'The Change Curve'

September is a big month for medical students. The start of a new phase in training, the end of a holiday period and often a location change for placement. Later in training, for foundation doctors, it marks the second month of being a new doctor and can be a time where change is felt particularly strongly. 

I wanted to write an article looking at the theme of change using an adapted model, which is based on the work of psychologist Elizabeth Kübler-Ross in her book ‘On Death and dying’. Her work was used to explore mental processing surrounding patients undergoing a terminal illness and dying. This model was later applied more broadly to explore the process of change itself and has been developed to explore management strategies to look at the process of resistance and acceptance within teams. These stages can be in a neat linear order like the models below, but more often can flow back and forth and can even repeat themselves. It is a framework rather than a solid structure or objective image of how our complex human brains process change. (1,2,3,4,5) 

The overall aim of this article is to use these models as a tool for self-reflection; which could be helpful in future reflective practice, in personal journalling or wellbeing practice, and to encourage self compassion and empathy. To demonstrate how this model could be used I have written a scenario from the aspect of a medical student starting a new academic year. This could be a useful way to understand some of the emotions you may experience when starting a new phase of training, and give some context behind why these transitions can have such a significant impact.

Firstly, for the change curve to begin, of course a significant change in circumstances or an upheaval of your expected normality needs to occur.

For the sake of this blog, imagine you have been moved to a hospital out of area and you have had to move to a new city. You have also started third year so you have gone from primarily academic learning to highly placement based and patient focussed learning. 

In reality, this is not one big change that you are dealing with. It is several changes that are all happening at the same time.

It is day 1 and you are receiving your hospital trust induction. 

Stage 1: 

‘Shock’ - a strong feeling of surprise as a result of something happening, especially something unpleasant.

Enter the first stage of the curve. You are told the expectation of starting hospital placements full time alongside high amounts of study/self directed learning, that you will need to complete hospital e-learning; and work out how to use the IT systems…

The induction then goes on with some slides that show the plan for the year, the exam dates, the sign-offs, the presentations, the teaching days, the new expected levels of responsibility, and then on top of all of that comes the never ending list of learning objectives… You sit there thinking 😱 ! ! ! !  

You may even feel that this cannot be real and that you are not ready to be sat in that classroom to start the year ahead. Then someone sitting next to you will tell you they already know the LOs and have started studying, and by some miracle already have experience in practical skills, and your brain begins to feel like it is about to explode. 

It is important to point out that comparison in the classroom of any medical school is absolutely not helpful because you have no idea what experience people come into medical school with. For example you may simply be sitting next to somebody who is repeating a year - or who used to work as a paramedic.

Stage 2: 

‘Denial’ - the act of refusing to accept that something unpleasant or painful is true.

You come home and you think that they must just be trying to scare you in the introduction talks and actually there is no way there can be as much to do as they have said. It must be the PowerPoint that makes it feel like so much. The learning objectives must overlap with each other enough that there cannot be such a high number of conditions to learn alongside a full week of placement. 

So you go home and over the first couple of weeks you have a slower look through the resources only to find the initial impression of the year was real, and that hopeful denial is in fact not correct. 

Stage 3: 

‘Frustration’ - feeling annoyed and impatient because you cannot do, have, or achieve what you want.

‘Anger & blame’ 

Initially the frustration may feel like anger as shown in model 1. You think ‘Why?Why? Why am I having to stay on placement until 5pm? Why are they checking how long I stay? Why do I have to spend so much time in the hospital when I have so much studying I need to do?’ Why are there so many learning objectives?’  You may even feel angry for choosing a medical degree to begin with when other friends do not start term until the start of October and you’re already locking in for Christmas exams. This can lead to anger and frustration at the move you have had, the change in your usual routine, and the lack of control you have on your day to day hospital learning experience. 

 I would like to add here that these feelings can be totally normal and it can be a really uncomfortable set of feelings to have. Especially when you have worked so hard to get into medical school in the first place and you know you really want to do well in your training so ultimately you can be a good doctor one day.

‘Fear and bargaining’

The anger and blame starts to settle as you spend time on the wards and you realise your frustration is not changing the circumstances you are in. 

Instead the approach of exams feels like it is looming and the stack of Anki cards are building up. Your initial blame towards the course structure can become internalised, turning into blame towards yourself for not being able to keep on top of things. The reality of the situation you are in overtakes anger and turns into fear.

‘Oh my gosh… Exams are three months away, how on earth will I cover enough revision and learning alongside placement to pass? What If I don’t pass?’

