Wald, Hedy S. PhD; Davis, Stephen W. MD, MPH; Reis, Shmuel P. MD, MHPE; Monroe, Alicia D. MD; Borkan, Jeffrey M. MD, PHD
Reflective practice is now widely recognized as a necessary competency in health care.1 Reflection is vital in medicine,2,3 because physicians are constantly challenged to critically appraise evidence within their own context, values, and beliefs, as well as those of their patients. Reflective practice affects the physician–patient relationship as it informs both clinical reasoning and clinical decision making.
Definitions of reflection abound. Mann and colleagues1 provided one of the most elegant and comprehensive reviews of the reflection domain. They endorsed definitions encompassing both reflective activity and its translation into professional practice, such as those offered by Dewey,4 Moon,5 and Boud and colleagues.6 Boud and colleagues defined reflection as “a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to [gain] a new understanding and appreciation.” Schoen’s7 “reflection-on-action” process, which Epstein8 stated is essential for mindful practice, further bridges the divide between theory and practice, because reconstructive mental reviews may indirectly shape future action.
Reflection facilitates deeper learning,9 gives meaning to experience,10 and is a process through which personal experience informs practice.11,12 The benefits of educating reflective practitioners13 include the development of critical-thinking skills and clinical judgment. In addition, the integration of the influence of reflection on action with role modeling is key to fostering medical professionalism14 and humanism.15,16 More recently, reflection has been promoted as an integral strategy for improving diagnostic accuracy and minimizing error.17,18 Finally, reflective learning has been recognized by the Accreditation Council for Graduate Medical Education as being a foundation for various competencies and for the development of reflective capacity in practitioners.19
Reflection is not intuitive,20 and thus it merits inclusion within medical education initiatives. Medical educators have been challenged to devise curricula that explicitly incorporate and evaluate reflective learning. One such mechanism has been the inclusion of various forms of reflective writing,13 including journaling, field notes, and other student-generated narratives.21–25 The practice of writing in a complex form about the patient’s experience of illness and about patient care and then reflecting on their meaning has been described by Charon as contributing to the capacity to see a patient’s illness in a “fully textured,” emotionally powerful form.26 This new capacity has the potential to extend both empathy and effective care.26,27 The use of practitioner- and student-generated text engages the writer in analogous processes of attention, representation, and affiliation that form the core of both reflective writing and clinical care.26 After the clinical interaction (i.e., attention to the patient), the use of the written word to materialize or represent perceptions (as is done routinely, for example, in patient charts) provides opportunities for deeper reflection and serves as a vehicle for affiliation (reviewing and sharing text or charts with colleagues). Writing in what Kerka24 has called the “learner’s authentic voice” (in addition to standard chart writing) has been postulated as adding a necessary affective element to the learning process.
The act of journal writing does not always imply critical reflection.28,29 Thus, interactive journals (with a reader who provides guidance)—in contrast to isolated writing—have been advocated as a means of fostering a more in-depth reflective process. As seasoned “travelers,”24 teachers who provide feedback to student narratives act as guides, helping the learner focus on the reflective moment,29 and therefore serve as more than transmitters of knowledge.8 Ideally, student-specific feedback that includes posing questions as a “critical other” or “devil’s advocate”2 in a supportive context and offering possible additional interpretations to consider30 can help to encourage broader thinking. Whereas such an interactive process has been advocated in the literature, a structured mechanism of longitudinal reflective writing integrated with feedback has not previously been described.
This article describes a curricular innovation within the “Doctoring” course at the Warren Alpert Medical School of Brown University (Alpert Med) that was aimed at fostering reflective capacity through encouraging students’ structured, longitudinal, reflective writing and providing those students with individualized feedback from an interdisciplinary faculty team. We propose that such innovations represent an incremental step forward for the discipline—a novel educational approach to promoting reflective practice through the use of structured field notes and guided feedback. These innovations are illustrated through a sample of students’ experiences with the paradigm.
