studies suggest that mental health worsens after students begin medical school and remains poor throughout training” [15]. Additionally, it is reported that unresolved reaction to stress bears both a personal risk of substance abuse, impaired relationships, suicide, and professional attrition as well as a professional risk in the care of patients, interaction with faculty, and the development of a mature professional identity. One study reports that 90 % of over 1,000 students at nine medical schools confidentially acknowledged “needing care for various health concerns” (including 47 % with at least one mental health or substance-related health issue) [15].
Erikson’s Life Cycle A Missing Ingredient? Less-than-ideal results of modified educational endeavors continue to be noted in the professional and lay press. In 1955, Eron [13] observed that freshmen medical students entered medical school as compassionate, caring, humanistic individuals and graduated as cold, cynical, dehumanized physicians after 4 years. There have since been many attempts to understand and to alter this discouraging situation [11]. Most efforts to address what is in all likelihood a complex phenomenon, have focused, again, largely on institutional changes in the belief that it is exposure to the curriculum structure and the medical school culture that accounts for the developmental impediments of the student.
Erikson’s [1] conception of the human life cycle posits a series of developmental stages, each of which must be encountered and mastered, from the basic trust of childhood to the stage of generativity of later years, before successfully transitioning to the next level of psychosocial maturity. According to Erikson, the psychological work of each stage presents a kind of “crisis” because of the sense of vulnerability that accompanies each shift in “instinctual energy” [1] (p. 95). The crisis for the adolescent is the sometimes “stormy” effort to establish an identity for oneself. Failure to achieve this can result in identity confusion, ego flaws, psychopathological behavior, and developmental arrest. Erikson states, “…it is the ideological potential of a society which speaks most clearly to the adolescent who is so eager to be affirmed by peers, to be confirmed by teachers, and to be inspired by
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worthwhile ‘ways of life’” [1] (p. 130) that will have the greatest developmental impact on him or her. If that society to which the medical student is exposed is medical school, then exposure to its new ideas, ideals, fears and threats, expectations and disappointments, behaviors, and techniques may result in considerable emotional turmoil and confusion for the aspiring student–physician.
The Medical Student’s “Life Cycle” The postadolescent student, often still in the midst of exploring identity issues, on admission to medical school may experience a developmental clash, with cataclysmic emotional repercussions, as in a first encounter with a cadaver [16]. Anxiety may accompany initial elation and excitement over acceptance itself to medical school. In anticipation of the challenge awaiting them, some students have even joked that it would be enough of an accomplishment merely to be accepted without having to go. Arriving at the threshold of medical school with already a high level of developmental maturity, students confront head-on aspects of medical education that threaten to derail—or at least to re-track—a process that is already part of the individual’s identity. With premature closure or inadequate mastery of tasks, students are confronted with a kind of life cycle asynchrony, fueled by doubt, identity confusion, inferiority, mistrust, and isolation. This collision of the normal life cycle with the unique demands of professionalization promotes the beginning of defensive adaptations to the realities of medical life that feels to the student like “dehumanization.” Such alien feelings arouse shame because they so abruptly clash with the idealization of medicine held before medical school admission. Strongly held values must be reassessed, socially endorsed taboos about looking at and touching the human body are reversed, and professional identity merges imperfectly with personal identity. Ideological commitments previously thought to be well stabilized may be stirred into a new sense of chaos, frequently reflected in remarks like “I don’t like what I see when I see how doctors treat patients” or “I wonder if this really is the right field for me” or “Medical education will never change me into a cold, cynical doctor,” and so on. Task accomplishments thought to be essentially closed matters before medical school admission may have to be reopened, and developmental processes still in a state of openness may experience a defensive premature closure, unless there is readiness and sensitivity of faculty to help modify such events. Studies have shown and observations confirm that some students between their first and fourth years come to resemble the very models of “good physicians” they had previously criticized as heartless and inconsistent with their own ideals; professional ambiguity and uncertainty engenders a sense of vulnerability as students embark on their professional adventure.
