Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings

Contrasting epistemologies: Biomedicine, narrative medicine and indigenous story medicine

BACKGROUND

Narrative Medicine (NM) and Indigenous Story Medicine both use narrative to understand and effect health, but their respective conceptualizations of narrative differ.

AIMS

I contrast the concept of narrative in NM with that of Indigenous Story Medicine.

MATERIALS AND METHODS

The article relies Western narrative theorists as well as Indigenous epistemologists to frame a discussion-by-contrast of the Judeo-Christian creation myth with a Haundenosaunee Creation Story.

RESULTS

I demonstrate that the deficiencies of Narrative Medicine exist because the latter's use of narrative is a mere application in an otherwise reductive field, whereas Indigenous epistemologies rely on story as medicine itself.

DISCUSSION

OMIT.

CONCLUSION

I call for more scholars to take up different narratives to further investigate the ethical space between NM and Indigenous Story Medicine.

By Medical Students, for Medical Students: A Narrative Medicine Antiracism Program

Objectives

Medical schools have sought to incorporate concepts of race and racism in their curricula to facilitate students' abilities to grapple with healthcare disparities in the United States; however, these efforts frequently fail to address implicit bias or equip students with cultural humility, reflective capacity, and interpersonal skills required to navigate racialized systems in healthcare. The purpose of this study was to develop and evaluate an antiracism narrative medicine (NM) program designed by and for preclinical medical students.

Method

Preclinical medical students at a single center were eligible to participate from June-July 2021. Program evaluation included a postprogram qualitative interview and electronic survey. The semistructured interview included questions about program experience, lessons learned, and perspectives on antiracism curricula in medical education. Interviews were qualitatively analyzed using open and axial coding. Survey data were analyzed with descriptive statistics.

Results

A total of 30 students registered. All (100%) respondents reported "somewhat true" or "very true" in the postprogram survey when asked about their ability to reflect on their own racial identity, racial identity of others, and influence of their racial identity on their future role as a healthcare worker through the program. Qualitative analysis revealed 3 themes: (1) curricular engagement; (2) racism and antiracism in medicine; and (3) group experience. Subthemes included: meaningful theoretical content; multimodal works and unique perspectives; race, identity, and intersectionality; deeper diversity, equity, and inclusion engagement; reconstructive visions; future oriented work; close reading and writing build confidence in discomfort; community and support system; and authentic space among peer learners.

Conclusion

This virtual, peer-facilitated antiracism NM program provided an engaging and challenging experience for participants. Postprogram interviews revealed the program deepened students' understanding of racism, promoted self-reflection and community building, and propagated reconstructive visions for continuing antiracism work.

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

"An invitation to think differently": a narrative medicine intervention using books and films to stimulate medical students' reflection and patient-centeredness

BACKGROUND

Narrative medicine purports to improve medical students' communication skills, self-reflection, empathy and professional development. These interpersonal skills and attitudes can facilitate more patient-centered care and positively impact patients' treatment outcomes. However, current studies report mainly on small study populations, leaving the efficacy of narrative medicine in larger study groups unknown. Therefore, this study aimed to evaluate a mandatory narrative medicine lesson in a large sample of medical students. We assessed if this narrative medicine lesson stimulated meaningful self-reflection on patient-centeredness in medical students.

METHODS

All fourth-year medical students of a Dutch medical school participated in this mandatory narrative medicine lesson. The four-step activity consisted of an introductory lecture, close reading and watching of a book and film, a discussion group and a short reflective writing exercise. Students were divided over three thematic pairings (or book and film combinations): 'The doctor as a patient,' 'The mysterious brain,' and 'Until death do us part.' A mixed-methods design was used. First, we qualitatively analyzed the content of 203 essays from the reflective writing exercise. A quantitative analysis of the reflective quality was conducted using a scoring-system based on the REFLECT rubric.

