Life Doesn’t Stop for School

Background

During his first clinical clerkship, a medical student’s mother—who had been experiencing chronic, disabling back pain—was diagnosed with advanced metastatic breast cancer. The student is an only child and described himself as very close to his mother, whose immediate family lives in Sweden. Because he considered his father to be a better follower than leader, he expressed concern about his father’s ability to help his mother negotiate her health care needs. Shortly after her diagnosis, he was provided an opportunity to travel across country to be at home with his mother, who lived on the West Coast, and to meet with her doctors. The student had experienced no academic difficulties during his first two years of medical school (GPA = 3.43, USMLE Step 1 = 229). During his first clerkship, his academic performance was not as strong as his pre-clinical work. However, he felt he was learning and believed that staying engaged with his studies was important to his mother. He successfully completed his clerkship, scoring at the 22nd percentile nationally on his NBME subject exam.

Family Medicine Clerkship Dilemma

Due to his mother’s diagnosis, the geographic location of the student’s second clerkship (family medicine) was changed at his request to a clinical site on the West Coast, in order to make it easier for him to visit her on weekends. Prior to the start of this clerkship, the student stopped in to meet with the course director to discuss options to allow him to take some additional days off to be with his mother. He articulated feeling very emotional about his mother’s illness and that he had significant concerns about her health care team. He was finding it hard to be away from her and to cope with her prognosis. He further reported that he had begun to seek counseling on these issues with his personal family physician. He felt that he was able to focus on his studies, but just needed some time to be at home. When approached with the idea of requesting a leave of absence, he was reluctant to do so since his success in school was so important to his mother. In consultation with the Office of Student Affairs, arrangements were made for him to have two, 4-day weekends of travel built into his family medicine clerkship schedule.

During the first week of his clinical training the following direct observations were made by the course director (N.B. week #1 of the 6 week clerkship occurs on the medical school campus, weeks #2-6 occur at the clinical site):

• In order to accomplish the travel arrangements due to the change in location of his clinical clerkship to the West coast clinical site, the student required significant one-on-one assistance from the course director to complete relatively simple tasks.
• His personal physician raised a concern about the student’s level of tearfulness, his overall mood, as well as his inability to share his fears about his mother’s illness with others.
• Throughout the first week of the training, the student repetitively expressed concerns about his mother’s care team and plan. Following a required training session in patient advocacy, he was openly tearful about these worries and reported wishing that he could find doctors who would advocate for his mother.

In response, the course director asked the student to self-assess his ability to concentrate and learn under the current circumstances. He once again denied any concerns. He affirmed his desire to continue in the rotation. Due to her observations, the course director discussed her concerns about the student’s well-being with the Office of Student Affairs. In addition, she contacted the student’s clinical site director to make him aware of the student’s ongoing personal issues and raise a concern about the potential impact of his mother’s illness on his upcoming clinical work. Further, the student and course director requested that the clinical site identify someone who would serve as a counselor for the student, but who would have no direct supervisory role over him. The student had agreed that this would be an important resource for him, as well as ongoing contact with his personal physician by phone or e-mail.

Upon arrival at his clinical site on week #2 of the clerkship, the student was noted to be quiet, but always professional and eager to learn. Though initially engaged, he became progressively disengaged and distracted. His knowledge was assessed as below expectations for his level of training. He struggled with time management and confidence.

Due to a growing concern about the impact of current events on his daily work, the physician assigned to serve as his counselor and confidant was asked to meet with the student to discuss these observations. During this session, the student broke down in tears, stating that he felt overwhelmed, conflicted and uncertain what to do. He reported difficulty with concentration and tremendous grief about not being with his mother while she underwent her treatment.

How should this physician, his clinical site director and the course director proceed? Who else in the faculty and the administrative structure should be notified? Should his schedule be voluntarily modified or should it be mandatorily modified? What are the implications if he chooses to withdraw? Should anything have been done sooner?

ACKNOWLEDGEMENT: This article represents the views of the authors and does not represent the views of the Uniformed Services University of the Health Sciences, the United States Air Force, or the Department of Defense.

Student Response

The attending physician-medical student relationship naturally fosters both a learning and a guidance seeking environment to which students are accustomed. As an individual with no administrative duties, the student’s physician counselor sits in a unique position to act as a role model for the student. This counselor can provide guidance and personal advice that the student can understand and which is neutral in concern with regards to his standing in school. The student can first raise his concerns and make decisions with this person without fear of any sort of disciplinary action. He can come away prepared with what he wants to do on a personal level and next follow up with his clinical site director and university faculty.

Following a session between the student and his physician counselor, the clinical site director should reevaluate the student in a personal meeting. Prior to the meeting this individual should consider speaking to the student’s university clinical affairs liaison about possibly classifying this student’s month as time off (if the student does indeed get vacation months) to prevent a failing grade from being placed on his transcript. During the meeting clear expectations should be laid down by the site director to the student with the understanding that the director’s primary responsibility to the student is their medical education. The student needs to know exactly how he is not meeting standards and that he may not pass if he continues to perform below standards. It should also be made clear that personal judgment is not the issue and that the student’s personal decisions about how he would like to proceed due to these life changing events are his to make. The student needs to be told that taking time off is in no way a sign of failure and is a continuing option. However, the clinical director’s main role is to reinforce to the student that he is not meeting performance expectations and that there are no exceptions to standards when training to become a physician.

