|Year : 2018 | Volume
| Issue : 4 | Page : 286-289
Analysis of reflective writing of 3rd year medical students during the pediatric clerkship
Padmini Venkataramani, Tharam Sadanandan
Department of Paediatrics and Child Health and Medical Education, UniKL Royal College of Medicine Perak, Ipoh, Malaysia
|Date of Web Publication||14-Nov-2018|
C/O UniKL Royal College of Medicine Perak, No. 3, Jalan Greentown, 30450, Ipoh, Perak
Source of Support: None, Conflict of Interest: None
Background: Reflection creates an understanding of the self and the situation so that the future actions can be informed. It helps in self-regulated and life-long learning. Guided reflection with the help of a mentor may help medical students entering their early clerkships, challenge their assumptions, and consider new perspectives. Methodology: This is a descriptive report of analysis of reflective writing in the logbooks of the year 3 medical students in pediatrics. Students were requested to identify any significant event in the wards or classroom each week and write a brief reflective report. Mentors had weekly meetings with them and discussed the reports. The reports were classified into four themes (related to children and caregivers, learning, motivation, and miscellaneous) after content analysis. Results: Sixty-six logbooks were analyzed. Twenty-five students did not write reports on one or more weeks. There were 29 reports on children, 18 on caregivers, 20 on how students derived inspiration from children and caregivers, 20 on empathy, 24 on upsetting events, 8 on bad experiences of caregivers, 62 on learning, 9 on motivation, and 3 on miscellaneous matters. Challenges: Regular and weekly mentee meetings and discussions are required for meaningful reflective reports. Language posed difficulties in expression. Conclusions: Reflection helped students to be more aware of what is going on in the wards and address troubling issues by discussion with their mentors. It helped mentors gain an insight into students' perspectives and concerns. Regular mentee meetings helped to establish rapport with mentors and submission of proper reflective reports.
Keywords: Medical students, pediatric clerkship, reflection
|How to cite this article:|
Venkataramani P, Sadanandan T. Analysis of reflective writing of 3rd year medical students during the pediatric clerkship. CHRISMED J Health Res 2018;5:286-9
|How to cite this URL:|
Venkataramani P, Sadanandan T. Analysis of reflective writing of 3rd year medical students during the pediatric clerkship. CHRISMED J Health Res [serial online] 2018 [cited 2018 Dec 10];5:286-9. Available from: http://www.cjhr.org/text.asp?2018/5/4/286/245457
| Introduction|| |
In Latin, the reflection means “to bend” or “to turn back.” Peter Drucker opines, “Follow effective action with quiet reflection. From the quiet reflection will come, even more effective action.” There is increased emphasis on reflection in undergraduate and postgraduate health professions education. The process involves: a trigger (an event or situation) – thoughts are “turned back” – interpreted and analyzed – there is increased understanding or awareness – these insights are used in the future in similar events or situations. As Kolb believed that reflection is essential for learning, his experiential learning cycle which is an ongoing process included “concrete experience – reflection – abstract conceptualization – active experimentation – concrete experience.” Reflection, an essential aspect of lifelong learning, guided by mentors in a safe environment will become an integral part of the gradual process of building up experience. Reflection is a useful tool for learning, developing a therapeutic relationship with people seeking health care and their caregivers and to develop professional practice. Reflections are used to prepare health-care professionals of the 21st century to function in complex and changing health-care systems, to continuously update their knowledge and skills, for solving complex health-care problems. At present, our 3rd year students have to pass the examinations in all the clerkships; however, an overall, combined pass score in the theory and clinical examinations is adequate to proceed to the next year. Therefore, there is a tendency among our students toward rote learning with an emphasis on theory, neglecting acquisition of clinical skills. In Malaysia, graduates have to spend 4 months in pediatrics during the 2-year internship when they may be the point of first contact with sick children. Reflective writing was introduced to stimulate them to think about the clinical environment critically, which might motivate them to spend more time in the wards to acquire clinical skills.
