Medical EducationBegin the BEGAN (The Brown Educational Guide to the Analysis of Narrative) – A framework for enhancing educational impact of faculty feedback to students’ reflective writing
Introduction
The surge of interest in medical professionalism [1] has challenged medical educators to develop innovative curricula as well as new types of evaluations addressing fundamental constructs such as empathy [2], moral development [3] and humanistic attitudes [1], [2], [3], [4]. In parallel, competency-based educational imperatives within undergraduate and graduate medical education (ACGME) have included professionalism as a core competency [5] with reflective learning highlighted as key to professional development [6]. Reflective capacity, defined as critical analysis of knowledge and experience to achieve deeper meaning and understanding [7], guides future behavior [8], and is deemed an essential characteristic of professionally competent clinical practice [9]. However, as activities to promote reflective competence are increasingly incorporated into health professionals’ instruction, evidence of its contribution remains largely theoretical [7]. Professionalism and reflective competence can be elusive and challenging parameters to define or measure within traditional instructional and assessment paradigms [10].
Narrative medicine [11] initiatives within medical education, including both the reading of literature and writing, have emerged in response to such challenges. The strengthening of narrative competence, it is posited, can help boost professionalism and guide clinical practice by helping practitioners understand patients’ experience of illness and what they themselves undergo in caring for patients [12]. Such endeavors aim to facilitate clinical practice informed by mindfulness [13], self-awareness [14], self-knowledge, and reflective and empathic competence [15]. Implementation strategies for the promulgation of such competencies include instruction in reflective writing [16], [17], [18] and assessment of portfolios [19].
Reflective writing as a means of supporting the development of reflective capacity is valued across various health professions including dentistry [20] and nursing [18], as well as in law [20] and the military [20]. Within the medical profession, reflective writing has been proposed as a powerful platform for personal and professional development within all three strata of the physician's professional life cycle: undergraduate, graduate, and continuing medical education [21]. Reflective writing has been applied toward teaching moments/opportunities [22], physician well-being, i.e. emotional equilibrium, self-healing, and building community [23], and enhancing reflective practice [16], [24]. Examples are increasingly evident in the medical literature, with greater ease of accessibility now available with Pub Med's addition of narration to its MeSH vocabulary, with the entry terms narrative medicine and narrative ethics in 2003 [25]. For Baldwin [6], professionalism is a state attained through a process of “action, reflection and formation”, resulting from both inner and outer experiences. Professionalism is described as a developmental process, attained gradually, if at all, and not achieved simply by doing [6]. However, the developmental trajectory through which learners elaborate personal experiences during medical training is not clearly defined [26], and directives for the evaluation and practice of professionalism, including reflective capacity [7] remain in flux.
Medical school and residency program curricular reforms [27] have recently targeted promotion of professionalism, including enhancement of reflective capacity, within their pedagogy. In line with this, our institution, the Warren Alpert Medical School of Brown University (Alpert Med), instituted a Doctoring course for first and second year students in 2005–2006 to socialize learners to the professional role of the physician, ensure mastery of clinical skills, and offer early clinical exposure. These activities were accompanied by reflective writing assignments, termed “field notes” as an integral component [28]. The novel educational approach of combining students’ reflective writing with ongoing individualized feedback from small group faculty and students’ perceptions of educational benefits of such a paradigm have been described [29], [30]. While the literature is replete with reports of reflective writing exercises in medical education [31], [32], the provision of structured, ongoing faculty feedback to such narratives is the exception.
Various methods of assessing level of reflection in reflective writing, both qualitative and quantitative have been reported including a multi-method approach [33], thematic or coding schemata for levels of reflection [18], elements of reflection coding instrument [34], and a modified Bloom's taxonomy [35]. Quantitative approaches include application of five different reflection scales [36] and the GRAS [Groningen Reflection Ability Scale] scale of reflection [37]. Mann et al. [7] assert that reflection measurement is at an early stage of development and qualitative and exploratory research approaches are appropriate to use toward achieving deeper understanding of this essential construct. These considerations have informed our research and assisted with both the focus and refinement of our efforts.
We report here on the development of a method to further enhance the educational benefit of the reflective writing/guided feedback experience, i.e. a framework for analysis of students’ reflective writing that informs the skillful crafting of feedback.
Section snippets
Context
Doctoring is a 2-year, pre-clinical, required course at Alpert Med. The course structure involves large group didactic sessions, small group processing and skill instruction, as well as community-based physician mentoring and skill practice. Students are assigned in groups of eight to a faculty team comprised of a physician and a social-behavioral scientist, and individually to community-based mentors. Small group faculty facilitate student exploration of curriculum topics (such as
Methods
The development of this tool involved a rigorous 3-year iterative process with multiple stages of immersion, analysis, and revision that resulted in the Brown Educational Guide to Analysis of Narrative (BEGAN). The process was informed by the narrative medicine, qualitative research, and education literature, as well as insights from field note analyses using the emerging model. Formal IRB approval was obtained. Informed consent of all students whose field notes were utilized for the research
Results
This research endeavor culminated in the BEGAN framework, a guide for crafting feedback to students’ reflective writing. Detailed descriptions of the BEGAN framework and its application to one representative field note as well as its integration within the Doctoring course in 2008 at Alpert Med are provided (Table 1, Table 2, Table 3, Table 4).
Discussion
This article describes the rigorous process of developing the Brown Educational Guide to the Analysis of Narrative (BEGAN) within the Alpert Med Doctoring course, a framework for both analyzing and crafting feedback to student reflective writing. The implementation of this framework within this interactive process (students’ writing-faculty feedback) is proposed as a means of fostering reflective capacity; serving as a concrete tool for faculty use. In our discussion of this innovation, we
Acknowledgements
The authors wish to acknowledge Prof. R. Charon of Columbia University College of Physicians and Surgeons Program in Narrative Medicine for her inspiration and counsel. The authors wish to acknowledge J.L. Godwin for the use of his field note.
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