An Overview of This Year’s Trainee-Authored Letters to the Editor

Abstract

Academic Medicine’s call for trainee-authored letters to the editor, which has occurred annually since 2016, has successfully provided a forum for collecting and amplifying trainee perspectives. In the latest call in 2022, trainees shared a transformative moment that occurred during their educational journey and how it shaped their identity as a health professional. In this Commentary, 2 members of the journal’s staff provide a brief retrospective of the annual call using key demographics of published letters and letter writers. The authors then delve into the published letters from the 2022 call. To showcase the myriad of transformations described, they conceptualize 3 themes that best characterize these special moments: (1) reshaping the trainee experience through advocacy; (2) exploring humanism, morals, and relationality; and (3) finding one’s mark within medicine. In addition, to display the depth and richness of transformative moments, the authors include an in-depth analysis of the letters by sampling those that were identified to each theme. In this overview, they hope to present readers with inspiration from trainees around the globe and invite them to reflect on and identify the significant experiences encountered in their own educational journey that altered their professional identity.

Editor’s Note: An author’s voice is a powerful instrument. When used effectively, it can enlighten individuals, galvanize communities, and evoke change. As such, for the previous 7 years, Academic Medicine has structured space to feature the trainee voice in one of its most authentic forms. Through Academic Medicine’s annual call for letters to the editor, early-career authors provide a window into the world of the 21st-century trainee, tasked with providing high-quality care in an increasingly complex health care system. I have asked Lala L. Forrest and Laura Blyton, 2 members of the journal’s staff who were deeply involved in the 2022 call for trainee-authored letters, to share with readers their overview of the many important and fascinating letters that will be published in the May, June, and July 2023 print issues.

The journal’s annual call for trainee-authored letters to the editor, which has occurred annually since 2016, has successfully provided a forum for collecting and amplifying trainee perspectives. Using simple linear regression analysis, we found that the number of submitted trainee-authored letters to the editor has steadily increased (slope, 46.86; F = 3.33; P = .13) from 2016 to 2022, as has the number of accepted letters (slope, 4.39; F = 5.65; P = .06). We have featured letters from trainees representing 159 institutions. Although most of the letters have come from institutions that span the United States and Canada, published letters have also come from international trainees at institutions in Australia, Austria, Canada, Ireland, Israel, Italy, Jordan, the Netherlands, Pakistan, Qatar, Venezuela, Mexico, and the United Kingdom. Likely due to the editorial focus of Academic Medicine, medical students and resident physicians have consistently written most of the accepted letters. Of note, every year, the number of accepted letters with a first author who was neither an MD-degree nor DO-degree trainee has been limited, with the highest number of such letters reaching 4 in 2020. We encourage submissions from trainees in all health professions to better understand the trainee experience, as explicitly stated in the 2022 call¹ and earlier ones.

Health care professions trainees, including one of the authors of this editorial (L.L.F.), are valuable stakeholders within academic medicine, capable of spearheading initiatives and making strategic advancements across medical education and patient care.² For the 2022 annual call for trainee-authored letters to the editor, we asked trainees across the health professions to write letters about

… a transformative moment in your professional journey [and] to reflect meaningfully on how the experience affected your professional identity formation. In other words, a successful letter will not simply tell us what happened, but will also illuminate the role of that experience in shaping your identity as a health care professional.¹

We received 310 letter submissions from trainees describing an array of transformative moments. We were fascinated to read about the different forms of transformations described, the eliciting contexts, and the profound effects. All submitted letters underwent a rigorous review process, and ultimately 57 letters were selected for publication. As in previous years, individual letters were initially reviewed by a diverse team consisting of editorial board members, associate editors, staff editors, journal reviewers, and rising scholars in academic medicine. Recommended letters were then carefully evaluated for publication by Academic Medicine’s current editor-in-chief Laura Weiss Roberts, MD, MA.

We received more captivating letters than we had space for unfortunately. While only 18% of submitted letters were accepted for publication, we identified several additional noteworthy letters as honorable mentions whose authors are recognized on Academic Medicine’s website (https://journals.lww.com/academicmedicine/Pages/2022-Honorable-Mentions.aspx). We encouraged those authors to share the link with faculty, program directors, mentors, friends, and family.

