A Graphic Transformation: A Qualitative Study of Transformative Learning in Medical Trainees during COVID-19 Using Comics as Data Presentation

Abstract

Phenomenon: Transformative learning is a theory in which individuals construct new or revised interpretations of the meaning of an experience. COVID-19 offers a rare opportunity to better understand how individuals respond to and make meaning within the shared context of an extraordinary event. We aimed to examine if and how residents and fellows engaged in transformative learning when caring for COVID-19 positive patients during the initial peak of the pandemic (Spring 2020).

Approach: We conducted an interpretive qualitative study to identify themes pertaining to transformative learning. We used semi-structured interviews of residents and fellows who were directly or indirectly involved in the care of COVID-19 positive patients admitted to the inpatient wards or the intensive care units during the first peak of the pandemic (defined as March 11th – May 28th, 2020) at our Mid-Atlantic academic health system. We used the medium of comics to depict select interviewees’ experiences during the pandemic as a novel way to represent themes from the interviews.

Findings: Three main themes arose from our qualitative analysis. These included “a sense of guilt,” “the impact on training,” and “venues and processes for reflection.” In comparing their experiences with colleagues and friends at other institutions with higher COVID-19 case volume, trainees reflected on how they felt lucky, and this led to guilt, although not necessarily transformation. The impact of COVID-19 on the training environment had transformative potential. Trainees challenged their previously held assumptions on the necessity of various surgeries, in-person visits, and physical examination maneuvers when COVID-19 posed a barrier. Finally, while trainees recalled multiple situations throughout the pandemic when they believed they were engaging in reflection, such reflection did not appear to reach so deep as to alter participants’ underlying assumptions until the research interview itself, suggesting that transformation was incomplete.

Insights: Our purposive sample of residents and fellows who cared for COVID-19 positive patients during the initial peak of the pandemic made meaning of their experience in multiple ways. The largest shift in worldview due to the pandemic appeared to be related to the instrumental utility of certain common medical practices or procedures. This, in turn, was the most prominent influence on how these trainees felt they would practice in the future, and translated to a shift in how they appraised evidence. However, lack of opportunity for reflection may have adversely impacted the ability for transformation to take place. Given that multiple trainees showed appreciation for the critical reflection venue that was the research interview, academic leadership should ensure similar venues exist during training, even after the pandemic ends.

Keywords:

• Transformative learning
• graduate medical education
• COVID-19
• graphic medicine
• comics-based research

Acknowledgments

The authors would like to thank Bethany Snyder and Heather Costigan for their support in preparing our research proposal and with transcribing our research interviews.

Declaration of interest statement

The authors report no conflicts of interest. This was an unfunded study. Support for transcription services from Penn State’s Qualitative and Mixed Methods Core was lent to the researchers as part of a departmental commitment to the Department of Medicine. The views expressed are those of the authors and should not be construed to represent the positions of the University of Colorado School of Medicine, the University of Colorado Hospital, UCHealth, the Pennsylvania State University College of Medicine, the Penn State Medical Group, the Milton S. Hershey Medical Center, or Penn State Harrisburg.

Funding/COI

The authors report no conflicts of interest. This was an unfunded study. Support for transcription services from Penn State’s Qualitative and Mixed Methods Core was lent to the researchers as part of a departmental commitment to the Penn State Department of Medicine.

Disclaimer

The views expressed are those of the authors and should not be construed to represent the positions of the University of Colorado School of Medicine, the University of Colorado Hospital, UCHealth, the Pennsylvania State University College of Medicine, the Penn State Medical Group, the Milton S. Hershey Medical Center, or Penn State Harrisburg.