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Learning to connect: Students’ reflections on doctor–patient interactions
Patient Education and Counseling 75 (2009) 149–154
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Education
Learning to connect: Students’ reflections on doctor–patient interactions Terry Kind a,b,c,*, Veronica R. Everett d, Mary Ottolini b,c a
Division of General Pediatrics and Community Health, Children’s National Medical Center, United States Medical Education, Children’s National Medical Center, United States c The George Washington University School of Medicine and Health Sciences, United States d Department of Family Services, Children’s National Medical Center, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 April 2008 Received in revised form 4 September 2008 Accepted 22 September 2008
Objective: Reflective writing is an established method for teaching medical students empathetic interactions, though little is known about students’ reflections on connecting with patients during the clinical clerkship. The purpose of this study was to describe factors that medical students perceive contribute to or detract from making connections with patients and families, as identified in a writing assignment during the pediatric clinical clerkship. Methods: Reflective essays submitted by third-year medical students about interacting with patients/ families during their pediatric clerkship were qualitatively analyzed for thematic content. Results: Major themes emerging in 44 essays analyzed included time, knowledge, language and culture, and actions. Barriers to connecting for some students were considered resources by others. Critical reflection was present in 31.8%. Conclusions: Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract their ability to make connections. Through reflection, medical students – amidst clinical responsibilities – can identify how, why, and whether or not connections with patients/families have occurred. Practice implications: Recognizing what factors medical students perceive as enhancing and detracting from connecting with patients/families will help preceptors foster those connections and mitigate barriers. Future study could assess how to best provide specific individualized feedback to best enhance critical reflection. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, as it may augment students’ ability to connect. ß 2008 Elsevier Ireland Ltd. All rights reserved.
This project is dedicated to Dr. Steven Miller who connected effortlessly with so many and whose message lives on today. Keywords: Reflection Doctor–patient relationship Qualitative Narrative medicine Connecting
1. Introduction Teaching humanism is increasingly recognized as an integral component of medical education [1]. Yet, as medical students progress to their clinical years, fostering a habit of humanism [2] and the ability to connect empathetically with patients remains a challenge. Empathy – where the clinician’s awareness of the patient’s concerns produces emotional engagement, compassion, and an urge to help – is a teachable skill [3,4]. Reflective writing has been established as a method for teaching medical students empathetic interactions, such as by having them write personal illness narratives [5]. The writing and telling of one’s story, i.e.
* Corresponding author at: Children’s National Medical Center, Children’s Health Center at Martin Luther King, 3029 Martin Luther King, Jr, Ave, SE, Washington, DC 20032, United States. Tel.: +1 202 476 6910; fax: +1 202 476 6579. E-mail address: [email protected] (T. Kind). 0738-3991/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.09.011
narrative, has been considered to have tangible health and behavioral benefits, and is an important method of reflection [6,7]. A strong rationale for the importance of reflection in clinical practice highlights that through the reflective process trainees can recognize what values, beliefs, attitudes, and assumptions they themselves hold and how these might differ from those of their patients and families [8]. Trainees can then consider how each might have an impact on their own clinical decision making or how closely patients and families might adhere to their recommendations. In the context of medical school, reflection and reflective writing, if included, is usually a component of a preclinical or an elective course rather than as part of a core third-year clinical clerkship. Yet medical students indeed have the capacity for a wide range of creative expression even while immersed in clinical responsibilities [9]. During our 8-week third-year pediatric clerkship at Children’s National Medical Center (CNMC), there is a weekly core seminar series and special teaching rounds for
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students. As part of this core series, students participate in humanism seminars where they practice reflecting in small group activities about connecting with families, and interpreting humanities literature as it relates to clinical experiences. At the close of one of the humanism seminars, students are asked to reflect further on connecting or difficulty connecting with families, by completing a writing assignment. During the humanism seminar that immediately precedes the writing assignment, an invited guest speaker models the reflective process around issues of doctor–patient interactions. This invited guest is either a trainee proximate in experience to the third-year students (i.e. a fourth-year student or a resident) who has had an exemplary or a difficult time connecting with patients/families, or a patients’ parent who has had notable experiences with medical students. We allow students guided practice sharing their reflections with each other in safe, small groups before asking them to reflect in writing. Following the submission of their anonymous writing, students receive feedback in the form of key insights about connecting with patients and families that were evident in their essays, and questions for ongoing reflection to enhance their ability to build relationships in the future. While the doctor–patient relationship has been studied extensively [10], as well as the nursing trainee–patient relationship [11], literature about medical students’ perspectives on connecting with families and what factors contribute or detract from their making connections is sparse. Guided by a theoretical framework (Fig. 1) derived from Scho¨n’s reflection-on-action and Scho¨n and Argyris’ Double Loop learning [12,13], in this study we have undertaken this content analysis to identify these factors evident in medical student’s reflective writings. Reflection-in-action allows students the opportunity to better understand their emotional reactions to various day to day doctor– patient interactions but is unlikely to result in sustained change. Reflection-on-action, like double loop learning, allows students to challenge their assumptions later and make changes and improvements. For the students, we provide feedback as part of their reflective cycle of their double loop learning. Much focus has been on educational efforts to promote empathic connections with patients, rather than on the factors themselves that contribute or detract from connections. Our purpose in the current study was to qualitatively analyze these factors, as depicted in a reflective writing assignment designed to understand the medical student’s perspectives and to promote professional growth.
Box 1. Question assigned to student participants on third-year pediatric clerkship* Over the next 1–2 weeks while on your pediatrics rotation, think about the connections you make or have difficulty making with your pediatric patients and their families. . . (choose one of the following) (1) Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were able to connect with a patient or patient’s family and why you think the connection was made. How has this affected your personal and professional growth? (2) Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were not able to connect with a patient or patient’s family and why you think a connection was not made. How has this affected your personal and professional growth? *Written responses provided anonymously by students as part of a homework assignment.
2. Methods 2.1. Design This is a qualitative study of reflective papers submitted by third-year medical students during their pediatric rotation, following a humanism seminar. 2.2. Setting Medical students were instructed to independently reflect about their interactions with patients during 2 weeks on the inpatient or ambulatory pediatric clerkship, following a humanism seminar, in a writing assignment (see Box 1). We introduced the hour-long humanism seminar during the 2005–2006 academic year. A typical seminar began with a fourth-year student sharing his/her experiences connecting empathetically with a patient and/ or family, reflecting aloud discussing aspects of the doctor–patient relationship that detracted from or enabled him/her to connect with the patient/parent. Third-year students then practice sharing their own reflections with each other in small groups facilitated by a chief resident or attending who can help address concerns that arise, such as appropriate professional boundaries.