The “Doctoring” Course
“Doctoring” is a required, two-year, longitudinal course for first- and second-year medical students that is designed to teach clinical skills and professionalism. The course was launched for the Alpert Med first-year class (72 students) in 2005–2006; it integrated reflective writing assignments (termed “field notes”) and instruction in medical interviewing, physical diagnosis, cultural competence, and medical ethics.31 The course structure includes large-group didactic sessions, small-group processing and skill instruction, and one-to-one, community-based physician mentoring and skills practice. Students are assigned in groups of eight to a faculty team composed of a physician and a sociobehavioral scientist, which models for students the value of interdisciplinary collaborations in health care. The faculty teams for the small-group component represent a variety of medical and behavioral science specialties, and they discuss curriculum topics (such as bias or prejudice and facilitating behavior change), teach clinical skills, provide feedback on field notes, and evaluate students’ emerging competencies.
Students complete field notes in response to structured questions that serve as guides for reflection on a range of topics, such as the development of interviewing skills, inspiring or difficult interactions with patients, and the challenges of promoting healthy lifestyle changes in patients. Students submit their field notes (without patient-identifying information) via e-mail directly to the small-group faculty, who provide in-depth, individualized feedback to the students, thus creating an interactive process. In contrast to the open discussions of thoughts, experiences, and feelings within the small-group interaction (which also occurs regularly), the content of field notes and feedback remains confidential between teacher and student. Given the proper nurturing of the relationship, a comfort zone for deeper and more authentic self-reflection can potentially be created.32
Quality feedback affects willingness and ability to reflect9 and should promote critical thinking.33 Students are guided not only toward the development of critical-thinking skills but also toward generalizing their specific patient interaction experiences to relevant themes in the field of medicine as a whole. The guided feedback process addresses the student’s position along the educational spectrum and supports and challenges the student to advance to the next level. In addition, the weaving in of anecdotes as well as the “seasoned traveler’s” life experiences (“been there, done that”—and, in some cases, still doing it) as relevant can help normalize certain student experiences, such as patient encounters, that may have led to feelings of uncertainty in the student. The course fosters both the courage to confront the sometimes unpleasant or challenging scenario and the building of a tolerance for uncertainty.
Within the affective domain, feedback includes exploration and validation of emotional responses to help the students gain further insights. In general, then, feedback goals include intellectual stretching9 and what may be described as building emotional muscle or resilience.
To support high-quality teaching and to enhance consistency across small groups, faculty members attend an orientation session before the start of the course and ongoing faculty development sessions during each semester to foster the use of effective teaching strategies and the sharing of best practices. During orientation, faculty members receive literature on promoting reflective learning. Examples of field note questions from the Doctoring course syllabus with excerpts from two students’ responses and from the guided feedback appear (with the students’ permission) in Appendix 1.
We undertook a pilot evaluation of students’ experiences with the field note and guided feedback curriculum innovation by using a sample of eight students in a first-year student small group (facilitated by two of the authors: H.S.W., a clinical psychologist, and S.W.D., a family physician) in the Doctoring course. We asked students to provide written answers (via e-mail) to seven structured queries regarding their evaluation and use of the 17 assigned field notes (Appendix 2). Participation was not linked to the course’s evaluation process in any way. We obtained informed consent from students in both oral and written form and obtained an exemption from the Brown University IRB.
We conducted qualitative content analyses of the students’ responses for theme extraction. Successive rounds of individual and group analyses used “immersion-crystallization,” a qualitative analytic style involving cycles of concentrated textual review of data, combined with reflection and intuitive insights, until reportable interpretation becomes apparent.34 Results of the independent analyses were melded through an iterative process into the crystallization of five salient themes, and we reached full agreement on the thematic content.
Four of the extracted themes highlighted educational benefits (including enhanced reflection) of the curriculum initiative; a fifth theme encompassed suggestions for paradigm improvement. We elaborate on these themes below and provide examples of student feedback.
