This past week my
classmates and I had the opportunity to join a second-year Portfolio session (a
recurring group session focused on reflective practice), focused on preparing
for clerkship and beyond. My role as a fourth-year student was to share my own
reflections on clerkship (and residency applications), considering what I would
write in a letter to my first or second year self. This concept of narrative
medicine has been on my mind a lot lately, especially in the context of
reflecting on my experiences (constantly!) as I applied to residency. In
addition to helping with residency preparation and decision-making, Portfolio
has often served as a vehicle for discussing challenging situations throughout
medical school, particularly through group discussion (more so than the written
reflection we are asked to provide, in my experience). These sessions also
create a space to engage in shared reflection with classmates, and hopefully
develop some insights for practice. At a more basic level, Portfolio lets you
catch up with friends. Commiserate about the challenges of a particular
rotation. Feel good about each other's moments of inspiration and clarity,
after a long day. Portfolio serves a lot
of roles - but what do we know about its role in clinical practice? And what
does reflecting really mean? And what is the use of formulaic structure in
these reflections (a challenge I faced during the last year)?
In a brief review of
the literature, a few conclusions have been made regarding reflective practice
in medicine. A review by Mann et al. (2009) suggests reflective practice may be
most useful as a learning strategy, with some correlations between iterative
reflections, and deeper learning and understanding of clinical knowledge and
skills. Other studies in their review supported the practice of group
reflection, with strengths in offering multiple perspectives from which to view
clinical dilemmas, and brainstorm solutions; this collaborative model is
something we've employed during each portfolio session over the last few years,
with similar positive results. Regarding the hypothesis that reflective
practice increases overall competence in care, the authors found no evidence;
however, they were encouraging of future research into this area, given the
existence of work suggesting benefits in learning (for instance) (which may
indirectly effect overall competence).
Regarding assessment
of learners in reflective practice, Wald et al. (2012) built a rubric
("REFLECT") to guide review and feedback for written reflections from
trainees; interestingly, the authors made clear recommendations against
employment of this rubric for summative evaluation, for fear of inadvertently
encouraging a formulaic approach to reflection, and diminished reflective
capacity. However, this idea of
assessment, and perceived value in trainees adhering to specific guidelines and
outputs in their reflection has been discussed elsewhere in the literature, and
in our own curriculum. Reflecting on these studies, and in my own experiences
struggling with balancing my own expression of experience and learning (while
also adhering to the prescribed goals and aims of the practice), it is evident
that it may not be clear at present how to best approach evaluation, and more
broadly, how to best support trainees in conducting a process of thorough and
meaningful reflection in clerkship and in residency.
This quick review
answered some (but not all) of my questions about narrative medicine and
reflective practice; I'm looking forward to spending the next few weeks reading
more, and discussing these ideas with my colleagues and staff (and looking
ahead on how I aim to build these strategies into my practice as a future
resident).
(1) K. Mann, J.
Gordon, and A. MacLeod. (2009) Reflection and reflective practice in health
professions education: a systematic review. Adv in Health Sci Educ, 14:595–621.
DOI 10.1007/s10459-007-9090-2
(2) H. Wald, J.
Borkan, J. Taylor, D. Anthony, and S. Reis. (2012) Fostering and Evaluating
Reflective Capacity in Medical Education: Developing the REFLECT Rubric for
Assessing Reflective Writing. Acad Med, 2012;87:41–50. DOI
10.1097/ACM.0b013e31823b55fa
-AS
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