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They also may endure a sense of frustration at the possibility of losing out on the broader social aspects of personal development missed because of the intensity of the work demands that lies before them. The result might be to delay the stage of intimacy, to compromise one’s autonomy, to revive doubts and distrust in oneself and in the “system,” and to once again bring into conscious awareness preoccupation with identity issues like “Just who am I, anyway?” [17]. This latter concern is most dramatically illustrated in the student’s first contact with a live patient, when he or she does not know how to, is awkward at, or feels deceitful in the attempt to introduce himself or herself to a patient as a “physician in training,” with a sense of exploiting rather than helping the patient. Students at the beginning of their second year have expressed to me the feeling that “there doesn’t seem to be any way for me to be comforting to the patient and to learn a technique.” One student said that he had come to regard the “exploitation” of patients as “a necessary evil; I need to learn the skills.” Another felt “It’s a game—you just have to get through it.” The emotional states experienced in these encounters generate feelings of fraudulence that are strongly defended against unless brought to the surface for exploration and clarification. To counteract discomfiting feelings during first interviews, students almost invariably have a tendency to “socialize” the encounters with patients to compensate for feelings of incompetence or lack of professional identity. Lacking the skills and knowledge at this emotionally charged stage of development, students defend against affect by focusing on operational skills, eagerness to use technology, retreat into knowledge for its own sake with dependency on computers and other electronic devices (and thus away from patients), and the high valence put on competence and knowledge as the most expedient solution to disquieting feelings of uncertainty. The comfort achieved through mastery of technique runs the risk of neglecting identification of those emotions in oneself and one’s patient so essential for an empathic response. Medical education trains students to deny or suppress affect [18]. There is little openness, enthusiasm, or encouragement for self-examination attending the student’s affective experience. It is as though “receptor sites” (Dr. Randall Paulsen, Harvard Medical School) for assimilation of such experience have been ablated or not yet developed. Nor are all faculties attuned to the developmental, life cycle, and identity issues that must first be recognized before they can be addressed. When preceptors, in their modeling roles, show a tendency to minimize or denigrate the importance of emotions, or to suggest that attention to that side of life and experience hampers the “real” purpose of medical encounters, then students are likely to believe that looking at their own emotions is a deterrent to progress toward their goal of becoming a physician. Some physicians, for example, observing that patients may cry during a psychiatric
Acad Psychiatry (2015) 39:63–69 Table 1 Addressing affect through life cycle • Require preadmission course in developmental psychology • Role play various stages of life • Continuity of mentoring by knowledgeable faculty member • Training of house staff in life cycle concept • Balint groups for case discussion and reflection • Workshop or focus group on curriculum building for students • Include assessment of self-knowledge in qualifying exams • Integrate life cycle concept throughout curriculum • Include developmental psychology and life cycle literature in psychiatric training
consultation, condemn the psychiatrist for “upsetting” the patient rather than acknowledging the potential value of helping patients express their emotion. Some physicians are experienced as abusive in their “teaching techniques.” Such reaction has a powerful influence over novice medical students looking for acceptable role models. Some physicians, noting students’ interest in psychiatry, have told them, not entirely jokingly, “You’re too smart to go into psychiatry.” Increased attention to the role of affect in medical education can be achieved through techniques listed in Table 1.
Where to From Here? It should be apparent by now, after decades of curriculum experimentation and modification, that the answer to more effective physician education is not likely to be found in environmental or “cultural” alterations of the curriculum, the structural surround, or the social environment. It is at least as (if not more) important to look at how medical students internalize their educational experience and deal with the affect that it generates. Efforts in this direction have been made with a focus on the use of “narrative,” “critical incident,”
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or “portfolio” review to encourage and promote selfreflection. Courses in literature, poetry, and art that focus on the humanistic aspects of life are often taught by nonphysician professionals rather than physicians “in the trenches,” perhaps unwittingly implying that these aspects of professionalization lie outside of medicine’s realm.
The “Doctor Tree” That early experience influences development, and later behavior is well established. All developmental psychologies posit that maturation evolves through stages, whether Freud’s psychosexual development, Erikson’s life cycle, or others. Such theories offer an analogy to the developmental tasks of the student and a basis for meaningful discussion. A thoughtful approach to such matters that addresses the complexity of the medical student’s developmental experience is found in the underappreciated book “The Doctor Tree,” by Zabarenko and Zabarenko [19]. The authors suggest that “one good way to think about physicians’ development” is to consider the manner in which five essential stages are addressed (Table 2). “Professionalization” is a complex process of multiple tasks that the student cannot accomplish alone or only through a “hidden curriculum” [20]. Monitoring and facilitating these tracks is the responsibility of faculty and mentors. Faculty and curriculum modifications that do not attend openly and overtly to these intrinsic tasks, no matter how innovative, will likely perpetuate many of the detrimental outcomes of medical education if they do not make personal development part of the process. This process cannot be postponed to postgraduate training. Changing attitudes and behavior is a notoriously difficult challenge [21]. Selective implications for educators have been found helpful (see list after “Conclusion”).
