Busy medical students who describe themselves as being “unreflective” are unlikely to spontaneously and creatively contemplate the existential stress, ambiguous emotions, brushes with mortality, and moral dilemmas of their initial clinical encounters. However, highly reflective students might independently pause to focus on these events, intentionally journaling, writing, or finding other outlets for creative expression. Medical educators see reflection as a critical and necessary skill for all physicians,1 and most U.S. medical schools assign reflective activities as required components of preclinical and clinical education. These curricular elements are often collected and assessed for evidence of reflective capacity and maturity, but students note that frequent, uncoordinated reflective activities can lead to “reflection fatigue.”2 Consequently, students who adapt quickly can learn to create and submit appropriate responses, which may not result from actual reflective effort.3
We were seeking opportunities to provide reflective and narrative-based skill-building activities for all students at the Medical College of Wisconsin (MCW)—particularly those having their initial clinical encounters—when we were asked to create and run a workshop for the entire third-year class on creating a personal statement for the Electronic Residency Application Service (ERAS). We proposed linking a reflective activity to the workshop. We acknowledged that reflective writing should be intensely personal, yet we also felt that there were advantages for the students in working with their peers.
Therefore, we designed a session in which students identify the seminal moments of their third year and explore them through a reflective writing exercise followed by meta-reflection (reflection on the reflective process) within a group of peers. We gathered questionnaire data before and after the session to help us better understand students’ perceptions of writing, reflective, and narrative exercises in general and of this session in particular.
Beginning in 2014, MCW added 2 required intersession weeks to the third year as part of continuous professional development interspersed throughout the medical school curriculum. The first week-long intersession program is held in January (the midpoint of the academic year) and the second in June (as students transition from the third to the fourth year). The intersession weeks encourage students to reconnect as a class and to engage in discussions on topics such as breaking bad news, conflicts of interest, diversity and inclusion, bioethics, end-of-life care, personal wellness, and residency preparedness.
We were invited to facilitate a Creating Your Personal Statement session based on our ongoing voluntary fourth-year Residency Application Personal Statement Writers Workshops.4 This new 1.5- to 2-hour session—first offered in 2015 and required for all third-year students as part of each intersession program—is detailed below and outlined in Chart 1. Although all students are expected to participate in the writing activities, they are explicitly told that the anonymous research questions we ask them to complete before and after the session are optional and that there is no expectation that they will either read their writing aloud or submit it at the end of the session.
The research portion of the project was approved by the MCW Institutional Review Board and endorsed by the senior associate dean for academic affairs.
Introduction to ERAS personal statements
Students sit in self-selected groups of up to 8 at tables in a room that is designed to hold the entire third-year class (approximately 200 students). The session begins with an introduction to personal statements, which summarizes information from the Internet, the literature, and our personal experience. Resources are shared in hard-copy format as well as electronically.
Warm-up writing: “Fun” writing exercise
After the introduction, students are asked to answer the first 5 questions on the session questionnaire using a 5-point scale (1 = strongly disagree to 5 = strongly agree; Table 1) and to set the questionnaire aside to complete at the end of the session. They are then guided through a “free write” of a simple, fun topic (writing continuously without editing, correcting, or rereading, and focusing on describing what “I saw” and “I did” more than what “I felt” and “I think”). Paper is provided and students are encouraged to write by hand, but many choose to work on their laptops instead. Once students choose their prompt, they write for 5 uninterrupted minutes. They are then invited to discuss the process with their tablemates. They are allowed to share the content of what they wrote if they choose, but they are encouraged to talk about the process of writing rather than the writing itself.
Reflective writing exercise
Next, the goals of the main reflective writing exercise are described (Chart 1) and students are reminded that they will never be asked to share what they have written with their peers or the faculty. The students are guided to create a series of potential writing prompts based on their clinical and nonclinical experiences over the prior months by jotting down 1 or 2 words in response to each of the scenarios listed in Supplemental Digital Appendix 1 (available at https://links.lww.com/ACADMED/A808).
After students work through the list of scenarios, they select 1 or 2 of the experiences to serve as the basis for a 20-minute free write, focusing on “show, don’t tell.” When the time is up, they review their writing and engage in small-group discussions. They are asked to focus on the insights and surprises that occurred during the writing process. The small groups then share these insights with the entire class.
At the end of the exercise, the students are reminded that the purpose of the session was to offer them an opportunity to reflect on their clinical rotations and patient care experiences. We suggest that what they wrote could end up as part of their personal statement. After a summary and a review of on-campus creative opportunities, the students are asked to complete the last 3 items on the questionnaire they were given at the beginning of the session (Table 1). Written comments are encouraged. The students leave their questionnaires behind but take their writing with them. Students who want extra help can speak directly with the faculty facilitating the session. Any student who feels traumatized by the experience is encouraged to talk to a faculty member or is directed to student mental health services.
The data from the questionnaires from the first 8 sessions (January 2015–June 2018) were entered into a Microsoft Excel for Office 365 database (Microsoft Corporation, Redmond, Washington). The data were analyzed with IBM SPSS Statistics 24.0 (IBM, Armonk, New York) to calculate Spearman rho correlations, analysis of variance, and Mann–Whitney U-tests. Free-response comments were classified as being positive, negative, or suggestions.
