“A memorable consultation”: Writing reflective accounts articulates students’ learning in general practice

Abstract

Objectives. To explore and analyse students’ learning experiences of a memorable consultation during a final-year attachment in general practice. Setting. After a two-week primary care attachment in the undergraduate curriculum, students were invited to write a reflective account of a memorable consultation. Design. A total of 52 reflective accounts were read and processed according to qualitative content analysis. Credibility of the analysis was validated by two co-authors reading the descriptions separately and trustworthiness was tested at local seminars. Results. Three main themes emerged. In “The person beyond symptoms” the students recognize the individual properties of a consultation. “Facing complexity” mirrors awareness of changing tracks in problem-solving and strategies of handling unclear conditions. “In search of a professional role” reflects the interest in role modelling and the relation to the supervisor. Conclusion. Involving students in writing reflective accounts appears to stimulate them to articulate practice experiences of the consultation.

• Consultation
• family practice
• general practice
• reflection
• supervision
• undergraduate medical education

Situated at the heart of medicine, the consultation is a very complex phenomenon. In the patient–doctor encounter, biological, psychological, and social aspects of medicine are integrated. Considering the central position of the consultation, how can medical educators facilitate students’ learning of consultation skills in a practice setting? This question has been addressed in several reports and reviews during the last few decades [1–7]. An experiential method of learning communication and consultation skills is nowadays implemented in most curricula. However, concerns have been expressed regarding the risk of superficial learning due to a too narrow approach of skills training [8].

In 1997, reflection on learning experiences was recommended in undergraduate ambulatory clinical education by Smith & Irby [9]. Main references for these recommendations are Kolb's and Schön's contributions to experiential learning theory in which reflection plays a central role [10], [11]. One definition of reflection is proposed as follows: “Reflection is an important, human activity in which people recapture their experience, think about it, mull it over and evaluate it” [12]. Different ways have been practised to encourage students to reflect on clinical practice by writing reflective accounts. In “portfolio learning”, which is a broad concept of learning tasks, the students could be asked to answer specific questions. The answers could constitute a framework of personal diaries aimed at enhancing the students’ reflective thinking [13]. In some curricula, students were asked to convey their feelings in the form of poetry, hence expressing difficult questions raised after seeing patients [14]. Reflective writing might help the students to articulate qualities of experiences not covered by traditional medical vocabulary. In primary care where patients are seen in an early and unorganized state of illness it could accordingly be appropriate to stimulate students to express personal reactions.

Reflection on experiences in practice is recommended as a learning method in medical students’ ambulatory clinical education. Students’ written reflective accounts of a memorable consultation in primary care were analysed qualitatively.

• Main themes of students’ learning experiences were “The person beyond symptoms”, “Facing complexity”, and “In search of a professional role”.

• Involving students in writing reflective accounts of consultations appears to stimulate them to articulate learning experiences.

Students’ attachments in general practice

In the Göteborg medical curriculum comprising 11 terms, a general practice attachment is arranged during the 10th term. Students are supervised by an experienced GP and see patients of their own. The purpose of this training is to expose students to patients and problems in primary care, in order to learn from personal experiences and to start to grasp the essentials of general practice. Before the 10th term, the students spend most of their time in hospitals, mainly in university clinics. Less than one year after the general practice attachment, most students start their internship (“allmäntjänstgöring”) implying gradually independent clinical work and high personal responsibility.

In 2001–2002, students were asked to recall and share a memorable consultation experienced during the PHC (Primary Health Care Centre) attachment in a small-group setting. Supervisors then heard many noteworthy and unexpected stories. Patients’ assorted symptom presentations and attitudes to their complaints were often highlighted in students’ oral reports. In addition, the students had captured new medical skills and various working manners of the GPs. We wanted to develop these presentations more systematically.

The study aimed at exploring and analysing students’ learning experiences of a memorable consultation during a final-year general practice attachment.