RESULTS

Students demonstrated reflection on a professional level and connected this to future intentions as medical practitioners, for example to use specific communication strategies or to deliver healthcare in a broader sense. They also reflected on a personal level by questioning their own worldview or beliefs. Furthermore, they stressed the importance of individual patient stories to gain understaning of patients' perspectives. Approximately half of the students showed an in-depth and authentic reflection, according to the REFLECT rubric. Additionally, reflection levels differed between book and film pairings.

CONCLUSIONS

This study supports the value of narrative medicine in the medical curriculum by validating its outcomes in a larger study population and in a mandatory course. Students reflected on themes related to the principles of patient-centeredness, namely personal attitudes towards patients and the uniqueness of patient stories. In additon, the majority of students demonstrated higher levels of reflection, which suggests that this exercise contributes to self-awareness and self-reflection, important qualities for delivering patient-centered healthcare.

The utility of an online discussion board for reflective writing in an emergency medicine rotation

Background

Narrative analysis and reflection have been found to support professional identity formation (PIF) and resilience among medical students. In the emergency department, students have used reflective practice to process challenging clinical experiences, such as ethical dilemmas or moral distress. An online discussion board, however, has not been described as a curricular component of emergency medicine (EM) rotations. The objective of this educational innovation was to support medical students in an EM clinical rotation via an online discussion board for reflecting on and debriefing clinical experiences with faculty and peers.

Methods

Fifty-two medical students enrolled in the pass/fail EM elective between May 13, 2019, and October 30, 2020. Each cohort of six students took part in a cohort-specific discussion using the Canvas learning management system. Students were encouraged to post about any observations, reflections, or emotions after their shifts. Faculty course directors responded to each post using concepts of debriefing, coaching, and trauma-informed teaching.

Results

Over 18 months, 49 of 52 (94%) students participated in the discussion board. Of 346 total posts, half were by students, and the other half were faculty responses. Students posted 3.27 times each, on average. Students rarely raised questions about scientific knowledge content, fact-based aspects of patient care, or specific skills. Rather, they often posted about intensely affective reactions to experiences that left them with complex emotions. Upon review of posts by the course directors, the majority (54%) of students' posts contained a range of affective responses. Students appreciated faculty responses and supported each other in their written responses to peers.

Conclusions

An online discussion board can be used successfully for asynchronous reflective practice to debrief clinical experiences during an EM rotation, if designed incorporating faculty and peer support using trauma-informed teaching principles to bolster well-being and PIF.

Narrative medicine workshops for emergency medicine residents: Effects on empathy and burnout

Background

Emergency medicine (EM) residents face unique affective challenges and barriers to interpersonal connection in their clinical environment which may contribute to decreased empathy and increased burnout. Narrative medicine (NM) might address these barriers and has had beneficial impacts in various populations but has never been studied in EM residents. In this study, we sought to evaluate the effect of NM workshops on burnout and empathy and to assess resident perceptions of the workshops.

Methods

We performed a quasi-experimental study at two EM residencies from June to October 2020. Residents at the intervention site participated in two NM workshops led by EM faculty that were composed of a close reading of a literary text, reflective writing, and group discussion. Residents were asked to complete the abbreviated Interpersonal Reactivity Index (IRI) and a single-item burnout measure pre- and postintervention. We fitted linear regression models to IRI subscores; we treated burnout as an ordinal variable and fitted a conditional logistic regression model. Residents completed a postintervention survey that we analyzed using summary statistics.

Results

A total of 46.7% of control (28/60) and 100% of intervention (48/48) residents responded (n = 76). While all respondents demonstrated worsening burnout with time (p = 0.001), residents at the intervention site exhibited less severe increases (interaction p < 0.001). Empathy remained unchanged. A total of 50% of intervention residents (24/48) responded to the postintervention survey; most (n = 20, 83.3%) agreed that the workshops should be a standard part of EM didactics.

