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Some lessons on reflective practice in medical education
Patient Education and Counseling 77 (2009) 4–5
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
Some lessons on reflective practice in medical education§ Yvette Koepke * Office of Medical Education, UND School of Medicine and Health Sciences, University of North Dakota, ND, USA
A R T I C L E I N F O
Article history: Received 19 January 2008 Received in revised form 10 November 2008 Accepted 2 March 2009
‘‘But I still don’t see how you can grade us on this stuff, since I can interpret it differently,’’ the medical student insisted. I tried to smooth out the tension in the muscles of my forehead, which had built up over 2 h of squinting into the hot light of the projected slides on the screen behind me—plus the last 15 min after class spent trying to defend the new medical humanities component of the curriculum. I did not want to appear to frown at him. My stomach sank as his voice rose. ‘‘If I had known we were going to have to do this, I would have gone to a different medical school,’’ he said. ‘‘There are no medical schools that don’t do this,’’ I replied. His eyes slid away as he shook his head with a little smirk: ‘‘See, I disagree about that too.’’ I had no idea as I drove home with tears in my eyes that this interchange would prove but a harbinger. I mentally tallied the challenges of the program, in which my sessions incorporate various medical humanities content and approaches to explore issues raised by each 8-week curricular block, and then assign a ‘‘reflective analysis’’ stimulating in-depth individual engagement with those issues through different modes of writing. Even the goal itself is probably uncomfortable for students: active, critical reflection on experiences and behaviors, on ethical professionalism, on medical culture and its interaction with society which would become the part of everyday practice. I forcefully reminded myself that I expected this type of reaction. The first years of medical school remain focused on ‘‘basic’’ sciences, a focus reinforced by structure and examinations—and medical students are defined by their success within this system. Anything that takes time away from this type of studying, anything that will not directly appear on Step 1, anything that students do not already know how to do and do well is going to cause anxiety, frustration, and resentment among a highly stressed population.
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–3. * Corresponding author at: Office of Medical Education, UND School of Medicine and Health Sciences, University of North Dakota, 110 Merrifield Hall, Grand Forks,
0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.03.003
But I did not expect the revolt. The medical students heavily critiqued the program during several regular weekly meetings with the Directors of Block 1 and of Clinical Education and questioned my evaluation of their writings to the Dean of Students, and the class president met with the Associate Dean of Medical Education. Their use of administrative outlets instead of the professor indicates that they did not view the medical humanities component in the same way as their other subjects, but rather as something separate that could be removed from the curriculum. Having been told the program was not going to be abolished immediately, the class spokesmen sent me two e-mails that unironically used the language of constructive feedback to offer ‘‘tweaks’’ amounting to the gutting or replacement of the program: talk instead of write; do not evaluate the writing; spend the time going to ‘‘soup kitchens’’ or being mentored by physicians instead. Yet as I frantically formulated possible answering messages, I realized that many of the students’ points revealed specific insights into ideas impacting reflective practice from which I could learn. Three important concepts emerged from the students’ arguments: (1) reflection authorizes individual opinions; (2) subjectivity equals emotion, which is devalued; (3) identity and experience are stable and unitary. Attempts to foster a reflexive medical culture must address these underlying notions. The key lesson is how these concepts work together to produce ethical professionalism as a solely personal characteristic, which excludes reflective practice. In my opening scene, the medical student’s argument about the impossibility of assessment within medical humanities grows from the first concept. Understanding reflection as the elaboration of an individual’s ideas undermines both the certainty of a common correct answer and the authority of the teacher. ‘‘What do I think?’’ seems to become the goal as well as the end. Statements that answer this question in turn seem unassailable since everyone is an expert on their own opinions and experiences. We can trace this concept in student block evaluations too. My colleagues and I were surprised by students’ use of words like ‘‘hostility’’ to describe their responses. I now think such descriptions vent outrage that their writings were not lauded simply because answers were given to the questions posed. From the perspective of the students, whatever they write would be by definition good reflection because it expresses their thoughts. The perceived uniqueness and force of individual voice, modeled by familiar genres like talk shows, also informs preferences like, ‘‘small-group discussion would be more valuable than writing.’’
