Cultivating Belongingness in Clerkship and Beyond

By Eve Purdy (@purdy_eve)

Anthropologists are fascinated by the concept of belonging – social membership in a particular group. How do individuals become a part of a group? How does one maintain membership? What happens to those who are excluded?

The need for belonging is universal. The desire for social inclusion likely roots itself in evolution. (1) Historically, belonging to a group could mean the difference between satiation and starvation, between hypothermia and warmth, between death and survival. Now, as our lives become more complex – with multiple work, home, and recreational circles – we find ourselves negotiating belonging in many different contexts. Though membership in these groups may not be as physically necessary as it once was, personal fulfillment and psychological well-being are dependent on inclusion.

Belonging in Clerkship 

A sense of belonging is often threatened in medical, particularly clerkship, education. In the first two years of medical school, most students develop an intense sense of belonging. They spend countless hours learning with their classmates in lecture, working on small group projects, and often their time together extends beyond the classroom to social events such as parties and intramural teams. For many, myself included, this might be strongest sense of membership to a group ever experienced. It feels lovely. Then, come clerkship, this sense of belonging changes dramatically. Here, students are transient members on clinical teams, often rotating to a new service every two weeks. With each new rotation comes a new set of norms, expectations, idiosyncrasies, rules of engagement, and social currency. In addition to learning the new type of medicine, clerks are trying to understand how to belong. Rarely are social expectations explicit. Sometimes the student sits in the wrong chair, or speaks at the wrong time. These seemingly minor transgressions can result in rejection from the group. By the time a student sorts out just how things work, it’s time to rotate to a new service and start the process all over again. In addition to scrambling, and sometimes failing, to belong in their work environments, erratic schedules and away rotations mean that clerks’ memberships in other circles important to them might also be at risk. All this to say, clerkship is a particularly vulnerable time. There is no shortage of data about high rates of depression and suicide in medical students. I find myself reflecting often on how belongingness might play into this tragedy we find ourselves in as a community.

Cultivating Belonging 

Recognizing belonging as a fundamental human necessity is an important step in clerkship education and discussions around medical student wellness. Simply stated, when students feel as though they belong, they will learn more and be happier. When I reflect on my richest learning experiences, they were times when I was in the inner circle. I was part of the team. In one circumstance I remember a surgical resident specifically finding me from another part of the hospital before going down to the emergency department because there was an interesting consult that she knew I would like to see. She went out of her way to include me. For the next two weeks on the service, with her as my senior resident, I was engaged and excited about the work. That experience, and sense of belonging, almost convinced me to be a general surgeon! Both educators, I will focus on residents as teachers, and medical students can cultivate belonging.

Tips for Residents

While trying to navigate their own belonging – which can certainly be a challenge on its own – residents also play an absolutely integral role in facilitating belonging for medical students. They are often the closest point of contact and, as a near peer, they are usually the least threatening potential ally on the team. Here are some ways that residents might cultivate belongingness for medical students.

• Be a human. Introduce yourself to new faces. Learn the names of those on your team. Ask about your student’s weekend, his dog, or her family.
• Literally invite medical students to the table. If you walk into rounds or a conference and notice a medical student sitting in a chair at the edge of the room deliberately invite them to sit at the main table. At rounds, sit down next to a clerk. Break the hierarchy that still permeates so much of our medical day to day existence.
• Be explicit about your expectations. A clear and proper orientation to the service is invaluable. Your expectations can certainly be high, but they must be clearly communicated. They could be very different from the last service the clerk was on.
• Share tacit cultural knowledge. As a resident you have a lot of inside information about how things on your service work. The further a resident gets into training, the less aware they may be of these idiosyncrasies, but if possible share unwritten rules with your clerks.
• Bond over food. Sharing food is a natural way for humans to bond. When possible buy your team coffee or ice cream but more importantly take a few minutes to drink that coffee or eat that ice cream together.
• Give benefit of the doubt. When a clerk does something that doesn’t fit within your team’s norms, remember that was likely not the intention. As Jenny Rudolph would say, instead of getting mad – or worse yet, silently writing the student off- get curious.
• Stand up. If someone is treating the clerk poorly, or unfairly, stand up for them. Whether it be a nurse, or attending physician, you have a responsibility to step up. NEVER throw them under the bus.
• Be curious. Ask your clerks how their experience is on the rotation is going. Be willing to adapt and incorporate their feedback.

At the end of the day, be the person who finds a way to bring others into your inner circle, not the person who finds a reason to keep others out.

Tips for Medical Students

As a learner there are also ways that you can also cultivate belongingness. The onus doesn’t just rest on the teams that work on to bring you in to the inner circle. Muscle your way in.

• Feel worthy of belonging. Before anyone can pull you into the circle, you must believe that you deserve to be there. You do. If you aren’t feeling that way, reach out to a mentor, friend, or counsellor to talk about it.
• Act like an anthropologist. See how people are interacting, what they are wearing, the language they are using, the values they are professing. This insight will allow you to understand the unwritten rules of the group. You can adapt your behavior, within the limits of who you are as a person, to fit within the norms.
• Be invested and keen. Find ways to contribute meaningfully. Even if you are having trouble sorting out exactly what that is, medical students can always bring an infectious energy to the team in the mean time.
• Seek guidance from peers. Your peers who have finished this rotation before you can be considered key informants. In anthropology a key informant is an individual that has important information that they are willing to share with you to give insight to the community. Before your rotation, chat with others who have been where you are about to go.
• Give benefit of the doubt. Sometimes your residents will seem grumpy or mean. As best as you can try to give them a pass. They likely don’t mean to be. This doesn’t mean they don’t value you or want you on the team. Having said that don’t be afraid to stand up for yourself or your peers in moments of abuse.
• Do an integrated clerkship. I cannot stress enough the centrality of belonging as a key differentiating factor in integrated clerkships. Being a contributing member of a stable team for months at a time, rather than a transient, absolutely gives you a sustained sense of belonging.
• Do electives where you have a point of contact. Electives are a unique threat to belonging because you are in a whole new institution and often a new city. I would encourage you to seek electives either in programs where you have some contacts or in a city where you have family or friends you can reconnect with.

How do you cultivate belongingness?

I hope that this article will spark a reflection and discussion about belongingness at all levels of our system. Belongingness can be cultivated and threatened at any educational and professional stage. Please comment below with suggestions about how you cultivate belongingness in your teams? What suggestions do you have for educators, residents, and medical students?

Reference

1. Wever-Rabehl G. 2006. The anthropology of belonging: the need for social inclusion. Suite 101. http://roddoneout.webs.com/Belonging.pdf