Fig. 1. Theoretical framework providing context for our content analysis of factors perceived by medical students as relevant to their making connections with patients and families. These factors influence their interactions, yielding positive or negative experiences. The experiences can feed back to affect future interactions with patients and families. Or, through further reflection, the assumptions underlying the factors themselves can be challenged. Our model draws upon on Argyris and Schon’s theories of learning (single-loop, double-loop) and reflection in and on action [12,13].
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Third-year medical students during their pediatric rotation at CNMC, which serves as the pediatric training hospital for the George Washington University School of Medicine.
the reflective assignments were shared with the students groups; (5) established tactics for generating meaning were employed, such as clustering, noting patterns, seeing plausibility, counting, and making contrasts/comparisons; and (6) peer review was solicited in regional and national conference settings.
2.4. Data sources
3. Results
Reflective essays written by medical students and submitted anonymously in response to the prompt, ‘‘Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were or were not able to connect with a patient or patient’s family and why you think the connection was or was not made.’’ Students were further asked to discuss how this affected their personal and professional growth. We continued to assess essays until we reached theoretical saturation, that is, until we ascertained through analysis that no new themes were being generated [14]. This study was approved as exempt by the CNMC Institutional Review Board.
3.1. Essay characteristics
2.3. Informants
2.5. Data analysis Standard qualitative data analysis techniques were used [15] to identify themes relating to students’ views on connecting or failing to connect with their pediatric patients and families. All essays were analyzed thematically by drawing upon principles of grounded theory, allowing meaning to emerge from the data, enhancing understanding and offering insight [14]. In the early stage of our analysis, two investigators (T.K. and V.R.E.) generated preliminary codes based on the occurrence of themes or the identification of patterns in the essay responses. A coding framework was developed. These two coding investigators reviewed all data, generating additional codes to represent emergent themes where indicated. Students’ essay text was analyzed individually rather than by clerkship group. Text was uploaded into HyperResearch 2.7 software (ResearchWare, Inc., Randolph, MA). This software allows for the organization, examination, and retrieval of annotated coded responses. The two coding investigators analyzed the text independently of each other, but met regularly throughout the process to discuss coding and resolve differing interpretations, modifying the coding framework until consensus was reached. Consensus was reached through discussion and joint re-review of the text passages where disagreement had initially occurred. In an iterative manner, we compared and contrasted themes and noted patterns. Key quotes exemplifying the dominant themes were identified. Each essay was categorized as either having no evidence of reflection, evidence of reflection, or evidence of critical reflection [16]. For this categorization, we drew upon Plack’s framework in which critical reflection is noted when a writer explores the existence of a problem, where the problem stems from, or the assumptions underlying the problem; the writer revisits an experience, begins to challenge his/her own assumptions, and may begin to modify his/her own biases [16,13].
We included all 44 essays from 2 rotation groups, submitted by students from November 2005 through February 2006, after which point thematic saturation had been attained. 81% of 54 students from two clerkship groups submitted essays. Mean word count per essay was 420 with a range from 174 to 1006 words. Critical reflection was present in 31.8% of the essays, in which underlying assumptions were explored and critiqued and the experience was revisited. Reflection was present in 26 (59.1%) essays, in which there was some evidence that the writer explored the experience with the intent to better understand it, while 4 of the essays (9.1%) did not include evidence of reflection, only a description of an experience without any evidence of questioning or evaluating that experience. In 27 of the essays (61%), the student writing the essay felt a connection was made, and in 7 of these 27 (26%), students felt that it was nonetheless difficult to make that connection. In 8 of the 44 essays students chose to write about a time when a connection was not made. Two essays were somewhere in between connecting and not connecting. Three students included two stories in their essay, one about connecting and one about inability to connect. Four essays were general without a specific scenario described. 3.2. Themes Students’ views on connecting or failing to connect with their pediatric patients and families were categorized thematically. Data included 44 essays to which we applied 28 codes. Dominant themes emerged from these codes, and key quotes exemplifying these themes are presented to provide thick description. 3.2.1. Time Time as a reason that students did or did not connect varied in its negative or positive impact, which suggests the subjective nature of time. Some students felt that although their time with patients is limited, it is not a barrier to connecting. Others felt that the limited amount of time is indeed a barrier. Still others elaborated that they have ‘‘extra time’’ to connect because they are medical students. In addition to key quotes below, Fig. 2 represents the theme of time and its complex relationship with connecting, where the amount of time can be viewed as a positive or negative factor in students connecting with patients and families. 3.2.1.1. Time is not a barrier.
2.6. Trustworthiness Several steps were taken to verify findings and ensure trustworthiness, a concept in qualitative research comparable to validity and reliability in quantitative research [15]. These steps included that, (1) essays were submitted in a manner that ensured anonymity, minimized group pressure, encouraged honesty and self-reflection; (2) data were triangulated by comparing written essays with the views expressed aloud by students in the classroom sessions that preceded the homework exercise; (3) the two coding investigators initially assessed data independently; (4) member checking occurred as summarized key insights from
At the end of our five minute conversation, she thanked me. I realized that it doesn’t take a whole lot of time or magic to show you care. It could be simply sitting in a chair when you talk to make them feel more comfortable, or the simple question, ‘‘anything else you would like to talk about?’’ At times, we become so rushed we forget the simple things that help us to better connect with our patients. 3.2.1.2. Not enough time. I unfortunately do not feel that I truly connected with my patients and their family. This may have been due to one of a number of
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Fig. 2. The theme of time and its complex relationship with connecting, where the amount of time can be perceived as a positive or negative factor in students connecting with patients and families. Students’ comments paraphrased.
reasons. Firstly, most of my patients were only in the hospital for one or two days, so there was not much time to build a relationship. It took me over 3 days to build any rapport with the patient. 3.2.1.3. Having ‘‘extra time’’ to connect. I would often spend extra time playing with the baby too on each visit, which gave them more face time with me. In all, it didn’t add up to that much more time, but it did add up in the end. Fortunately, I have the time as a medical student to devote to them.
3.2.3. Language and culture Language and culture were seen by some students as a bridge to a connection, for others it was a barrier, and still for others it was a non-issue. 3.2.3.1. Speaking the same language of toddlers/children. The children I see may not speak my language, but we are able to communicate with facial expressions, touch and tone of voice. 3.2.3.2. Speaking the same language (non-English) helps to connect.