Y. Koepke / Patient Education and Counseling 77 (2009) 4–5
Another scene illustrates the second concept. Students filed in as I was removing my materials from my bag in the back corner of the auditorium. I stiffened to hear them laughing while picking up their next writing assignment: ‘‘Oh great. Just what I wanted.’’ kept my head down, face burning, as a student yelled across the room, ‘‘We’ll have to get drunk at bowling so we can all get in touch with our feelings.’’ These responses express the general challenge of emotional reflection, as well as its perceived foreignness to scientific medicine. Yet this remark signals more: it reduces reflection to emotion and dismisses ‘‘feelings’’ as relevant or worthy of analysis. The phrase ‘‘get in touch’’ indicates the supposedly concrete or given status of emotion, as well as its perceived lesser, bodily – rather than intellectual – nature. It also locates feelings elsewhere, and the motivation to explore them as external instead of a component of self-care. This attitude dovetails with the first concept by defining self-reflexiveness as personal emotion. Student assertions that they already recognize the need to be ‘‘caring,’’ and complaints that no one ‘‘loves’’ the program, likewise show the collapse of subjective thinking into feelings, which are then compartmentalized and devalued. These two concepts rely on a third, a model of identity as unitary and stable at odds with the underlying premise of reflective practice that contexts shape medicine. This model positions reflection as self-expression, largely ignoring the social construction of identity and of medicine. Experience thus becomes a secure good in and of itself not requiring examination, as suggested by the students’ calls for service learning and mentoring. These three concepts represent not just obstacles to reflective practice, but a fundamental challenge because together they produce the trump card brandished by the medical students, ‘‘Morality is already in a person. Professionalism can’t be taught.’’ On this view, reflection collapses into its literal sense: decisions, experiences, practices mirror the self. We can see this in the students’ writings on William Carlos Williams’ ‘‘The Use of Force.’’ Those students who reported a strongly negative emotional response in one part of the assignment did not critique the physician portrayed in the story from a professional perspective in another part. Many of their discussions associated such critique with declaring the physician a bad person. This association would significantly limit the critical analysis and feedback on peers and self so important to ongoing professional development. Further, it could curtail examination of ethical decision-making by equating it with personal moral belief. Many compelling versions of this story featuring myself as the hero struggling against the students and the system are possible, but dangerous. The real struggle is not to adopt this reductive
5
model of reflection myself, by thinking that I am enlightening students. Instead of hoping that students mirror my insights, I must hope to model the kind of collaborative negotiation that ideally characterizes therapeutic relationships. Though my own ongoing story of struggle and hope exceeds the boundaries of this piece, I will share a few initial lessons in three areas – structure, students, and self – nurtured by this clinical analogy. Like a physician, I search for creative ways to cope with severe structural time constraints, including calling on faculty outside the medical school to lead concurrent small-group discussions and using online technology to facilitate communication. I have learned that a wider circle of collaboration could have helped modulate student concerns, which were shared with faculty who felt uninformed. Moreover, the integration of our curriculum entails actively involving science colleagues in what might be seen as an aspect of clinical education. Student suggestions have prompted many changes to the program ranging from the mundane to the conceptual, such as adherence to the dominant pedagogical style (concrete objectives, focused information, rigid scheduling) and incorporation of patient interactions. Despite strong performance on writings and case exams that shows student learning, perceptions have not been profoundly altered thus far, due in part to the strength of the three concepts identified above. I have found it productive, though, to think about negative response less in terms of resistance and more in terms of educational autonomy. Judging by student comments, this attitude has worked at least to some degree: ‘‘I really have a lot of respect and admiration for Dr. Koepke for modifying her curriculum and objectives this block. She took a lot of criticism, some probably unfairly harsh, but used it all positively. I also really respect her professionalism, because it may have been difficult at times to put on a smile during Block 1 when there was so much resistance (by the students) to what she was trying to accomplish.’’ I continue to strive to shift my own focus from outcome to process so that any student analysis, even if critical of my own work, marks progress toward my goals. Likewise, my own difficulties and questions can do important reflective work, yielding insight both into practical measures to improve communication such as finding common ground and into underlying beliefs such as those identified here. Just as important as these efforts is respectful acceptance of their limits. My emotional response to this experience makes me newly aware of the continual impact of my own subjectivity at the same time that it provides empathetic understanding of the physician–patient relationship.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