Table 2 The “Doctor Tree” Phase
Developmental stage
Tasks
I
Balancing objectivity and empathy
II
Managing nurturance and executive necessities
III
Regulating control of omnipotence and tolerating uncertainty
IV
Forming a professional ego ideal
V
Consolidating a professional identity
Maintain flexibility between attention to facts (“science”) and feelings (“empathy”) Begin developing confidence Distinguish between “giving” and “getting” Learn to assume responsibility, “take action” Relinquish childhood fantasies of omnipotence Learn use of control in oneself and others Appreciate the “real world” Identify with role models and realign values Reaffirm commitment to standards and industry Integrate all “bits and pieces” of educational process Accept entrance into “physicianhood” and identity as physician
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The Challenge Integrating “humanizing” experiences is an especially challenging objective. If a student’s acceptance of emotionality in himself or herself is not reinforced or at least accepted in various stages of the educational process, greater conflict and confusion may occur. For example, an especially talented and empathic student in an early course on patient–doctor relations confessed to me during her first residency year that she was frustrated, guilty, and ashamed not to be able to make use of what she had learned because it was not supported by her ward staff. And the pressures of time made her find ways to avoid “meaningful time” with patients or to engage family members of her patients. Such problems will continue with the increased pressures and time constraints of health-care delivery and scarcity of role models who value behaviors and attitudes respected in emerging physicians.
Conclusion In medical education, it is easier to be a critic than an innovator. Curriculum reforms have been tried for centuries; modifications will always be necessary as times, needs, and progress change. Evaluation of these many changes is beyond the scope of this paper. Although this commentary reflects a selective interpretation of the literature, it is my opinion that the matter of the medical student’s personal development has been relatively neglected. In an educational experience that becomes more burdened with technology, burgeoning knowledge, and stressful pressures (e.g., managed care, health-care rationing, bioethics), such neglect can escalate. Unless special concern is expressed by those who serve on faculties and on admissions and curriculum committees, this dimension of physicianhood will be at risk to continue to be obscured by other more dazzling aspects of medicine. Francis Peabody, in 1927, warned of the pitfalls of “medical progress” [23]. He wrote, “When one considers the amazing progress of science … it is not surprising that the schools have tended to concern themselves more and more with this phase of the education problem,” to the detriment of the personal and humanistic sides of medicine. This, more than 85 years ago! If Peabody fretted over the affront of scientific progress to humanism in his day, what would he think of the hazards of today’s dramatic advances in neuroscience, genomics, and pharmacology? We must guard against losing the student in the welter of demands made upon him and her. Words like humanism, compassion, empathy, and so on must not become mere buzzwords or shibboleth, obscuring real deficiencies and diverting attention from an energetic pursuit of new resolutions for old problems. In the face of expressions of growing dissatisfaction with medical practice, it is heartening to observe increased
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attention in some instances to the personal psychosocial development of the medical student, the emotions that accompany transitions in the professionalization process, and the nodal points of vulnerability throughout the 4-year journey and beyond. With this, we may see an escape from the “collateral damage” to our future physicians. “Weathering inner and outer conflicts” is a perpetual challenge of the medical education process. It is, indeed, as Dean Berry stated, “a formidable task.” Implications for Educators • The sharing of “critical events” in student groups has been a useful technique for observing and acknowledging feelings. • Balint groups, used successfully with practicing physicians to learn about one’s own influence on patient behavior and illness outcome, can be applied to students as well, but the curriculum must make time and skilled faculty available for it. • Faculty who encourage and protect open interaction with students as well as with patients can have a salutary effect. • The experience of transference and countertransference is seen in all aspects of the physician–patient relationship, not only in psychiatry, and should not be dismissed by faculty as some archaic Freudian concept. • It is useful to include in the curriculum conversation about vulnerability, shame, resilience, confidence, and uncertainty. • Curriculum committees that provide “equal opportunity” for matters of the mind as well as matters of the body will be rewarded with improved attitudes in students toward emotional life—their own as well as their patients. • The screening of applicants for interest in subjects like psychology and sociology as well as chemistry and physics may start students off with a scaffold on which to build interest in their own emotional life. Jordan Cohen, president emeritus of the Association of American Medical Colleges, has stated, “The first and most obvious implication for medical education of the link between professionalism and humanism centers on the admission process” [22] (p. 1029). A major challenge for admission committees, according to Cohen, is “to identify candidates who, in addition to the requisite academic background and scholarly achievements, also possess the character traits indicative of success as humanistic physicians” [22] (p. 1030). • Obligatory courses in medical school on developmental and interpersonal psychology and life cycles can provide students with skills to learn as much about a patient as might be gleaned, for example, from yet another CT scan. • Obligatory training for faculty in the recognition and management of emotional life in students and life cycle theory (Erikson or others) may be of some help. • Assign “personal mentors or advisors” for each student throughout the medical school experience, without abruptly having to confront stigma or fear, when dealing with stress, anxiety, depression, and burnout. Many precursors of mental health problems can be ameliorated before they become “urgent,” but the cultural context must be one of understanding, acceptance, and support. • Students should be encouraged to report “abuse” by faculty to their dean.
Disclosures The author states that there is no conflict of interest.
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