Medical Education
Learning to connect: Students’ reflections on doctor–patient interactions

This project is dedicated to Dr. Steven Miller who connected effortlessly with so many and whose message lives on today.
https://doi.org/10.1016/j.pec.2008.09.011Get rights and content

Abstract

Objective

Reflective writing is an established method for teaching medical students empathetic interactions, though little is known about students’ reflections on connecting with patients during the clinical clerkship. The purpose of this study was to describe factors that medical students perceive contribute to or detract from making connections with patients and families, as identified in a writing assignment during the pediatric clinical clerkship.

Methods

Reflective essays submitted by third-year medical students about interacting with patients/families during their pediatric clerkship were qualitatively analyzed for thematic content.

Results

Major themes emerging in 44 essays analyzed included time, knowledge, language and culture, and actions. Barriers to connecting for some students were considered resources by others. Critical reflection was present in 31.8%.

Conclusions

Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract their ability to make connections. Through reflection, medical students – amidst clinical responsibilities – can identify how, why, and whether or not connections with patients/families have occurred.

Practice implications

Recognizing what factors medical students perceive as enhancing and detracting from connecting with patients/families will help preceptors foster those connections and mitigate barriers. Future study could assess how to best provide specific individualized feedback to best enhance critical reflection. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, as it may augment students’ ability to connect.

Introduction

Teaching humanism is increasingly recognized as an integral component of medical education [1]. Yet, as medical students progress to their clinical years, fostering a habit of humanism [2] and the ability to connect empathetically with patients remains a challenge. Empathy – where the clinician's awareness of the patient's concerns produces emotional engagement, compassion, and an urge to help – is a teachable skill [3], [4]. Reflective writing has been established as a method for teaching medical students empathetic interactions, such as by having them write personal illness narratives [5]. The writing and telling of one's story, i.e. narrative, has been considered to have tangible health and behavioral benefits, and is an important method of reflection [6], [7]. A strong rationale for the importance of reflection in clinical practice highlights that through the reflective process trainees can recognize what values, beliefs, attitudes, and assumptions they themselves hold and how these might differ from those of their patients and families [8]. Trainees can then consider how each might have an impact on their own clinical decision making or how closely patients and families might adhere to their recommendations.

In the context of medical school, reflection and reflective writing, if included, is usually a component of a preclinical or an elective course rather than as part of a core third-year clinical clerkship. Yet medical students indeed have the capacity for a wide range of creative expression even while immersed in clinical responsibilities [9]. During our 8-week third-year pediatric clerkship at Children's National Medical Center (CNMC), there is a weekly core seminar series and special teaching rounds for students. As part of this core series, students participate in humanism seminars where they practice reflecting in small group activities about connecting with families, and interpreting humanities literature as it relates to clinical experiences. At the close of one of the humanism seminars, students are asked to reflect further on connecting or difficulty connecting with families, by completing a writing assignment.

During the humanism seminar that immediately precedes the writing assignment, an invited guest speaker models the reflective process around issues of doctor–patient interactions. This invited guest is either a trainee proximate in experience to the third-year students (i.e. a fourth-year student or a resident) who has had an exemplary or a difficult time connecting with patients/families, or a patients’ parent who has had notable experiences with medical students. We allow students guided practice sharing their reflections with each other in safe, small groups before asking them to reflect in writing. Following the submission of their anonymous writing, students receive feedback in the form of key insights about connecting with patients and families that were evident in their essays, and questions for ongoing reflection to enhance their ability to build relationships in the future.

While the doctor–patient relationship has been studied extensively [10], as well as the nursing trainee–patient relationship [11], literature about medical students’ perspectives on connecting with families and what factors contribute or detract from their making connections is sparse. Guided by a theoretical framework (Fig. 1) derived from Schön's reflection-on-action and Schön and Argyris’ Double Loop learning [12], [13], in this study we have undertaken this content analysis to identify these factors evident in medical student's reflective writings.

Reflection-in-action allows students the opportunity to better understand their emotional reactions to various day to day doctor–patient interactions but is unlikely to result in sustained change. Reflection-on-action, like double loop learning, allows students to challenge their assumptions later and make changes and improvements. For the students, we provide feedback as part of their reflective cycle of their double loop learning.

Much focus has been on educational efforts to promote empathic connections with patients, rather than on the factors themselves that contribute or detract from connections. Our purpose in the current study was to qualitatively analyze these factors, as depicted in a reflective writing assignment designed to understand the medical student's perspectives and to promote professional growth.

Section snippets

Design

This is a qualitative study of reflective papers submitted by third-year medical students during their pediatric rotation, following a humanism seminar.

Setting

Medical students were instructed to independently reflect about their interactions with patients during 2 weeks on the inpatient or ambulatory pediatric clerkship, following a humanism seminar, in a writing assignment (see Box 1). We introduced the hour-long humanism seminar during the 2005–2006 academic year. A typical seminar began with a

Essay characteristics

We included all 44 essays from 2 rotation groups, submitted by students from November 2005 through February 2006, after which point thematic saturation had been attained. 81% of 54 students from two clerkship groups submitted essays. Mean word count per essay was 420 with a range from 174 to 1006 words. Critical reflection was present in 31.8% of the essays, in which underlying assumptions were explored and critiqued and the experience was revisited. Reflection was present in 26 (59.1%) essays,

Discussion

This qualitative study of original reflective essays written by medical students on their pediatrics clinical clerkship was conducted in order to gain insight into factors contributing to and detracting from their abilities to connect with patients and families. Our findings reveal that time was an important though complex factor in connecting, depending on whether students perceived that it took a lot or a little time to connect and whether they felt they had enough time to do so. It should be

Acknowledgments

This project was supported by a grant from the Arnold P. Gold Foundation for Humanism in Medicine and also by the Master Teacher Leadership Development Program at The George Washington University. We wish to thank Ms. Wilhelmina Bradford for her tireless efforts coordinating and connecting with medical students. The authors confirm that all patient/personal identifiers have been removed or disguised so the patients/persons described are not identifiable and cannot be identified through the

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