Finally, the student’s clinical affairs office needs to be directly involved with the situation. They are in an appropriate position to develop, in consultation with the dean of clinical affairs, options for the student.

At this juncture, following two separate points of intervention, the student needs to be made aware that if he were to choose to continue in his studies, his performance must remain at or above expectations. Otherwise, university directed modification of his status will be mandatory. A “3 strike, you’re out” parallel would be appropriate for this situation. The interventions that have taken place thus far have been generous in accommodating the student’s requests, as well as giving him a sanctuary for free thought and guidance for him to formulate future paths.

Faculty Response

This case demonstrates the emotional and psychological toll of a devastating illness in a parent on medical students. Not only are students deeply affected by the illness itself, but they may feel compelled to take on medical decision-making for their family, even when they are not fully trained. This conflict can further contribute to the student’s sense of helplessness and powerlessness.

The student in this case shows growing signs of depression but finds these difficult to accept. Clearly these feelings are affecting the performance of this competent student. One option would be for the student to meet with his most trusted advisor or his physician (meeting with three faculty members could be overwhelming) and urged to meet with a psychiatrist to address the depression. With the student’s permission, perhaps this advisor or the psychiatrist could reach out to the father, and even possibly the mother, so that they would not be worried that a leave of absence would be detrimental to the student’s grades or career. Reconnecting with the father might be very affirming in this difficult situation. With more information the parents might join with the physician and/or faculty in giving the student permission to spend time with his mother.

Regarding a change in the student’s schedule, a voluntary change would be optimal, but with psychiatry input, if the depression remains serious, a mandatory withdrawal might have to be considered. Students fear this can impact their residency selection and career. When handled well, however, such leaves of absence can show caring and maturity. In my experience I have not seen leaves of absence in such settings detrimental, so some reassurance might be in order.

For this student, earlier counseling about grieving and the importance of taking time off would have been optimal. Administrators could have assured the student that such leaves are common when a parent has a terminal diagnosis. Clearly the school has followed the student closely, which is positive, but by the end of the case definite interventions are needed.

Administrator Response

Many students are relatively inexperienced in balancing life and work which in their case is school. Consequently, a student will often view stepping away from school as an admission of weakness or failure. It is our job, as faculty, mentors, and advisors, to keep students’ best interests in mind. This means we must help them to see the long-term implications of decisions they make today. “Powering through” is not always the best answer, even if it may be the most natural reaction for a driven medical student. We should help our students consider creative ways to meet all of their needs, both personal and academic, but not always simultaneously.

It is only natural to want to help this medical student to continue on with his studies, particularly at a time when so much else in his life is going through upheaval. Given that this student had a track record of pre-clinical academic success, it seems appropriate to initially explore special accommodations that allow the student to spend more time caring for his mother.

However, the first warning sign came with the student’s uncharacteristically low performance in his first clerkship. It seems that the geographical accommodations created for the second clerkship may have been proposed without knowledge of the student’s performance in his first clerkship. It would have been helpful, early on, to have a planning discussion among people familiar with the student and his situation, including the clerkship directors from the first two clerkships and members of the Office of Student Affairs. In this situation, inclusion of the first clerkship director in these early discussions would likely uncover evidence that this student would benefit from closer, local supervision at the main medical campus, particularly if these special long-distance arrangements only result in creating two weekends for the student to spend at home. These discussions may also serve as the first step toward considering a temporary leave of absence for the student.

Given that some medical schools have the option to take electives during the third year, it would be nice to explore scheduling alternatives that could convert an elective period into a short break for the student to spend with his family. In some cases, taking a short break may help to resolve the personal issues, or it may open the students’ eyes to the value of a longer leave of absence. Either way, taking a break of a few weeks during an elective period is likely to be easier for the student to contemplate and carries less of the stigma of letting a parent down.

In the absence of this earlier intervention, another turning point is evident in the beginning of the second clerkship. When the student is openly struggling during the on-site week of his second clerkship, asking the student to self-assess his fitness for continued study is inadequate. The observations of the clerkship director, together with the concerns of the student’s physician about his emotional state, should have triggered more serious intervention, precluding sending the student off-site. Although the appointment of a counselor at the clerkship clinical site was an important positive step, it is not a substitute for careful oversight on the main medical campus from a team of mentors who know the student well and would be able to recognize significant mental health issues as they emerged. A discussion should also have been initiated with the student about the potential of these circumstances to hurt his academic record in his required clerkships. Since these grades in particular are of significant importance when program directors evaluate potential residents¹, the student should be reminded of the consequences of poor clerkship performance on his ability to competitively match for residency. If a proposed leave of absence is framed with respect to the student’s long-term career trajectory, it may be seen as a more viable possibility.

Ultimately, the overarching goals should be ones that blend the student’s best interests with gentle but firm guidance. If left to his own devices, a troubled student might make a problematic situation worse. However, with appropriate direction and perspective from his mentors, he would hopefully become better equipped to make difficult decisions himself before a mandatory change in course is imposed on him.

¹Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-367.

Respondents

Student Respondent
Chad Meshberger MS III, 2LT Minnesota Army National Guard, Des Moines University, Des Moines, IA
Faculty Respondent
Lynn Bickley MD, Clinical Professor of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
Administrator Respondent
Shoumita Dasgupta, Ph.D., Assistant Professor of Medicine, Genetics Program, Assistant Dean of Admissions, Boston University School of Medicine, Boston, MA