‘The Loss of My Elderly Patient:’ Interactive reflective writing to support medical students’ rites of passage

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Practice points

Reflective capacity fostered through reflective writing is posited to help develop critical thinking skills and empathic stance, informs clinical reasoning, and is an essential component of professionally competent practice. The use of interactive reflective writing (student writer – faculty feedback provider dyad) in medical education can support students with critical rites of passage, such as a student's first experience with the death of a patient, an often challenging pivotal event in the process of professional identity development. The BEGAN, a tool devised to guide medical educators with crafting quality individualized feedback to students’ reflective writing, is offered to facilitate faculty's more fully capturing professional development opportunities offered by student narratives. The use of the BEGAN framework can enhance students’ exploration, understanding, and management of emotions (developing emotional intelligence), deemed essential to core competencies of interpersonal and communication skills and professionalism and can potentially bolster student well-being. Interactive reflective writing (including quality feedback) on patient encounters including emotionally powerful events can help facilitate the transformation of student to professional through reflection within medical education.

Table 1.  Brown Educational Guide to Analysis of Narrative

Context – consider:

• Setting

• Student's identity and background, stage of training

• Assignment/prompt

• If available, knowledge of student's previous reflective skills.

Step1: Read carefully from beginning to end without pen or keyboard (overall undifferentiated gut impressions and reactions to the learner's written expression).

Step 2: Record initial impressions triggered by the learner's written expression (overall impressions and reactions, as well as your clinical and/or personal experiences, views, and biases).

Step 3: Reread and analyze the text – use pen or keyboard and record:

a. underline learner's salient quotes and key concepts, expressed emotions (e.g. verbs such as ‘surprised’, ‘scared’) and reflections

b. extract key themes, categories, patterns

c. extract the lessons learned – consider both what the learner expresses and what you see as learning opportunities

d. additional considerations (3dI. and II) – apply close reading approach and/or integrate reflection-inviting questions as relevant/useful

Step 4: Craft feedback using key themes and lessons learned, reflection-inviting questions (3dII), and concrete recommendations.

• Filter and prioritize what is educationally valuable to the learner.

• Look for opportunities to provide positive feedback.

• Defend your impressions with actual text.

• Use coaching rather than evaluative language.

Step 5: Critique feedback – pause and edit before pressing the SEND key (e.g. be concise – remember sometimes ‘less is more’, make your relevant beliefs and biases transparent).

Additional considerations for analysis of narrative with the BEGAN

Step 3d. I. Close reading approach (Jacobus 1989; Charon 2006a):

• How is the story or writing framed (what is inside and outside the border)?

• Is there an introduction? Is plot (story line) being evoked?

• Plot thickening/complexity? Subplots? Ironic turns in plot? Ironic reversal? Pivot point(s)? Conflict in the plot?

• Time line/temporality? (analogy: chief complaint, HPI, social history, diagnosis)

• First person? Characters entering the story/interrelation of characters? Conflict in characters?

• Humor (derives from improbability of circumstances)

• How detailed? (more forceful)

• Metaphor, imagery, symbolic content.

• Does the end of the narrative cast new light on the beginning?

• Resolution (sense of conclusiveness?)

Defend your impressions with the actual text

Step 3d. II. Reflection-inviting questions:

• For the patient encounter/observation described, how are both the patient's (when attending to an encounter) and student's explanatory model informed by culture, belief, gender, family structure, personal and familial illness history, life experiences?

• Why are you doing it? (action taken, words spoken)

• How did your actions influence the outcome?

• What were you feeling (from what you've written, I interpret you felt ________, is that true?)

• How did you feel about your interaction (Reflection on action)?

• What assumptions did you make about this situation? What else might be affecting this situation? Might there be alternative explanations? What could they be? (Fostering multiple perspectives)

• Consider what may be puzzling, inadequately explained, or inconsistent with your expectations (Avrahami 2008)

• What skills did you learn? What new insights did you derive?

• How would you apply what you learned in your future work? How might you do things differently if you had a chance to repeat this situation? What could be an action plan for improvement?

• What valuable insights gained and/or anything uncomfortable about community mentor's clinical encounter with a patient.

Table 2.  BEGAN process notes – HSW

Context and careful reading:

Step 1:

• Midyear

• Setting: assisted living facility component of Doctoring course.

• Student has chosen to not respond to assigned writing prompt for this week, is using option to respond to an event that moved him.

Initial impressions:

Step 2: Personal: considerations:

• my recent loss of my father

• trying to maintain professional stance when grieving – I had to teach geriatrics topics including end-of-life considerations during my father's last days

• only one father

• jumbled emotions: loss of a patient vs. your own loss, similarities/differences (affect)

Clinical

• seeing that empty bed on the ward, no one prepares me

• it is a person, a totality, with a life, a family, hopes, goals, then an empty bed

• medical staff bustles about, business as usual. Or is it?

Step 3: Reread and analyze text

• Are we adequately addressing our educational obligations to these students: pre-loss preparation, and post-loss debriefing, use of a protocol to guide faculty/student teaching? (context)

• Bereavement is a process – emphasize student can approach us later as well or consult us at any time(Lesson learned – LL).

• Educate regarding bereavement process, there are stages…embrace emotion, do not push it aside – ‘incredible learning experience but I need to move on’ – do not rush it. (LL)

• who is this person, the patient? A drummer, CHF but more…the drumming of the heartbeat is no longer.

• personal experience/emotions in conjunction with professional persona/demeanor – personal experience can help inform. (affect)

• ‘not ready to hear it or digest it’ – clinical experience can help us prepare. ‘I think I knew and Dr. Stewart recognized this too’ – role of mentor, pattern recognition (LL)

• reflection-inviting questions – how do we frame death with our words? (LL with further reflection)

• ‘helping me in my medical education’ – rite of passage – loss but gain. (LL)

Step 4: Craft feedback and filter, provide concrete recommendations as applicable.

Jacobus L. Writing as thinking. Macmillan, New York 1989

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Charon R. Narrative medicine: Honoring the stories of illness. Oxford University Press, New York, NY 2006a

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Avrahami E, 2008. Personal communication

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