Medical Students Are Patients Too: An Interview with Therapist Darrell Phillips, LCSW, MBA
/Interview with Darrell Phillips by Kortni Ferguson
Transcription by Priya Roy
So Darrell, can you start off by introducing yourself to our readers?
My name is Darrell Phillips. I’m a licensed clinical social worker. I also have my master’s degree in business administration. I’m originally from San Antonio, Texas, but I’ve lived in Pittsburgh now for 18 years. My professional career has been really varied. I’ve worked in industry before, in pharmaceutical sales. I’ve also worked with people living with HIV/AIDS at the Pittsburgh AIDS Task Force. Currently, I’m in private practice. But before starting a private practice as a therapist, I actually worked at the University of Pittsburgh Counseling Center for 3 years.
That’s great. And I know that you work with a lot of medical students. How many years have you been working with medical students? And what are some of the most common reasons that medical students come to therapy?
I’ve been working with medical students now for 6 years. My practice is very diverse, so I do get to see a lot of different people in different stages of life.
I think generalized anxiety disorder brings in most people. There’s anxiety that’s inherent in being a student, but it’s also multiplied because you’re investing two things that you will never get back: time and money. There’s also the investment of paying for school and trying to live off a limited income, all while pursuing your passions.
There’s a lot of stress and adjustment disorder for first years. For first years, a lot are stellar students, and you’re in a community and a culture where everyone is hyper-focused and everyone is on edge. It creates a lot of adjustments and identity shifts. I’ve noticed that students are really disappointed if they don’t do as well as they would like to in their first course. They have anxiety and a fear of failing.
Then you go into second year, and the anxiety is about Step One. The dedicated study period is well-meaning, however, at that point, you may start to see some depression. In my practice, it’s becoming more common that in those weeks of dedicated study, a lot of people will isolate. It creates a lot of loneliness. There are some that keep their coping skills in their schedules and proactively build their mental health treatment into it.
Third year is another adjustment period of being in clerkships while being evaluated and learning the dynamics. Some students report that adjusting to the schedule of clerkships is frustrating. Depending on which clerkship they are in, they may be getting there as early as 5AM and staying there until 5PM--there’s a lot of variety. Also, let’s not forget, they still have to take shelf tests and wonder about how they are being evaluated.
By the time I see students in fourth year, it starts all over again. ERAS opens in June, and fourth years become anxious about getting letters, grades, worrying about who’s going to say what. “Where will I match for residency? Will I match for residency?” There’s a constant “What if?” “How do I ___?” “How am I doing?”
There’s a culture of anxiety and fear. And if generalized anxiety isn’t controlled appropriately, it may morph into depression because you’re so overwhelmed, you can’t stop. You can’t think. And what that depression looks like is isolating, withdrawing, and not performing to your best. It becomes very dysregulated. The two most common things that I see are generalized anxiety disorder (that can morph into depression) and adjustment disorder--adjustment disorder that takes place every year, quite honestly. Every year of your journey, it seems like you’re adjusting to a new role.
And how often does the topic of grief come up in therapy?
Well, it presents in a lot of different ways. You know, most times when we think about grief, we think immediately of death. But there are also other forms of grief, whether it be breaking up with a partner, not doing well on a test, but the most prevalent one and most difficult one for students is the loss of a loved one.
And how often do you find that your patients haven’t come to terms with the fact that what they’re experiencing is grief?
I would say out of the students that I’ve worked with, it’s probably 70-75%.
Specifically when it comes to medical students, their anxiety, their dreams, their hopes, and just being at school doesn’t leave a lot of space for grief. So what happens is that not only are there some people who are in denial, but there are others who choose to compartmentalize. They will avoid their grief. They may become hyper-focused on their studies, go above and beyond in clerkships or research to avoid having to deal with their grief. So when they try to compartmentalize it, ultimately it just becomes so overwhelming for them and they can’t focus. That avoidance is pretty normal as far as the grieving process goes.
By the time I get to work with them, though, they’re pretty much open to the fact that something is not going well for them. They’re aware that the grief is too overwhelming. I think most people are comfortable with feeling sad and getting that support. However, when it comes to grieving in a high-stakes environment, a lot of people move way too quickly, so they don’t want to identify denial or even try to process grief.
Unfortunately grief isn’t very commonly discussed in medicine. What would you share with the medical community to help them better understand grief’s complexities?
I actually have the privilege of working with some current residents as well as attendings. And it surprised me that when they lost patients, there rarely was any type of debriefing. I don’t know if that’s just unique to certain hospitals, but that kind of floored me. Because even if you may not have an intimate relationship with someone, I would imagine as a physician charged with protecting and sustaining life, losing a patient is a pretty big loss. I think that the medical community would benefit from being comfortable acknowledging that grief is a part of life. That there is no one or anything that goes on forever and ever.
I would also like to see medicine appreciate what grief looks like and the complexities of it and recognize that grief is different for every person. If not processed appropriately, some people will choose maladaptive coping skills such as: substances, others will gamble, have sex, or participate in other high-risk behaviors.
I’m glad that you mentioned what kinds of behaviors manifest from grief because there can be a lot of shame associated with one’s behavior.
Well, there’s a whole lot of shame and there’s a whole lot of judgment. And there’s the internal pressure for students to be perfect: score this way, be evaluated on rotations, be that way, meet all these deadlines. There also may be external pressures for some students, whether it be from the university or family members.
It’s almost like patient care is the number one priority, but medical professionals aren’t patients.