| Methodology|| |
Weekly reflective writing was introduced, guided by discussions with mentors as part of the logbook, to 66 third year medical students during their 4-week, pediatric clerkship. On the 1st day, during the briefing about logbooks, students were introduced to Borton's model of reflection: they were asked to select an incident that affected them and describe what happened (students were advised to explain what happened), so what (they were advised to explain what they learned, after analyzing the situation) and what next (based on this experience, they were advised to make a plan for the future). They were expected to write weekly reflective reports on any significant event in the wards or classrooms. The importance of weekly meeting with their mentors for discussions and feedback was stressed. During the 4 weeks, students were expected to meet their mentors once a week. Reflective writing was not used as an assessment tool. All the logbooks of students in the first three rotations were included. As it was not a research study, ethical approval and informed consent were not sought. Each rotation had 22 students (a total of 66 students in the first three rotations) and 4 full-time lecturers; 5–6 students (mentees) were assigned to one lecturer. The mentees were expected to meet the mentors at the end of each week, and the mentors were expected to discuss the reflections with the mentees, guide them in refining the reflections and respond to their queries. Rubrics were not used to assess the reflections. Content analysis of the reports was done using free listing. Codes and themes were identified.
| Results and Discussion|| |
This is a descriptive, qualitative report of the analysis of these reflective writings. Sixty-six logbooks from 49 female and 17 male students, majority of them Malays, were analyzed. Overall 37.9% (38.7% of females and 35.3% of males) did not write any reflections. Not all the mentors met their mentees regularly or guided them on reflections. One of the lecturers with training in medical education had regular meetings with 27 students once a week and these students wrote 92 reflections of an expected total of 108 reflections. Only one student did not submit all the four reflections for the clerkship and one had submitted three reflections instead of four. The same mentor had to take on two more groups of mentees as two lecturers were on leave during the third rotation. Three other lecturers with limited training in medical education and reflections met 39 students who submitted 34 reflections of an expected total of 156 reflections. Fifty-four weekly reflections were not written even though the students met the mentors and obtained signatures in their logbooks for the meetings; 81 meetings did not take place and no signatures were obtained from the mentors for the weekly activities of the students. This illustrates the importance of faculty development before the launch of any innovations in teaching-learning activities.
The reflections were coded, from which emerged four themes [Table 1]: those related to children and caregivers (120), learning (62), motivation, (9), and miscellaneous (4). Some reflections had more than one theme.
Pediatricians may not realize that the students' first experience in the pediatric wards may be disconcerting and that students may find it challenging to establish rapport with unwell children. Descriptions of students related to children and caregivers included: their first experience with children in pediatric wards; the challenges in establishing rapport with children; how happy they were to see friendly children; how they were inspired by the courage of parents; consoling a crying child; feelings of empathy for parents with chronically ill children; they were upset (when children cried during procedures done without sedation, observing resuscitation; by poverty); bad experiences of parents in clinics outside; bad experience of the children in the wards (repeated poking to start an infusion – wanted to be more skillful; history of disabled children being bullied); seeing children with Down syndrome; poor family dynamics (mother not allowed by mother-in-law to breastfeed her child;); being scared when children had seizures; bad experience of parents in the wards; comments on parents' reactions to their children; exploration of understanding of young parents, observations of parents, children, and doctors; helping parents when child vomited or by giving oral rehydration solution; advising and consoling parents; advising parents who did not want immunization; doctors and nurses not advising properly; death of a child broke their heart; wondering if mother would be upset if they wore gloves to examine a child with skin lesions; and that they were saddened by poverty. Pediatricians may not anticipate the impact of a ward full of crying, sick and dying children on students, many from the lower socioeconomic background, during their first pediatric clerkship. The reflections of students could serve as an eye opener, help us to understand their concerns, counsel them, and treat them with empathy.