Some lessons on reflective practice in medical education§ Yvette Koepke * Office of Medical Education, UND School of Medicine and Health Sciences, University of North Dakota, ND, USA
A R T I C L E I N F O
Article history: Received 19 January 2008 Received in revised form 10 November 2008 Accepted 2 March 2009
‘‘But I still don’t see how you can grade us on this stuff, since I can interpret it differently,’’ the medical student insisted. I tried to smooth out the tension in the muscles of my forehead, which had built up over 2 h of squinting into the hot light of the projected slides on the screen behind me—plus the last 15 min after class spent trying to defend the new medical humanities component of the curriculum. I did not want to appear to frown at him. My stomach sank as his voice rose. ‘‘If I had known we were going to have to do this, I would have gone to a different medical school,’’ he said. ‘‘There are no medical schools that don’t do this,’’ I replied. His eyes slid away as he shook his head with a little smirk: ‘‘See, I disagree about that too.’’ I had no idea as I drove home with tears in my eyes that this interchange would prove but a harbinger. I mentally tallied the challenges of the program, in which my sessions incorporate various medical humanities content and approaches to explore issues raised by each 8-week curricular block, and then assign a ‘‘reflective analysis’’ stimulating in-depth individual engagement with those issues through different modes of writing. Even the goal itself is probably uncomfortable for students: active, critical reflection on experiences and behaviors, on ethical professionalism, on medical culture and its interaction with society which would become the part of everyday practice. I forcefully reminded myself that I expected this type of reaction. The first years of medical school remain focused on ‘‘basic’’ sciences, a focus reinforced by structure and examinations—and medical students are defined by their success within this system. Anything that takes time away from this type of studying, anything that will not directly appear on Step 1, anything that students do not already know how to do and do well is going to cause anxiety, frustration, and resentment among a highly stressed population.
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–3. * Corresponding author at: Office of Medical Education, UND School of Medicine and Health Sciences, University of North Dakota, 110 Merrifield Hall, Grand Forks,
0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.03.003
But I did not expect the revolt. The medical students heavily critiqued the program during several regular weekly meetings with the Directors of Block 1 and of Clinical Education and questioned my evaluation of their writings to the Dean of Students, and the class president met with the Associate Dean of Medical Education. Their use of administrative outlets instead of the professor indicates that they did not view the medical humanities component in the same way as their other subjects, but rather as something separate that could be removed from the curriculum. Having been told the program was not going to be abolished immediately, the class spokesmen sent me two e-mails that unironically used the language of constructive feedback to offer ‘‘tweaks’’ amounting to the gutting or replacement of the program: talk instead of write; do not evaluate the writing; spend the time going to ‘‘soup kitchens’’ or being mentored by physicians instead. Yet as I frantically formulated possible answering messages, I realized that many of the students’ points revealed specific insights into ideas impacting reflective practice from which I could learn. Three important concepts emerged from the students’ arguments: (1) reflection authorizes individual opinions; (2) subjectivity equals emotion, which is devalued; (3) identity and experience are stable and unitary. Attempts to foster a reflexive medical culture must address these underlying notions. The key lesson is how these concepts work together to produce ethical professionalism as a solely personal characteristic, which excludes reflective practice. In my opening scene, the medical student’s argument about the impossibility of assessment within medical humanities grows from the first concept. Understanding reflection as the elaboration of an individual’s ideas undermines both the certainty of a common correct answer and the authority of the teacher. ‘‘What do I think?’’ seems to become the goal as well as the end. Statements that answer this question in turn seem unassailable since everyone is an expert on their own opinions and experiences. We can trace this concept in student block evaluations too. My colleagues and I were surprised by students’ use of words like ‘‘hostility’’ to describe their responses. I now think such descriptions vent outrage that their writings were not lauded simply because answers were given to the questions posed. From the perspective of the students, whatever they write would be by definition good reflection because it expresses their thoughts. The perceived uniqueness and force of individual voice, modeled by familiar genres like talk shows, also informs preferences like, ‘‘small-group discussion would be more valuable than writing.’’