3.2.2. Knowledge When students’ reflections included the theme of ‘‘knowledge’’ it was usually in a positive way. Students often described that the knowledge they possessed allowed them to provide information to the family, helping them form a connection, as exemplified in the following text:
When I first [met] him we connected immediately because we spoke the same language, Arabic. 3.2.3.3. Cultural barriers. I think that people need to be sensitive to ones beliefs when asking questions. Obviously, the mother was very upset with the fact that someone questioned her beliefs regarding the child’s medications and immunizations. Perhaps if that had not have happened, the mother would not have been so angry.
I learned from her; she learned and had a friend in me. I tried to educate her regarding her son’s health which took a turn for the worse when he was diagnosed with bacterial meningitis. I have learned that parents feel more comfortable and are able to connect better if physicians explain their child’s disease process to them.
3.2.3.4. Overcoming cultural barriers.
Less frequently, students struggled with their own lack of knowledge or perceptions of their lack of knowledge by others, and how that was a barrier to making a connection with families. The perception by a family of the student’s lack of knowledge is portrayed here:
Seeing my interest to learn more about him and his way of life, seemed to allow him to feel more comfortable. After that occurrence we had a nice relationship. From then on, he was always warm and asked many questions. It’s important to realize how often a sense of superiority can be conveyed unintentionally.
They gave me that look of ‘‘what do you know. You’re only a med student’’. As we ended the interview I told mom that we wanted to examine the baby. She gave me a look of disgust and I could read her body language that she was very annoyed.
3.2.4. Actions Students reflected on their own actions and physical behaviors that helped them connect with families by gaining trust and by showing that they were human. Common behaviors mentioned
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included playing a game, getting a blanket, or cleaning up some bodily fluid. Doctors are healers, but they are also humans too. And it is the human touch and the showing of compassion and understanding that makes all the difference. If baby pukes up some milk on the table, I am more than happy to help clean up that puke. That’s when the patients and their families know that they can trust you as not only a healer but also a human being. That’s when a real connection is made. It was easy for me to make a connection with him, all I had to do was poke my head in whenever I had a spare minute and was near his room. In those brief moments I would play a quick game of catch, say ‘‘hi’’, or simply get a hi five. 3.2.5. Perceptions Perceptions by students of themselves, of families, and of patients had an impact on every level of a connection in both positive and negative ways. Personality served at times as a building block for developing relationships, but often the perception of another’s personality was more indicative of a connection or non-connection. 3.2.5.1. Student’s self-perception. My ability to react with children is one of the reasons I came to medical school. I believe that my ability to communicate with people is what will ultimately make me a great doctor. 3.2.5.2. Taking colleague’s perceptions of families into account. My resident and I were warned by the ER attending that this was a difficult family. The dad was very over-protective and did not think that his infant son should be admitted for RSV bronchiolitis. We were prepared for dad and gave him some time to cool off before entering the room. . .. Dad seemed to cooperate. My intern warned me that the parents are a bit difficult to deal with and that they might expect a lot from a medical student. I didn’t let that bother me. I first met the mom and she seemed like she was in a lot of despair. 3.2.5.3. Student’s perceptions of a family as difficult. The problem was not with the patient himself but his father. This man was one of those very entitled parents where nothing was ever good enough for him. He basically second guessed every decision that we made. 3.2.5.4. Student’s perception of patient. Mom quickly told me that he just did not like anybody with a white coat. I waited until we were situated in the room to ask her to elaborate a bit more. Apparently, he had had his adenoids and tonsils removed the year before and had a really tough time while in the hospital. He has been terrified of the hospital and doctors ever since. His reaction suddenly made much more sense and signaled me to conduct both my interview and exam in a slightly different way. 3.2.6. Reflections on connections: resulting feelings of ambivalence and surprise In their essays describing connections with patients and families, students further reflected on their own feelings about having made or not made connections. In doing so, students described various feelings such as anger, excitement, disappoint-
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ment, and a sense of reward. Among the feelings most frequently depicted were students’ own ambivalent feelings towards families and often their surprise that they had made a connection or that the family felt connected to them. As a result, I truly feel I cared for A. better than many of my other patients, which is an unsettling feeling. Afterwards, I was a bit surprised that this woman had actually wanted to confide in and share such personal information with me, especially since I had barely talked with her before and I had not felt that we had connected well. Yet, after thinking about these events for a while, I realized that we impact every patient and their family’s lives whether we realize it or not.
4. Discussion and conclusions 4.1. Discussion This qualitative study of original reflective essays written by medical students on their pediatrics clinical clerkship was conducted in order to gain insight into factors contributing to and detracting from their abilities to connect with patients and families. Our findings reveal that time was an important though complex factor in connecting, depending on whether students perceived that it took a lot or a little time to connect and whether they felt they had enough time to do so. It should be noted that this is the medical student’s own perception of time, and patients often conceptualize time differently than do physicians [17]. Students’ written reflections also highlighted their own lack of knowledge, but this was not always seen as a barrier. They reflected upon language, culture, perceived personality, and actions as having an impact upon their ability to connect. Students have described that these factors can both contribute to or detract from their making connections. In reflecting on connections, they also described their feelings, often of ambivalence or surprise. At times, students’ reflections reveal that what they hear about patients’ personalities may not be true, and that they are often surprised about having made a connection despite apparent differences or lack of time. Although the literature on reflective writing by medical students during their clinical years is sparse, some themes expressed by students on their pediatric clerkship in our study are consistent with what has been described in other educational settings (i.e. on electives, primary care rotations, or via critical incident reports) where identification with the patient, recognizing ‘‘the person behind the symptoms,’’ and expressions of empathy, helped students identify with patients and contributed to their professional development [18,19,20,21]. Our findings also build on the literature regarding medical students’ early clinical experiences (i.e. in the second year) where investing the time to build relationships and sharing commonalities can foster the doctor–patient relationship [22]. For those further along in training, residents believe that lack of knowledge about other cultures can cause communication difficulties, but they spend little time reflecting on their professional culture and beliefs [23]. The themes expressed by our students can inform faculty when discussing the trainees’ role in the doctor–patient relationship and effective communication. For example, despite busy clinical schedules, medical trainees should develop an awareness that time need not be a barrier to connecting, as one student wrote, ‘‘it doesn’t take a whole lot of time or magic to show you care.’’ In the context of our theoretical framework using reflection-on-action, creativity and a deeper understanding of how to make the most of the available resources may ultimately improve a student’s ability to consistently make connections with families and patients.
