Narratives In Medical Education: The Next Steps

[Letter]. Perm J 2014 Fall; 18(4):93 [Full Citation]

Re: Johna S, Woodward B, Patel S. What can we learn from narratives in medical education? Perm J 2014 Spring;18(2):92-4. DOI:

Dear Editor,

Johna et al1 have offered an intriguing insight into reflective narratives written by medical learners. Although their study was small, they have succeeded in getting the learners to reflect on their practice, to express such reflections in a written narrative, and to express positive feelings about the experience. It will be interesting to see where their further research leads.

The first challenge in this field is that of taking a great idea, in this case reflective written narratives, and rolling it out to a wider group. Problems start to occur when reflection is made compulsory, which in itself sounds like an oxymoron. In the United Kingdom, many continuing professional development bodies require learners to reflect on every learning activity that they undertake. When you have to write 50 reflections on 50 hours of learning, what should be a life-affirming activity becomes a life-draining one. Learners repeat the same reflections or worse sometimes copy what they think is the "right answer" from another source. Reflection can be encouraged; reflective practice skills can be nurtured; a culture of reflecting on practice and on learning can be engendered, but reflection should not become a tick-box exercise. Another challenge is developing a system of assessment of reflective practice: the first test is to assess whether reflection has occurred or not—this is a simple binary choice for the assessor. However, assessing the quality of reflection is more challenging. But this has been done—sometimes in quite challenging domains. For example, Moon et al2 have analyzed reflective narratives to assess the ethical reasoning of pediatric residents. In their case too, the study was small and required substantial and expert input—however, feasibility was demonstrated. Assessment is vital: it drives learning, and it is incumbent on medical educators to ensure that assessment motivates the learners in the right way and moves them in the right direction—that is, so that they engage in real and meaningful reflection on their practice and that such reflection ultimately has an impact on their practice and their patients.

Yours Sincerely,

Kieran Walsh, MD, FRCPI

Clinical Director of BMJ Learning

BMJ Learning, London, UK


   1.  Johna S, Woodward B, Patel S. What can we learn from narratives in medical education? Perm J 2014 Spring;18(2):92-4. DOI:

   2.  Moon M, Taylor HA, McDonald EL, Hughes MT, Beach MC, Carrese JA. Analyzing reflective narratives to assess the ethical reasoning of pediatric residents. Narrat Inq Bioeth 2013 Fall;3(2):165-74. DOI:


Response to Dr Walsh

We read with interest and enthusiasm the letter written by Kieran Walsh, MD, in reference to narratives in medical education. Dr Walsh raises some important questions and concerns, to most of which we have no clear answers. Like other educators, we face many challenges in teaching and evaluating domains of Accreditation Council for Graduate Medical Education (ACGME) core competencies.

Reflective writing through narratives, at least in our opinion, is just another tool that can be added to the armamentarium of the educator. We agree that there are several challenges associated with the use of narratives; fostering a culture of self-introspection rather than mandating it is just one. Measuring its effectiveness toward achieving competence is another one. Our experience, as of yet, has not been validated. We took our research a step further when we conducted a prospective, randomized, cross-over study among family medicine residents not previously exposed to this tool. Only 19 residents (convenience sample) were randomized in two arms, an intervention group (n = 9) and a control group (n = 10). Our intervention was to introduce the learners to sample narratives that were analyzed with the help of the senior author. The events that were reflective of the ACGME core competencies were highlighted. Although we could not demonstrate a difference, post hoc analysis showed some very interesting findings that we will consider in our future research. The study is pending publication in one of the journals focusing on education and curricula development.

Perhaps as important, if not more important than the use of narratives in teaching ACGME core competencies, is the fact that such narratives were the mirror reflecting what happens in our teaching environment day in and day out. Some of what we learned was very telling. Negative role modeling, unethical behavior, poor professionalism, and living examples of the hidden curriculum were just some examples. Reflective writing gave us an opportunity to enforce positive behaviors and mediate negative ones through structured faculty development programs.

We thank Dr Walsh for his insight. We remain optimistic about the use of narratives, and we hope that our future research will help us prove our point.


Samir Johna, MD; Brandon Woodward, MD; Sunal Patel, MD

Arrowhead Regional/Kaiser Fontana General Surgery
Residency Program



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