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

Abstract

Background: The fostering of reflective capacity within medical education helps develop critical thinking and clinical reasoning skills and enhances professionalism. Use of reflective narratives to augment reflective practice instruction is well documented.

Aim: At Warren Alpert Medical School of Brown University (Alpert Med), a narrative medicine curriculum innovation of students’ reflective writing (field notes) with individualized feedback from an interdisciplinary faculty team (in pre-clinical years) has been implemented in a Doctoring course to cultivate reflective capacity, empathy, and humanism. Interactive reflective writing (student writer/faculty feedback provider dyad), we propose, can additionally support students with rites of passage at critical educational junctures.

Method: At Alpert Med, we have devised a tool to guide faculty in crafting quality feedback, i.e. the Brown Educational Guide to Analysis of Narrative (BEGAN) which includes identifying students’ salient quotes, utilizing reflection-inviting questions and close reading, highlighting derived lessons/key concepts, extracting clinical patterns, and providing concrete recommendations as relevant.

Results: We provide an example of a student's narrative describing an emotionally powerful and meaningful event – the loss of his first patient – and faculty responses using BEGAN.

Conclusion: The provision of quality feedback to students’ reflective writing – supported by BEGAN – can facilitate the transformation of student to professional through reflection within medical education.

Introduction

Medical students experience critical rites of passage, often of a challenging nature, in the process of professional identity formation. A student's first experience with the death of a patient is generally a pivotal event within their personal and professional development and represents one particularly cogent rite of passage. Pedagogic support at such important junctures may enable successful educational transitions and promote development of professional identity (Hoifodt et al. 2007). Death may become a frequent companion for the evolving physician, and such a first encounter may imprint the learner, particularly if they have had little contact with such losses.

While earlier clinical exposure within medical education is now the norm rather than the exception (Dornan et al. 2006), the literature is scant regarding cultivating emotional awareness in relation to self and others. Similarly, there is little attention to effective management of emotions as students in the pre-clinical years typically confront death within early clinical exposure and attempt to cope with their own grieving process under such circumstances (Williams et al. 2005). Supervising physicians have been encouraged to utilize ‘teachable moment’ opportunities to help trainees with the emotionally powerful experience of patient's death (Jackson et al. 2005), however, in practice, this is not always realized. Inadequate supervised exposure and support with emotional challenges that surround death and dying have been highlighted in physician/medical student-writers’ descriptions of their medical education trajectory (Rhodes-Kropf et al. 2005; Chen 2007). The attempt to find an emotional middle ground between strong feelings of attachment and efforts at emotional detachment when confronting patient mortality as a healthcare professional is a central theme (Chen 2007).

We propose the use of reflective writing in medical education as a key opportunity for supporting the student's first encounter with death in a healthcare context. Students’ reflective writing constructs meaning from their experiences (including their affective responses), and combined with guided faculty feedback is useful in fostering reflective capacity (Mann et al. 2007; Wald et al. 2009) and developing emotional intelligence (Grewal & Davidson 2008). It also offers valuable opportunities for transformative professional growth and student well-being.

The use of structured reflective writing to augment reflective practice instruction within medical education is well documented (Brady et al. 2002; Fiege 2006; Kumagai 2008). Narrative competence (both close reading of literature and generating reflective narratives) guides clinical practice by helping practitioners achieve a more fully ‘textured’ understanding of the patient's experience of illness (‘getting’ and interpreting patients’ stories) as well as their own experience of providing patient care (Charon 2006a). Reflective writing in small group process has been described as cultivating insights into the process of patient care and promoting professionalism and practitioner well-being (Shapiro et. al. 2006). The development of narrative competence and emotional self-reflective ability (supported with reflective writing initiatives) can potentially bolster resilience to emotionally challenging situations (Kuper 2006). At initial stages, however, student narratives may lack sophistication in reflective capacity and emotional awareness in relation to self and others, tending to be more descriptive in nature (Morey 2008). To assist with the process of building reflective capacity, we have instituted an interactive reflective writing innovation of guided feedback to students’ longitudinal reflective writing – provided by an interdisciplinary small group faculty team. At the Warren Alpert Medical School of Brown University (Alpert Med), ‘field notes’ – reflective writing assignments with structured prompts or ‘triggers’ – have been integrated within a Doctoring course for first and second year students (Monroe et al. 2005; Taylor et al. 2008). Such narratives are a vehicle to assist students in developing reflective capacity as they explore complexities within initial physician–patient interactions. Built-in flexibility within the course syllabus allows students some control and discretion with these writing assignments should they wish to reflect on meaningful rites of passage (e.g. the privilege of the white coat, the taking of a sexual history, the first patient they lose; Wald & Reis 2008).