In an analysis of reflections of the final year medical students in their portfolios, Ann-Christin Haffling et al. found an emphasis on affective issues, particularly on self-awareness of feelings, attitudes, and concerns though not exactly the same, these appear to be similar to the concerns of our students. While their students were able to write reflections of 250–500 words, our students were not proficient in language to do so and wrote brief reports. Using the local language may help them to express their thoughts in greater depth and detail.
Reflections related to learning included: those on presentations by students, listing of skills learned without reflecting and short case practice before assessment week; stating it was examination week; learning from house officers in the ward; wanting to use what was taught to parents, in their practice later; appreciation of mother's help during examination; and disappointment when parent refused examination or when child got discharged and had to clerk again.
By spending adequate time in the wards, the students could learn from junior doctors, nurses, therapists, and even when parents are given health education or counseling by senior doctors. They also learn that a mother could be so tired as to resist being clerked, and they should respect and understand her; that in any health-care facility, the children and their caregivers are the most important people though in the college, students may be considered most important.
Reflections related to motivation included: role models in class and in the hospital – doctors and nurses; social service in wards by others using “star wars” theme; motivation to be good doctors on hearing parents' bad experience and by the skill of ward doctor. This reiterates the importance of role models; reflections reveal the hidden curriculum to the facilitators.
Reflections related to miscellaneous topics included: how fortunate they were compared to the sick children; reinforcement of faith in God. The importance of physical and spiritual well-being appears to have been reinforced to the students.
Stark et al used guided reflection related to professionalism with the help of seven questions for the 1st year students whereas we have used an open method requesting students to identify any critical incident that caught their attention.
To avoid plagiarism, the students were met in groups though counselled separately; the topics used for reflections were discussed by the mentors to look for similarities. However, sometimes when students were in the ward as a group, they did see similar problems and reflected on them.
| Conclusions|| |
Advantages of reflections to students: it helped them to be more aware of what is going on in the wards, address troubling issues by discussion with their mentors, discuss issues not included in routine teaching, understand challenges faced by parents, their children, and the practicing doctors; it motivated them to be better doctors, to improve their knowledge and skills and to improve their soft skills (empathy and communication). Studying the reflection of students helped mentors to gain an insight into students' perspectives and concerns; reflect on the adequacy of their role as facilitators; improved their rapport with mentees with regular meetings; and helped in the submission of proper reflective reports.
Regular mentee meetings and discussions are required for meaningful reflective reports; unless the mentors met the students regularly and guided them, students did not submit their reflections. Language posed difficulties in expression to the students.
Organization of a more intensive faculty development program is being considered. Introduction of eportfolios to document clinical skills with regular, guided reflections with assessment, after faculty development program in eportfolios, studying the facilitating factors and barriers and feedback from students would be the next step.
Take home message
Early introduction of reflective writing, despite its challenges, is a rewarding experience to the learner and mentor, if implemented appropriately. Faculty development is key to the success of this endeavor.
The authors would like to thank AP Dr M. Hadhrami M. Hussain, Head of Department for his support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sandars J. The use of reflection in medical education: AMEE guide no 44. Med Teach 2009;31:685-95.
McClure P. Making Practice-Based Learning Work-Reflection on Practice A resource Commissioned by the Making Practice Based Learning Work Project, an Educational Development Project Funded through FDTL Phase 4 Project Number 174/02 and Produced by Staff from the University of Ulster. Available from: http://www.practicebasedlearning.org
. [Last accessed on 2017 Aug 07].
Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: A systematic review. Adv Health Sci Educ Theory Pract 2009;14:595-621.
Haffling AC, Beckman A, Pahlmblad A, Edgren G. Students' reflections in a portfolio pilot: Highlighting professional issues. Med Teach 2010;32:e532-40.
Stark P, Roberts C, Newble D, Bax N. Discovering professionalism through guided reflection. Med Teach 2006;28:e25-31.
Chaffey LJ, de Leeuw EJ, Finnigan GA. Facilitating students' reflective practice in a medical course: Literature review. Educ Health (Abingdon) 2012;25:198-203.