CRITICAL REFLECTION - APPD€¦ · Promoting Critical Reflection and Using Feedback to Stimulate Reflective Capacity APPD March 28, 2012 Lavjay Butani, MD Michele Long, MD Objectives

CRITICAL REFLECTION APPD 2012

Lavjay Butani, MD and Michele Long, MD

PRESENTATION from workshop

CRITICAL REFLECTION EVALUATION Template

CRITICAL REFLECTION FEEDBACK Template

NARRATIVES o Large Group o Small Group o Extra Narratives A and B o Suggested Evaluation: Small Group Narrative, Narrative A, Narrative B o Suggested Feedback: Small Group Narrative, Narrative A, Narrative B

SELECTED ANNOTATED BIBLIOGRAPHY

Lavjay Butani, MD [email protected] Michele Long, MD [email protected]

Promoting Critical Reflection Promoting Critical Reflection and Using Feedback to and Using Feedback to Stimulate Reflective CapacityStimulate Reflective Capacity

APPD March 28, 2012

Lavjay Butani, MDMichele Long, MD

Objectives Objectives

1. Discuss how 'critical reflection' differs from 'reflection'

2. Analyze reflective writings to assess depth of reflective capacity

3. Promote the value of giving formative feedback to enhance reflective capacity

4. List ways to incorporate reflection at your own institutions

‘‘ReflectionReflection’’ in an educational context in an educational context is differentis different

‘turning back’ thoughts for analysis and

interpretation

‘sense making’

PROFESSIONALISM

ETHICAL AND LEGAL KNOWLEDGE

COMMUNICATION SKILLS

CLINICAL COMPETENCE

EX

CE

LL

EN

CE

HU

MA

NIS

M

AL

TR

UIS

M

AC

CO

UN

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BIL

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Arnold L, Stern DT: Measuring Medical Professionalism, Oxford Univ Press2006

FOCUS ENGAGEMENT PERSPECTIVES MOTION

No problem(Overgeneralization)

↓↓↓↓

Rich, specific learning

focus/conflict

Distant,Intellectualized,

indifferent

↓↓↓↓

Deep personalstruggle,

Full engagement

Singular, narrow

↓↓↓↓

Multiple perspectives

No action plan

↓↓↓↓

Commitment to growth,

New perspective

Progression of reflective capacityProgression of reflective capacity



↓↓↓↓


focus/conflict


indifferent

↓↓↓↓


Full engagement

Singular, narrow

↓↓↓↓


No action plan

↓↓↓↓


New perspective

Progression of reflective capacityProgression of reflective capacity

CRITICAL

Critical reflectionCritical reflection

•Analysis & reframing of experience•Goal of understanding experience & own value systems•Multiple perspectives•Commitment to growth



↓↓↓↓


focus/conflict


indifferent

↓↓↓↓


Full engagement

Singular, narrow

↓↓↓↓


No action plan

↓↓↓↓


New perspective

Large Group Activity:Large Group Activity:Evaluating Learner ReflectionsEvaluating Learner Reflections

•Variable depth of reflection•Goals

•Build emotional resilience•Validate experiences & feelings of uncertainty, value conflict

•Intellectual ‘stretching’•generalize ‘specific’ to ‘global’ learning

Giving Feedback Giving Feedback -- the the ‘‘whywhy’’

Critical reflection and diagnostic Critical reflection and diagnostic accuracyaccuracynot just fluffnot just fluff

Shouldn’t we stop to consider our options?

Why bother? Everything’s going fine.

Mamede et al, Medical Education, 2008Mamede et al, Medical Education, 2008

Giving FeedbackGiving Feedback-- the the ‘‘howhow’’FOCUS ENGAGEMENT PERSPECTIVES MOTION

Ask for more description

What is the specific conflict?

What was done or said?

Ask reason for choosing focus

What about the experience affects YOU in particular?

What prior experiences give this focus particular meaning to you?

Ask if all perspectives were

explored

Who else may have been affected?

Did you explore for a possible solution in the literature?

Assess what was learned, application to

future

Has this experience changed how you think?

How are you going to be able to use this information in the future?

How will you maintain commitment when faced with value conflicts?

