Previous research has demonstrated that medical students may bring certain attitudes about mental illness and psychiatry to medical school, including lower levels of respect for the field and beliefs that psychiatry is unscientific and that psychiatrists do not experience satisfaction in their work (1—3). Writing exercises have been used in medical education to enhance students' capacity for self-reflection about their attitudes and to provide opportunities to develop professional self-awareness (4).

At the University of Texas Southwestern Medical Center, we instituted a new clerkship requirement: a pass/fail "reflection" paper. Students received the following instructions: "Write no more than two pages reflecting on some aspect of your psychiatry rotation. We are interested in hearing something about what surprised, inspired, or disturbed you. What did you learn, and what else would you have liked to learn? The goal of this exercise is for you to take some time to consider and reflect on your exposure to psychiatry and mental suffering."

Although our intent for the exercise was primarily to deepen the students' learning, we also hoped that clerkship educators could use the papers to understand our medical students' attitudes toward mental illness and their personal experience of the psychiatry clerkship. We then might use this insight to optimize our limited didactic time and advise attending physicians about the greatest developmental challenges for the students.

Each reflection paper was read by one of the clerkship co-directors but not by any member of the student's treatment team. A passing grade was determined on the basis of the student's fulfilling the objectives of the exercise. Two papers were returned to students with the direction that they add a reflection about their thoughts or feelings (along with the narrative of events or discussion of an idea about psychiatry that they had submitted). Both were then passed on re-submission.

Using a web-based random-number generator, we selected for review 100 of the 218 reflection papers submitted for the 2008—2009 academic year, analyzing the papers using a qualitative software research package (NVivo v. 8) according to the established guidelines of grounded theory research (5). (The software itself does not code for concepts, but provides a useful tool for organizing and tracking conceptual material.) We read through all of the papers and generated a list of major themes and then reread all papers and did line-by-line coding to identify emergent concepts. We frequently consulted with an expert in qualitative research to test concepts and mitigate bias. There was no limit to the number of themes for which an individual essay could be coded. This report will describe and analyze the most common conceptual themes. The University of Texas Southwestern Medical Center Institutional Review Board deemed this study exempt from review.

The most common themes were society's response to mentally ill persons, difficulty in forming an alliance with psychiatric patients, the therapeutic impact of human connection, the stress of identifying with patients, questions about the real biologic nature of psychiatric illness, and confronting the reality of trauma.

Many students (45%) were troubled by society's response to those with psychiatric disease. This concern can be further broken down into issues of stigma, patients' rights, and the scarcity of resources.

Twenty-three percent of the students raised the issue of social stigma of mental illness—that the illness is a mark of disgrace or cause for rejection—and reported about progress in diminishing their personal bias. One student wrote, "The clerkship has helped me to see people not as ‘crazies’ or ‘drama queens’ or any other label that we typically put on those that suffer mentally, but as people."

Nine percent of the students raised the theme of moral discomfort with involuntary treatment. Medical students, who do not yet have significant experience with the acute dangerousness of mental illness, may find the restriction of a patient's liberty (through commitment, restraint, or seclusion) profoundly disturbing. In the words of one student, "She screamed desperately for us to let her out. We could hear her clearly inside the Psych ER office. I could not help but feel like we were robbing her of the dignity she had left."

The theme of social resources and fairness was raised by 23% of the students, who were disturbed by the overall scarcity of funding and care for mentally ill patients and the disparities of resources available to different populations One student summed up the experience of inequity: "The minute I walked into the psychiatric ward (at the private university hospital) and noticed the sunbeams dancing through the large glass windows onto the mini-grand piano, I could not help but feel sad for my patients on the (public psychiatric team) who would never be cared for in such a facility."

Twenty-eight percent of the essays addressed the theme of difficulties in the alliance with psychiatric patients. These students felt frustrated by patients who seemingly refused to allow a working partnership to develop with their treatment teams. The students described a variety of reasons why patients have difficulty forming an alliance, such as paranoia and other psychosis, character pathology, addiction, and dementia. As one student reported, "I remember feeling so disgusted and frustrated with Ms. X. I kept thinking to myself, ‘How can we help this patient if she is unwilling to even talk to us?’"

