This piece is part of in-Training Mental Health Week.
For most medical students, the third year of medical school is their introduction to life in the hospital. This results not only in exciting learning opportunities, but also emotional tolls — grief, fear, anxiety, exhaustion — that can lead to serious problems including burnout, depression and anxiety.
In the first week of my clinical rotations, a patient in the psychiatric emergency wing looked me in the eye and told me she wanted to murder someone. A few weeks later during my surgery rotation, I was part of a discussion that involved telling a patient with esophageal rupture that he had approximately 48 hours to live. On my neurology rotation, I attempted a lumbar puncture at the bedside, slowly plunging a frightfully long needle into a woman’s back as she moaned in fear and discomfort. During my OB/GYN rotation, I moved an ultrasound probe over the belly of a woman who had noticed bleeding and decreased fetal activity; this pregnancy was highly desired by her and her partner and I remember beads of sweat forming on my face as I searched for the elusive, oceanic sound of a heartbeat. I am sure my classmates have also encountered similarly jarring, stirring or frightening situations in their third year.
Despite all of these events, when asked by friends or family, “How are you?” I occasionally return them a blank stare or phone silence. One day, I realized why this was happening: I was depersonalizing. When in the comfort of my own home, I locked away the emotionally heavy events of the day, separating and distancing myself from them. In a way, trying to be a normal 20-something year-old coming home from work to relax and watch some Netflix, instead of a future professional in charge of saving lives who had witnessed a grisly acute event on the floor or watched someone be told they had cancer or miscarried. The empty gaze and the delayed response: external manifestations of an internal struggle to open the door to those experiences again.
So whenever this happens, I know I need to do three things: slow down, reflect and recover.
Depersonalization is the development of distorted perceptions of oneself and others, a separation of oneself from emotions that ultimately manifests as a lack of empathy. It is unfortunately a common phenomenon among medical students, starting from their first-year gross anatomy course when many students encounter death for the first time. It is difficult to memorize every single orifice and nerve fiber in the human body, but to do so while encountering mortality and the strong emotional reactions that come with it is an even greater challenge. So, while coping, students inadvertently fall into the trap of locking their emotions away. In general, students depersonalize to protect themselves from being hurt by negative experiences — they objectify patients or dull their emotional reactions to certain situations. It just so happens that depersonalization is one of the aspects of burnout, a syndrome also characterized by dysphoria and emotional exhaustion. The emotional burdens of clinical clerkships are also enormous and many students find that burnout gets worse in their third year.
For this reason, writing has been personally important for me throughout medical school and even more so in my third year. Writing offers reflective opportunities that allow students to process powerful emotions or struggles, to slow down and face the emotions that they may have suppressed in the process of coping with the demands of medical school.
For me, this has meant jotting down a few lines on my service lists when I wasn’t too busy, sitting down to write a simple haiku or scribbling the events of the day in a journal or planner. These exercises helped me unlock and reclaim my emotions. They helped me recover from exhaustion and depersonalization. And looking back on them, these scraps of writing tell the story of my third year. I have faith that continuing to create more of them will help stave off cynicism and burnout, they will someday tell the story of my transformation into a physician.
There are many interesting papers concerning the effects of writing and reflection on care providers. In a recent randomized clinical trial, journaling, reflection and group discussion helped physicians experience significant improvements in meaning, empowerment and engagement in work. A 2013 survey revealed that the majority of medical students at one institution found that reading a medical school literary publication promoted patient-centered care, prevented burnout and helped them understand their colleagues and classmates. But when I mention writing to my classmates there tends to be a sigh, followed by a declaration that runs along the lines of: “But I’m an awful writer!”
We all have experiences, and experiences can be captured in writing by anyone, regardless of their publication history, their creative writing training and their knowledge of literature. I firmly believe that it doesn’t matter how much Whitman a person can quote or how many local coffee-shop readings a person has ever been to: everyone has a story to tell.
As I shared at the most recent “Examined Life” conference at the Roy J. and Lucille A. Carver College of Medicine in Iowa City, I discovered that there are many writing exercises that can not only help get a poem started, but also document and dissect a medical student’s experience. For instance, simply jotting down a to-do list or dissecting the contents of a briefcase or backpack can lead to the creation of a catalog poem that captures a snapshot of medical school life. Spending a few minutes to recall the events of a day in the form of a journal entry or writing about a patient encounter from the perspective of an object in the room can help a student relive an experience through new eyes, rediscover emotional responses or find opportunities for change. These exercises only take a few minutes, and anyone can do them.
All you need is to set a timer for five, 10, 20 minutes and to resolve not to lift your pen from your paper during that time. Just write. Not for publication. Not to impress anyone. Write for yourself.
My school has a third year extra-clinical curriculum called Safe Harbor, which unites my class from our varied rotations for a short discussion session concerning topics like bias, conflicts of interest, professionalism and work-life balance. It has been an excellent forum for reflection, a resource that I know students at other medical schools do not have. As I attended the “Examined Life” conference, I watched presentations concerning the development of reflective curricula that were similar to Safe Harbor and are new and in high demand among the students at other schools. This made me grateful to have a safe space to reflect, a place to reconnect with my friends again and listen to their stories.
But I would also advocate individual reflection through writing — or any other activity, like prayer, meditation, exercise, music, art and more — as a means for students to slow down, stay balanced and stay emotionally intact throughout the challenges of medical school.
We find ourselves in some terrible situations in third year, but we also get to have the most amazing experiences: birth, healing, hope. And, even the worst experiences are slices of patients’ lives we should consider ourselves privileged to encounter.
Because of that, when someone asks me how my day was in clinic or in the hospital, I want to say something more along the lines of, “It was incredible! Let me tell you…” And so I try to slow down, reflect and recover as often as I can.
As medical students, we shadow physicians to learn about the nature of medicine from them and their patients. In this column, Diem traces her own shadow, preserving and illustrating her experiences—in class, in the hospital, and in between—as a humble medical student.