Material and methods

In 2003 the students (n = 60) on two courses were asked to select a memorable consultation and write down their learning experiences and reflections. The task was voluntary and the students were notified that the purpose of the reflective descriptions was to explore in more depth their experiences of a memorable consultation. Students were also informed that their texts would not be assessed by marks and grades. It was stressed that participation was voluntary and the students could omit the names on the sheets if they wanted. The GP–patient encounter could deal with any kind of problem, purely medical as well as mainly human. The students’ own choice was entirely decisive. The task was to answer three questions: What happened to the patient before the consultation? What happened when meeting the patient at the PHC? What did I learn from the consultation?

The accounts were maximized to two pages, collected on a follow-up day and processed according to qualitative content analysis [15], [16]. The whole data material comprised 78 pages of text, which was analysed accordingly:

1. The first author, KS, read the reports three times. The core content of each account was identified and units of meaning were grouped to get a view of the entire material.

2. The accounts were read by KS again and BM to get an overview of the material and the initial analysis made by KS was discussed at three meetings.

3. In a couple of sessions the units of meaning were condensed and coded into preliminary categories.

4. The categories were grouped and condensed into themes.

5. The third researcher (MW) read all accounts independently.

6. Categories and themes were discussed in new sessions and re-evaluated in order to confirm the findings.

Perspectives used in interpretation of data were a learner-centred model of education and Ian McWhinney's model of a theory for family medicine [17], [18].

Results

A total of 54 students (90%, 31 female and 23 male, mean age 27 years) submitted their accounts. Two accounts deviated from the others by not answering the three questions in the task and by lacking reflection. These accounts were omitted from the analysis.

A framework of the content analysis of students’ reflective descriptions is depicted in Table I.

Table I.  A framework of content analysis of students’ reflective accounts: General practice course, 10th term, medical curriculum, Göteborg university.

Units of meaning, citations from students’ texts (examples)	Categories	Themes
“Worry and anxiety means a lot”	What's behind the patient's story?
“Social problems might hide a disease”
“The real problem could be something else”		The person beyond the symptoms
“Listening is more important than prescribing pills”	Importance of consultation skills
“There has to be a dialogue between the patient and the doctor”
“When leaving the room the patient might say something important”
“Do not hurry to establish a diagnosis”	Changing tracks
“The presenting symptom was quite different from the real problem”
“Behind a common cold a serious disease might hide”		Facing complexity
“In primary care you wait and see”	Dealing with uncertainty
“Difficult to know when to refer”
“It was necessary to think broadly”
“Be prepared – the patient is”	Personal style in the consultation
“Take your time – try to be quiet together with the patient”
“No superior tone towards the patient”		In search of a professional role
“The supervisor argued irritably with the patient”	Supervisor scrutinized
“The supervisor avoids eye-to-eye contact with the patient”
“The patient liked the supervisor's manners”

Themes and categories supporting themes are presented below. In order to illustrate and clarify the analysis, additional examples of quotations from students’ texts are given in italics.

Theme: The person beyond symptoms

Underpinning this theme were the categories “What's behind the patient's story?” and “Importance of consultation skills?”

Category: What's behind the patient's story? Many accounts dealt with the patient's personal conditions relevant to the visit and frequently the person behind the symptom emerges. Fear of cancer, family and social problems were sometimes, noted the students, expressed as physical complaints. The students experienced that presenting symptoms like back pain, headache, or a common cold could be an “admission ticket” to the PHC. In the subsequent encounter the focus was narrowed and another realm of interest appeared: So much seems to be hidden behind the problem that brings the patient to the PHC.

Importance of consultation skills

The students elicited the importance of good consultation skills and the significance of listening to the patient's story: If you try and give yourself and the patient some time to be quiet together you can learn more than by just asking a lot of questions.

Facing complexity

Categories supporting this theme were “Changing tracks” and “Dealing with uncertainty”.

Changing tracks

The students noted in their stories that you have to improve your ability to wait and see and reassess your preliminary judgement. You need not, and cannot, immediately transfer the problems into diagnostic terms: It was an impressive chain of events and consultations that, finally, led to the underlying diagnosis.

Dealing with uncertainty

These statements tell of the uncertainty that a future doctor has to learn to live with and the implication of this insecurity in clinical work: I don't understand his symptoms but I do not think it is anything urgent.

In search of a professional role

The theme was established by the categories “Personal style in the consultation” and “Supervisor scrutinized”.