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Our study was limited to medical students at one urban academic institution. We did not collect demographics on this student population, but note that the students in this study were about halfway through their third year of medical school (their first clinical year) when submitting these reflective essays, and were undifferentiated, in that they had not yet selected their specialty field. The coding investigators reached consensus, but inter-rater reliability was not assessed. Another limitation is that while most students submitted essays, those that did not might hold other viewpoints on connecting with families that were not discovered in the above analysis. Finally, while our analysis revealed that critical reflection was present in about one-third of the essays, determining the level of critical thinking [24] was not the primary focus of our study. Students had the opportunity to discuss, but given their anonymity in submitting their reflective pieces, the only feedback they received was in the form of general group key insights. More specific individualized feedback could further enhance critical reflection. One strength of our study is the use of qualitative methodology in that this allows for a rich understanding of the meaning and complexities of students’ perceptions about a topic with no one right answer, that is, how trainees make connections with families in the clinical setting. As noted above, several methodological steps were made to increase the trustworthiness of the data acquisition and its interpretation. 4.2. Conclusions Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract from their ability to make connections. When narrative and reflection is integrated into the pediatric clerkship, medical students – amidst their clinical responsibilities – can identify how, why, and whether or not connections with patients and their families have occurred. Although it is a daunting task to explicitly teach how to connect with patients, this can instead become part of one’s professional identity in other ways such as through reflective thinking, writing, feedback, and deliberate practice [13,25,26]. Ideally, facilitating the reflective process on the pediatric clerkship would allow students to challenge their own assumptions about the underlying factors contributing to the doctor–patient relationship such as time, knowledge, language/culture, and actions. Ongoing reflection is enhanced through discussion and feedback over time. Students in the present study indeed had the opportunity to discuss, but feedback was provided as general group key insights. More specific individualized feedback would likely further enhance critical reflection. 4.3. Practice implications Recognizing what medical students perceive as barriers to connecting with patients and families and what they see as enhancing their abilities to connect can help precepting physicians and other providers foster those abilities. Promoting reflective learning through narrative may help students understand how to make the most of the available resources and ultimately augment their own ability to consistently make connections with families and patients. Future research could compare different types of reflective activities among medical students, including the provision of individualized feedback, with an assessment of the impact on degree and ability of student reflection. Ultimately, an assessment or observation of change in trainees’ interactions with patients could be performed. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, so that we promote critical thinking not only about differential diagnoses, but also about the approach to the doctor–patient relationship.
Acknowledgments This project was supported by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and also by the Master Teacher Leadership Development Program at The George Washington University. We wish to thank Ms. Wilhelmina Bradford for her tireless efforts coordinating and connecting with medical students. The authors confirm that all patient/personal identifiers have been removed or disguised so the patients/persons described are not identifiable and cannot be identified through the details of the story. Conflict of interest: The authors have no conflicts of interest to disclose. Role of funding: This project was supported by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and also by the Master Teacher Leadership Development Program at The George Washington University. The funding sources had no involvement in study design, data collection, data analysis, data interpretation, or the decision to submit the paper for publication. References [1] Gracey CF, Haidet P, Branch WT, Weissmann P, Kern DE, Mitchell G, Frankel R, Inui T. Precepting humanism: strategies for fostering the human dimensions of care in ambulatory settings. Acad Med 2005;80:21–8. [2] Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med 1999;74:800–3. [3] Benbassat J, Baumal R. What is empathy, and how can it be promoted during clinical clerkships? Acad Med 2004;79:832–9. [4] Benbassat J, Baumal R. Enhancing self-awareness in medical students: an overview of teaching approaches. Acad Med 2005;80:156–61. [5] DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med 2004;79:351–6. [6] Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Educ Couns 2004;54:251–3. [7] Charon R. Narrative medicine: honoring the stories of illness. New York, NY: Oxford University Press; 2006. [8] Plack MM, Greenberg L. The reflective practitioner: reaching for excellence in practice. Pediatrics 2005;116:1546–52. [9] Rucker L, Shapiro J. Becoming a physician: students’ creative projects in a third-year IM clerkship. Acad Med 2003;78:391–7. [10] Teutsch C. Patient-doctor communication. Med Clin N Am 2003;87:1115–45. [11] Suikkala A, Leino-Kilpi H. Nursing student-patient relationship: a review of the literature from 1984 to 1998. J Adv Nurs 2001;33:42–50. [12] Argyris C, Scho¨n D. Theory in practice: Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974. [13] Scho¨n DA. The reflective practitioner. How professionals think in action. London: Temple Smith; 1983. [14] Strauss AL, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory, 2nd edition, Thousand Oaks: Sage Publications; 1998. [15] Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook, 2nd ed., Thousand Oaks: Sage Publications; 1994. [16] Plack MM, Driscoll M, Blissett S, McKenna R, Plack TP. A method for assessing reflective journal writing. J Allied Health 2005;34:199–208. [17] Klitzman R. Patient-time’’, ‘‘doctor-time’’, and ‘‘institution-time’’: perceptions and definitions of time among doctors who become patients. Patient Educ Couns 2007;66:147–55. [18] Hatem D, Ferrara E. Becoming a doctor: fostering humane caregivers through creative writing. Patient Educ Couns 2001;45:13–22. [19] Svenberg K, Wahlqvist M, Mattsson B. A memorable consultation’’: Writing reflective accounts articulates students’ learning in general practice. Scand J Prim Health 2007;25:75–9. [20] Nogueira-Martins MC, Nogueira-Martins LA, Turato ER. Medical students’ perceptions of their learning about the doctor–patient relationship: a qualitative study. Med Educ 2006;40:322–8. [21] Branch W, Pels RJ, Lawrence RS, Arky R. Becoming a doctor—critical-incident reports from third year medical students. New Engl J Med 1993;329:1130–2. [22] Dyrbye LN, Harris I, Rohren CH. Early clinical experiences from students’ perspectives: a qualitative study of narratives. Acad Med 2007;82:979–88. [23] Lingard L, Tallett S, Rosenfield J. Culture and physician-patient communication: a qualitative exploration of residents’ experiences and attitudes. Ann Roy Coll Physicians Surg Can 2002;35:331–5. [24] Plack MM, Driscoll M, Marquez M, Cuppernull L, Maring J, Greenberg L. Assessing reflective writing on a pediatric clerkship by using a modified bloom’s taxonomy. Ambulatory Pediatrics 2007;7:285–91. [25] Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861–71. [26] Brookfield SD. Becoming a critically reflective teacher. New York, NY: JosseyBass Inc.; 1995.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Education
Learning to connect: Students’ reflections on doctor–patient interactions Terry Kind a,b,c,*, Veronica R. Everett d, Mary Ottolini b,c a
Division of General Pediatrics and Community Health, Children’s National Medical Center, United States Medical Education, Children’s National Medical Center, United States c The George Washington University School of Medicine and Health Sciences, United States d Department of Family Services, Children’s National Medical Center, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 April 2008 Received in revised form 4 September 2008 Accepted 22 September 2008
Objective: Reflective writing is an established method for teaching medical students empathetic interactions, though little is known about students’ reflections on connecting with patients during the clinical clerkship. The purpose of this study was to describe factors that medical students perceive contribute to or detract from making connections with patients and families, as identified in a writing assignment during the pediatric clinical clerkship. Methods: Reflective essays submitted by third-year medical students about interacting with patients/ families during their pediatric clerkship were qualitatively analyzed for thematic content. Results: Major themes emerging in 44 essays analyzed included time, knowledge, language and culture, and actions. Barriers to connecting for some students were considered resources by others. Critical reflection was present in 31.8%. Conclusions: Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract their ability to make connections. Through reflection, medical students – amidst clinical responsibilities – can identify how, why, and whether or not connections with patients/families have occurred. Practice implications: Recognizing what factors medical students perceive as enhancing and detracting from connecting with patients/families will help preceptors foster those connections and mitigate barriers. Future study could assess how to best provide specific individualized feedback to best enhance critical reflection. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, as it may augment students’ ability to connect. ß 2008 Elsevier Ireland Ltd. All rights reserved.