Table

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.

Interactive reflective writing in the Doctoring course

Doctoring is a two-year, longitudinal, required course for first and second year medical students designed to teach clinical skills and professionalism. ‘Interactive’ reflective writing assignments (‘field notes’) are integrated with instruction in medical interviewing, physical diagnosis, cultural competence, and medical ethics, with more ‘advanced’ field note topics included in second year. The course structure involves large group didactic sessions, small group processing and skill instruction as well as one-to-one community-based physician mentoring and skill practice. Students are assigned to groups of eight and meet weekly with an interdisciplinary faculty team comprised of a physician and a social-behavioral scientist. Small group faculty discusses curriculum topics (such as bias/prejudice, facilitating behavior change), teach clinical skills, provide feedback on field notes, and evaluate students’ emerging competencies. During orientation, faculty receives literature on how to promote reflective learning, including a faculty guide on providing quality feedback to students’ narratives (Wald 2008a). The suggested protocol for addressing ‘risky’ narrative content that may emerge (e.g. depression or other affective issues in need of consultation) is also discussed within faculty orientation. Students are also provided with a student guide to reflective writing in the Doctoring course (Wald 2008b).

Students complete field notes in response to structured questions which serve as guides for reflection on topics such as development of interviewing skills, inspiring or difficult interactions with patients, and delivering bad news. A total of 17 field notes were assigned during the academic year 2007–2008 for first year students (the year the ‘loss of my elderly patient’ narrative provided below was written) and eight field notes for second year students (total number was reduced in subsequent course curriculum due to time constraints). Students submit their field notes (without patient identifying information) via e-mail directly to small group faculty who provides in-depth, individualized written feedback to the students, creating an interactive process. While small group interaction provides an opportunity for sharing of thoughts, experiences, and feelings, field note and feedback content remains confidential between small group faculty and the individual student. An initial pilot study revealed positive feedback from first year students about the value of interdisciplinary feedback to their reflective writing (Wald et al. 2009).

Faculty training in narrative analysis and feedback preparation can help faculty to more fully capture the professional development opportunities presented by student narratives. In line with narrative medicine pioneer Rita Charon's insightful observation (Charon 2006b) that reading or listening as a teacher is a ‘remarkable obligation to another human being’, we devised BEGAN, The Brown Educational Guide to the Analysis of Narrative, a tool for crafting quality feedback to students’ reflective writing (Reis et al. 2010). The BEGAN tool enriches the interactive reflective writing process by guiding faculty (some of whom may be novices in this work) with formulation of concise individualized feedback which integrates pertinent quotes from the student's narrative, relevant anecdotes from the faculty's clinical and personal experiences, elements of close reading, and reflection-inviting questions. The latter two components are termed ‘additional considerations’ within the BEGAN tool as faculty may integrate these feedback features as deemed appropriate to enhance educational utility of feedback content. Faculty development in ‘workshop’ format includes instruction in the use of the BEGAN framework as an optional tool for feedback crafting, application to a sample field note, and group discussion of application outcomes. Creating a ‘comfort zone’ (Wald 2008c) for self-revelation within quality feedback, thus engendering students’ sense of trust as they potentially expose their vulnerabilities and uncertainties within the learning environment and providing quality feedback, can be a critical segue to professional development for the proto-professional. At the conclusion of the course, the degree of growth in reflection within field notes (with exemplars such as competent and exceeds competence) is included in summative assessment.

Student narratives which help students recognize and reflect upon their emotions and those of patient and family can enhance teaching about end-of-life care including palliative care (Wear 2002; Rosenbaum et al. 2005; Romanoff & Thompson 2006). Such initiatives are timely given the increasing geriatric patient population, inclusion of assisted living and/or skilled nursing facility components within Doctoring course curricula, and reports of pre-clinical students fearing facing families and responding to grief with the death of a patient (Williams et al. 2005; Wald 2008d). The power of narrative, it has been posited, includes intellectual growth once writers find words to express their emotional lives (Bucci 1995).

