Have researchers in health professions education pathologised medical training?

Abstract

Researchers in the field of health professions education typically approach scientific inquiry with a pragmatic lens, seeking to elucidate shared problems and, in turn, their solutions.¹ In this issues of Medical Education, Pattinson, Savelberg and Atherley use longitudinal audio diaries to explore the ‘problem’ of transitioning from medical student to junior doctor.² While that transition was indeed stressful, the authors note, ‘Challenges can be seen as opportunities for valuable personal and professional development where transformational experiences are lived and reflected on’. They call for a conceptual shift away from seeing transitions as discrete events, which health professions education almost invariably frames as problematic, and toward seeing them as ongoing, complex processes.

We endorse this frameshift. As longitudinal qualitative researchers, we are uniquely positioned to follow the trajectory of these ‘problems’ as they evolve over time. One of us interviewed 15 women throughout their 4 years of medical school to understand their process of becoming doctors within a gendered organisation.³ Another interviewed six medical students as they became residents, fellows and ultimately practicing physicians over the course of 12 years, exploring the challenges they faced when constructing a career in medicine or surgery.⁴ Having the privilege of sustained engagement with participants in these studies, both of us found ourselves asking, has health professions education pathologised medical training? Have we made training a condition that needs to be treated, if not cured?

Clearly, there are problems. For instance, suicide was the most prevalent cause of death for US medical residents and fellows from 2015 to 2021, a statistic that is wholly unacceptable.⁵ Moreover, the very structure of medical training is one rooted in exclusion and still struggles to recruit and support a diverse student body.⁶ In health profession education, researchers' problem-based focus may suggest that the long arc of training inevitably bends toward depletion. In our experience, however, when trainees narrated their own growth as aspiring doctors, they viewed their paths in a much less pathological manner.

Take empathy, for example. Research reporting a decline in empathy with clinical training may be interpreted as an inevitability for medical students.⁷ Aspiring doctors believed the research that foreshadowed an inevitable decline in empathy as training progressed; they worried that they would become jaded. But, to their own surprise, they did not. Rather, how they conceptualised empathy changed through time, in response to the challenges of medical training. When asked about earlier warnings that empathy would decline, one newly minted neonatologist pushed back: ‘I think if anything, I have more empathy’. She struggled with conceptualising her care as empathy, per se, recognising that she could not completely understand what someone else was feeling. But her commitment to empathic care did not decline: ‘In the context of [this hospitalization] being one of the worst things that ever happened to them, I'm just being good to them. And trying to help’. What we heard by listening to aspiring doctors across years of training was not simply a pathological decline in empathy but an evolving relationship with empathy: the complex pathophysiology of training.

Focusing on problems might be at the core of the field of health professions education, but it is time to ask: What is at stake for trainees if we continue to pathologise training? As Thomas and Ellaway advise, considering everything as a problem restricts how we view training in health professions education.⁸ We take that assertion one step further, speaking from our experience with longitudinal research relationships with trainees. If we focus only on pathology and what is wrong, we lose sight of pathophysiology and how trainees respond to the highs, the lows and the in-betweens of medical training. When problems dominate the discussion, medical trainees lean into how medical education has damaged them—or, as one participant said, ‘the trauma inherent to medical education’. What is missing is the longer view. Three years later, that same participant said this when asked to offer career advice to her younger self: ‘I would just tell myself to trust that your career will work out. No, not trust that it will work out but trust that YOU will make the best of what happens’.

If we continue to pathologise training, we may narrow the moral and imaginative space of their chosen profession. Trainees are not flattened by training; they are transformed by it—sometimes painfully, often imperfectly, but almost always meaningfully. As Pattinson, Savelbert and Atherley call out, challenge is not always a problem.² Shifting our research perspectives to value longer engagement with trainees may help us recognise how they traverse the terrain of their learning. In doing so, we may be helping to make stories of flourishing and hope come true.

Dorene F. Balmer: Conceptualization; writing—original draft; writing—review and editing. May Shum: Conceptualization; writing—original draft; writing—review and editing. A. Emiko Blalock: Conceptualization; writing—original draft; writing—review and editing.

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.