This project is dedicated to Dr. Steven Miller who connected effortlessly with so many and whose message lives on today. Keywords: Reflection Doctor–patient relationship Qualitative Narrative medicine Connecting
1. Introduction Teaching humanism is increasingly recognized as an integral component of medical education [1]. Yet, as medical students progress to their clinical years, fostering a habit of humanism [2] and the ability to connect empathetically with patients remains a challenge. Empathy – where the clinician’s awareness of the patient’s concerns produces emotional engagement, compassion, and an urge to help – is a teachable skill [3,4]. Reflective writing has been established as a method for teaching medical students empathetic interactions, such as by having them write personal illness narratives [5]. The writing and telling of one’s story, i.e.
* Corresponding author at: Children’s National Medical Center, Children’s Health Center at Martin Luther King, 3029 Martin Luther King, Jr, Ave, SE, Washington, DC 20032, United States. Tel.: +1 202 476 6910; fax: +1 202 476 6579. E-mail address: [email protected] (T. Kind). 0738-3991/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.09.011
narrative, has been considered to have tangible health and behavioral benefits, and is an important method of reflection [6,7]. A strong rationale for the importance of reflection in clinical practice highlights that through the reflective process trainees can recognize what values, beliefs, attitudes, and assumptions they themselves hold and how these might differ from those of their patients and families [8]. Trainees can then consider how each might have an impact on their own clinical decision making or how closely patients and families might adhere to their recommendations. In the context of medical school, reflection and reflective writing, if included, is usually a component of a preclinical or an elective course rather than as part of a core third-year clinical clerkship. Yet medical students indeed have the capacity for a wide range of creative expression even while immersed in clinical responsibilities [9]. During our 8-week third-year pediatric clerkship at Children’s National Medical Center (CNMC), there is a weekly core seminar series and special teaching rounds for
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students. As part of this core series, students participate in humanism seminars where they practice reflecting in small group activities about connecting with families, and interpreting humanities literature as it relates to clinical experiences. At the close of one of the humanism seminars, students are asked to reflect further on connecting or difficulty connecting with families, by completing a writing assignment. During the humanism seminar that immediately precedes the writing assignment, an invited guest speaker models the reflective process around issues of doctor–patient interactions. This invited guest is either a trainee proximate in experience to the third-year students (i.e. a fourth-year student or a resident) who has had an exemplary or a difficult time connecting with patients/families, or a patients’ parent who has had notable experiences with medical students. We allow students guided practice sharing their reflections with each other in safe, small groups before asking them to reflect in writing. Following the submission of their anonymous writing, students receive feedback in the form of key insights about connecting with patients and families that were evident in their essays, and questions for ongoing reflection to enhance their ability to build relationships in the future. While the doctor–patient relationship has been studied extensively [10], as well as the nursing trainee–patient relationship [11], literature about medical students’ perspectives on connecting with families and what factors contribute or detract from their making connections is sparse. Guided by a theoretical framework (Fig. 1) derived from Scho¨n’s reflection-on-action and Scho¨n and Argyris’ Double Loop learning [12,13], in this study we have undertaken this content analysis to identify these factors evident in medical student’s reflective writings. Reflection-in-action allows students the opportunity to better understand their emotional reactions to various day to day doctor– patient interactions but is unlikely to result in sustained change. Reflection-on-action, like double loop learning, allows students to challenge their assumptions later and make changes and improvements. For the students, we provide feedback as part of their reflective cycle of their double loop learning. Much focus has been on educational efforts to promote empathic connections with patients, rather than on the factors themselves that contribute or detract from connections. Our purpose in the current study was to qualitatively analyze these factors, as depicted in a reflective writing assignment designed to understand the medical student’s perspectives and to promote professional growth.
Box 1. Question assigned to student participants on third-year pediatric clerkship* Over the next 1–2 weeks while on your pediatrics rotation, think about the connections you make or have difficulty making with your pediatric patients and their families. . . (choose one of the following) (1) Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were able to connect with a patient or patient’s family and why you think the connection was made. How has this affected your personal and professional growth? (2) Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were not able to connect with a patient or patient’s family and why you think a connection was not made. How has this affected your personal and professional growth? *Written responses provided anonymously by students as part of a homework assignment.
2. Methods 2.1. Design This is a qualitative study of reflective papers submitted by third-year medical students during their pediatric rotation, following a humanism seminar. 2.2. Setting Medical students were instructed to independently reflect about their interactions with patients during 2 weeks on the inpatient or ambulatory pediatric clerkship, following a humanism seminar, in a writing assignment (see Box 1). We introduced the hour-long humanism seminar during the 2005–2006 academic year. A typical seminar began with a fourth-year student sharing his/her experiences connecting empathetically with a patient and/ or family, reflecting aloud discussing aspects of the doctor–patient relationship that detracted from or enabled him/her to connect with the patient/parent. Third-year students then practice sharing their own reflections with each other in small groups facilitated by a chief resident or attending who can help address concerns that arise, such as appropriate professional boundaries.