In this article, we present a first year medical student's narrative about the loss of his first patient (IRB approval obtained) and provide examples of guided individualized feedback by four faculty members using the BEGAN framework (Table 1). BEGAN process notes generated prior to feedback crafting are also presented (Table 2). The BEGAN tool permits faculty to address content, context, affect, and lessons learned that can be applied to future encounters.

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.

Student narrative

The loss of my elderly patient

There are times when I put off assignments due to procrastination. There are times when I put off assignments due to a test. This week was the first time I put off writing this note because I was scared. I was scared that I would not be able to write about how losing my elderly patient felt. I tried several times during the week to express how I felt but I wasn’t ready.

On Tuesday, I was informed by the nurses at my assisted living facility that my elderly patient had passed away. I wish I was informed in a better way. We were told that someone had passed away (and immediately I had this heavy feeling in my heart). Paul was 93 and his health had deteriorated significantly the last time I went and interviewed him. I couldn’t help but think that there was a strong chance that it was Paul. Well, the nurses didn’t know who it was until at the end, after hesitation, I asked them if it was Paul. It was true. I had to immediately leave the conversation and I joined Kim in interviewing her patient. I expected it yet still wasn’t ready to hear it or digest it.

Half way through the interview, I had to go to the bathroom and I teared up a little. I had developed a great relationship with Paul and now I had to let go. The first thing that came to my mind was that he had asked me to bring another certificate of appreciation as he had misplaced the previous one. My mind soon thought about what Paul told me last time – ‘I hurt from the inside.’ I think I knew and Dr. Stewart recognized this too that Paul's last few days were here.

I realized that I needed to hear the complete story of what happened so I could figure out my feelings. Paul suffered Congestive Heart Failure for a second time (he suffered from CHF in 2002) and was taken to the hospital. He never really bounced back from it and was deemed unsuitable to return to the Assisted Living Facility. He spent the last few weeks at a Nursing home not too far away. The most positive news all day was that he was at the same nursing home as his wife. This made me feel a little better.

I tried to think positively about the situation. Paul would have probably wanted to spend the last few days with his wife. He had had a great music/drum playing session a few months ago. He was getting tired of fighting his conditions so he probably thought it was time to let go. As much as I miss Paul and will remember him for being a friend and helping me in my medical education, I think that it was time for him to go. He told me that because of divine intervention, he had led a very successful life. He wouldn’t want to be remembered for anything else but the positives of his life.

I could write a lot more about how I feel, how I needed to cry that evening to feel a little better, how it was an incredible learning experience – but I need to move on and continue the medical education that I am seeking and realize that unfortunately such occurrences will happen during my medical career. It has strengthened my need of building a positive and strong rapport with patients – I want to remember them for their positives.

BEGAN Feedback – Hedy S. Wald, PhD, psychologist – Doctoring course preceptor

Thank you for sharing, for reflecting on this array of emotions during and after ‘an incredible learning experience’, a rite of passage that has moved you in a profound way. Paul, you write, ‘helped me in my medical education’ – loss but gain.

You highlight a potential conflict between the personal (emotions/reactions) and maintaining professional demeanor – can they co-exist? Can one inform the other? I recently lost my father and your note re-evoked many of my own emotions – how do we not repress such emotions but embrace them and use them to better understand? Paul was his wife's only husband – you recognized him as a person, a drummer, not only a CHF diagnosis and his heart beats no longer. The loss of life hurts.

‘I need to move on’, you write. Don’t rush it – bereavement for you and for the family is a process, Kubler-Ross wrote about the stages, it takes time. Please feel free to consult with us about this journey at any time, even later in the year. And perhaps you could help guide faculty in establishing protocol for preparing students for and informing them of such a loss as well as ‘debriefing’, providing post-loss assistance.

‘I think I knew and Dr. Stewart recognized this too’ – over time, you’ll develop greater clinical expertise in recognizing certain inevitabilities. But I ask: do we use terms such as ‘passing’, ‘expired’, to cushion the blow? Are we ever truly prepared for the finality of death? You, the emerging doc, has now experienced the loss of a patient and it is a changed reality.