Conclusions

These findings establish the feasibility and desirability of NM in residency education and offers a model for EM-centered narrative workshops. Additionally, while our outcomes are limited, we found that exposure to an NM curriculum may be protective against worsening burnout.

The coping insights evident through self-reflection on stressful military training events: Qualitative evidence from self-reflection journals

Research has demonstrated that adaptive forms of self-reflection on stressor events and insight may strengthen resilient capacities. However, the coping insights that emerge during self-reflection are notoriously under-researched. In this research, we sought to explore the evidence for the self-reflective activities and coping insights drawn from the Self-Reflection and Coping Insight Framework and find evidence of new reflections or insights not captured within the framework. Qualitative analysis was used to examine weekly, written self-reflective journals completed by Officer Cadets involved in a randomised-controlled trial of Self-Reflection Resilience Training. Sixty-eight Officer Cadets who submitted their journals for analysis were included. Journals were analysed using a deductive thematic approach. Findings revealed that self-reflective activities occurred frequently over the course of the intervention. Coping insights were comparatively less frequent, but conveyed complex ideas about the self in the context of stressor exposure, broad principles about stress and coping, and nuanced interpretations regarding the interaction between the efficacy of coping approaches and broader contextual and intrapersonal factors. These findings demonstrate the critical role of coping insight during Self-Reflection Resilience Training, with implications for developing a validated self-report measure of self-reflective activity and coping insight.

A Critical Review of Professional Identity Formation Interventions in Medical Education

PURPOSE

Professional identity formation (PIF) can be defined as the integration of the knowledge, skills, values, and behaviors of a profession with one's preexisting identity and values. Several different, and sometimes conflicting, conceptualizations and theories about PIF populate the literature; applying these different theories in PIF curricula and pedagogic strategies can profoundly impact the PIF of future physicians. The authors conducted a critical review of the recent literature on PIF interventions in medical education to explore the conceptualizations of and theoretical approaches to PIF that underlie them.

METHOD

The authors searched articles on PIF educational interventions published in 5 major medical education journals between 2010 and March 2021. The articles' context and findings were extracted, analyzed, and summarized to identify conceptualizations and theoretical approaches to PIF.

RESULTS

The authors identified 43 studies examining medical education interventions aimed at influencing PIF. The majority of the studies (n = 31) focused on undergraduate medical education. Reflective writing and the use of narrative reflections were the dominant modes of student activity in PIF interventions, supporting the dominant individualist approach to PIF. Less commonly PIF was understood as a socialization process or as an active process with both individually and socially focused influences.

CONCLUSIONS

Relying on reflective writing as the intervention of choice to impact PIF feeds the dominant individualist perspective on PIF. An unintended consequence of this individualist orientation is that cultural problems embedded in the profession can become burdens for individual physicians to personally bear. Future education and research into PIF should account for theoretical preferences and the impact of these preferences.

Integration of Arts and Humanities in Medical Education: a Narrative Review

This narrative review aims to identify and review the extant literature describing methods and outcomes of embedding the arts and humanities (AH) into medical school curricula. The Association of American Medical Colleges changed the Medical College Admission Test (MCAT) in 2015 to place new emphasis on the role of liberal arts in the process of developing well-rounded physicians. Consequently, medical schools have been implementing more connections to creative writing, literature, theater, movies, music, and the visual arts into their curricula. To review the current literature, we focused on methods medical educators used to embed content related to AH into their curricula to shape and drive associated learning outcomes. We conducted searches in PubMed, CINAHL, PsycINFO, and ERIC for peer-reviewed articles from 2011 to 2020. The authors selected three dyads in medical humanities and reviewed articles independently followed by discussion to identify thematic links to major findings. Out of 261 articles, a total of 177 full-text articles were reviewed with 34 selected for final inclusion. Our review included articles describing curriculum development and delivery in publications from Australia, Canada, India, New Zealand, and the USA. This review showed medical educators are implementing didactic and experiential instructional approaches to embedding the arts, humanities, and social sciences into the medical school classroom. Medical educators' attempts to embed AH into medical school curricula show promising results. Unfortunately, small sample sizes, short-term interventions, and an over-reliance of subjective assessment measures limit our knowledge of the true impact of these interventions. More rigorous assessments of required and longitudinal coursework are necessary to know the true impact of participation in AH coursework for medical students.

