Medical education: Guiding professional identity to prevent burnout

ROVIDENCE, R.I. [Brown University] -- Medical educators and students are paying unprecedented attention to the idea that the way doctors arrive at a professional identity may have a lot to do with whether they survive and thrive in the profession. More than just inspiration, professional identity formation -- PIF -- is increasingly seen as a crucible in which doctors become tempered against burnout, cynicism, and ethical decay.

This subject has exploded into the pages of a special June issue of Academic Medicine, where medical educator and clinical psychologist Hedy Wald, clinical associate professor of family medicine in the Warren Alpert Medical School of Brown University, was guest editor for a set of 23 papers on professional identity's myriad implications. As many of the articles make plain, fortifying doctors' professional identity is key as those lacking a deep personal clarity and commitment of purpose are more susceptible to the considerable stresses of the job.

The purpose of the special issue is to develop an explicit understanding across the profession of what drives PIF and how to guide and nurture it -- not only in medical school, but throughout a doctor's career. In articles that have begun to appear online, educators compare their notes on how practices such as mentoring, ethics courses, and reflective writing equip students for the difficulties ahead.

"We're seeing a shift to a broadened focus on being a physician as well as on doing the work of a physician," Wald said. "Not that there weren't wonderful educators that always cared about cultivating humanistic, ethically vigilant, socially responsive and responsible practitioners, but I think what's happened in more recent years is that there has been an increased nod to the scholarship of teaching."

Scholarship is what allows educators to integrate intuition with proven methods. Ultimately, she said, the stakes are patient care.

"[As a doctor you are] trying to remain your authentic self, that beautiful self that chose this amazing career, this profession that has a calling to help the sick -- what a privilege -- and to hold onto the humanized person that you are so you don't become dehumanized and then dehumanize the patient," she said.

That happened in the extreme during the Holocaust where doctors went from being healers to killers -- a complete loss of anyone's definition of professional medical identity. One of the papers in the special issue, co-authored by Wald and Dr. Shmuel Reis, adjunct professor of family medicine, describes a curriculum for guiding students to draw upon the lessons of that dark cautionary example.

Students speak

In another of the papers, a panel of four Brown students and a Massachusetts General Hospital resident speak for themselves about PIF. It's clear that the process, when explicitly considered, is not easy. One difficulty is the feeling that they are imposters when they wear their white coats and meet with patients, but are still just beginning to learn what it will mean to be a doctor.

Robert Cook, now a fourth-year Brown University medical student, confesses in the journal that sometimes he wishes he could skip the process, even as he acknowledges how necessary it is.

"I am tempted to escape the present moment (with its difficult lessons) and imagine that I have already passed through the fires of medical school and residency and have emerged on the other side without needing to be burned and shaped by them," he wrote. "I struggle with remaining present through this difficult process of PIF, so I can fully experience what it is like to be ignorant, even as I strive to gain knowledge."

Fourth-year Brown medical student Joanna Sharpless, who organized the paper's panel, enrolled in Brown's undergraduate and medical dual-degree program. Her emerging professional identity was tested by ordeals in her first year of medical school. After an undergraduate career as an English concentrator, she faced an avalanche of physiology and intensive memorization. She struggled to sustain the connection between what she was doing and her original motivation: to meet and care for underserved patients and to know their stories.

She credits her parents, especially, for helping her get through the early days before her first clinical rotation, when she realized that her gut inclination toward medicine had been right and that it truly was her calling. Her first clinical rotation was in internal medicine at Memorial Hospital where she became part of a medical team that tackled complicated cases among patients who often had trouble communicating, and who carried difficult medical and socioeconomic histories.

"I loved it, oh my gosh I loved it!" she said. "I had that reward I had been waiting for the first two years. This is where I belong. These are my people."

She's now set to begin a family medicine residency at Montefiore Medical Center in the Bronx.

Theory to practice

For many students, PIF is a journey that while personal, is not always intuitive. It can be guided, many authors write in the journal. In one of the papers, for example, Wald and several colleagues, including Dr. David Anthony, Associate Professor of Family Medicine, present and discuss the techniques they employ.

At Brown, and in seminars all over the country, Wald wields the "power tool" of reflective writing. In their first- and second-year doctoring course, and again in their third-year family medicine clerkships, students write about their thoughts and feelings about what they are going through and gather in small groups for collaborative reflection. Sharpless said she's observed plenty of students who are at first hesitant but then realize the power of self-revelations and those of colleagues through this process.

Brown has developed two frameworks to help instructors assess students' writings and provide constructive feedback that contributes to PIF, Wald said.

Students express and examine their responses to various professional situations. Sometimes the exercise clarifies where students can find joy in their profession. As fourth-year Brown medical student Grayson Armstrong wrote, "Through reflective writing, I realized I was beginning to draw satisfaction from patient interactions instead of purely from successful medical treatment/patient outcomes."

Meanwhile, at McGill in Canada, instructors focus on preparing students to remain resilient in the face of adversity. The "ethically challenging clinical scenarios" module, for example exposes them to events such as "being verbally abused by a physician in authority, being put under pressure to perform an ethically questionable procedure on a patient, [or] being manipulated by a resident to not answer questions posed by attending staff."

The focus is not on the response, but on learning how to manage the process of responding. "We focus primarily on a student's ability to remain congruent and mindful in his or her response to a stressful scenario," the authors wrote.

A third technique involves using some technology to sustain residents' involvement in PIF, even as they begin medical practice. At Reading Health System in Pennsylvania, residents maintain an electronic professional development portfolio to keep them and their mentors engaged with their professional reflection. The busy professionals convene in three sessions a year to discuss the trainee's writings and thoughts on specific professional development exercises.

Though it is deeply personal and almost spiritual, PIF can be described within a few key themes, Wald said: reflection, relationship and resilience. Students explore and discuss their motivations and responses, they gain guidance on how to appreciate the good and process emotionally challenging scenarios, and they interact with trained mentors, patients and each other -- all to gain wisdom.

Sharpless said she is sure that explicitly considering PIF has helped her.

"It's pretty impossible to go through that entire four-year grueling, tiring process and not come out with values and interests and some sense of self that is different from what you had when you had no information," she said. "But that being said, people who go through that process and are able to develop coping skills and are able to focus on the things that energize them about medicine come out with probably a healthier professional identity than people who go through and are really trapped and bogged down by the things that are difficult."

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