Twenty-seven percent of the essays described the therapeutic effects of relationship and human connection. They described instilling hope, decreasing isolation, and diminishing the sense of alienation—similar to the common factors observed in effective psychotherapies (6). As one student put it, "While he will continue to have struggles with his illness, I got to be a small part of giving him back something he hadn't felt for a long, long time … hope."

Some students processed the clerkship on a very personal level, and 26% referred to personal identifications. Medical students are taught that physicians are at high risk for depression and addiction and are aware that they are in the age-range where major mental illness may first appear. As one put it, "Seeing a professional get so out of control that she basically lost everything really hits too close to home." For others, the clerkship prompted a reflection on painful aspects of their personal history or the experience of a family member with mental illness. One student wrote, "At first I was not sure of the source of my immediate deep-rooted sense of empathy and pity … I realized I was getting a look at what my siblings and I went through as we grew up."

Thirteen percent of the student essays described a reduction of skepticism about the biologic basis of psychiatric illness. Some students attributed this skepticism to psychiatry's reliance on subjective reporting for diagnosis. Students also noted that many psychiatric symptoms are on a continuum with normal experience. One wrote, "I'm guilty. I admit. For the longest time I was in the camp that had no sympathy for those with depression. We all have bad days, but now all of the sudden it is a clinical illness? A disease just like heart disease? I did not buy it. I thought that what separated me from them were mental strength, fortitude, and persistence."

In 12% of the essays, students described confronting the reality of trauma. The clerkship may be a medical student's first opportunity to witness psychic damage resulting from experiences of abuse and terror (including domestic violence, childhood abuse, military combat, and natural disasters). As one student wrote, "It was inarguably tragic to think that this young girl has been forever affected by her environment in a manner that has paralyzed the way she appreciates her life." In their essays, these students described a successful struggle to find the balance between being overwhelmed by their patients' stories and defensively withdrawing or numbing themselves.

Although we tried to encourage openness by making the reflection exercise pass/fail and not having the paper read by the students' team, the fact that the clerkship directors were readers may still have had an effect on the students' choice of topics and expression of attitudes. Some students may have held back opinions that they anticipated would displease the readers, and others might have skewed their reflections toward what they thought psychiatric educators would want to read. The study is also limited by having only one reader coding the papers, although this is generally considered within acceptable practice in qualitative research (5).

Another limitation is the question of generalizing from the experience of a small selection of students at only one medical school, but this is also a potential strength. Texas has one of the lowest rates of state funding for mental health (7), which may lead students to a heightened concern for stigma and scarcity of resources. Although in gender, college major, and future specialty choice, our students represent national averages, approximately 90% of our students are from Texas, which may have influenced the prominence of issues of social justice in the themes. In response, we are now planning a discussion group on mental health funding and stigma within the clerkship curriculum. Another discussion group has been added to focus specifically on issues related to the physician's experience of the patient's trauma. Our students' interest in trauma is possibly related to the prominence of a veterans hospital in our medical school curriculum.

Our required case report and standardized multiple-choice ("shelf") exam assess the students' knowledge-base, and our OSCE (objective structured clinical examination) assesses basic clinical skills, but the reflection papers provided information about educational challenges beyond cognitive knowledge and skills. The students almost uniformly made good use of the exercise; a requirement to reflect seemed to foster attention to their assumptions about mental illness, the difficulties in engaging in psychiatric work, and the grave difficulties with which psychiatric patients live. The clerkship directors have used the results of this exercise to provide feedback to attending physicians and residents regarding specific areas of interest and concern on which they might focus with our medical students.

In conclusion, reflection exercises may highlight topics of concern to students—topics that can then be targeted in the clerkship didactics. Although some issues raised by students may be universal, others may be specific to the region or to the clerkship site. A reflection exercise can provide a window through which psychiatric educators can learn about the areas of greatest concern to the students at their institution, while the students practice the skills of critical self-awareness that support the growth of professionalism and empathy.

The author gratefully acknowledges the encouragement and support of Simon Craddock Lee, Ph.D., regarding the use of qualitative methods of research.

Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer-review, applied to all manuscripts. Also, the editor is recused from any editorial decision-making.