HSW

BEGAN Feedback – Shmuel P. Reis, MD, MHPE, Family physician – Doctoring course preceptor

Thanks for daring to share. It took you time, and it was scary to face it and to write about this most painful first loss.

I am especially touched because your processing is the opposite of what used to be mine. I can’t even recall when I first lost a patient.

The way you found out about Paul's passing away was unfortunate, probably compounding the confusion and pain.

You were courageous to open yourself, in your own pace, to figuring out your feelings. Where are you now in figuring them out?

You have somewhat reconciled yourself to Paul's death, by finding the positive in his life and his readiness to let go. Can you recognize when a person is ‘satiated with life’ and finds respite in death?

SPR

BEGAN Feedback – Jeffrey M. Borkan, MD, PhD – Family Physician

Thank you for your thoughtful and reflective field note. Thank you for your honesty and willingness to put down in words what you were feeling in this difficult situation.

Losing one's first patient is often a difficult experience. I remember the experience myself and how deeply it affected me.

Finding the positive in the situation, such as that the patient was able to spend his last days in the same nursing home as his wife, may be particularly helpful – both in terms of understanding the loss in some framework, and for your sense of well being.

Questions you may want to ask yourself:

1. How can you hold onto your humanity in medicine (feeling the sadness and loss) while still being able to ‘move on and continue my medical education’?

2. How can you build in the positives for yourself in such situations?

You might want to discuss this with Dr. Stewart – how did a veteran physician and teacher react? Thank you again. You may want to save this note and reflect upon it again in one, five, and ten years.

JMB

BEGAN Feedback – Alicia D. Monroe, MD – Family Physician, Director – Doctoring Course

I wish to express that I am sorry for your loss. Losing your first patient or any patient is difficult for a caring provider.

I appreciate your willingness to write about your feelings about your patient's death. It is difficult to express feelings but it is important to acknowledge your feelings to remain sensitive and to nourish your humanity.

Your field note captures several important reflections/thoughts worth remembering:

1. How we both give and receive difficult information can help us cope positively.

2. How fast do we need to move onto the next task? (‘I teared up a little … and now I had to let go’) How much time does it take for healthy grieving?

3. It is common for physicians to rapidly shift from the personal/emotional to the medical aspects of the case to distance ourselves emotionally from our sadness and loss.

4. Remembering the positive aspects of a person's life is important.

What can you learn about your reactions to this loss?

How can you use your insights to help you care for future patients?

ADM

Discussion

Medical students experience rites of passage during their training, which serve to facilitate professional identity formation. Interactive reflective writing, i.e. providing individualized guided feedback to students’ reflective writing about such experiences can help support learners during important transitions in an authentic, transparent manner. The loss of one's first patient is particularly poignant and the value of ‘writing exercises’ to help students recognize and reflect upon their emotions (as well as those of patient and family) has been noted (Williams et al. 2005; Levine et al. 2008). Reflective writing on such a rite of passage with provision of guided faculty feedback, which can be enhanced with the BEGAN framework, represents a curricular innovation that can help boost professional competencies which include both cognitive and affective elements.

Students represent their experience through narrative, creating meaning. The BEGAN framework for crafting individualized feedback then helps to foster students’ reflective capacity, self-awareness, and self-confidence as the insights they share are illuminated (extracted from their actual text, often with quotes), reflection is invited with targeted queries, lessons are derived, and concrete recommendations are provided, as relevant. The proliferation of reflective writing courses within medical school curricula to enhance students’ self-awareness and management of emotions as well as to meet core competency requirements highlights potential utility and generalizability of a tool such as the BEGAN. Use of the BEGAN framework in response to student narratives, especially those describing emotionally powerful events as presented here, guides students to acknowledge, explore, and learn from their emotional experience, potentially bolstering resilience and student well-being (Shapiro 2008). Thus, emotional intelligence, defined as distinct yet related abilities of perceiving, using, understanding, and managing emotions (Akerjordet & Severinsson 2007; Mayer & Salvey 2007) may be further developed through the use of such a guided feedback paradigm. The relevance of such critical abilities has recently been highlighted as contributing to the Accreditation Council for Graduate Medical Education (ACGME 1998) core competency of interpersonal and communication skills (Grewal & Davidson 2008).

