In Reply to "'I Started to Feel Like a "Real Doctor"': Medical Students' Reflections on Their Psychiatry Clerkship".

To the Editor: I read with interest the excellent report by Schatte et al. [1] on the reflective writing of medical students during the psychiatry clerkship experience. I strongly agree that narrative reflection can greatly help students process complex and challenging experiences during training, and I think it is particularly useful for us educators to understand and respond to the most important themes that emerge from such reflection. At our institution, we have required students to write a 500word reflective essay at some point during their clerkship, with the general prompt of picking a patient they worked with that stood out for them, writing about what made them stand out. This essay counts for 10 % of their final grade, with student papers assessed for empathy, ability to reflect on meaning, and presentation of broader issues beyond the case. An informal look at the past year of essays shows very similar themes to the ones reported by Schatte et al. Out of 159 essays, 18 % emphasized themes of context (that patients do not exist in a vacuum, that family and social forces matter, etc.). Another 17 % addressed the struggle of patients with mental illness, particularly recognizing the severity of illness and functional effects. The third most common theme (16 %) related to challenges in the doctor-patient relationship, particularly countertransference, provider limitations, and resistance. To our surprise, only 5 % of essays addressed issues of patient autonomy or paternalism (e.g., coercion, capacity, etc.). We were particularly interested in examining if there were any differences in themes between essays written at the very start of the students’ clerkship year, compared to the writing of students at the very end. Although the combined sample is small (n=38), it does appear that students just starting clerkships were more likely than their veteran peers to write about issues of context and the doctor-patient relationship (50 vs. 25 % for both) and less likely to address issues of autonomy, severity, or patient-centered care. When we sit down with students to discuss the clerkship experience, these are the issues we now highlight, both at the outset and during the clerkship, in an effort to help students more productively and safely grow into their professional identity and role. Using reflective writing as a prompt for group discussion can further deepen the value of such writing [2]. Finally, it also seems important that such a process takes place throughout the medical curriculum, not just on psychiatry. Although the psychiatry clerkship certainly raises unique and powerful issues related to patient care, the most common themes raised by students certainly occur in many clinical contexts, and students are likely to benefit from reflection on all clerkships. At our institution, we have successfully encouraged other clerkships to add a writing component to the requirements, and other medical schools do reflective writing throughout the curriculum, which seems to be a particularly useful way to help students with their professional development.