Y. Koepke / Patient Education and Counseling 77 (2009) 4–5
Another scene illustrates the second concept. Students filed in as I was removing my materials from my bag in the back corner of the auditorium. I stiffened to hear them laughing while picking up their next writing assignment: ‘‘Oh great. Just what I wanted.’’ kept my head down, face burning, as a student yelled across the room, ‘‘We’ll have to get drunk at bowling so we can all get in touch with our feelings.’’ These responses express the general challenge of emotional reflection, as well as its perceived foreignness to scientific medicine. Yet this remark signals more: it reduces reflection to emotion and dismisses ‘‘feelings’’ as relevant or worthy of analysis. The phrase ‘‘get in touch’’ indicates the supposedly concrete or given status of emotion, as well as its perceived lesser, bodily – rather than intellectual – nature. It also locates feelings elsewhere, and the motivation to explore them as external instead of a component of self-care. This attitude dovetails with the first concept by defining self-reflexiveness as personal emotion. Student assertions that they already recognize the need to be ‘‘caring,’’ and complaints that no one ‘‘loves’’ the program, likewise show the collapse of subjective thinking into feelings, which are then compartmentalized and devalued. These two concepts rely on a third, a model of identity as unitary and stable at odds with the underlying premise of reflective practice that contexts shape medicine. This model positions reflection as self-expression, largely ignoring the social construction of identity and of medicine. Experience thus becomes a secure good in and of itself not requiring examination, as suggested by the students’ calls for service learning and mentoring. These three concepts represent not just obstacles to reflective practice, but a fundamental challenge because together they produce the trump card brandished by the medical students, ‘‘Morality is already in a person. Professionalism can’t be taught.’’ On this view, reflection collapses into its literal sense: decisions, experiences, practices mirror the self. We can see this in the students’ writings on William Carlos Williams’ ‘‘The Use of Force.’’ Those students who reported a strongly negative emotional response in one part of the assignment did not critique the physician portrayed in the story from a professional perspective in another part. Many of their discussions associated such critique with declaring the physician a bad person. This association would significantly limit the critical analysis and feedback on peers and self so important to ongoing professional development. Further, it could curtail examination of ethical decision-making by equating it with personal moral belief. Many compelling versions of this story featuring myself as the hero struggling against the students and the system are possible, but dangerous. The real struggle is not to adopt this reductive
5
model of reflection myself, by thinking that I am enlightening students. Instead of hoping that students mirror my insights, I must hope to model the kind of collaborative negotiation that ideally characterizes therapeutic relationships. Though my own ongoing story of struggle and hope exceeds the boundaries of this piece, I will share a few initial lessons in three areas – structure, students, and self – nurtured by this clinical analogy. Like a physician, I search for creative ways to cope with severe structural time constraints, including calling on faculty outside the medical school to lead concurrent small-group discussions and using online technology to facilitate communication. I have learned that a wider circle of collaboration could have helped modulate student concerns, which were shared with faculty who felt uninformed. Moreover, the integration of our curriculum entails actively involving science colleagues in what might be seen as an aspect of clinical education. Student suggestions have prompted many changes to the program ranging from the mundane to the conceptual, such as adherence to the dominant pedagogical style (concrete objectives, focused information, rigid scheduling) and incorporation of patient interactions. Despite strong performance on writings and case exams that shows student learning, perceptions have not been profoundly altered thus far, due in part to the strength of the three concepts identified above. I have found it productive, though, to think about negative response less in terms of resistance and more in terms of educational autonomy. Judging by student comments, this attitude has worked at least to some degree: ‘‘I really have a lot of respect and admiration for Dr. Koepke for modifying her curriculum and objectives this block. She took a lot of criticism, some probably unfairly harsh, but used it all positively. I also really respect her professionalism, because it may have been difficult at times to put on a smile during Block 1 when there was so much resistance (by the students) to what she was trying to accomplish.’’ I continue to strive to shift my own focus from outcome to process so that any student analysis, even if critical of my own work, marks progress toward my goals. Likewise, my own difficulties and questions can do important reflective work, yielding insight both into practical measures to improve communication such as finding common ground and into underlying beliefs such as those identified here. Just as important as these efforts is respectful acceptance of their limits. My emotional response to this experience makes me newly aware of the continual impact of my own subjectivity at the same time that it provides empathetic understanding of the physician–patient relationship.