Service-Learning Programs and Projects for Medical Students Engaged With the Community

Introduction

The medical school curriculum has changed from using the term “pedagogy” to framing adult learning theories with the goal of applying knowledge to a clinical situation or real-life experiences. Service-learning programs (SLPs) in medical schools illustrate one of several adult learning principles and practices now used in today’s curriculum that better prepare medical students for working with a variety of patients. 

Objective

The researchers’ aim was to assess medical students’ learning experiences while participating with nonprofit organizations during a curricula-designed SLP.

Method

The authors analyzed 60 reflective essays over a three-year academic period from 192 medical students placed in teams of two to four. A qualitative study with a thematic analysis research design was employed in our study. This iterative approach allowed the researchers to identify themes and interpret meaning. The study was completed in 2020 using data from 2017-2020.

Results

Four major themes and one overarching theme emerged that reflect adult learning theories including: (1) transfer learning of one’s skills and knowledge to community and practice; (2) articulate a variety of ways to communicate with multiple, diverse community audiences; (3) employ a creative process for quality improvement strategies; (4) create positive trusting and rewarding relationships that highlight an enhanced level of conduct and professionalism. An overarching theme found was: collaboration emerges almost without forethought. Medical educators may find that replicating this SLP into the curriculum infrastructure provides agency and student buy-in. We established an SLP as part of the medical school curriculum that brings privilege and reward to students and to the community. Reflection provides for meaningfulness from SLP and helps students identify how experiential learning affects their professional development as members of the community and future health care providers.

Conclusion

Implementing SLPs into any medical school curriculum strengthens the adult learning theoretical delivery approach. Disseminating projects and lessons learned to and from the community also showcases experiential learning opportunities for medical students and other professionals. Many aspects of awareness from the medical students’ engagement during the SLP emerged. They learned about specific aspects of community engagement and found it a privilege to give and take many lessons from the experiences and opportunities.

Tell Me More®: A medical student focused humanistic communication model to enhance student professional identity formation through meaningful patient encounters

INTRODUCTION

The Tell Me More (TMM)® program provides a template for guided interviews to help providers procure an expansive social history from patients and connect with them as people beyond their illness. (TMM)® may provide a dual benefit: it improves the patient's experience with their healthcare team and the medical students' experience in developing their identity as a physician. Our aim was to characterize the impact of the patient-student conversations in TMM® on the participating medical students through analysis of their written reflections throughout the program.

METHODS

Students conducted interviews with hospitalized patients using the TMM® template, Through narrative medicine and individualized posters, patients were able to highlight their unique qualities.

RESULTS

Qualitative analyses of 63 journal reflections from 14 students, across 7 hospital settings, identified 6 themes. These included connection, humanism, discovery, impact, privilege, and perspective.

CONCLUSION

Reflective practice as a learning pedagogy created an opportunity to enhance the medical students' awareness of empathy and compassion during the TMM® program. Documentation of reflections assured students would process the encounter as a profound learning experience and develop their professional identity formation as a student preparing to become a physician.

PRACTICAL IMPLICATIONS

TMM® provides an opportunity for medical students to practice and apply their interpersonal and communication skills through authentic patient encounters.

Medical Student Portfolios: A Systematic Scoping Review

PHENOMENON

Medical Student Portfolios (MSP)s allow medical students to reflect and better appreciate their clinical, research and academic experiences which promotes their individual personal and professional development. However, differences in adoption rate, content design and practice setting create significant variability in their employ. With MSPs increasingly used to evaluate professional competencies and the student's professional identity formation (PIF), this has become an area of concern.