Personal style in the consultation

Consultations revealing that theory and practice do not always fit have a high instructive value. The importance of finding a personal style of one's own – and that it takes some time – was emphasized: … the most important thing is to find yourself as a doctor … and another student: My discreetness must not prevent me from putting a question that the patient might find embarrassing … .

Supervisor scrutinized

The supervisor, an experienced GP, had a key position and in some cases the student described the supervisor as an object of identification. You imitate and praise some of the GP's behaviour whereas other manners were less striven for: When summarizing the patient's story to my supervisor, he sat with his back to the patient, looking at the computer.

Discussion

Comments on methods

After informing the students about the motive of the study, the procedure was carried out smoothly. The number of participants was high (90%). The non-responding six students did not vary from the others regarding sex and age. In addition, the two courses examined did not differ from adjacent student groups in respect of course design. Two accounts were removed from the analysis. They lacked answers to the three questions originally put and were more in line with a short hospital record. For different reasons, these two students had obvious difficulties with reflection. We refrain from speculation as to why this was the case.

Limitations of our research method concern credibility. Credibility was increased by thoroughly conveying the analysis and perspectives used in interpretation of data [15], [16]. During 2001–2003, two other GP academics participated in a group presentation by the students at an oral session on “a memorable consultation”. Altogether, these GPs have listened to more than 50 students and a preliminary version of our results has been presented to them. Our analysis matches well their experiences of the students’ oral reports and this increases the trustworthiness of the study.

Comments on results

The theme “The person beyond the symptoms” tells us how the students are confronted by the psychosocial perspective and the “first contact function” of general practice. Patients often see the GP in a zone of transition between society and healthcare. Similar findings are reported from students’ attachments in primary care and community medicine [19], [20]. In addition, this theme is quite close to McWhinney's description of a patient-centred approach: “to enter the patient's world, to see the illness through the patient's eyes … ” [21].

The theme “Facing complexity” indicates that the students have identified a certain predicament in almost every form of medical work. It mirrors the fact that many students have acquired an awareness of the complexities doctors see in clinical practice. Reality is seldom close to the textbooks so recently shut and dealing with clinical uncertainty is definitely experienced during the PHC attachments [22], [23].

“In search of a professional role” raises questions concerning the students’ relation to their supervisor. In our study the students were on the threshold of clinical work with individual responsibilities. At this stage, the supervisor is important as a role model. Committed supervisors were reported as pivotal to learning in studies of students’ views of attachments in primary care [24], [25]. Indeed, the teacher–learner relationship is reported to have a considerable impact on the quality of teaching and learning [26]. Moreover, learning clinical and professional skills in the clinical context is vital in a socialization process of gradually entering into a “community of practitioners” [27]. A few students expressed criticism concerning their supervisor. An explanation for this could be the student's position as an observer, “sitting in” with the GP without responsibility for the patient.

One may question whether the written reflective accounts really mirror the students’ genuine learning experiences. There might be a risk of bias from students’ pragmatic opportunism in order to pass the course – described as a “chameleon phenomenon” [28]. However, students’ reflections were voluntary and not assessed by marks and grades. We think these circumstances have lessened the risk of opportunistic writing and strengthen the validity of the data.

To interpret and understand physical signs and signals is taken for granted as a learning objective in medical education. Symptoms have a grammar of their own, often with a medical key signature. This order, in many cases, is a prerequisite for a correct diagnosis and treatment. But it has to be developed and completed. An active search for the patient's thoughts and feelings regarding his/her current complaints is needed to grasp and understand the complex symptoms of many patients. This view is often expressed in the students’ accounts.

Implications

Patient encounters in ambulatory practice represent a rich and authentic source of learning experiences. In our exploration of students’ reflective accounts, the complexity of the clinical encounter, containing both medical and psychosocial problems, is elicited. Consequently, what is particularly learned and remembered by the students after spending some weeks at a PHC carries the distinctive character of the essentials of general practice [18], [29].

In conclusion, involving students to write and reflect on a memorable consultation appears to stimulate them to articulate learning experiences and key features of general practice. It could also be a useful tool for supervisors in order to better understand students’ perspective and learning process during general practice attachments [9], [30], [31].

Acknowledgements

The authors would like to thank the participating students who made this study possible.