Deeper and more purposeful reflection
Students perceived that the field note learning paradigm enriched the Doctoring course through promoting deeper and more purposeful reflection and helping to promote an empathic stance in medical student–patient interactions. For example, a student described how reflecting on patient encounters through field notes allowed her to “take a walk in someone else’s shoes”; another commented, “[F]ield notes can be an effective tool for deeper and more purposeful reflection. Writing thoughts and reflections require[s] students to put words to what are often unformed ideas or thoughts and require[s] more concentration than [does] simply vocalizing.” Another student wrote, “The biggest advantage of the field notes is the fact that some of them made you reflect on topics that you would never have otherwise thought about—or, I should say, really thought thoroughly and reflectively about.” Students commented on the value of field notes (presented to health care professionals) for organizing thoughts, forming ideas, and promoting insights into interactions with patients—for example, “I really just wanted to put onto paper what that patient had been through and what it was like for me to peer into her world and try to understand what she was going through. It was an extremely reflective experience … [and it] also taught me insight into the humanity of doctoring.”
Value of feedback
The students enthusiastically endorsed the individualized feedback to field notes that the small-group faculty team provided. Benefits such as enhanced reflection, new insights, and the value of receiving specific, concrete suggestions were highlighted—for example, “Sometimes the comments would push me to continue my reflections and take it to a deeper level …. Other times, comments were ‘just what the doctor ordered’ when it came to answering questions … that I’ve struggled with as a first-year medical student. The advice and suggestions often helped me approach my clinical experiences.”
The students perceived feedback to have a role in helping to build tolerance for uncertainty. As one student stated, “The feedback not only assured me that the confusion I was going through was normal, but that it was also part of the learning process.” Feedback, one student said, helped her not feel as if she were “writing in a vacuum”; in general, having an “audience” in mind (e.g., “What would my teachers think of this?”) helped add meaning to the field notes. Students noted that feedback on the field notes positively affected small-group and teacher–student relationships, enhancing the bonding.
Students uniformly appreciated the opportunity to receive feedback from two professionals (dyad) within the disciplines of medicine and psychology (“truly a gift,” noted one student). According to one student, “I look to the doctor to find [out] if what I did was right and look to the psychologist to find out if how I did things was right.” One student reflected on how this multidisciplinary approach contributed to her own emotional growth: “Basically the physician tells you that the experiences you may have are normal (assures me that everyone goes through the same learning process), and the psychologist tells you that it’s normal to have the feelings that you do about those experiences …. One … help[s] affirm the realities of being a doctor and one … help[s] you grow emotionally to accept those realities.”
Enhancement of group process
The analysis revealed group process as a key theme within student responses. All students identified a sense of safety and trust as a central issue and to be of value—for example, “[T]he field notes have brought us together in some very unique and interesting ways. I have no doubt I could trust every student group member and small-group leader.” Whereas spontaneous discussion of field note content within certain small-group sessions remained the students’ prerogative rather than part of the course structure per se, the introduction of one student’s field note within the small group was recognized by the faculty team as a potentially valuable learning experience. The field note (used with the student author’s permission) served as a “springboard to deeper discussion and reflection,” as one student phrased it, and several students noted deepened interpersonal connection through the sharing. Views were mixed on the importance of the confidentiality of field notes.
Personal and professional development
Several students commented on how they were shaped by the reflective process engendered by field notes—for example, “[W]eek to week, I realized how much more open I started to become about writing about my experiences …. I would say that in the past I’ve kept many of my feelings and painful experiences to myself. It’s been very rare, until this year, for me to be so reflective and in touch with my emotions and thoughts.” “Field notes,” another student stated, “are an opportunity to take all those mixed emotions (like how you felt the first time a patient broke down and cried while talking to you) and put … [them] down on paper, where it makes those feelings real.” Students viewed the field notes as a vehicle for representing transformative experiences at their community clinical experience and mentoring site, such as “aha moments” of realizing how deepthe changes were that were “going on in my head.”