Correct. So here’s the narrative I’d like to start: that you can be human. You don’t have to be this superior entity. I imagine that would have to be frustrating. Because let’s acknowledge: depression, anxiety, and grief? They’re all human emotions. And we’ve all felt them at different times.
And when it comes to therapy, have you noticed a different mindset in medical trainees in comparison to people outside of healthcare?
As far as presenting concerns, no, I don’t think so. But I do think that with the acuity and the stress of their work, some of their coping skills may become exhausted after years of working to become a physician.
With regards to the stigma surrounding mental health, it still seems quite taboo for healthcare professionals to seek help. In your experience, have students expressed that? And how has that impacted them?
Well, there is a lot of concern. In Western Pennsylvania, we only have one psychiatric hospital, and it’s located directly across the street from the medical school. That does create another level of concern: if they were to have an episode of feeling suicidal or depressed, some of the students that I’ve worked with will not go there out of fear that they’ll do rotations there, or that someone may access their files. Medical training is done in the same hospitals that they seek care in, so that attending could be your OB/GYN or your proctologist or your general practitioner.
So that’s the bigger concern for most students. You know, when they get to the point of coming to therapy, I think that they’re ready to begin treating some of their symptoms. The thing that they’re most concerned about is their confidentiality and being treated by someone who one day may be their attending on clerkships.
So what would you say to healthcare professionals who are hesitant to seek behavioral therapy for mental health problems?
I’m a firm believer that you need to practice what you preach. I think that if we are going to take care of vulnerable people, we have to take care of ourselves. So I ask them to answer this question: What would they say to a patient who was going through an episode? How would they respond if it was a loved one they saw going through an episode?
I think you lead by example. We have to de-stigmatize and demystify that therapy is this taboo thing that means “weakness.” It actually means “courage” and “intelligence.” I encourage them to try to lean into their own discomfort and I try to encourage them to approach the discomfort with openness and a desire to heal themselves.
And how often do you have clients that seek a referral to a psychiatrist for medication?
I build rapport with my clients over time and learn what their presenting concerns are before attempting to make a referral to psychiatry. I like to have more of a baseline. Some of the things that I think indicate being evaluated for medication are when I hear people saying, “I’m unable to sleep,” or “I’m getting dark thoughts.” They’ll speak to being unable to sleep, drinking more, smoking marijuana more, etc. I can hear the narrative: their coping skills are becoming maladaptive.
So I will encourage them to try a medication if they’re open to it, depending on what their experience has been with medication in the past. The thing about working with medical students is that they understand how the medication works and what it will do, so they’re pretty open to it. I’ve not interacted with anyone who has been resistant to an evaluation by a psychiatrist.
That’s really encouraging to hear. Changing gears here a little bit, I’d like to ask more about you. Is there anything that you think you’ve personally learned from medical students after interacting with them for so long?
A lot, and it’s all been positive. It’s been an education.
I’ve learned a lot about what it takes to become a doctor. I’ve also learned what special people doctors are. I hear their commitment. I hear their desires. I hear their motivations. And I get the opportunity to hear their belief systems and why they chose to become a physician. I’ve yet to come across anyone who says that they’re motivated by money, which is very refreshing.
I’ve also learned that students make changes with their administration. That they will advocate for changes. And I’ve been happy to hear that the administration is willing to hear them.
What I’m still learning is that many people will choose to put their lives on hold while in medical school: they’ll choose not to date, or they won’t want to date seriously, or if they are marrying a partner, they won’t want to have children. I just can’t imagine what that feels like, to have to put your life on hold on that level while the rest of your peers are graduating from law school, getting PhDs, or pursuing whatever career choices they have made. I’m learning that that comes at a cost to some medical students. I’m hoping to work with people to treat medical school like school as opposed to your entire life. I’m trying to remind them that they got there because they are capable and competent. I try to let them be open to the idea that a goal that is attainable--that is a journey--should not be one that has to come with heightened anxiety and difficulty for them. That it’s very normal to be stressed, however not everyone will get into AOA, and you don’t have to match at the best programs or get Honors in everything.
That’s a really good point. A lot of students are in their 20’s and it’s almost as if they think that enjoying themselves while in this process is not part of the culture. But I don’t think that’s very healthy. You should be able to be passionate and committed to your work but also be reassured that happiness can definitely be in the cards, too.
Absolutely. However as a country we don’t reward that. We rarely say that happiness ever really matters.
Yeah, it’s tough. The culture really does change your perspective at times.
And it’s an active exercise to remind yourself of who you are and what you value. Sometimes you have to check in with yourself and ask: What are my values when it comes to being a physician? And do I have to be the physician who discovers the next big thing? Or is it okay to say, “I want to be a physician, and that’s enough. I don’t have to be Physician of the Year.”
Oh man. And that’s a hard pill to swallow.
Right?
It’s funny, because there’s this intersectionality of being a medical student and being a person. It’s difficult sometimes when you have family members or friends outside of medicine who think you’re the smartest person in the world, and meanwhile, you’re still coming to terms with the realization that, “I’m probably just going to be an average doctor.” And that’s okay. Being an average doctor is still phenomenal.
I wish that the conversation would start sounding that way. I think it would be healthy in all disciplines if we moved away from fear-based learning and toward a love of learning. That mindset of, “What if I don’t ace this test? What if I don’t pass this course? What if I don’t get this paper in?” is always fear-based. As opposed to “How do you best learn? How can we help you?” But hopefully it’s getting better.
I do think that they need to start having more narratives around what it looks like for all of you to try to normalize it: that you’re intelligent, that you will be successful, that we’re going to help you through this, and that our goal is to help you be grounded.