Hedy S. Wald

Beyond the Margins: Reflective Writing and Development of Reflective Capacity in Medical Education

Reflective capacity has been described as an essential characteristic of professionally competent clinical practice, core to ACGME competencies. Reflection has been recently linked to promoting effective use of feedback in medical education and associated with improved diagnostic accuracy, suggesting promising outcomes. There has been a proliferation of reflective writing pedagogy within medical education to foster development of reflective capacity, extend empathy with deepened understanding of patients’ experience of illness, and promote practitioner well-being. At Alpert Med, “interactive” reflective writing with guided individualized feedback from interdisciplinary faculty to students’ reflective writing has been implemented in a Doctoring course and Family Medicine clerkship as an educational method to achieve these aims. Such initiatives, however, raise fundamental questions of reflection definition, program design, efficacy of methods, and outcomes assessment. Within this article, we consider opportunities and challenges associated with implementation of reflective writing curricula for promotion of reflective capacity within medical education. We reflect upon reflection.

Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback.

The promotion of reflective capacity within the teaching of clinical skills and professionalism is posited as fostering the development of competent health practitioners. An innovative approach combines structured reflective writing by medical students and individualized faculty feedback to those students to augment instruction on reflective practice. A course for preclinical students at the Warren Alpert Medical School of Brown University, entitled “Doctoring,” combined reflective writing assignments (field notes) with instruction in clinical skills and professionalism and early clinical exposure in a small-group format. Students generated multiple e-mail field notes in response to structured questions on course topics. Individualized feedback from a physician–behavioral scientist dyad supported the students’ reflective process by fostering critical-thinking skills, highlighting appreciation of the affective domain, and providing concrete recommendations. The development and implementation of this innovation are presented, as is an analysis of the written evaluative comments of students taking the Doctoring course. Theoretical and clinical rationales for features of the innovation and supporting evidence of their effectiveness are presented. Qualitative analyses of students’ evaluations yielded four themes of beneficial contributions to their learning experience: promoting deeper and more purposeful reflection, the value of (interdisciplinary) feedback, the enhancement of group process, and personal and professional development. Evaluation of the innovation was the fifth theme; some limitations are described, and suggestions for improvement are provided. Issues of the quality of the educational paradigm, generalizability, and sustainability are addressed.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity? The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician–patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME. These strategies as “bridges from theory to practice” embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

'The Loss of My Elderly Patient:' Interactive reflective writing to support medical students' rites of passage

Background: The fostering of reflective capacity within medical education helps develop critical thinking and clinical reasoning skills and enhances professionalism. Use of reflective narratives to augment reflective practice instruction is well documented. Aim: At Warren Alpert Medical School of Brown University (Alpert Med), a narrative medicine curriculum innovation of students’ reflective writing (field notes) with individualized feedback from an interdisciplinary faculty team (in pre-clinical years) has been implemented in a Doctoring course to cultivate reflective capacity, empathy, and humanism. Interactive reflective writing (student writer/faculty feedback provider dyad), we propose, can additionally support students with rites of passage at critical educational junctures. Method: At Alpert Med, we have devised a tool to guide faculty in crafting quality feedback, i.e. the Brown Educational Guide to Analysis of Narrative (BEGAN) which includes identifying students’ salient quotes, utilizing reflection-inviting questions and close reading, highlighting derived lessons/key concepts, extracting clinical patterns, and providing concrete recommendations as relevant. Results: We provide an example of a students narrative describing an emotionally powerful and meaningful event – the loss of his first patient – and faculty responses using BEGAN. Conclusion: The provision of quality feedback to students’ reflective writing – supported by BEGAN – can facilitate the transformation of student to professional through reflection within medical education.

Introducing technology into medical education: Two pilot studies

OBJECTIVES Educators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners. METHODS We voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy. RESULTS Pilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring. CONCLUSIONS In our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation. PRACTICE IMPLICATIONS Educators should continue to further examine innovative opportunities for introducing technology into medical education.

Reflection rubric development: evaluating medical students’ reflective writing

Context and setting Can innovation replace tradition in order to resolve a communication problem? This was the conundrum we faced at our university medical school in China. In a country with one-fifth of the world’s population, medical education was failing. Patients and doctors spoke Chinese, but medicine was a foreign language. A country steeped in the tradition of mentor-based, listen-and-learn teaching methods was challenged by dissatisfied patients and unhappy encounters in the hospital. The listen-and-learn method trained doctors to be passive listeners, without the skills to communicate with patients. Why the idea was necessary Although the rapid development and implementation of scientific research had greatly improved the overall diagnosis and treatment of many diseases, doctors faced increasing resistance from unhappy patients. Escalating tensions between doctors and patients created charges of conflicts of interest on both sides. Tensions were particularly high in the surgical disciplines, which carry greater risks of morbidity and mortality. A doctor would tell a patient about his or her disease and the associated risks and prognosis, but the patient would not comprehend or accept the information. Unrealistic expectations and unhappy outcomes led to complaints and the erosion of trust in the health care system. In China, medical education has emphasised using natural science to identify the disease and select the appropriate treatment strategy. The concept of humanism, of understanding, treating and educating the patient, had been lost over the decades as traditional Chinese medicine turned its attention to science. What was done Chinese medical education underwent a revolutionary change in 2004. Problem-based learning (PBL), humanism and communications skills training swept though the educational system and into our hospital. In our training programme, we introduced the medical students to PBL and to the notion of how it prepares them to communicate with their patients efficiently and effectively. We set up scenarios of doctor–patient conflict and medical students took turns as patients and doctors in role-playing the interaction and resolving the problem. We raised questions about what is central to communications skills, the importance of understanding the core issue, and how this helps to establish a common ground between doctor and patient. The goals of these activities were to build up medical students’ confidence, encourage willingness to communicate and better prepare doctors for clinical practice. Currently, student performance on internship is not judged by an examination paper, but by a combination of class reviews, interview results with patients and case analyses to generate an overall assessment of the individual intern student. Evaluation of results and impact The problems of making a transition from the mentor-based system, incorporating PBL into a system dominated by the mentor-based model, and meeting the needs of a society in transition were all experienced within the microcosm of our department. However, when we surveyed the medical students, we found widespread satisfaction with the programme. The doctors remained concerned about misdiagnosis and missed diagnosis, but they said role-playing enhanced their interest in medicine and their confidence with patients. If such a sea change can take place in tradition-bound China, it may very well be successful anywhere.

