Amid the frenetic pace of a hospital emergency department, a truism can be overlooked: patients go to the ED because they need care. They are sick, but may not express their conditions in a clear or even truthful way.

Geoffrey Z. Liu, M.D. ’15, recalled a patient he met as a second-year medical student at Yale. In the ED examination room, the patient complained of paralysis along her body’s entire left side. “When someone says she cannot move a side of her body, you immediately think neurological—is it a lesion on the brain?” said Liu, now a psychiatry resident at Massachusetts General Hospital in Boston. He asked follow-up questions to narrow his diagnosis. Did she see spots in her vision? A tingling on the left side of the face? Her answers didn’t fall into categories of related symptoms. On top of a potentially debilitating medical situation, the patient explained she’d just lost her job and was in the midst of a divorce after her husband’s infidelity. “Her story tugged at our heartstrings,” Liu said. Her condition, he and his colleagues decided, was from a cortical stroke. The attending physician complimented the team’s analytical thinking, then gave the diagnosis: opioid addiction. According to her medical records, the patient had visited several local EDs and presented with different symptoms, but always requested a prescription for Vicodin, made from acetaminophen and hydrocodone, an opiate. “This patient may be lying, but she still needs your help,” Liu said, recalling what his preceptor said. Still, Liu felt betrayed. To sift through his emotions, Liu chronicled the experience in his journal.

As a third-year student, Liu found a way to share the power of such reflective writing with his classmates. After students completed their surgery clerkship, Anthony W. Kim, M.D., then associate professor of surgery, asked Liu and his classmates to give a workshop—they could choose any topic—to their colleagues to practice presentation skills. Liu, who had majored in philosophy as an undergraduate at Yale, created a series of writing prompts. “I thought things would go down poorly,” Liu said of his workshop. He didn’t want to come across as touchy-feely. Surgery has a reputation as a specialty in which physicians and staff keep an airtight seal on emotions. Liu started with low-hanging fruit: Write for one minute about the most boring moment of the past week. Or: Since being on this clerkship I have become more _________. After a half-hour of warming up, Liu went deeper: Write about a patient who made you deeply uncomfortable during your clerkship.

The students’ response was enthusiastic. “If you don’t have the right person leading this, students can think it is a hokey exercise,” said Kim, now chief of thoracic surgery at the University of Southern California. “But Geoff understands people. He really helped the students open up about their experiences.” Kim and Richard J. Gusberg, M.D., director of the surgical clerkship, asked Liu to lead the workshop again after the next group finished. Liu obliged and volunteered his time for periodic workshops for the next 18 months. Kim, Gusberg, Liu and others published a 2015 study in the Journal of Surgical Education that detailed how reflective writing could be incorporated into the medical school curriculum. And that’s exactly what happened next in the medical school.

Institutional support

After Liu graduated and left for his residency in Boston, Anna Reisman, M.D., associate professor of medicine (general medicine) and director of the Program for Humanities in Medicine, approached Michael L. Schwartz, Ph.D., associate professor of neuroscience and associate dean for curriculum, about incorporating reflective writing workshops into the four clerkship rotations as a pilot program. Schwartz agreed, and members of the curriculum committee will decide later whether the workshops should be permanently included. Next, Reisman looked for a successor to Liu. Initially, she seemed a likely candidate. “But we decided what is so unique and wonderful about this is that it is led by students,” Reisman said. Daniel Zheng, a fourth-year medical student, volunteered to fill Liu’s spot, having been impressed with the exercise the year before. Zheng and Reisman recruited 11 additional workshop leaders and created a training program. Besides learning how to lead discussions around sensitive topics, the team took a course in Title IX compliance reporting for issues of sexual harassment.

Already, certain themes have emerged from the students’ writing after each of the clerkships. After the medicine/neurology clerkship, students have written about the emotional burden of being a health care provider and how social determinants affect the quality of care. Following the surgery/emergency department rotation, students have struggled with a loss of empathy and challenging team interactions and power dynamics. Pediatric and obstetrics/gynecology rotations have resulted in stories about unexpected emotion, or lack of emotion, while witnessing births and abortions.

Kayleigh Herrick-Reynolds, a fourth-year who will lead third-years through the workshop this year, said she rarely writes in her spare time but felt reassured by the structure of the workshop. “It’s a good setting for people who aren’t used to writing—you’re not thrown in the deep end,” she said. She also noticed that her writing was more intimate and personal in her clerkship workshop than in other writing she’d done for assignments in medical school. Herrick-Reynolds, Reisman, and Zheng are collaborating to publish a journal article about the workshops. This past fall, the group collected responses from 102 students and eight workshop leaders.

Students were asked whether they would be more willing to write about certain topics—medical hierarchy, sexual harassment, patient interactions—with a peer leader than with a faculty member. The team will also analyze anonymous writing samples from previous workshops according to a four-point scale to determine if, based on word choice, empathy increased among students throughout the course of the four workshops.

When asked whether he writes now, Liu said he has taken a break from formal writing, but still keeps a diary. Herrick-Reynolds and Zheng had similar situations. With institutional support, Kim said, reflective writing could be more commonplace for third-year students. That would be significant, added Kim, who sees this exercise as “a potential tool that mitigates the effect of physician burnout.”