The fear turns into bargaining:

‘Surely if I speak to a teaching fellow they will let me leave early to go to the library and study?’ Surely there is another way to avoid the current reality? I must be able to figure out a way to change this, the rules can’t be as strict as they say…’ 

Stage 4: 

‘Depression’ - Important in the context of this model and blog, this refers to a period of sadness, discouragement and a sense of loss. This is not referring to a clinical definition of depression. 

The teaching fellow says ‘No, attendance in hospital placement is mandatory and is an important part of your medical training’. They advise the work load is possible and instruct you to adjust your routine to match the current change in circumstance. 

You feel a bit overwhelmed by the last four weeks of placement, the move, the change in routine that has already taken place, and the lack of control over your stress variables. You start to think ‘I’m not going to be able to do this, is there any point in me trying? If there is so much work and learning on the wards how will I ever keep up?’  Motivation feels low, self esteem can take a hit, and the grief of life ‘before’ can start to settle in. 

I cannot stress enough that at this point it is really important to talk with your peers, teaching fellows, medical school, ask for support from your wellbeing team, speak to friends and family - honestly whatever works for you. On top of this if you ever feel as though sadness or low mood is not clearing and it is impacting your every day or beginning to affect your ability to function, it is so so so important to seek appropriate support. 

After this low point, the curve begins to change and the acceptance starts to spark transformation from the previous norm to create a new norm. Somehow the deadlines seem closer, you have had to turn up to placement so you haven’t missed a day, and you start to realise you are already starting the journey to getting everything done that they said you would in that initial induction. 

As if by magic you have begun adapting to your new norm before you even knew it was happening!

Stage 5: Acceptance (3 stages) 

‘Exploration’ 

As you have spent a good amount of time on the wards and feel more comfortable with the team - and with deadlines approaching -  you start to think it would be worth attempting some sign offs. One of the F1s kindly asks you in the morning what you would like to get out of the day, and bravely you say you’d like to take bloods. You feel nervous and ask for lots of support, but then you manage to do it and come home feeling great! This brings a shift to a more positive mindset and you start to think maybe placement could be something you enjoy. 

  The next day you come in, you take an opportunity to meet a new patient and gather a history, and you find it helped consolidate some of the learning you had in a teaching session earlier in the week. (This is a great feeling!) When you get home that day you revise that condition and realise that experience made things easier to remember because you think of that patient when you see the condition on the Anki card. This positive feedback gives you more motivation and you think ‘it’s time to lock in’ - and this is a crucial part of exploration to transition through the acceptance phase. 

Acceptance doesn't necessarily mean liking the situation. Instead it can mean recognising the reality of the situation you are in and working out how best to respond to it with the options available to you. 

‘Decision’

You start trying to do two hours of study when you get home from placement but you find it is too tiring and you don’t focus after the first hour. So you decide to try coming home, having an hour break, then do an hour studying before having dinner. You find this is an effective hour and it allows you to enjoy more of your evening. You have found a way of learning that works for you, and from then on this is your new routine plan up until exams. Mentally you make a conscious decision to accept your current reality and aim to work with the new circumstances to get an outcome that will be positive for yourself. Decision leads and encourages behaviour change which takes us finally too.. 

‘Integration’

You now feel used to the routine. When you turn up to placement you start offering to help the F1s take bloods, write ward round notes, ask to get sign offs and take histories from new patients. You have a good lunch break and you finish placement on time. You manage to study and then switch off for the evening. You start seeing things on the wards that you have studied at home and things start to ‘click’. You start to feel like you are progressing in your training and your confidence begins to return. You find a way that works for you! The comparison to your classmate at the induction at the beginning of the year and disbelief in your abilities has been washed away and you have realised that the way other people approach studying/placement does not need to be your approach. 

(I think it is a very important note here that everybody’s method of surviving placement and studying is totally different so do not compare yourselves!) 

Written by: Dr H Thompson

References:  

1. Kübler-Ross, E. (1969). On Death and Dying. New York: Macmillan.

2. Avis KA, Stroebe M, Schut H. Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal. Frontiers in Psychology. 2021;12:772696. doi:10.3389/fpsyg.2021.772696.

3. Kübler-Ross Foundation. On Death and Dying / Five Stages of Grief.

4. Malone ED. The Kübler-Ross change curve and the flipped classroom: Moving students past the pit of despair. Education in the Health Professions. 2018;1(2):36–40. doi:10.4103/EHP.EHP_26_18.