APPROACH

We adopt Krishna's Systematic Evidence-Based Approach to carry out a Systematic Scoping Review (SSR in SEBA) on MSPs. The structured search process of six databases, concurrent use of thematic and content analysis in the Split Approach and comparisons of the themes and categories with the tabulated summaries of included articles in the Jigsaw Perspective and Funnelling Process offers enhanced transparency and reproducibility to this review.

FINDINGS

The research team retrieved 14501 abstracts, reviewed 779 full-text articles and included 96 articles. Similarities between the themes, categories and tabulated summaries allowed the identification of the following funnelled domains: Purpose of MSPs, Content and structure of MSPs, Strengths and limitations of MSPs, Methods to improve MSPs, and Use of E-portfolios.

INSIGHTS

Variability in the employ of MSPs arise as a result of a failure to recognise its different roles and uses. Here we propose additional roles of MSPs, in particular, building on a consistent set of content materials and assessments of milestones called micro-competencies. Whislt generalised micro-competencies assess achievement of general milestones expected of all medical students, personalised micro-competencies record attainment of particular skills, knowledge and attitudes balanced against the medical student's abilities, context and needs. This combination of micro-competencies in a consistent framework promises a holistic, authentic and longitudinal perspective of the medical student's development and maturing PIF.

Medical Students' Creation of Original Poetry, Comics, and Masks to Explore Professional Identity Formation

INTRODUCTION

This study examines differences in students' perceived value of three artmaking modalities (poetry, comics, masks) and whether the resulting creative projects offer similar or different insights into medical students' professional identity formation.

METHODS

Mixed-methods design using a student survey, student narrative comments and qualitative analysis of students' original work.

RESULTS

Poetry and comics stimulated insight, but masks were more enjoyable and stress-reducing. All three art modalities expressed tension between personal and professional identities.

DISCUSSION

Regardless of type of artmaking, students express concern about encroachments of training on personal identity but hoped that personal and professional selves could be integrated.

Reading the Self: Medical Students' Experience of Reflecting on Their Writing Over Time

PURPOSE

To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors.

METHOD

In 2018, the authors conducted 5 focus groups with 18 third-year students from the Columbia University Vagelos College of Physicians and Surgeons class of 2019 to examine students' experience with Signature Reflections. Using an iterative, thematic approach, they developed codes to reflect common patterns in the transcripts, distilled conceptually similar codes, and assembled the code categories into themes.

RESULTS

Three core themes (safe space, narrative experience, mirror of self) and 1 overarching theme (moving through time) were identified. Students frequently experienced relief at having a safe reflective space that promoted grappling with their fears or vulnerabilities and highlighted contextual factors (e.g., trusted faculty-mentors, protected time) that fostered a safe space for reflection and exploration. They often emphasized the value of tangible documentation of their medical school journey (narrative experience) and reported using Signature Reflections to examine their emerging identity (mirror of self). Overlapping with the core themes was a deep appreciation for the temporal perspective facilitated by the Signature Reflections (moving through time).

CONCLUSIONS

A longitudinal narrative medicine-based portfolio curriculum with pauses for meta-reflection allowed students, with faculty support, to observe their trajectory through medical school, explore fears and vulnerabilities, and narrate their own growth. Findings suggest that narrative medicine curricula should be required and sufficiently longitudinal to facilitate opportunities to practice the skill of writing for insight, foster relationships with faculty, and strengthen students' temporal perspectives of their development.

Moral judgement development during medical student clinical training

BACKGROUND

Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training.

METHODS

A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory.

RESULTS

Thirty five medical students from years 3-5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship.

CONCLUSIONS

Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress.