The Becoming: Students' Reflections on the Process of Professional Identity Formation in Medical Education

Professional identity formation (PIF) within medical education is the multifaceted, individualized process through which students develop new ways of being in becoming physicians. Personal backgrounds, values, expectations, interests, goals, relationships, and role models can all influence PIF and may account for diversity of both experience and the active constructive process of professional formation. Guided reflection, including reflective writing, has been used to enhance awareness and meaning making within the PIF process for both students and medical educators and to shed light on what aspects of medical education are most constructive for healthy PIF. Student voices about the PIF process now emerging in the literature are often considered and interpreted by medical educators within qualitative studies or in broad theoretical overviews of PIF. In this Commentary, the authors present a chorus of individual student voices from along the medical education trajectory. Medical students (years 1–4) and a first-year resident in pediatrics respond to a variety of questions based on prevalent PIF themes extracted from the literature to reflect on their personal experiences of PIF. Topics queried included pretending in medical education, role of relationships, impact of formal and informal curricula on PIF (valuable aspects as well as suggestions for change), and navigating and developing interprofessional relationships and identities. This work aims to vividly illustrate the diverse and personal forces at play in individual students’ PIF processes and to encourage future pedagogic efforts supporting healthy, integrated PIF in medical education.

The use of abstract paintings and narratives to foster reflective capacity in medical educators: a multinational faculty development workshop

Reflective capacity is integral to core healthcare professional practice competencies. Reflection plays a central role in teacher education as reflecting on teaching behaviours with critical analysis can potentially improve teaching practice. The humanities including narrative and the visual arts can serve as a valuable tool for fostering reflection. We conducted a multinational faculty development workshop aiming to enhance reflective capacity in medical educators by using a combination of abstract paintings and narratives. Twenty-three family physicians or physicians-in-training from 10 countries participated in the workshop. Qualitative assessment of the workshop showed that the combined use of art and narrative was well received and perceived as contributing to the reflective exercise. Participants generally felt that viewing abstract paintings had facilitated a valuable mood transformation and prepared them emotionally for the reflective writing. Our analysis found that the following themes emerged from participants’ responses: (1) narratives from different countries are similar; (2) the use of art helped access feelings; (3) viewing abstract paintings facilitated next steps; (4) writing reflective narratives promoted examination of educational challenges, compassion for self and other, and building an action plan; and (5) sharing of narrative was helpful for fostering active listening and appreciating multiple perspectives. Future research might include comparing outcomes for a group participating in arts–narrative-based workshops with those of a control group using only reflective narrative or in combination with figurative art, and implementing a combination of qualitative and quantitative methods of assessment.

Reflection through the arts: focus on photography to foster reflection in a health care context. Living Beyond – an interactive photographic exhibit

This paper considers reflection and the arts in relation to health care, focusing on the use of photography to foster reflection in health care contexts. We describe an interactive photographic exhibit aimed at fostering individual and collective reflection and community dialogue for health care professionals, patients and patients’ families at the National Cancer Institute, Mexico City, Mexico, November 2008. The paper highlights reflections of one of the authors, Joel Walker, a psychiatrist and professional photographer, on the experience of using photography to foster reflection in practice. Four photographs in the exhibit are described and patient, practitioner and photographer reflections are presented as exemplars.

Promoting resiliency for interprofessional faculty and senior medical students: Outcomes of a workshop using mind-body medicine and interactive reflective writing

ABSTRACT Background: Health care professions faculty/practitioners/students are at risk for stress and burnout, impacting well-being, and optimal patient care. Aims: We conducted a unique intervention: an interprofessional, experiential, skills-based workshop (IESW) combining two approaches: mind-body medicine skills and interactive reflective writing (RW) fostering self-awareness, self-discovery, reflection, and meaning-making, potentially preventing/attenuating burnout and promoting resiliency. Methods: Medical and nursing faculty and senior medical students (N = 16) participated in a 2-hour workshop and completed (1) Professional Quality of Life measure (ProQOL) and (2) a questionnaire evaluating understanding of professional burnout and resiliency and perceived being prepared to apply workshop techniques. Thematic analyses of anonymized RWs exploring meaningful clinical or teaching experiences were conducted. Results: Participants reported better understanding of professional burnout/resiliency and felt better prepared to use meditation and RW as coping tools. RW themes identified experiencing/grappling with a spectrum of emotions (positive and negative) as well as challenge and triumph within clinical and teaching experiences as professionally meaningful. Conclusions: Positive outcomes were obtained within a synergistic resiliency skills building exercise. Successful implementation of this IESW provides good rationale for studying impact of this intervention over a longer period of time, especially in populations with high rates of stress and burnout.