“thanks for sharing that beautiful and painful story...

your story brings out, so poignantly, why culturally responsive care is important,

especially in today's diverse world. Every person is unique and rather than stereotyping people, it is our obligation and duty, to listen, empathize

and develop shared plans based, not on our goals and wishes, but those of the family. …“

“I was wondering if you could comment on one thing-in your writings, I see very frequent

mention of 'quality of life.' How does one make a judgment (and know one is making the right judgment) in presuming to know what 'quality

of life' would result from a hypothetical intervention, especially in a child (let alone a

developmentally delayed one) who has no real 'voice' or ability to effectively understand the

complexities of such situations and share his/her perspective? How would you approach

such an event?”

Thank you for asking this question; I have actually been wrestling with the definition of “quality of life” for quite a while now because it comes up in many ethical conversations. I’ve decided that defining “quality of life” depends entirely on the individual,

the family and the situation. This is why communication is so powerful in these ethically and emotionally charged scenarios. Communication with the patient and their family is the only way we can understand their “quality of life” because inevitably it is

different for every person. Such communication becomes impossible when the patient is not capable of conversing, as in Dr. XXX’s story, and as is true for many pediatric patients. In these cases, the parents are the legal medical decision makers and

their decisions are recognized and supported by most ethics committees and legal systems (unless there is suspicion of mistreatment or neglect).

As far as predicting how the “quality of life” will be affected by a hypothetical intervention – I think in every field of medicine we will face this predicament. All interventions are supposed to better the life of the patient, or else why would we propose them? But again, that’s where defining “quality of life” becomes vital. Once the wishes and goals of the patient are determined, the

conversation of the risks and benefits can begin. In every situation, as healthcare providers, we will need to discuss all possible outcomes of our proposed interventions, and the patient, or legal medical decision maker, will need to weigh the risks and

benefits to make a decision.

In conclusion, (although I know I will continue to think about this concept throughout my career and undoubtedly change my ideas), I believe that communication is the key. It’s difficult to ever be sure that your judgment or your decision to move forward

in a certain way is appropriate, or the right way, but again, it all depends on the situation and the people involved. These situations are complex and often multilayered, and to commit to a single approach would be naïve. As I struggle with the

question of how to approach such ethically complex situations, I at least know that I will always start with a conversation. I will always begin by determining the wishes and goals of the patients and their families, just as Dr. XXX did. And I will allow those

sensitive conversations to help guide my care for that family.

Learner responseLearner response

““I have actually been wrestling with the definition of “quality of life” for quite a while now …… I’ve decided that defining ‘quality of life’ depends entirely on the individual, the family and the

situation.””












“It’s difficult to ever be sure that your judgment or your decision to move forward in a certain way is appropriate…. situations are complex and often multilayered, and to commit to a single approach

would be naïve. ”












“..know that I will always start with a conversation. I will always begin by determining the wishes and goals of the patients and their

families..”

Small Group Activity:Small Group Activity:Evaluating, Articulating FeedbackEvaluating, Articulating Feedback

Hmmmm….now how can I incorporate reflection in my setting?

ThinkThink--pair sharepair share Objectives Objectives have we been successful?have we been successful?

1. Discuss how 'critical reflection' differs from 'reflection'

2. Promote the value of giving formative feedback to enhance reflective capacity

3. Analyze reflective writings to assess depth of reflective capacity

4. List ways to incorporate reflection at your own institutions

CRITICAL REFLECTION EVALUATION TEMPLATE*

* Based on (1) Wald et al: Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med Jan 2012 and (2) Devlin et al: Clerkship‐based Reflective Writing: A Rubric for Feedback. Med Educ Oct 2010.

Step 1‐ Read the entire narrative.

Step 2‐ Assess reflection for presence of each; identify (may include actual examples from text) Consider these elements of critical reflection: FOCUS, ENGAGEMENT, PERSPECTIVES, MOTION

The critical reflector develops and defines a rich, specific area of FOCUS. (S)he demonstrates ENGAGEMENT via self‐

immersion and by exploring the personal struggle that (s)he, as an individual, has with that conflict/focus area. The

critical reflector engages in comparative viewpoint analysis via exploration of alternate PERSPECTIVES on the focus area.

Finally, (s)he emerges with a plan for MOTION in future situations/a deepened commitment to growth/transformation.