Fig. 1. Theoretical framework providing context for our content analysis of factors perceived by medical students as relevant to their making connections with patients and families. These factors influence their interactions, yielding positive or negative experiences. The experiences can feed back to affect future interactions with patients and families. Or, through further reflection, the assumptions underlying the factors themselves can be challenged. Our model draws upon on Argyris and Schon’s theories of learning (single-loop, double-loop) and reflection in and on action [12,13].
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Third-year medical students during their pediatric rotation at CNMC, which serves as the pediatric training hospital for the George Washington University School of Medicine.
the reflective assignments were shared with the students groups; (5) established tactics for generating meaning were employed, such as clustering, noting patterns, seeing plausibility, counting, and making contrasts/comparisons; and (6) peer review was solicited in regional and national conference settings.
2.4. Data sources
3. Results
Reflective essays written by medical students and submitted anonymously in response to the prompt, ‘‘Describe a time (the case, the situation, how you felt, how the patient/family felt) when you were or were not able to connect with a patient or patient’s family and why you think the connection was or was not made.’’ Students were further asked to discuss how this affected their personal and professional growth. We continued to assess essays until we reached theoretical saturation, that is, until we ascertained through analysis that no new themes were being generated [14]. This study was approved as exempt by the CNMC Institutional Review Board.
3.1. Essay characteristics
2.3. Informants
2.5. Data analysis Standard qualitative data analysis techniques were used [15] to identify themes relating to students’ views on connecting or failing to connect with their pediatric patients and families. All essays were analyzed thematically by drawing upon principles of grounded theory, allowing meaning to emerge from the data, enhancing understanding and offering insight [14]. In the early stage of our analysis, two investigators (T.K. and V.R.E.) generated preliminary codes based on the occurrence of themes or the identification of patterns in the essay responses. A coding framework was developed. These two coding investigators reviewed all data, generating additional codes to represent emergent themes where indicated. Students’ essay text was analyzed individually rather than by clerkship group. Text was uploaded into HyperResearch 2.7 software (ResearchWare, Inc., Randolph, MA). This software allows for the organization, examination, and retrieval of annotated coded responses. The two coding investigators analyzed the text independently of each other, but met regularly throughout the process to discuss coding and resolve differing interpretations, modifying the coding framework until consensus was reached. Consensus was reached through discussion and joint re-review of the text passages where disagreement had initially occurred. In an iterative manner, we compared and contrasted themes and noted patterns. Key quotes exemplifying the dominant themes were identified. Each essay was categorized as either having no evidence of reflection, evidence of reflection, or evidence of critical reflection [16]. For this categorization, we drew upon Plack’s framework in which critical reflection is noted when a writer explores the existence of a problem, where the problem stems from, or the assumptions underlying the problem; the writer revisits an experience, begins to challenge his/her own assumptions, and may begin to modify his/her own biases [16,13].
We included all 44 essays from 2 rotation groups, submitted by students from November 2005 through February 2006, after which point thematic saturation had been attained. 81% of 54 students from two clerkship groups submitted essays. Mean word count per essay was 420 with a range from 174 to 1006 words. Critical reflection was present in 31.8% of the essays, in which underlying assumptions were explored and critiqued and the experience was revisited. Reflection was present in 26 (59.1%) essays, in which there was some evidence that the writer explored the experience with the intent to better understand it, while 4 of the essays (9.1%) did not include evidence of reflection, only a description of an experience without any evidence of questioning or evaluating that experience. In 27 of the essays (61%), the student writing the essay felt a connection was made, and in 7 of these 27 (26%), students felt that it was nonetheless difficult to make that connection. In 8 of the 44 essays students chose to write about a time when a connection was not made. Two essays were somewhere in between connecting and not connecting. Three students included two stories in their essay, one about connecting and one about inability to connect. Four essays were general without a specific scenario described. 3.2. Themes Students’ views on connecting or failing to connect with their pediatric patients and families were categorized thematically. Data included 44 essays to which we applied 28 codes. Dominant themes emerged from these codes, and key quotes exemplifying these themes are presented to provide thick description. 3.2.1. Time Time as a reason that students did or did not connect varied in its negative or positive impact, which suggests the subjective nature of time. Some students felt that although their time with patients is limited, it is not a barrier to connecting. Others felt that the limited amount of time is indeed a barrier. Still others elaborated that they have ‘‘extra time’’ to connect because they are medical students. In addition to key quotes below, Fig. 2 represents the theme of time and its complex relationship with connecting, where the amount of time can be viewed as a positive or negative factor in students connecting with patients and families. 3.2.1.1. Time is not a barrier.
2.6. Trustworthiness Several steps were taken to verify findings and ensure trustworthiness, a concept in qualitative research comparable to validity and reliability in quantitative research [15]. These steps included that, (1) essays were submitted in a manner that ensured anonymity, minimized group pressure, encouraged honesty and self-reflection; (2) data were triangulated by comparing written essays with the views expressed aloud by students in the classroom sessions that preceded the homework exercise; (3) the two coding investigators initially assessed data independently; (4) member checking occurred as summarized key insights from
At the end of our five minute conversation, she thanked me. I realized that it doesn’t take a whole lot of time or magic to show you care. It could be simply sitting in a chair when you talk to make them feel more comfortable, or the simple question, ‘‘anything else you would like to talk about?’’ At times, we become so rushed we forget the simple things that help us to better connect with our patients. 3.2.1.2. Not enough time. I unfortunately do not feel that I truly connected with my patients and their family. This may have been due to one of a number of
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Fig. 2. The theme of time and its complex relationship with connecting, where the amount of time can be perceived as a positive or negative factor in students connecting with patients and families. Students’ comments paraphrased.
reasons. Firstly, most of my patients were only in the hospital for one or two days, so there was not much time to build a relationship. It took me over 3 days to build any rapport with the patient. 3.2.1.3. Having ‘‘extra time’’ to connect. I would often spend extra time playing with the baby too on each visit, which gave them more face time with me. In all, it didn’t add up to that much more time, but it did add up in the end. Fortunately, I have the time as a medical student to devote to them.
3.2.3. Language and culture Language and culture were seen by some students as a bridge to a connection, for others it was a barrier, and still for others it was a non-issue. 3.2.3.1. Speaking the same language of toddlers/children. The children I see may not speak my language, but we are able to communicate with facial expressions, touch and tone of voice. 3.2.3.2. Speaking the same language (non-English) helps to connect.
