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Using Student Reflective Narratives to Teach Professionalism and Systems-Based Practice

2017; Elsevier BV; Volume: 187; Linguagem: Inglês

10.1016/j.jpeds.2017.04.049

1097-6833

Thomas R. Welch, Amy Brown, Ann S. Botash,

Innovations in Medical Education

Professionalism and systems-based practice are 2 of the 6 core competencies of graduate medical education.1Accreditation Council for Graduate Medical Education The Pediatrics Milestones Project.http://www.acgme.org/Portals/0/PDFs/Milestones/320_PedsMilestonesProject.pdfGoogle Scholar Although not as explicit in undergraduate medical education, they are also reflected within the Liaison Committee on Medical Education's Standard 7.6: "the development of core professional attitudes" and "… provide coordinated care to patients."2Liaison Committee on Medical Education Functions and structure of a medical school, effective academic year 2016-17.http://lcme.org/publications/Date: 2015Google Scholar While there is little dispute regarding the importance of these skills in medical education, it is not at all clear how they can best be incorporated into clinical curricula. Because of the inherent difficulties in assessing these competencies, methods for incorporation into clinical clerkship experiences often use checklists regarding professional conduct, and participation in morbidity and mortality conferences or other patient safety exercises. However, the concepts of professionalism and systems-based practice are multidimensional and encompass many aspects of medical care. Recognition of professionalism and systems issues are integral to medical student competency. Reflective writing exercises have been employed in some areas of medical education.3Braun U.K. Gill A.C. Teal C.R. Morrison L.J. The utility of reflective writing after a palliative care experience: can we assess medical students' professionalism?.J Palliat Med. 2013; 16: 1342-1349Crossref PubMed Scopus (34) Google Scholar We report their use during the pediatric clerkship at our institution. The State University of New York Upstate Medical University is a state medical school that admits about 168 students each year. The third-year pediatric clerkship is a 5-week rotation, mostly conducted on the inpatient and outpatient services at Upstate Golisano Children's Hospital; some community practices also host students. Beginning in 2011, all students in the clerkship are required to complete an essay reflecting upon an incident during the clerkship, with the goal of teaching them about professionalism and systems-based practice. They are asked to write no more than 1000 words and to comment on the impact of the experience on their education. All the essays are reviewed by the clerkship director, department chair, and a pediatrician/bioethicist. Approximately one-quarter of the narratives address systems issues. Concurrently, all students in the third-year class participate in a clinical bioethics class, which provides much of the knowledge base upon which the assignment is predicated. Toward the end of each rotation, the authors choose 3-5 narratives for group discussion. Criteria for selection include originality, relevance, and likelihood of provoking discussion. The content for at least 1 of the selected essays includes systems issues. The selected narratives are edited and anonymized, and circulated to the entire group. On the penultimate day of the rotation, the group meets for an hour with the authors and the hospital chaplain; other faculty members are invited, depending on the topics. The group then engages in a guided discussion of the selected narratives, with continued assurance that the session is a "safe space" for candid remarks. The facilitators attempt to clarify the professionalism principles illustrated by the narratives, as well as to discuss the systems factors contributing to the observations in more depth. All students are encouraged to participate during the discussions. Tables I and II summarize the major types of issues identified in coding of the narratives. Excerpts from the individual student's narrative are sometimes included in the overall clerkship evaluation. Once or twice a year, one of the narratives uncovers a professionalism or systems issue that the authors recognize as needing attention. Initially, the clerkship director approaches the student to discuss the potential need to break anonymity. If the student chooses to remain anonymous, the chair or a designee then investigates the situation and addresses it while maintaining student anonymity. Student perceptions of systems and professionalism issues often catalyze new approaches to old problems. For example, students have identified the use of some outdated treatment protocols, spurring change and improvement, and have witnessed both very professional and unprofessional behaviors. We have used the narratives for faculty and resident development sessions to further discuss and improve the learning environment and as a model for starting a similar program with first-year residents. This approach, which is low-cost and popular with students, has effectively addressed an important curriculum need in an innovative fashion. Occasionally, it has also uncovered significant concerns that might otherwise go unrecognized. Furthermore, student narratives and the corresponding discussions have indicated that third-year medical students are capable of identifying and analyzing professionalism and systems-based practice issues to the benefit if the department. Table ISystems-based practice themesThemesExample issueAccess to careProvider (resident) did not refer patient to WIC despite patient needs. Not reported to attending.CommunicationMultiple interruptions during sign-outsCostTwo radiographs ordered by mistake on same nightElectronic medical recordMatching billing codes and related diagnosis issuesSafetyDelayed apology after patient given wrong dose of medicationResident scheduleResident left shorthanded by another residentEfficiencyPatient wait times for MRIMRI, magnetic resonance imaging; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children. Open table in a new tab Table IIProfessionalism themesThemesExample issueCommunication (challenging families, difficult conversations, provider to provider, interprofessionalism)Vaccine-hesitant familyCompassion/empathy (boundaries, altruism, patience, compassion fatigue)Generalist devoting office time to addressing special concerns of a familyEthical dilemma (confidentiality, other)Patient disclosure of behaviors unknown to parentClinical excellence (leadership, knowledge, skills, scholarship)Recognition of outstanding faculty role modelingMedical education (mistreatment or positive experience)Parent refusal to have a student see her child Open table in a new tab MRI, magnetic resonance imaging; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.