- Guiding Our Learners in Reflective Writing: A Practical Approach
A recent commencement ceremony at Alpert Medical School of Brown University held poignant meaning for me. As a Doctoring course preceptor, I witnessed my initial group of students become physicians with all the rights, privileges, and honors pertaining thereto.
The Doctoring course integrates medical interviewing and physical exam instruction, ethics, and cultural competency topics, and reflective writing—“field notes” with small group teaching.1 Four years earlier, at the course’s inception, I had facilitated group discussions and assessed these eight students’ encounters with standardized patients, but it was the sharing of their reflective narratives about their educational journey, including early clinical experiences at community mentor sites, that left a profound impact on me, and I hoped on them as well. Rita Charon has described the “intimacy” of the written word within narrative medicine, and this intimacy can become part of the lived experience of medical students.2 I had certainly sensed such intimacy within the intersubjective context of the teacher-student relationship where narrative was offered as a vehicle for grasping some essential “how-tos” in medicine which may appear rather elusive: how to be present, how to perceive the subtle, how to capture the clinical encounter, how to listen in order to really hear. Thus, it was not surprising that within all the pomp and circumstance of that graduation day, I was especially struck by a quote in the commencement speaker’s comments: “Illness,” he said, “often tells its secret in casual parentheses.”3 Do we adequately prepare our learners, I wondered, to appreciate such parentheses (both literal and figurative) as they approach the mystery of medicine? This essay emerged from that question.
Narrative medicine practitioners strive to promote narrative competence within medical education by getting the story, seeking out the [End Page 355] untold story, appreciating the unfinished story, using the context of a life story to bring us the person who is the patient, and employing these stories to guide diagnosis and treatment. The theoretical bases for pedagogies designed to develop narrative competence have been elegantly expounded and include Charon’s fundamentals of attending (achieving mindful presence in the clinical encounter), representing (experiencing the written word to give it meaning, including affective responses) and affiliating (sharing texts with colleagues), all of which mirror processes of clinical practice.4,5 There has been a surge of interest in the strengthening of narrative competence within medical education through initiatives such as writing reflective narratives and reading literature, both of which help to develop competencies such as achieving a more fully “textured” understanding of the patient’s experience of illness (including emotional factors and the contextualization of illness),6 developing an empathic stance,7 and building reflective capacity.8
Ronald Epstein, in his seminal work “Mindful Practice,” describes how to be empathic: “I must witness and understand the patient’s suffering and my reactions to the patient’s suffering to distinguish the patient’s experience from my own;”9 hence, a role for narrative competence through reflective writing to help learners make such distinctions is proposed. While definitions of reflective capacity abound, Karen Mann and her colleagues’ recent review provided some relevant conceptualizations, including David Boud, Rosemary Keogh, and David Walker’s concept of reflection as a “generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to [gain] a new understanding”10 and Donald Schön’s “reflection-on-action” process (reconstructive mental reviews can shape future action).11 Promotion of reflective capacity within medical education is posited to help develop critical thinking skills,12 inform clinical reasoning,13 enhance professionalism (including self-directed learning),14 and deepen humanism.15 David Hatem and Elizabeth Rider link empathy and reflection; in their view, the opportunity to reflect and to become more self-aware potentially counters unrecognized attitudes and feelings which may contribute to sub-optimal physician-patient communication and empathic failure.16 Rachel Levine, David Kern, and Scott Wright; Donald Brady, Giselle Corbie-Smith, and William Branch; and numerous other narrative medicine proponents have described structured reflective writing (under the rubric of narrative medicine) as a means of...