Accepted letters were then analyzed to determine a conceptual framework to describe how transformative moments impacted professional identities among trainees. Three major themes emerged that will be featured in the May, June, and July 2023 issues, respectively: (1) reshaping the trainee experience through advocacy; (2) exploring humanism, morals, and relationality; and (3) finding one’s mark within medicine. Identifying these themes was difficult, as we felt that we were adopting a reductionist lens focused on the cause and effect of each moment, perhaps not accurately representing the complexity and beauty of the transformational processes eloquently detailed in the letters. Thus, to better depict the diversity and richness of the trainee experience, we included in this commentary in-depth descriptions of the “transformational moments” connected to these themes.

Reshaping the Trainee Experience Through Advocacy

Personal transformation often leads to deliberate action. After emerging from a transformative moment, many trainees felt compelled to enhance the learning and training environment. Some trainees also discussed health care at large and how trainees, regardless of their position in the hierarchy of medicine, have the ability to change practice. One surgery resident wrote:

In fact, those lower in the hierarchy are often the ones who can make a real impact. Whereas those at the top are far removed from day-to-day care delivery, those on the ground see opportunities for improvement first-hand.³

Many trainees also discussed the importance of the physician’s role, at times raising the question of the extent of physicians’ duties and responsibilities. A resident trainee summarized this point by stating, “To be a physician today is to confront the profound social, economic, and political questions of our time; whether we like it or not, these are our lanes.”⁴

Trainees used different instruments of advocacy to steer change. Many trainees discussed how their lived experience shaped their views on academic medicine and influenced their values and beliefs. One resident shared how her experience of miscarrying helped her to find her voice as an advocate for her female colleagues:

I see the flaws in not only the training system for female physicians, but the working environment, and I cannot remain silent about them. I openly share my experience and have found many more women, even inside my own institution, who are struggling with infertility and miscarriage. It provides them with comfort knowing they are not alone. If we do not talk about it, it will not change.⁵

Another trainee, a medical student, recounted how the “informal curriculum of medical culture”⁶ affected their ability to adequately grieve the death of a family member from metastatic pancreatic cancer. They realized that the medical culture needs to change to prevent burnout, which not only affects their peers but also their patients. They wrote:

Death and dying are ubiquitous in medicine. Therefore, it is imperative to teach medical trainees how to acknowledge and attend to our own grief.⁶

Trainees recognize the value in using their voices to speak out about topics of importance to them. Three medical students discussed the power of the pen: how writing and publishing opinion articles can “amplify the voices of our Black, Asian-American, and youth communities … lifting underrepresented voices and shaping key health care debates.”⁷ Trainees also spoke out about the need for policy engagement to address gun violence, the opioid epidemic, and the climate crisis. One trainee stated:

As health care professionals, we have a duty to understand how environmental health factors affect the day-to-day lives of our patients…. Our role does not end with providing treatment but must also extend to taking action as community members, voters, and advocates.⁸

These letter-writing trainees are actively changing the culture of medicine and enhancing patient care by sharing lived experience, engaging in curricular development, writing opinion articles, creating student organizations, and translating their skills and knowledge to policy work. Through advocacy and action, they are striving to directly reshape and improve their learning environment, and, more broadly, the community environment that impacts their patients.

Exploring Humanism, Morals, and Relationality

Many trainees discussed how experiences of the human condition through the patient–physician relationship influenced their professional identity development. Transformations in which trainees gained a better appreciation for the significance of compassion and humanity in medicine were commonly reported. One fourth-year medical student discussed how the exacerbation of health disparities by the COVID-19 pandemic impacted not only the type of care individuals received but also their perception of the value of care. For instance, the student articulated how a patient’s purposeful choice of dressing formally at their doctor’s appointment was a silent statement: “I deserve good health care.”⁹ The medical student explained how this encounter became a lesson about patient dignity and equality, writing, “This experience made me realize that I am now on the other side of the stethoscope, holding the power and privilege to honor my patients’ humanity no matter what they are wearing.”⁹

Compassion and humanity came to the forefront for a second-year resident who shared how a diagnosis of stage IV breast cancer shifted their role from healer to patient, which shaped their perspective on the importance of good patient care:

I will never forget how comforting it was when my hands were held without gloves by my doctors; how anxiety-provoking it was to wait for scan results; how much relief I got from my workup being expedited by even a few days; how the calm, patience, and confidence from my care team helped me hold onto hope while I was at my most vulnerable.¹⁰