The use of the BEGAN as a guiding tool for approaching a student's reflective narrative engages faculty in a parallel process of acknowledging their own affective responses that can potentially tap into relevant, educationally enriching clinical and general life experiences. Written feedback incorporating such content is provided to the student after a filtering process informed by clinical and teaching experience and expertise. In one feedback example, the physician faculty (SPR) transparently shares a past episode of emotional blocking, reflecting on his own clinical experience as he highlights the student's alternative emotional response for the student's potential benefit. In line with this, reclaiming authentic emotions has been endorsed as an aid to communication and well-being in medicine (Bub 2007). Additionally, on this ‘two-way street’, faculty remains open to student input as such writing exercises can provide a ‘window’ (Williams et al. 2005) into curricular elements that may warrant consideration (e.g. establishing protocols to assist students with receiving and coping with news of a patient loss).

The interactive nature of faculty providing individualized feedback to students’ reflective writing, we propose, additionally exemplifies the role of relationships in educational interventions supporting the professional formation of physicians (Haidet et al. 2008). The value of relationship-enhanced learning process (Haidet et al. 2008) is highlighted by the Alpert Med Doctoring course structure of interactive reflective writing with faculty feedback scaffolding small group process, purported to nurture self-awareness, promote empathy, and lessen the sense of individual isolation (Pololi & Frankel 2001).

Interactive reflective writing, such as faculty commentaries provided on emergency residents’ reflective writing portfolios (Fiege 2006; Caudle 2008) provides a foundation for professional growth through promotion of reflection and self-knowledge and can help facilitate transformation from student to professional. In line with this, a theme of personal and professional development enhancement through interdisciplinary faculty feedback to longitudinal reflective writing assignments emerged in our recent study of Doctoring course (first year) students’ evaluative comments (Wald et al. 2009). Recent comments by the student author of the presented ‘field note’ illuminated the potential educational benefits of such an interactive reflective writing paradigm during a pivotal event in medical education:

‘It was the first time I’d dealt with death in a clinical setting, and it was really helpful to be able to document that in a field note and discuss it confidentially with my faculty members. Later in the year, when we talked about delivering bad news in the clinical environment, it was helpful again to refer back to it. And I’ll be able to look back at that note in the future, whenever I need to refresh that memory.’ (O’Gara-Kurtis 2008)

Joining with the student through the sharing of narrative carries us (writer–reader dyad) into a ‘universe of shared experience and shared humanity’ (MacCurdy 2000). Contextualizing the student's experience through feedback commentary creates a ‘commonality of experience’ (MacCurdy 2000), a sense of community, and in essence, helps to define a profession. Poised at that fork in the road, we, the educators, provide quality feedback to reflective writing, accompanying students at critical educational junctures. With new insights, we hope, they then continue on their journey.

Acknowledgment

The field note of Nitin Aggarwal (identifying details altered) is used with permission and appreciated.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Hedy S. Wald

HEDY S. WALD, PhD, is a clinical assistant professor of Family Medicine, Warren Alpert Medical School of Brown University, a psychologist with advanced training in Narrative Medicine and Neuropsychological Assessment, and a reflective writing consultant to the Doctoring course and Family Medicine clerkship. She conducts research on use of reflective writing and faculty feedback in medical education.

Shmuel P. Reis

SHMUEL P. REIS, MD, MHPE, is a professor and chair, Division of Family Medicine, Technion-Israel Institute of Technology, Haifa, Israel, and an adjunct associate professor, Alpert Medical School. He is a medical educator with expertise in Medical Education and Narrative Medicine and conducts research on use of reflective writing and faculty feedback in medical education.

Alicia D. Monroe

ALICIA D. MONROE, MD, is the vice dean for Educational Affairs, professor of Family Medicine, University of South Florida College of Medicine. She was previously an associate dean for Diversity and the course director and curriculum developer for the Alpert Medical School Doctoring course. She has extensive experience in leading workshops for clinicians and students.

Jeffrey M. Borkan

JEFFREY M. BORKAN, MD, PhD, is professor and chair, Department of Family Medicine, Warren Alpert Medical School of Brown University and a key contributor to the Doctoring course. His training and expertise in medicine, anthropology, mixed methods research, and Narrative Medicine has helped to guide the use of reflection in the Doctoring course.