What Can We Learn From Narratives in Medical Education?
Perm J 2014 Spring; 18(2):92-94 [Full Citation]
Medical literature has demonstrated the effectiveness of narrative writing in enhancing self-reflection and empathy, which opens the door for deeper understanding of patients' experiences of illness. Similarly, it promotes practitioner well-being. Therefore, it is no surprise that narrative writing finds a new home in medical education. The Accreditation Council of Graduate Medical Education (ACGME), through its Outcome Project, established six core competencies that every residency program must teach. However, no specific pedagogies were suggested. We explored the role that narrative writing can play in reconciling the ACGME core competencies with daily encounters in medical education. Our study suggests a hidden wealth in reflective writing through narratives with a promising potential for application in medical education. Reflective writing may turn out to be an innovative tool for teaching and evaluating ACGME core competencies.
Reflective writing is not a new method of introspection or evaluation. It has been used over the years for various professions, most recently in the realm of medical education. Since 2002, medical educators have been exploring various venues to teach essential core competencies in medical education. The Accreditation Council for Graduate Medical Education (ACGME) mandated that every resident must reach a competency level in medical knowledge, patient care, interpersonal and communication skills, practice-based learning and improvement, system-based practice, and professionalism.1 To comply with the mandate, residency programs tapped into some of the traditional educational activities that are already in use; to name a few, the morbidity and mortality conference, teaching in the operating room, and clinical teaching rounds. However, such activities focus mainly on patient care and medical knowledge.2-4 Program directors continue to explore other educational activities that may be as effective and able to cover the more advanced core competencies.5-10 The current educational activities in use, though useful, demand time and resources that may not always be available, particularly for small residency programs. Reflective writing lends itself to such a potential.11-16 To examine this possibility, the authors reviewed their experience using reflective writings through solicited narratives that were collected from different learners over the preceding two years.
SJ asked his learners, students and residents, at the Fontana Medical Center to reflect on their experiences at any of the locations through which they had rotated during their school years or residency training, whether the experiences were positive or negative, in an anonymous way. Learners who agreed to participate sent their narrative writings to SJ via e-mail. We collected a total of 33 narratives. Learners from Loma Linda University wrote a total of 16 narratives, third-year medical students 12, and physician-assistant students 4. Third-year students from a Caribbean medical school wrote 3 narratives. Fourteen narratives were written by different-level residents from the Arrowhead Regional/Kaiser Fontana General Surgery Residency Program. SJ used a printed form that lists the 6 ACGME core competencies and their subcompetencies as a yardstick. SJ analyzed every narrative and identified every embedded overt or covert ACGME core competency or subcompetency. They were subsequently inserted within the text of each narrative. The narratives were discussed at a later date with the learners, one-on-one, with a focus on the identified ACGME core competencies to show them how to place such core competencies in perspective. Later, an anonymous survey was conducted using SurveyMonkey (Palo Alto, CA) to look at learners' reactions (Kirkpatrick level I evidence) and gained knowledge (Kirkpatrick level II evidence), with a focus on the perceived effectiveness of this educational intervention. The survey questions were:
1. Was the analysis of the reflection successful in identifying one or more of the ACGME core competencies?
2. Was the analysis of the narrative able to demonstrate how the ACGME core competencies interlace with one another within the same encounter?
3. Do you think that such narratives are useful resources for teaching the ACGME core competencies outside structured classes or workshops?
Finally, the data were collected and analyzed using descriptive statistics.
Thirty-three narratives were collected over the course of 2 years. Each narrative analysis took some 10 to 15 minutes to complete. Narrative discussion with each learner took a similar length of time. The median number of paragraphs per reflection was 3 (range, 1 to 9). The median number of words per reflection was 438 (range, 184 to 1152). The median frequency for each core competency per reflection was 0 for medical knowledge (0 to 2), 3 for patient care (0 to 6), 2 for interpersonal and communication skills (0 to 6), 2 for practice-based learning and improvement (0 to 9), 1 for system-based practice (0 to 7), and 3 for professionalism (1 to 7). The median for collective number of core competencies per single reflection was 4 (4 to 6) (Figure 1). All learners were surveyed. Only 23 (69.7%) learners responded. One responder skipped question 3 on the survey. All surveyed participants responded with "yes" to every question (100%). The learners perceived that reflective writing through narratives was a useful educational intervention for learning ACGME core competencies through daily encounters.
More than ever, program directors are under pressure to explore new horizons and come up with more innovative educational tools, not only to teach the ACGME core competencies but also to properly assess each resident's performance before s/he is deemed competent. Some of the ACGME core competencies may be easy to teach and evaluate, such as medical knowledge and patient care. Other advanced competencies are more challenging. In addition, a limited number of structured classes or workshops during any given year may not be sufficient to achieve the task. Limited resources, particularly in small residency programs, limitations on residents' work hours, and the pressure on the faculty for more clinical productivity add fuel to the fire.
An ideal educational activity would be an intervention that is versatile, effective, cheap, and can be implemented anytime and anywhere with no additional resources or expertise. Even better, when the intervention is capable of showing how one or more of the ACGME core competencies interlace with each other, we can potentially reconcile such competencies with daily encounters. After all, the ACGME core competencies should probably not be taught or evaluated separately. Recent data show that the current measurement tools are not able to measure the core competencies independent of each other.17
Our experience with the use of narratives in medical education has been very satisfying to say the least. No matter how short a narrative is, it is able to encompass one or more core competencies. It is also able to demonstrate how the core competencies interlace with each other within the same encounter. Narratives are versatile. They can be written anytime, anywhere, and at the learner's leisure, with no need for additional resources and skills. They also add little or no additional pressure on the faculty. Furthermore, narratives can be a real-time mirror of what happens on the front lines on a daily basis. Some of the reflective writings that we collected were eye-openers. Whereas the majority of the narratives referred to positive role modeling that we endorsed and reinforced, some narratives, to our dismay, exposed poor professionalism, poor interpersonal communication skills, poor patient care, and poor system-based practice, which needed to be addressed. As an example, one learner described what he perceived as a negative encounter between his attending physician and a patient who had newly received a cancer diagnosis. He said,
After we left the room, I was thinking of how shocking and overwhelming that was to the patient. I was wondering if being busy can be an acceptable excuse for not showing empathy and respect when talking to patients about their serious illnesses … I now realize how much contradiction and incongruity there is between what we have been taught and what actually happens in real life.16
In this narrative, the learner struggles as he tries to reconcile what he was taught in the classroom with what he saw in the examination room. He eloquently describes the dilemma of a hidden curriculum: teachers who do not walk their talk!
Our study has several limitations. The sample is small and is a convenience sample obtained through solicitation of all learners who rotated with SJ. The fact that not everyone participated may depict an inherent bias. Likewise, the 100% positive response rate to the survey may cast some doubts. We do not believe these doubts, given that the response represented the participants' personal perceptions. And finally, our data cannot predict how successful our learners would be in applying what they learned to encounters in everyday practice during their schooling, residency training, and beyond. Therefore we propose to use our data as a pilot study to help guide future research.
There is a hidden wealth in reflective writing through narratives, which have promising potential for application in medical education. Reflective writing may turn out to be an innovative tool for teaching and evaluating ACGME core competencies. Even a simple narrative can expose several core competencies and how they interlace with each other within a single encounter. Such narratives may serve as a versatile tool for every residency program. We hope that every learner will be enriched by this hidden wealth and will learn how to apply it during residency training and beyond, when s/he enters real-life practice. Further research may support this potential.
The author has no conflicts of interest to disclose.
Leslie Parker, ELS, provided editorial assistance.
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