FOCUS: (Consider tying into the Professionalism Pillars: Altruism, Accountability, Excellence, Humanism)

ENGAGEMENT: PERSPECTIVES: MOTION:

Step 3‐ Assess reflection for each of 4 Dimensions, ranking “Degree of Reflection” for each element (circle arrow)

LEVEL

Defines Conflict/ FOCUS

Personal ENGAGEMENT

Comparative PERSPECTIVES

Change or Future Plan MOTION

Habitual action (Non‐reflective)

Thoughtful Action

Reflection

Critical Reflection

No problem or question [Overgeneralization]

↓ ↓ ↓ ↓

Rich, specific learning focus or conflict

Distant, intellectualized,

indifferent

↓ ↓ ↓ ↓

Deep personal struggle,

full engagement

No alternate views; Singular, narrow

↓ ↓ ↓

↓

Multiple, meta‐perspective self‐reflective

No mobilization or reconsideration of

perspective, no future plan

↓ ↓ ↓ ↓

Change or deepening, commitment to growth,

new perspective

CRITICAL REFLECTION FEEDBACK TEMPLATE*

* Based on (1) Wald et al: Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med 2009 and (2) Wald et al: Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med Jan 2012 and (3) Devlin et al: Clerkship‐based Reflective Writing: A Rubric for Feedback. Med Educ Oct 2010.

GOAL: Craft feedback that both (1) builds emotional resilience and (2) promotes intellectual ‘stretching’ VALIDATION of student’s emotional responses/current reflective capacity to build emotional resilience

PROBING: Identification of 1‐2 specific areas to promote intellectual ‘stretching’ (See Table) with specific reference to the reflection

Ask probing question(s)

Tell: Provide perspective on why question(s) important

Ask: Readdress probing questions

VALIDATION: Reinforcement, support for strength in future encounters

VALIDATION suggestions

Offer comments such as, “I’ve been there. I know what you mean.” “It can be difficult being challenged in such a way.” Share how you, the reader, were impacted by the writing/how you were affected. Offer support for abilities e.g. the strength required to be open to different perspectives, risks taken in self‐analysis/self‐reflection. Support emotional response/ courage to confront difficult, challenging issues. Support emotions of fear, disappointment, optimism. (Consider) Share personal, professional experiences. (Consider, at end) Challenge with a different perspective [Devil’s advocate] Reiterate that as life‐long learners, we will continue to be challenged which will help us improve and grow.

PROBING/STRETCHING questions

Conflict/ FOCUS

Personal ENGAGEMENT

Comparative PERSPECTIVES

Change/ Future Plan/ Transformation: MOTION

Theme Questions

Ask for more description of event and more detail: What is the specific conflict? What was done or said?

Ask reasons for choosing focus; how learner was impacted or affected by the experience: What about the experience affects YOU in particular? WHY do you think this affected you? What prior experiences give this focus particular meaning to you?

Ask if all perspectives, including learner’s own were explored, if all relevant perspectives were included, if they differed and in what way: What did all involved in /affected by the situations think? Who else may have been affected? Was evidence‐based perspective sought (literature, etc.)?

Assess what was learned and if will have application to future, if learner’s established assumptions were confirmed or transformed: Has this experience changed how you think? In what way and why? How are you going to be able to use this information in your life and future interactions? In what way and Why? How will you maintain commitment to transformation when faced with value conflicts?

CRITICAL REFLECTION FEEDBACK TEMPLATE*

* Based on (1) Wald et al: Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med 2009 and (2) Wald et al: Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med Jan 2012 and (3) Devlin et al: Clerkship‐based Reflective Writing: A Rubric for Feedback. Med Educ Oct 2010.

VALIDATION ideas PROBING/STRETCHING questions for area #1: PROBING/STRETCHING questions for area #2:

NARRATIVE (LARGE GROUP) Prompt

APPRECIATIVE INQUIRY ASSIGNMENT PART ONE: Interview a faculty member, summarize the response in a <1 page write up “SUMMARY”. Include specific reasons/examples why you chose this particular person as the interviewee. Pose one of the following questions: “Tell me about a time when you [or another physician]:

went the extra mile to help a patient.” followed the highest standards of behavior and refused to violate his/her personal and/or professional code.” Felt most involved in, most excited about, or most satisfied with your practice of medicine.”