MCW third-year students participating in the 8 Creating Your Personal Statement sessions held between January 2015 and June 2018 returned 1,139 anonymous questionnaires, representing a questionnaire completion rate of about 71%. (Each MCW class had approximately 200 students, and each student was assigned to participate twice, for a possible total of 1,600 questionnaires. We were unable to determine how many students either attended without completing a questionnaire or failed to attend as attendance was not taken.) On the 1,139 questionnaires that were turned in, valid responses varied from 1,115 to 1,125 per question (Table 1). Three hundred and thirty-eight (30%) of the questionnaires also included at least one additional written comment.
The data demonstrated that students misperceived how their peers viewed reflective activities. Twice as many students agreed or strongly agreed (hereafter agreed) that their peers felt writing, reflective, and narrative exercises were a waste of time as they themselves did (440/1,119 [39%] vs 209/1,115 [19%]).
Students also appeared to benefit from the exercise more than they anticipated. Only 472/1,125 (42%) came into the session agreeing that they were comfortable with creative writing, yet after the session, 634/1,118 (57%) agreed that they were surprised by the amount, quality, and/or insight of their writing during the session and 863/1,117 (77%) agreed that the session had helped them think more clearly about some of their clinical encounters. Most students (951/1,115 [85%]) believed that they had several encounters and experiences during their first months of clinical rotations that they would always remember.
Using Spearman correlations (Table 2), one of the strongest relationships we found was that students who reported taking more English or writing classes in high school and college than their peers were less likely to view writing, reflective, and narrative exercises as a waste of time; these students were also more comfortable with creative and reflective writing. Students who reported that the session helped them think clearly about clinical encounters were more likely than their peers to be surprised by the amount, quality, and/or insight of their writing. Students who reported that they were thinking about their upcoming personal statements were more likely than their peers to be surprised by the quality of their writing and to indicate that the session helped them think more clearly about some of their clinical encounters.
Weaker but still significant associations we found included that the students who reported taking more English or writing classes than their peers were more likely to believe that their peers viewed writing, reflective, and narrative exercises as a waste of time. The students who were most comfortable with writing were more likely to have had several initial clinical encounters they believed they would always remember. Students who reported believing that they would always remember several of their initial clinical experiences were more likely to be surprised by the amount, quality, and/or insight of their writing, believe that the session helped them think more clearly about their clinical experiences, and be thinking about their personal statements.
Conversely, students who viewed reflective writing as a waste of time were more likely to believe that their peers felt the same way. In addition, they were more likely to believe that they took fewer English and writing classes than their peers; were less likely to believe they would always remember several of their initial clinical encounters; were less likely to be surprised by the amount, quality, and/or insight of their writing; were less likely to believe that the session was useful in clearly thinking about clinical encounters; and were less likely to be thinking about their personal statements.
The only question that elicited different responses between the January (midyear) and June (end-of-third-year) sessions was question 8, “I am starting to think about what I might include in my residency application personal statement,” confirming that students were more likely to be thinking about their personal statements as the ERAS deadline approached. Mann–Whitney U-testing demonstrated that responses to all the other questions were stable between the sessions.
In 2018, we added a question asking students if they had done any reflective activity (writing or otherwise) during the third year. Of the 280 students who responded to this question, 105 (38%) reported some reflective or creative activity.
Written, anonymous comments gathered at the end of the sessions were supportive of continuing the reflective writing sessions (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/A808). Of the 338 comments received, 275 (81%) were positive (e.g., “Great session!” “Cool way to put thought into words”), 18 (5%) were negative (e.g., “Too long to write. Carpal tunnel.” “How could this be a positive experience?”), and 44 (13%) offered suggestions (e.g., “Say more about reflective or descriptive writing.” “Do this earlier in the year.”).
Potential limitations with this study include that (1) it was performed at only one campus using nonvalidated questionnaires, and (2) given the large sample size, some of the statistically significant associations might be unimportant.
Based on our review of the students’ written comments regarding the length of time they were asked to write, in 2019 we shortened the reflective writing portion of the sessions to 10 minutes, although we have yet to settle on the perfect duration for the free-writing exercises. We also replaced the warm-up “fun” writing exercise with a close-reading exercise5,6 to expose students to narrative medicine techniques: We read a short passage of fiction7,8 or an essay9 together, asked the students to engage in small-group discussions, and then had the students write to a prompt “in the shadow” of the reading. The rest of the session remained the same. Based on written comments, the close-reading experience was well received.
We continue to offer our peer-editing Residency Application Personal Statement Writers Workshops to the fourth-year students in the weeks before the ERAS submission deadline. The combination of these workshops offers each student multiple opportunities to work on their personal statements and, hopefully, engage in meaningful individual and group reflection.
We hope that each of our third-year sessions, incorporating reflective writing and close-reading activities in a group setting, offers students a private place to think and write about their experiences while better understanding narrative moments in clinical settings. These sessions attempt to meet twin goals: Faculty hope that the students become more reflective, and the students have a desire to kick-start their personal statements. The timing is optimal since students are immersed in early, required clinical rotations while pondering their residency application personal statements. More data are needed to learn how this approach fits with the larger goal of equipping all medical students—reflective and unreflective, alike—for their journeys toward becoming caring, compassionate, competent, and insightful physicians.
The authors are grateful to the MCW intersession course directors, the senior associate dean for academic affairs, and the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education for support of narrative and reflective activities at the Medical College of Wisconsin. The authors also thank Kim Suhr, MFA, director of Red Oak Writing, Milwaukee, Wisconsin, for help with session design.
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