In addition, a theme of enhanced professional development with fostering of identity formation and role clarification emerged. Reflecting on experiences led to insights that yielded tangible benefits in subsequent student–patient interactions. One student indicated how field note reflection helped to differentiate patients, avoiding a “blur” at a fast-paced community clinical experience and mentoring site and ultimately having the student–patient interactions be more meaningful; another acknowledged field notes as a way to “practice recording a patient’s story after the fact …. I started to notice what things I remember most, what things I tend to write down while interviewing, and how important it is to record these data as soon after talking to the patient as possible …. [T]his knowledge helped when I returned to the clinic ….” Another student wrote, “This is the area that field notes were most beneficial for me, in thinking about what kind of doctor I want to be and how I want to interact with patients.”
Evaluation of the innovation
Whereas students recognized that field notes with structured topics were valuable, some students requested a greater degree of flexibility for field note response after a memorable patient encounter or when a meaningful personal experience occurred. One student suggested the availability of a third option for an “open” topic (field notes generally were structured as a choice between two presented topics), which could potentially allow greater opportunity for reflection on compelling patient interactions. Students recommended that fewer field notes be related to assigned readings, to avoid a sense of “homework.”
Whereas some students noted that maintenance of field note confidentiality helped to promote greater freedom of expression, many students requested greater opportunities for sharing field note content (with the student author’s permission) within the group context. The successful use of a field note for group discussion (described above) generated interest in having more such experiences; reasons for this interest were that field notes “open the floor” for discussion, allow students to learn from others, and sometimes spark the realization that students share the same feelings.
The value of cultivating reflective capacity
The promotion of reflective capacity and critical thinking to help develop clinically competent, mindful practitioners is widely recognized as integral to quality medical education. Various curriculum initiatives including student-generated narratives have been formulated in an attempt to address this core competency. Narrative writing within internal medicine35 and emergency medicine36 residency programs, for example, has been used to promote reflection. We propose the inclusion of an innovative curriculum component of students’ reflective writing (structured field notes) with guided individualized feedback from an interdisciplinary faculty team (in the preclinical years) as a means of cultivating the capacity for reflection, which is key to fostering empathy and professionalism. The use of structured prompts or “triggers” for field notes (examples provided in Appendix 1) in conjunction with guided feedback from an interdisciplinary team are innovative curriculum features geared toward addressing concerns raised in the literature regarding less-structured journal writing not necessarily implying critical reflection.28,29 The application of these features toward fostering reflective capacity is highlighted as distinguishing our innovation from other narrative writing curriculum initiatives.
As reported earlier, pilot evaluation of this paradigm was conducted. Five themes were extracted from first-year medical students’ queries about their experience with structured field notes and guided feedback in a Doctoring course at Alpert Med. The fostering of reflective capacity, the building of narrative competence, and the growth in personal and professional development were described as outgrowths of this educational intervention. Additional benefits of this educational methodology that emerged from the students’ observations included the value of individualized feedback from an interdisciplinary team and the enhancement of group process (small-group teaching). The themes were predominantly positive and complementary to our observations (one theme of relatively minor suggestions for improvement), which supports the premise that the combination of students’ structured reflective writing and individualized feedback accomplishes stated goals.
