Grappling with complexity: Medical students’ reflective writings about challenging patient encounters as a window into professional identity formation

Abstract

Aim: Clerkship-specific interactive reflective writing (IRW)-enhanced reflection may enhance professional identity formation (PIF), a fundamental goal of medical education. PIF process as revealed in students? reflective writing (RW) has been understudied.

Methods: The authors developed an IRW curriculum within a Family Medicine Clerkship (FMC) and analyzed students? reflections about challenging/difficult patient encounters using immersion-crystallization qualitative analysis.

Results: The qualitative analysis identified 26 unique emergent themes and five distinct thematic categories (1. Role of emotions, 2. Role of cognition, 3. Behaviorally responding to situational context, 4. Patient factors, and 5. External factors) as well as an emergent PIF model from a directed content analysis. The model describes students? backgrounds, emotions and previous experiences in medicine merging with external factors and processed during student?patient interactions. The RWs also revealed that processing often involves polarities (e.g. empathy/lack of empathy or encouragement/disillusionment) as well as dissonance between idealized visions and lived reality.

Conclusions: IRW facilitates and ideally supports grappling with the lived reality of medicine; uncovering a “positive hidden curriculum” within medical education. The authors propose engaging learners in guided critical reflection about complex experiences for meaning-making within a safe learning climate as a valuable way to cultivate reflective, resilient professionals with “prepared” minds and hearts for inevitable challenges of healthcare practice.

Ethical approval

This study was reviewed and approved by the institutional review board of the Memorial Hospital of Rhode Island.

Acknowledgments

The authors gratefully acknowledge Dr. Paul George for taking a role in preliminary narrative analysis, Dr. Roberta Goldman for her helpful feedback on methodology, and the small group facilitators and students of the Family Medicine Clerkship.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Glossary

• Interactive Reflective Writing: Health professions educators facilitate development of reflective capacity with crafting individualized written feedback to students’ reflective writings. Such feedback includes supportive challenging of assumptions, exploring emotional responses (of patient and student), encouraging consideration of new perspectives as relevant, and highlighting lessons learned as well as sharing of relevant personal and/or clinical anecdotal experiences.

Additional information

Funding

Dr Wald is grateful for the support from Brown University Predoctoral Training grant #D56HP2068.

Notes on contributors

Hedy S. Wald

Hedy S. Wald, PhD, is a Clinical Professor of Family Medicine, Warren Alpert Medical School of Brown University; Director, Residency Resilience/Wellbeing, Residency Programs in Child Neurology & Neurodevelopmental Disabilities, Boston Children’s Hospital – Harvard Medical School. She conducts workshops internationally on interactive reflective writing-enhanced reflection as well as on promoting resilience/wellbeing.

Jordan White

Jordan White, MD, MPH, is a family physician and the Assistant Dean for Student Affairs at the Warren Alpert Medical School of Brown University.

Shmuel P. Reis

Shmuel P. Reis, MD, MHPE, is a family physician and medical educator; Academic Director, The Center for Medical Education, Faculty of Medicine, Hebrew University/Hadassah, Jerusalem, Israel; Adjunct Professor of Family Medicine, Warren Alpert Medical School of Brown University, and Chair, Israel Society of Medical Education (HEALER).

Angela Y. Esquibel

Angela Y. Esquibel, MD, is a second-year resident at La Crosse-Mayo Family Medicine Residency, Mayo Clinic Health System Franciscan Healthcare, La Crosse, Wisconsin.

David Anthony

David Anthony, MD, MSc, is an Associate Professor of Family Medicine at the Warren Alpert Medical School of Brown University where he serves as the Director of Medical Student Education for the Department of Family Medicine.