We interviewed 10 pre-clerkship medical students representing various training years (Table 1). All participants took part in the 4-week Pen-pal Project. They described their experience partaking in the project, as well as their views on current homelessness health curricula and the utility of the Pen-pal Project. Within these narratives, we identified the four overarching themes: (1) evaluation of experience, (2) personal connection with a community member, (3) skill development, and (4) implementation into medical education curriculum.
Table 1: Demographic Characteristics of 10 Pre-Clerkship Medical Students Interviewed About Their Experience in the Pen-Pal Project, 2020
Participant Type
|
No. of Students (%)
|
Training Level
|
MS1
|
3 (30)
|
MS2
|
6 (60)
|
MD/PhD
|
1 (10)
|
Gender
|
Female
|
10 (100)
|
Male
|
0 (0)
|
Abbreviations: MS1, medical student year 1; MS2, medical student year 2
Evaluation of experience
Medical student participants provided a general appraisal of their experience being part of the Pen-pal Project. While sentiments were overwhelmingly positive, students shared constructive feedback for areas of improvement.
The premise of an anonymous hand-written letter exchange was rated as enjoyable and facilitated a “comfortable form of communication that is also veiled with anonymity” (9). Students also seemed to appreciate the timing flexibility of the anonymous letter exchange. Specifically, students felt that participating was “not time-consuming” (5) and “very easy to fit into my schedule” (10).
This project provided students with the ability to gain deeper insights into the life of a community member. One student felt “blown away with how in-depth my pen-pal was willing to go for this letter. It was really moving reading her story and... it was really emotionally engaging” (4). A student discussed the value of exposure to this specific population:
… I loved that I was able to get connected with someone who either was struggling with mental illness and/or experienced homelessness. [...] I just wanted to know more about their story, we don't necessarily get to interact with people from vulnerable populations outside of the clinical setting. (5)
However, students acknowledged the complex challenges of the anonymous, written communication. One student found that the “written medium was hard, just given the nature of the conversation ...I also felt a little bad not knowing their name” (1). In addition, while participants appreciated the facilitated communication with a specific marginalized population, one student felt “weariness of claiming that perspectives have shifted drastically given such a brief encounter... I think to understand another population would take a lot more work and time on the ground” (9). Finally, eight (80%) students discussed that an opportunity to exchange more letters longitudinally in future iterations of the Pen-pal Project would be beneficial to developing an ongoing meaningful relationship.
Personal connection with community member
This theme highlights the personal bonds and meaningful relationships between medical students and their pen-pal, wherein both parties reciprocated support, shared insight on lived experiences, and in some cases, developed an ongoing relationship.
Students recognized the uncommonness of connecting with someone that has experienced homelessness on an informal yet deeply personal level. One student shared the letter exchange provided “insight into somebody’s life that I would have otherwise not met” (3). One student described the valuable mutual benefit from the letter exchanges:
… We both put a lot of time and effort into this...we were both so invested… I think that was a huge, really impactful moment for me. To see that somebody I never even met, really cares and is invested in my well-being and it was the same on my end as well. (7)
All ten (100%) medical students shared that they gained new perspectives from learning about their pen-pals’ sobering realities and lived experiences. One student elaborates: “My pen-pal specifically said that they had felt like they were being ignored, like unheard, by the physicians that they had interacted with in the past” (1). Another student described how “being able to connect to someone that has experienced homelessness on a more personal level made me more cognizant of some of the really real problems this population might be facing” (4). In addition, students learned about the multifaceted nature of homelessness and its intersection with socioeconomic status and mental health. A student explains:
…A lot of times we’ll learn about addictions, we'll learn about mental health, we’ll learn about issues with homelessness, but when you see all of it come together and you see one person face all these issues at once… it's so eye-opening… (10)
While the intended timeframe for this project was 4 weeks, five of the ten medical student participants (50%) continued or expressed a desire to continue communicating with their pen-pal beyond the project. One student shares: “I love that I am still keeping in touch with my pen-pal” (5).
Skill development
This theme encompasses medical students’ development of their capacity to empathize, communicate, and advocate in the setting of homelessness and mental health.