Trainee authors also shared how transformative moments reflecting upon the human condition allowed them to hone and strengthen their professional skills. One trainee learned from a patient’s fatal prognosis the limitations of using evidence-based medicine in clinical practice. They wrote, “the art of medicine exists within the conflict between evidence-based medicine and each patient’s life.”¹¹ Another trainee described how an adolescent patient challenged them to “think about my words” and “that it is not only important that I ask [a question], but also how I ask.”¹²

Trainees also formed beliefs around physicians’ responsibilities and morality in medicine following transformative moments. After experiencing an active shooting, a second-year medical student described the courage of “Dr. B” to decide to remain in the hospital, not only treating his own colleagues suffering from gunshot wounds but also caring for his other surgery patients.¹³ Dr. B told them, “I have a commitment as a doctor. I will never leave my patient,”¹³ which shaped the medical student author’s view of a physician’s responsibility. Many trainees also described having their mindsets changed through encounters with critically ill patients and death. A pulmonary and critical care medicine chief fellow wrote, “We are programmed to always act. But after sitting with my dying patient that day, I realized how crucial it can be to sometimes wait instead.”¹⁴

Trainees beautifully detailed the power of relationships. From colleagues to patients, relationships have the ability to impact individuals, families, communities, and society. One trainee discussed how their new understanding of coauthorship as being relational instead of transactional has transformed their training experience: “A good coauthor pushes you to a better end product and sharpens your thinking in the process. Collaboration with such coauthors can be contagious and fun.”¹⁵

As trainees strived to better understanding the extent of their professional skills and responsibilities, they were driven by these principles of humanism, morals, and relationality. Their letters showed their realization that a health care professional’s role includes valuing the person in front of them and the people they engage with—from colleagues to patients.

Finding One’s Mark Within Medicine

Trainees are learning who they can be and the type of impact they want to make within academic medicine. Many trainees discussed the idea of embracing their whole selves. Medical students reinforced their identities as doctor–artists by learning “to see art and medicine not as competing interests, but as synergistic passions informing each other.”¹⁶ A pediatric gastroenterology fellow shared how they harnessed their identity as a “gay physician of color with inflammatory bowel disease (IBD)” on rounds to create awareness for lesbian, gay, bisexual, trans, and queer patients with IBD.¹⁷ They wrote, “By sharing my experience with health care, I try to create a safe space for patients … [I] strive to understand the person before me in all their identities.”¹⁷

Other trainees described overcoming imposter syndrome in different ways, from building an authentic connection with a 10-year-old patient by playing Star Wars Legos¹⁸ to trusting their instincts and obtaining a bedside electrocardiogram for a patient with “anxiety surrounding [an] ongoing foot rash.”¹⁹

Trainees are also realizing their professional purpose to combat health disparities by advancing justice and equity. “My role as an immigrant doctor will be to care for the tempest-tossed in this country, remembering how I, too, had arrived on its shores as a foreigner,” wrote an MD–PhD student after completing forensic medical evaluations at an asylum clinic.²⁰ Another trainee conveyed their passion for practicing research-informed individualized medicine after witnessing first-hand the health of a family member deteriorate from a hepatitis B virus infection:

I promised my mother and myself that one day I will provide the best evidence-based medicine in my field and fight for a better solution for people like her.… I want not just to publish papers with a so-called solution for a disease but papers that give us the capacity to become disruptors, creators, and advocates to close disparities in medicine, going beyond knowledge.²¹

Experiences in which trainees overcame failure were paramount for professional identity formation. A resident described how having to navigate failure has allowed them to work more closely with patients: “In my case, failure has made me a better, more compassionate physician because my patients sometimes fail to reach their desired results too.”²²

Taking space in the form of an early-career sabbatical or a medical leave of absence to address mental health were key experiences for some trainees. A third-year resident shared: “I owe a large part of my personal and professional development to my sabbatical year and believe that such experiences should be normalized and encouraged.”²³

Trainees are better able to identify their career paths and potential impact by embracing their whole selves, overcoming setbacks, combating health injustice, and strategically taking space to promote self-development. Furthermore, these letters reveal the ways trainees are discovering and creating unique spaces in medicine in which they can be influential.

An Invitation

In this issue and the following 2 issues, we invite you to learn more about the transformative moments of our future health care professions leaders. We hope that by exploring this topic, those of you who are now health professionals are inspired to recall the special experiences that have transformed your own professional journey and have made your purpose more visible.