3.2.2. Knowledge When students’ reflections included the theme of ‘‘knowledge’’ it was usually in a positive way. Students often described that the knowledge they possessed allowed them to provide information to the family, helping them form a connection, as exemplified in the following text:
When I first [met] him we connected immediately because we spoke the same language, Arabic. 3.2.3.3. Cultural barriers. I think that people need to be sensitive to ones beliefs when asking questions. Obviously, the mother was very upset with the fact that someone questioned her beliefs regarding the child’s medications and immunizations. Perhaps if that had not have happened, the mother would not have been so angry.
I learned from her; she learned and had a friend in me. I tried to educate her regarding her son’s health which took a turn for the worse when he was diagnosed with bacterial meningitis. I have learned that parents feel more comfortable and are able to connect better if physicians explain their child’s disease process to them.
3.2.3.4. Overcoming cultural barriers.
Less frequently, students struggled with their own lack of knowledge or perceptions of their lack of knowledge by others, and how that was a barrier to making a connection with families. The perception by a family of the student’s lack of knowledge is portrayed here:
Seeing my interest to learn more about him and his way of life, seemed to allow him to feel more comfortable. After that occurrence we had a nice relationship. From then on, he was always warm and asked many questions. It’s important to realize how often a sense of superiority can be conveyed unintentionally.
They gave me that look of ‘‘what do you know. You’re only a med student’’. As we ended the interview I told mom that we wanted to examine the baby. She gave me a look of disgust and I could read her body language that she was very annoyed.
3.2.4. Actions Students reflected on their own actions and physical behaviors that helped them connect with families by gaining trust and by showing that they were human. Common behaviors mentioned
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included playing a game, getting a blanket, or cleaning up some bodily fluid. Doctors are healers, but they are also humans too. And it is the human touch and the showing of compassion and understanding that makes all the difference. If baby pukes up some milk on the table, I am more than happy to help clean up that puke. That’s when the patients and their families know that they can trust you as not only a healer but also a human being. That’s when a real connection is made. It was easy for me to make a connection with him, all I had to do was poke my head in whenever I had a spare minute and was near his room. In those brief moments I would play a quick game of catch, say ‘‘hi’’, or simply get a hi five. 3.2.5. Perceptions Perceptions by students of themselves, of families, and of patients had an impact on every level of a connection in both positive and negative ways. Personality served at times as a building block for developing relationships, but often the perception of another’s personality was more indicative of a connection or non-connection. 3.2.5.1. Student’s self-perception. My ability to react with children is one of the reasons I came to medical school. I believe that my ability to communicate with people is what will ultimately make me a great doctor. 3.2.5.2. Taking colleague’s perceptions of families into account. My resident and I were warned by the ER attending that this was a difficult family. The dad was very over-protective and did not think that his infant son should be admitted for RSV bronchiolitis. We were prepared for dad and gave him some time to cool off before entering the room. . .. Dad seemed to cooperate. My intern warned me that the parents are a bit difficult to deal with and that they might expect a lot from a medical student. I didn’t let that bother me. I first met the mom and she seemed like she was in a lot of despair. 3.2.5.3. Student’s perceptions of a family as difficult. The problem was not with the patient himself but his father. This man was one of those very entitled parents where nothing was ever good enough for him. He basically second guessed every decision that we made. 3.2.5.4. Student’s perception of patient. Mom quickly told me that he just did not like anybody with a white coat. I waited until we were situated in the room to ask her to elaborate a bit more. Apparently, he had had his adenoids and tonsils removed the year before and had a really tough time while in the hospital. He has been terrified of the hospital and doctors ever since. His reaction suddenly made much more sense and signaled me to conduct both my interview and exam in a slightly different way. 3.2.6. Reflections on connections: resulting feelings of ambivalence and surprise In their essays describing connections with patients and families, students further reflected on their own feelings about having made or not made connections. In doing so, students described various feelings such as anger, excitement, disappoint-
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ment, and a sense of reward. Among the feelings most frequently depicted were students’ own ambivalent feelings towards families and often their surprise that they had made a connection or that the family felt connected to them. As a result, I truly feel I cared for A. better than many of my other patients, which is an unsettling feeling. Afterwards, I was a bit surprised that this woman had actually wanted to confide in and share such personal information with me, especially since I had barely talked with her before and I had not felt that we had connected well. Yet, after thinking about these events for a while, I realized that we impact every patient and their family’s lives whether we realize it or not.
4. Discussion and conclusions 4.1. Discussion This qualitative study of original reflective essays written by medical students on their pediatrics clinical clerkship was conducted in order to gain insight into factors contributing to and detracting from their abilities to connect with patients and families. Our findings reveal that time was an important though complex factor in connecting, depending on whether students perceived that it took a lot or a little time to connect and whether they felt they had enough time to do so. It should be noted that this is the medical student’s own perception of time, and patients often conceptualize time differently than do physicians [17]. Students’ written reflections also highlighted their own lack of knowledge, but this was not always seen as a barrier. They reflected upon language, culture, perceived personality, and actions as having an impact upon their ability to connect. Students have described that these factors can both contribute to or detract from their making connections. In reflecting on connections, they also described their feelings, often of ambivalence or surprise. At times, students’ reflections reveal that what they hear about patients’ personalities may not be true, and that they are often surprised about having made a connection despite apparent differences or lack of time. Although the literature on reflective writing by medical students during their clinical years is sparse, some themes expressed by students on their pediatric clerkship in our study are consistent with what has been described in other educational settings (i.e. on electives, primary care rotations, or via critical incident reports) where identification with the patient, recognizing ‘‘the person behind the symptoms,’’ and expressions of empathy, helped students identify with patients and contributed to their professional development [18,19,20,21]. Our findings also build on the literature regarding medical students’ early clinical experiences (i.e. in the second year) where investing the time to build relationships and sharing commonalities can foster the doctor–patient relationship [22]. For those further along in training, residents believe that lack of knowledge about other cultures can cause communication difficulties, but they spend little time reflecting on their professional culture and beliefs [23]. The themes expressed by our students can inform faculty when discussing the trainees’ role in the doctor–patient relationship and effective communication. For example, despite busy clinical schedules, medical trainees should develop an awareness that time need not be a barrier to connecting, as one student wrote, ‘‘it doesn’t take a whole lot of time or magic to show you care.’’ In the context of our theoretical framework using reflection-on-action, creativity and a deeper understanding of how to make the most of the available resources may ultimately improve a student’s ability to consistently make connections with families and patients.