Students often grappled with their pen-pal’s emotional narratives, rendering a student to feel “sadness and a little bit of helplessness” (9) and another student sharing they “couldn’t believe the things that [their pen-pal] had gone through… and the way certain medical professionals had made them feel” (2). Nonetheless, reading these raw, personal accounts “brought you a lot closer to the gravity of these situations” (1) and “having a personal connection with someone definitely improved empathy” (6). A student explains:
… The biggest thing that I learned was just a greater sense of empathy because I could tell this person just wanted to be heard and wanted to be validated and that they had been lacking that in so many of their medical experiences… they seemed to be very happy that somebody… going to be a doctor was getting the experience to talk to them. (2)
Students described learning from their pen-pals’ letters as “powerful” (8), “really humanizing” (3), and overall contributing to one’s understanding and appreciation of their pen-pal’s unique lived experience. Important learning outcomes for one student was “not making assumptions and taking the time to listen to people’s stories and being empathetic” (7). In reference to a particularly impactful moment in the project, one learner shared:
My pen-pal had really lived through some really challenging things. Both from the perspective of mental health and [...] their life experiences and circumstances. And so, it definitely gave me a lot to reflect on in terms of my privileges as a human being, but also the ways I’m going to interact with people who have different lived experiences... (1)
By being reflexive when encountering communication barriers, five students (50%) endorsed development of their communication skills during this initiative. Some students encountered obstacles such as different literacy levels, language barriers, and sensitive discussion topics. However, students tailored their vocabulary and communication by “using clear, concise, and simple language” (2) and “not say anything that would come off as hurtful or offensive” (10). Furthermore, students affirmed the importance of active listening in their future clinical practice by being “cognizant that your patients might have a lot to say...you should put the effort into listening and hearing about it” (9). Another student described their perspective:
I think that [the Pen-pal Project] reinforced the idea that there is so much more to a person’s story than you can just pack into like a 10- or 15-minute appointment… [and] the importance of listening and not making assumptions (7)
Following the letter exchanges, six (60%) students demonstrated an awareness about their professional obligation to advocate on behalf of marginalized communities. One student acknowledges this revelation, “I can use my roles, and duties, and privileges as a physician to make sure that people are like not only getting the best quality medical care that they can but also being supported in other ways” (1). In response to their pen-pal’s experience with discrimination from healthcare providers, one student shared: “I want to do everything to make sure that I never make one of my patients feel that way, and that I could also educate my colleagues and my friends and make sure they weren’t making these mistakes as well” (2). Another student sought recommendations from their pen-pal on patient advocacy:
I asked what [my pen-pal] would like to see in the future physicians, what kind of things worked and didn't work when they were dealing with their healthcare professionals, and I think getting to hear what they think really helped me with advocacy because you can use their perspectives and use your own voice, that has [...] perhaps more impact than themselves to raise issues to be heard. (6)
Implementation into medical education curriculum
This theme explores participants' opinions regarding incorporating the Pen-pal Project into the medical education curriculum. Specifically, this theme includes discussions regarding the importance of homelessness health education, current gaps in pre-clerkship medical education, and the educational value and barriers of implementing the initiative into the curriculum.
Students felt that teaching about homelessness health in medical school is important, especially in the context of learning and living in a large urban city, “in a place like Toronto, where we have a significant homeless population” (2). Despite the perceived importance of homelessness health education, all students (100%) that were interviewed felt that their institution’s pre-clerkship curriculum is lacking in this aspect. For example, two learners elaborate:
I think [the Pen-pal Project] definitely opened my eyes to where efforts in education need to go… We just kind of glazed over it in medical school… What is that showing to our professional identity when we do become doctors and serve many diverse patients? (8)
Do I think [homelessness health] is adequately taught?... No. Not at all... I think that’s part of the reason I was drawn to this project. I think I felt that kind of gap... (9)
In addition, participants shared their sentiments about the medical program’s limited educational materials on homelessness health. A common perspective was the lack of human connection and its hindrance to empathy-building in the current homelessness health curriculum. Specifically, one student shares teaching on homelessness is “very quantitative... it lacks the empathy component and it lacks that personal connection.” (5). Another student shares a similar sentiment:
I think a lot of times especially in medical school we talk about marginalized populations, it's always from a population lens, never really from, like, a person-to-person sort of lens. (4)
Finally, some students also discussed potential obstacles they foresee with implementing the Pen-pal Project in pre-clerkship medical education. Some considerations include the ethical implications of scaling up this project. One student recommends, “it’s important for us to never approach the line of exploiting certain populations in our attempts to learn about them and learn from them” (1). In addition, students speculate that the projects’ successful implementation may be contingent on medical students’ and community members' interest and dedication in participating.
Nonetheless, the all students interviewed (100%) endorsed the Pen-pal Project as an impactful supplement for the current homelessness curriculum. Moreover, students' ideas for reforming medical education on homelessness often revolved around implementing immersive experiential learning because it “is so much more meaningful than just having a lecture about it, or watching a video telling you the issues on homelessness” (10).