Recognizing Reflection: Computer-Assisted Analysis of First Year Medical Students' Reflective Writing

BACKGROUND

Reflective writing is used throughout medical education to help students navigate their transformation into medical professionals. Assessment of reflective writing, however, is challenging; each available methodology of assessment has distinct advantages and disadvantages. We tested if combining two independent assessment mechanisms-a faculty-designed rubric and Academic Writing Analytics (AWA), an automated technique-could be used together to form a more robust form of evaluation.

METHODS

We obtained reflective essays written by first year medical students as part of a clinical skills course. Faculty scored essays using a rubric designed to evaluate Integration, Depth, and Writing. The same essays were subjected to AWA analysis, which counted the number of reflective phrases indicative of Context, Challenge, or Change.

RESULTS

Faculty scored the essays uniformly high, indicating that most students met the standard for reflection as described by the rubric. AWA identified over 1400 instances of reflective behavior within the essays, and there was significant variability in how often different types of reflective phrases were used by individual students.

CONCLUSIONS

While data from faculty assessment or AWA alone is sufficient to evaluate reflective essays, combining these methods offer a richer and more valuable understanding of the student's reflection.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians

OBJECTIVES

Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians.

METHODS

Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature.

RESULTS

Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians.

CONCLUSIONS

From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Reflective Writing as a Window on Medical Students' Professional Identity Development in a Longitudinal Integrated Clerkship

Phenomenon: Integral to the formation of a professional identity is the concept of professional identity construction, an essential part of becoming a competent physician. In this framework, identity is dynamic and shaped by experiences and relationships. Minimal work has addressed the impact that clinical care settings and relationships with patients have in the construction of professional identity for medical students. This study explores how patient interactions and intentional curriculum design support professional identity construction in students participating in a longitudinal integrated clerkship focused on care for the underserved. Approach: This qualitative analysis investigated students' professional identity construction as detailed in 45 reflective essays from 15 students while enrolled in an 11-month longitudinal integrated clerkship (LIC) in a safety-net hospital system. Researchers used an inductive analytic approach. Findings: Students provided rich and complex descriptions of their experiences. Six themes emerged: care for the underserved; therapeutic alliance; humility and gratitude; altruism; resilience; and aspirations. Insights: Professional identity construction was observable through students' reflective essays. Student interactions with patients provided rich material for professional identity construction, and role models in patient care enhanced this process. This study suggests that clinical learning in a safety-net hospital system, coupled with an LIC curriculum that prioritizes continuity with vulnerable patients, faculty role models, and ongoing reflection, supported the professional identity construction of students as patient-centered caregivers providing equitable care and advocacy for the underserved, described here as an Equity Identity.

Content and outcomes of narrative medicine programmes: a systematic review of the literature through 2019

OBJECTIVES

Narrative medicine (NM) incorporates stories into health sciences paradigms as fundamental aspects of the human experience. The aim of this systematic review is to answer the research question: how effective is the implementation and evaluation of NM programmes in academic medicine and health sciences? We documented objectives, content and evaluation outcomes of NM programming to provide recommendations for future narrative-based education.

METHODS

We conducted a systematic review of literature published through 2019 using five major databases: PubMed, Embase, PsycINFO, ERIC and MedEdPORTAL. Eligible NM programming included textual analysis/close reading of published literature and creative/reflective writing. Qualifying participants comprised individuals from academic medicine and health sciences disciplines. We reviewed and categorised programme goals, content and evaluation activities to assess participant satisfaction and programme efficacy. Two members of the research team assessed the risk of bias, independently screening records via a two-round, iterative process to reach consensus on eligibility.

RESULTS

Of 1569 original citations identified, we selected 55 unique programmes (described in 61 records). In all, 41 (75%) programmes reported a form of evaluation; evaluation methods lacked consistency. Twenty-two programmes used quantitative evaluation (13 well described), and 33 programmes used qualitative evaluation (27 well described). Well-described quantitative evaluations relied on 32 different measures (7 validated) and showed evidence of high participant satisfaction and pre-post improvement in competencies such as relationship-building, empathy, confidence/personal accomplishment, pedagogical skills and clinical skills. An average of 88.3% of participants agreed or strongly agreed that the programme had positive outcomes. Qualitative evaluation identified high participant satisfaction and improvement in competencies such as relationship-building, empathy, perspective-taking/reflection, resilience and burnout detection/mitigation, confidence/personal accomplishment, narrative competence, and ethical inquiry.

