Courage & Renewal at Work in Medicine: Retreat series for Harvard Medical Students

By Hanna Sherman, MD

Courage & Renewal Facilitators Bill Clark, MD and Hanna Sherman, MD were invited to develop and lead a retreat series for 36 Harvard medical students addressing how reflective practice, mindfulness, and relationship-building could impact their development as medical professionals and influence their experience of the stress of medical education. Designed as a research project, the program was funded by the Arnold P. Gold Foundation for Humanism in Medicine.

The retreat program, “Sustaining and Balancing Oneself in a Life of Service,” was offered to pre-clinical students, most of whom were in their second year. The curriculum included four sessions:

• Identity and Integrity: Knowing and Sustaining the Self Who is Becoming the Professional
• Balance: Finding It and Sustaining It
• Relationships and Communication: Inviting and Offering Personal Support during an Unpredictable Journey
• The Emerging Physician: Putting Professionalism into Action

The intention was to help students build solid foundations for an engaged, conscious professionalism. Session themes were based on supporting personal aspects of professional development, directly linking what they learned to daily work as a healthcare professional, and enabling students to better express humanism in their work.

The bimonthly four hour sessions were designed to be learner-centered and experiential, grounded in the principles and practices of Courage work. Each session opened with checking in, examining the agenda, and a brief meditative silence. Poetry and prose were often used to introduce ideas and open discussion about difficult issues. Activities included appreciative inquiry with personal story telling, guided self-reflection, small group process and discussion, and whole group dialogue. Students’ continuous feedback assured the course evolved according to their needs and wishes.

The first session, “Identity and Integrity: Knowing and Sustaining the Self Who is Becoming the Professional,” invited the students to examine how their identity is changing as they undergo their transition to being physicians. In order to create a safe and trustworthy community that could discuss matters of great meaning, the concepts of a circle of trust and touchstones were introduced. Students were taught how to engage each other with honest, open questions, honoring the inner wisdom of each student.

To look at their evolving identity, students were invited to consider their understanding of their identity as they approached medical school, how they imagined their education might change them, in what ways their identities were being affirmed, challenged, or changed, and what aspects of their identity they wanted to be certain to maintain and bring forward into their professional identities. The students appreciated the opportunity to speak with peers about parts of their professional development they had not formally examined. Some students were moved to tears as they traced what they valued and what felt at risk of being deformed in their educational experiences. Students were relieved to find commonalities and were especially appreciative of having judgment–free and non-interventional conversations.

In the second session, “Balance: Finding It and Sustaining It,” students examined their stresses, what constitutes balance, and how to manage time effectively. Students were invited to view balance as an alignment of personal values and meaning with apportioning time and energies. They noted how being in balance impacts one’s actions towards others, and suggested that being in balance allowed them to be more generous, kind, and compassionate. They readily linked that awareness to their roles in caring for patients. Next they were asked to list activities and relationships important to them and to group them into three categories of meaning: always present, present when able to attend to, only present when time is very spacious. In doing so, the students were able to see how they assign meaning to different aspects of their lives and whether they align their limited free time and efforts with what is meaningful to them.

Session three, “Relationships and Communication: Inviting and Offering Personal Support During an Unpredictable Journey” focused on listening and communicating for effective relationships. The students practiced various kinds of listening, noticing what each type of listening brought to self-knowledge, understanding of the other person, and development of a relationship. Students explored how different ways of listening apply to the care of patients and their experiences as care providers. They next explored individual “hot buttons”, or emotional triggers. The students shared compassion and humor in identifying their trigger points, while gaining greater understanding of how to moderate their reactions and expand their interpretation of situations and interactions. Students were given a take-home activity for enhancing empathy in a chosen relationship. Students particularly enjoyed this session. They readily linked their personal growth, communication, and relationship skills with their future patient care.

The final session was “The Emerging Physician: Putting Professionalism into Action.” The intention for this session was to help students gain an awareness of the benefits of their full presence in their healthcare practices and to identify their humanism as core to their professionalism. The session began with a re-cap of the year, tracing the movement of learning from the need to sustain identity and integrity to the role of mindfulness and balance in self-care and giving of themselves, and on to the essential nature of communication and relationship to healing. In the initial exercise, students explored the wisdom gleaned from understanding our own and others’ wounds. Students identified many attributes such as courage, facing fear, dealing with uncertainty, perspective, optimism, faith, empathy, humanism, and resilience. To look at the role of humanism in medicine, the students reflected on where their humanistic traits and attributes are affirmed or challenged by their studies and work. The students then identified how they will notice if they are expressing their humanism in their clinical careers and to articulate for themselves how they will sustain their ability to stay emotionally and spiritually present and able.

The year-long program concluded with students writing a few sentences of discoveries and what they learned from the year, which were later shared anonymously with the group. In a final circle students shared reflections from the year and celebrated each other in their wholeness, presence, and growth. Closing sentiments expressed hope, gratitude, love, acceptance, excitement, calm, community, and opportunity.

The sessions seemed to lay important groundwork and skills for the students. The students were drawn to the exercises and skill development and appreciated the opportunity to look inward and better understand their motivation, values, and capacities. They especially enjoyed being able to engage each other in honest, open conversation about difficult issues often kept more closely and private. The students observed changes in their behavior and openness as a community over the course of the year. They faced their strengths and fears with increasing courage as they harvested both their inner and collective wisdom. Some of their discoveries included “Practicing presence and coming to wholeness requires ongoing work, continual revisiting” “I’m grateful for having time set aside for reflection and thought. …I think I will take away knowing that I need to stay aware of myself in this profession, and how grounding it is to do so.” “To validate others’ pain and listen with full attention and without judgment.”

Evaluation of the program showed significant changes in several areas. As students moved into clinical practice in the hospital, they felt able to be present with patients, were actively reflecting, and found themselves turning to other students from the program to discuss their experiences in a continuation of their community of trust. One student described feeling drained from a challenging day as she went to see a patient. Pausing at the doorway, she noted her fatigue and distraction. Recalling what she had learned in the retreats, she then consciously laid down her stress, turned her attention to the patient, and entered the room. Subsequently the patient wrote a note to her care team, thanking the student for her presence and compassion. Courage & Renewal were at work in healthcare.