in-Training: hahtories from Tomorrow’s Physicians, edited by Ajay Major and Aleena Paul (Pager Publications, Inc., 2016).
I was interested to review in-Training because it provides a collection of contemporary students’ perspectives of medical training in the USA. I wondered what has changed or remained the same since I was a UK medical student over 30 years ago. These essays and poems offer a glimpse into the transformative journey from pupil to physician.
The idea for in-Training arose when two fourth year medical students, Ajay Major and Aleena Paul from Albany Medical College, started an online publication in 2012 and invited their peers to write about any aspect of their experience of medical education. Their intention was to create a space for students ‘to express their innermost passions and their greatest fears about their chosen profession’ (p. xix). The response was enthusiastic and they published over 850 articles and poetry in the next four years. This compendium provides just over a hundred examples of the writing submitted. The book is divided into eleven themed sections that reflect the student journey from the dissection room to becoming a fully-fledged doctor, including writing about burnout and severe mental illness.
The authors state that they hope the book will be used as a resource for students and educators to encourage self-reflection, discuss the nature of medical education and to promote humanism and compassion in medicine. The Preface emphasises the importance of acknowledging the social determinants of health for patients and is evident in the articles included in the section entitled ‘Systemic Afflictions’ (pp.105-139). We do not often hear medical students’ views on health inequalities such as the effects of structural racism and poverty on patients, issues that need discussion if our future doctors are going to appreciate the role of socio-economic factors in disease development.
Articles in the ‘Global Health’ section (pp. 297-324) raise ethical and political issues about healthcare delivery in some of the poorest countries in the world. There are perceptive contributions from students who worked in Haiti, Chennai and South America. It made me question how much teaching about international health takes place in current UK and USA medical curricula and whether as educators we do enough to encourage debate among students about global health.
Reading this book brought back the intensity of student experience from the shock of dissection in Year 1 to dealing with death and distraught relatives on the wards in later years. A strength of the compendium is that it is easily accessible both to students contemplating a career in medicine and to those already in training. Much of the writing is raw and sincere and will speak to readers at the same stage in their journey towards qualification. The book will also encourage reflection in — and on — practice (Schön 1983), as well as situated learning (Lave and Wenger 1991), providing ample examples of student experience in different clinical settings with detail on students’ reactions at the time in addition to their thoughts afterwards.
There is humour as well as poignancy. ‘Hello Sir’ (p. 19) by Haikoo Shah, is an apologetic and honest letter to the overweight cadaver she has just finished dissecting. She recognises that she has been treating the body as an inconvenient and often frustrating mass of fatty tissue. It is only when she discovers the lung metastases and considers the person of the corpse that he regains his humanity. Her letter is an acknowledgement of this fact, for which she is grateful and humble.
Jennifer Hong’s thoughtful article ‘On Empathy: can these shoes ever fit?’ (p. 37) questions whether empathy can be taught alongside clinical skills and suggests that ‘we should be caring for patients in spite of understanding them,’ an interesting argument that might spark a discussion on ethics and the nature of patient-centred care. The section entitled ‘From the Other Side’ includes reflective accounts by students dealing with family illness or death and how these experiences alter their attitudes to patients. There are also articles about student experience of being a patient.
As the editors of in-Training point out, these personal narratives reflect successes and failings by peers that may help other students to cope with the stress of medical school and to try and remain compassionate and humane carers of their patients.
There are some omissions. There are very few articles in the book about the relevance of the arts to medicine or medical humanities as a discipline. An exception was Olivia Low’s article ‘Learning to See’ (p. 40), which describes her interest in photography and her recognition that the discipline of making photographic portraits increased her sensitivity to visual cues from patients. The eloquence of this short piece of writing could easily be used to stimulate discussion and reflection on the ‘art of medicine’ and the importance of developing observation skills.
It also surprised me that there was comparatively little discussion about interaction with health professionals other than doctors such as the nursing staff, whereas encounters with patients and senior clinicians abound.
A weakness of the book is its length and over-inclusiveness, presumably because the student editors wanted to do justice to the large number of manuscripts they had received. Several themes recur and the format of three or four questions at the end of each essay or poem to encourage reflection is repetitious and formulaic. It is a pity that no other methods of self-reflection are offered such as graphic medicine or links to other art forms such as painting or music. Another shortcoming of the compendium is that almost all the writing is based on hospital-based care experiences. This may reflect the difference between curricula in the USA and in the UK but was a disadvantage as far as I was concerned as a GP involved in primary care medical education.
In conclusion, in-Training provides a useful resource of medical student writing that could be used selectively by students and educators to stimulate discussion, particularly about the role of socio-economic factors in health and disease. The book might also encourage readers to try and write themselves and recognise the value of this medium as a way of reflecting on their experiences and providing catharsis. It is unlikely to appeal to students training in related professions other than medicine. The way healthcare is accessed in the USA offers some contextual differences to medical training in the UK but the transformative experience of becoming a physician remain universal and is clearly expressed in the articles and poetry within this volume.
Reviewed by Dr Emma Storr, a GP and Clinical Lecturer in Primary Care, Academic Unit of Primary Care, University of Leeds. She has worked in medical education since 1997 to develop primary care teaching and placements for students. She has a particular interest in Medical Humanities and has run student selected modules in Writing Well, Medicine and the Arts and the Ill Child in History. She is currently doing an MPhil in Writing at the University of South Wales with the aim of producing a poetry collection.
Correspondence to Dr Emma Storr.
Lave, Jean, and Etienne Wenger. 1991 Situated Learning: Legitimate Peripheral Participation. Cambridge, UK: Cambridge University Press.
Schön, Donald. 1983. The Reflective Practitioner. New York: Basic Books.