The theme of advantages/benefits of field notes highlighted reflection on experience and appeared consistent with literature themes of “stimulated thought/questions” as a strength of a student learning journal for primary care professionals37 and “cognitive reflection” in journals13—that is, students thinking about what they did and why and how they integrated information. Students’ reflective comments supported the interactive paradigm of structured field notes/guided feedback in the initial stages of medical education as a means of enhancing the role of narrative medicine as students are trained to listen (to patients’ stories and to their own inner voice) so that they can really hear.32
Students endorsed the value of individualized feedback from an interdisciplinary team on their reflective writing (a second theme). This innovative approach does not appear to have been described in the medical education literature and may offer substantial advantages. Feedback from two disciplines, medicine and psychology, offers exposure to the insights and skills of both medical and mental health professionals. Mental health professionals bring skills relevant to medical practitioners because they routinely work with patients in emotional pain, frequently discuss sensitive issues, and counsel people experiencing minor and major stressors.38 Such skills can potentially enhance the feedback process because real and challenging reflection requires another person (trainer or tutor) to help the student think through and explore not only what has been happening to him or her but also how he or she is responding emotionally.39 Whereas students can use positive emotional responses in the learning process, affective barriers may obscure understanding of an experience.6 Thus, it has been argued, feedback that facilitates recognition of such barriers can enhance reflective capacity and help restore flexibility and creativity in responding to situations.6 Finally, interdisciplinary team feedback on students’ reflective writing can help build tolerance for uncertainty, which has been postulated as potentially helping practitioners maintain an attitude of openness to reflection even when confronted with a difficult or unfamiliar problem—an essential component of reflective practice in medicine.23
The third theme of the enhancement of group process highlights the perceived positive contribution of student-generated narrative to this valuable learning modality. Small-group teaching of medical students has been noted to be particularly effective for teaching humanistic medicine, because caring and intellectual capacity develop side-by-side,40 and receptivity to patients is encouraged and maintained.41 The focus on process within small-group work with peer support facilitates critical thinking by challenging schemata and attitudes with change.30 The establishment of a “safe” learning environment2 within the group promotes reflective analysis of experience (gaining of multiple perspectives) and development of critical-thinking skills, which becomes the basis for future action—that is, quality medical practice. Small groups help to nurture self-awareness, promote empathy, and lessen the sense of individual isolation,42 which may help decrease medical student distress that is due to unintended negative effects of some aspects of training.43
The fostering of personal and professional development through field notes and guided feedback, a fourth theme, was consistent with the use of reflective writing portfolios in attaining personal and professional development by first-year medical students,44 with online text-based discussions for first- through third-year medical students,45 and with “transformation” through interactive journals for occupational therapy students.21 Our feedback encompassing the affective domain with clarification and exploration of affective responses was consistent with responses to critical incident reports of third-year medical students46 in which faculty helped students to clarify their feelings while seeking to gain perspective on events themselves.
Finally, the theme of field note limitations/suggestions for improvement was an example of critical thinking applied to educational process evaluation. Revisions of field note triggers and options are already underway.
Our initial qualitative analysis of one student group and its faculty team was a pilot evaluation and, thus, has limited generalizability. Broader analyses (across small groups) including analyses of growth in reflective capacity have been proposed. An additional potential limitation of our work is the lack of anonymity of student responses to posed queries, which raises a question of “social desirability.” However, a culture of candor remains strong at Alpert Med, and suggestions for improvements in the paradigm were provided.
In general, the results of the pilot evaluation highlight successful implementation of this innovative method of structured field notes and guided feedback within medical education, which is consistent with the theoretical framework and stated goals of promoting reflection and fostering professionalism. We propose this curriculum innovation as an incremental step forward within medical education toward the realization of such goals. Proposed future studies include testing these findings prospectively, both qualitatively and quantitatively, to further support the present results and conclusions.
The “Doctoring” course was designed and the syllabus was written at the Warren Alpert Medical School of Brown University by Drs. Alicia Monroe, Fred Ferri, Arthur Frazzano, Jeffrey Borkan, Michael Macko, and Catherine Dube. The authors of this article are indebted to the participants in the Doctoring course small group that was facilitated by H.S.W. and S.W.D. for their valuable insights and contributions (names are given in reverse alphabetical order): Stacey Weinstein, Clifford Voigt, George Turini III, Jack Rusley, Erin McDermott, Connie Lee, Salma Faghri, and Jeremy Boyd. Students’ comments on their field notes were included with permission. Excerpts from the field notes of Jack Rusley and George Turini III were used with permission and are appreciated.
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