CONCLUSION

Evaluation suggests that NM programming leads to high participant satisfaction and positive outcomes across various competencies. We suggest best practices and innovative future directions for programme implementation and evaluation.

The Patient Experience Debrief Interview: How Conversations With Hospitalized Families Influence Medical Student Learning and Reflection

PURPOSE

To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning.

METHOD

The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from May 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Interrater reliability was examined using kappa. REFLECT scores were analyzed using a chi-square test; essays were analyzed using content analysis.

RESULTS

Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the 2 highest levels of reflection, compared with 71% of the intervention group; 2% of the control group attained critical reflection, the highest level, compared with 31% of the intervention group (χ(3, N = 189) = 33.9, P < .001). Seven themes were seen across both groups, 3 focused on physician practice and 4 focused on patients. Patient-centered themes were more common in the intervention group, whereas physician-focused themes were more common in the control group.

CONCLUSIONS

Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.

Narrative medicine as a medical education tool: A systematic review

Aim: Narrative medicine has been promoted as an innovative and effective means of stimulating medical students' professional development by teaching them to approach their patients' experiences of illness with more understanding and compassion. This systematic literature review aims to answer the following question: what evidence of effect is available in the literature about models for teaching narrative medicine? Methods: We conducted a narrative review of 36 articles and used the Best Evidence in Medical Education (BEME) Global Scale and Kirkpatrick Scale for strength and importance of evidence to categorize reported assessment strategies and to evaluate the effectiveness of their narrative medicine programs. Results: We found evidence that narrative medicine is an effective pedagogic tool with a clear and replicable structure and methodology. We also determined that a positive impact could be measured when pertaining to participation and modification of attitudes, knowledge, and skills. However, unequivocal evidence of the effect of narrative medicine on students' behavior or ongoing interaction with colleagues and patients is still lacking. Conclusion: While many recent publications describe the goals and virtues of a narrative-based approach, more research is needed to determine whether or not there is an ideological consensus undergirding this approach. In addition, it is still unclear whether the long-term impact of narrative medicine classroom interventions are felt by patients, or whether such interventions positively impact patient care.

A qualitative study of the impact of a dementia experiential learning project on pre-medical students: a friend for Rachel

BACKGROUND

With Alzheimer's disease and other dementias affecting approximately 7 million people in the United States, comprehension of the multitude of issues facing individuals with dementia and their families and compassion for them are essential components of good healthcare. The service learning program, A Friend for Rachel, was developed in 2011 to train pre-medical students about dementia and give them sustained exposure to people with dementia to foster understanding and compassion and decrease stigma,. The purpose of this study was to evaluate the impact of the program on pre-medical students.

METHODS

Since 2011, 101 students participated in A Friend for Rachel. They were required to write weekly reflections about their interactions with their friends living with dementia. Each study author read these reflections to identify major recurrent themes. The authors discussed the themes and came to consensus. The reflections were then reread to analyze for sub-themes.

RESULTS

Analysis of students' reflections exposed five major themes: learnings about dementia, learnings about caregiving, their own experienced emotions, impact on career choice and learnings about good medicine, and impact on life. The reflections demonstrated appreciation of the issues raised by dementia, empathy for individuals living with dementia and their families, and comfort with people with dementia. The reflections also demonstrated how the program had a positive impact on the personal lives of the students.

CONCLUSIONS

Through experiencing a sustained relationship with a person living with dementia, A Friend for Rachel allows pre-medical students to re-evaluate their beliefs about dementia and appreciate the need for compassionate care for people with dementia. A Friend for Rachel also provides students with the opportunity to examine their personal lives and goals.