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Our study was limited to medical students at one urban academic institution. We did not collect demographics on this student population, but note that the students in this study were about halfway through their third year of medical school (their first clinical year) when submitting these reflective essays, and were undifferentiated, in that they had not yet selected their specialty field. The coding investigators reached consensus, but inter-rater reliability was not assessed. Another limitation is that while most students submitted essays, those that did not might hold other viewpoints on connecting with families that were not discovered in the above analysis. Finally, while our analysis revealed that critical reflection was present in about one-third of the essays, determining the level of critical thinking [24] was not the primary focus of our study. Students had the opportunity to discuss, but given their anonymity in submitting their reflective pieces, the only feedback they received was in the form of general group key insights. More specific individualized feedback could further enhance critical reflection. One strength of our study is the use of qualitative methodology in that this allows for a rich understanding of the meaning and complexities of students’ perceptions about a topic with no one right answer, that is, how trainees make connections with families in the clinical setting. As noted above, several methodological steps were made to increase the trustworthiness of the data acquisition and its interpretation. 4.2. Conclusions Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract from their ability to make connections. When narrative and reflection is integrated into the pediatric clerkship, medical students – amidst their clinical responsibilities – can identify how, why, and whether or not connections with patients and their families have occurred. Although it is a daunting task to explicitly teach how to connect with patients, this can instead become part of one’s professional identity in other ways such as through reflective thinking, writing, feedback, and deliberate practice [13,25,26]. Ideally, facilitating the reflective process on the pediatric clerkship would allow students to challenge their own assumptions about the underlying factors contributing to the doctor–patient relationship such as time, knowledge, language/culture, and actions. Ongoing reflection is enhanced through discussion and feedback over time. Students in the present study indeed had the opportunity to discuss, but feedback was provided as general group key insights. More specific individualized feedback would likely further enhance critical reflection. 4.3. Practice implications Recognizing what medical students perceive as barriers to connecting with patients and families and what they see as enhancing their abilities to connect can help precepting physicians and other providers foster those abilities. Promoting reflective learning through narrative may help students understand how to make the most of the available resources and ultimately augment their own ability to consistently make connections with families and patients. Future research could compare different types of reflective activities among medical students, including the provision of individualized feedback, with an assessment of the impact on degree and ability of student reflection. Ultimately, an assessment or observation of change in trainees’ interactions with patients could be performed. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, so that we promote critical thinking not only about differential diagnoses, but also about the approach to the doctor–patient relationship.
Acknowledgments This project was supported by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and also by the Master Teacher Leadership Development Program at The George Washington University. We wish to thank Ms. Wilhelmina Bradford for her tireless efforts coordinating and connecting with medical students. The authors confirm that all patient/personal identifiers have been removed or disguised so the patients/persons described are not identifiable and cannot be identified through the details of the story. Conflict of interest: The authors have no conflicts of interest to disclose. Role of funding: This project was supported by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and also by the Master Teacher Leadership Development Program at The George Washington University. The funding sources had no involvement in study design, data collection, data analysis, data interpretation, or the decision to submit the paper for publication. References [1] Gracey CF, Haidet P, Branch WT, Weissmann P, Kern DE, Mitchell G, Frankel R, Inui T. Precepting humanism: strategies for fostering the human dimensions of care in ambulatory settings. Acad Med 2005;80:21–8. [2] Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med 1999;74:800–3. [3] Benbassat J, Baumal R. What is empathy, and how can it be promoted during clinical clerkships? Acad Med 2004;79:832–9. [4] Benbassat J, Baumal R. Enhancing self-awareness in medical students: an overview of teaching approaches. Acad Med 2005;80:156–61. [5] DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med 2004;79:351–6. [6] Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Educ Couns 2004;54:251–3. [7] Charon R. Narrative medicine: honoring the stories of illness. New York, NY: Oxford University Press; 2006. [8] Plack MM, Greenberg L. The reflective practitioner: reaching for excellence in practice. Pediatrics 2005;116:1546–52. [9] Rucker L, Shapiro J. Becoming a physician: students’ creative projects in a third-year IM clerkship. Acad Med 2003;78:391–7. [10] Teutsch C. Patient-doctor communication. Med Clin N Am 2003;87:1115–45. [11] Suikkala A, Leino-Kilpi H. Nursing student-patient relationship: a review of the literature from 1984 to 1998. J Adv Nurs 2001;33:42–50. [12] Argyris C, Scho¨n D. Theory in practice: Increasing professional effectiveness. San Francisco: Jossey-Bass; 1974. [13] Scho¨n DA. The reflective practitioner. How professionals think in action. London: Temple Smith; 1983. [14] Strauss AL, Corbin J. Basics of qualitative research: techniques and procedures for developing grounded theory, 2nd edition, Thousand Oaks: Sage Publications; 1998. [15] Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook, 2nd ed., Thousand Oaks: Sage Publications; 1994. [16] Plack MM, Driscoll M, Blissett S, McKenna R, Plack TP. A method for assessing reflective journal writing. J Allied Health 2005;34:199–208. [17] Klitzman R. Patient-time’’, ‘‘doctor-time’’, and ‘‘institution-time’’: perceptions and definitions of time among doctors who become patients. Patient Educ Couns 2007;66:147–55. [18] Hatem D, Ferrara E. Becoming a doctor: fostering humane caregivers through creative writing. Patient Educ Couns 2001;45:13–22. [19] Svenberg K, Wahlqvist M, Mattsson B. A memorable consultation’’: Writing reflective accounts articulates students’ learning in general practice. Scand J Prim Health 2007;25:75–9. [20] Nogueira-Martins MC, Nogueira-Martins LA, Turato ER. Medical students’ perceptions of their learning about the doctor–patient relationship: a qualitative study. Med Educ 2006;40:322–8. [21] Branch W, Pels RJ, Lawrence RS, Arky R. Becoming a doctor—critical-incident reports from third year medical students. New Engl J Med 1993;329:1130–2. [22] Dyrbye LN, Harris I, Rohren CH. Early clinical experiences from students’ perspectives: a qualitative study of narratives. Acad Med 2007;82:979–88. [23] Lingard L, Tallett S, Rosenfield J. Culture and physician-patient communication: a qualitative exploration of residents’ experiences and attitudes. Ann Roy Coll Physicians Surg Can 2002;35:331–5. [24] Plack MM, Driscoll M, Marquez M, Cuppernull L, Maring J, Greenberg L. Assessing reflective writing on a pediatric clerkship by using a modified bloom’s taxonomy. Ambulatory Pediatrics 2007;7:285–91. [25] Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861–71. [26] Brookfield SD. Becoming a critically reflective teacher. New York, NY: JosseyBass Inc.; 1995.