East meets West: Shadow coaching to support online reflective practice

OBJECTIVES

A structured, reflection-based electronic portfolio program (ePortfolio), with novel faculty development initiative, involving 'shadow coaches', was shared with the newly formed Ottawa-Shanghai Joint School of Medicine (OSJSM). OSJSM is a partnership between Shanghai Jiao Tong University and the University of Ottawa. As the world's first Sino-Canadian Joint Medical School, OSJSM introduced North American undergraduate medical curriculum to China. 'Shadow coaching' involved trans-Pacific pairing of coaches, supplemented by local faculty development.

FRAMEWORK

(a) Pre-implementation: The well-established online ePortfolio platform at the University of Ottawa was mirrored at OSJSM. University of Ottawa ePortfolio coaches were recruited to serve as shadow coaches to their OSJSM counterparts. Shadow coaches provided mentoring and resources while maintaining awareness of cross-cultural issues. Faculty development consisted of face-to-face faculty development in Shanghai, several online synchronous sessions, and familiarization of University of Ottawa coaches with the Chinese medical education system. (b) Description/Components: This intervention, introduced in 2016-2017, involved five University of Ottawa shadow coaches paired with five OSJSM ePortfolio coaches. Student reflection encourages open frank discussion which is a new paradigm for Chinese students and faculty. Shadow coaches were encouraged to challenge new OSJSM coaches to widely explore physician roles and competencies.

RESULTS

Initial results indicate that the experience served to effectively develop OSJSM coaches' skills as evidenced by shadow coaches' review of anonymized OSJSM student reflective writing.

CONCLUSIONS

Our project describes a novel tool using shadow coaching for faculty development for a cross-cultural partnership. Similar approaches can be utilized for culturally-sensitive long-distance faculty development.

A Novel Web-Based Experiential Learning Platform for Medical Students (Learning Moment): Qualitative Study

BACKGROUND

Experiential learning plays a critical role in learner development. Kolb's 4-part experiential learning model consists of concrete experience, reflective observation, abstract conceptualization, and active experimentation in a recurring cycle. Most clinical environments provide opportunities for experiences and active experimentation but rarely offer structured means for reflection and abstract conceptualization that are crucial for learners to learn through experience. We created Learning Moment, a novel Web-based educational tool that integrates principles of asynchronous learning and learning portfolios to fulfill the reflection and abstract conceptualization aspects of Kolb's learning cycle in the modern clinical learning environment. Medical students log concise clinical "pearls" in the form of "learning moments" for reflection, review, and sharing with peers in a community of practice.

OBJECTIVE

We sought to evaluate learners' experiences with Learning Moment via a qualitative study.

METHODS

We employed purposive sampling to recruit medical students who used Learning Moment during their rotation. We conducted 13 semistructured interviews (10 individual interviews and one 3-person group interview) between January and March 2017 using an ethnographic approach and utilized a general inductive method to analyze and code for potential themes.

RESULTS

A total of 13 students (five in their third year of medical school and eight in their fourth year) voluntarily participated in our qualitative interviews. Five of the 13 (38%) students intended to pursue emergency medicine as their chosen field of specialty. The median number of "learning moments" logged by these students is 6. From our analysis, three key themes emerged relating to the perceived impact of Learning Moment on student learning: (1) logging "learning moments" enhanced memorization, (2) improved learning through reflection, and (3) sharing of knowledge and experiences in a community of practice.

CONCLUSIONS

Learning Moment was successfully implemented into the educational infrastructure in our department. Students identified three mechanisms by which the application optimizes experiential learning, including enabling the logging of "learning moments" to promote memorization, encouraging reflection to facilitate learning, and fostering the sharing of knowledge and experiences within a community of practice. The Learning Moment concept is potentially scalable to other departments, disciplines, and institutions as we seek to optimize experiential learning ecosystems for all trainees.