“Tell me a story about something(s) you value deeply—specifically about (1) yourself, or (2) the nature of your work” “Describe a physician who seems to carry their responsibilities towards patients easily and freely commit to serving patients or others without feeling burdened.” PART TWO: Write a 1 page REFLECTION narrating a) how you felt about this experience b) what this story taught you about being professional and c) how you plan on changing/adapting your approach or attitude as a result of this experience

Summary

A Ukrainian couple and their 4-month old daughter presented for medical care. The 4 month-old girl had multiple anomalies including microcephaly, cardiac, skeletal, genitourinary malformations, gastroesophageal reflux and recurrent urinary tract infections; a constellation of features that mimicked Cornelia de Lange syndrome. The Ukrainian medical system had given up on this little girl; they claimed that she would most likely not survive her first few months of life. Four months later, the family came to the US for a second opinion. To make the situation more complex, the father of this girl died in a car accident a few months after seeking care in the US. Already overwhelmed with the health of her daughter, and now the recent death of her husband, the mother was left alone. Around 7 months of age, the littler girl experienced another urinary tract infection. Tubes were placed to help the little girl feed, antibiotics started and a surgical procedure was suggested to correct the genitourinary anomalies. At this point Dr. XXX was involved with this little girl’s care and felt there was something missing.

With the help of a translator, Dr. XXX asked the mother about her concerns and more importantly about her goals for her daughter. She explained that the surgery would not heal the underlying syndrome and that this little girl would still be vulnerable to a life in and out of the hospital. After much discussion the mother decided the surgical procedure was not what she wanted for her daughter; she did not want to put her daughter through such suffering if inevitably it would not improve the quality of her life. Dr. XXX, deep down, agreed.

To check herself professionally, Dr. XXX called the ethics committee. The committee held meetings for three days and eventually decided that even though medical interventions would possibly prolong the child’s life, the mother’s concerns were grounded in sincere love for her child and it was appropriate to follow through with her wishes to refuse the surgery.

Dr. XXX also attempted to have a DNR and DNI discussion with the mother at that time, but the mother was not ready. After the most recent UTI had resolved, the mother and child followed up with her primary physician. Here, the mother initiated the DNI and DNR conversation herself and a few months later the little girl passed away.

NARRATIVE (LARGE GROUP) Reflection

This little girl’s story is not an example of how westernized medicine beat a once hopeless diagnosis. Instead it is a demonstration of how heroic a simple conversation can be. Dr. XXX’s physical, mental and emotional exhaustion after this encounter proved that she went the extra mile for this family. There were multiple challenges, concerns, cultures, ethics and philosophies to juggle, but she took time to address the mother’s wishes, to consult the ethics committee and to focus the care on the quality of this little girl’s life. She now realizes that sometimes such a conversation is more valuable and more meaningful than any medical procedure or intervention.

Dr. XXX seemed a little tentative at first; she wondered if her story was a true example of “going the extra mile” for her patient. I believe it is a perfect example. Her story demonstrates the balance we, as healthcare providers, must struggle to find. We must balance our expert knowledge, our newest technologies, our advanced surgeries and complex treatment regiments, with our patients’ wishes and goals. Although we have so much to offer, medically, we also have so much to learn. Speaking with Dr. XXX about her little Ukrainian patient, made me realize that sometimes our voice and our ability to listen allows us to know our patients better than any blood test or physical exam ever will.

Dr. XXX’s story was complex; it combined pediatric ethics, end of life care, palliation, and quality of life with an unfamiliar culture, language and family dynamic. These complexities made communication even more vital. In our Ukrainian girl’s case, the direct and honest communication initiated with the mother changed the end of this little girl’s life. She was spared the trauma of major reconstructive surgery, weeks of recovery and possible nosocomial infections. The surgery probably could have prevented or at least decreased the frequency of her urinary tract infections, and maybe it would have prolonged life, but she would have inevitably spent time in the hospital for other reasons and other complications.

This controversy of fixing and curing versus palliate, is something I know I will encounter over and over again in my practice. As a medical student, we are constantly overwhelmed with disease processes, pathophysiologies and how to manage and treat such conditions, but we often forget the patient goals and wishes. What if the treatments are worse than the disease? What if the treatments will prolong the life, but not improve it? What if the treatments are available but are futile? What if the patient just can’t handle it anymore? These questions are difficult; they are heavy. They elicit internal struggle and challenge our ethical foundations. But, more importantly, these questions are real and they cannot be avoided. Sometimes we will need to address them, consider them and help the family decide how best to move forward.

Dr. XXX may not realize how much her story inspired me. She reminded me that even when we may feel powerless as physicians, even when a disease process is not giving in to our treatments, we still always have our voice. Dr. XXX’s conversation with the mother turned her life around. I suspect that hopelessness was overwhelming the mother and her thoughts. Dr. XXX was able to offer another solution. We can’t even imagine being in that mother’s shoes; having to make that decision, having to realize that there is nothing that will improve the quality of this little girl’s life. Even as I sit here and write this, I feel sad for that mother, but also happy that Dr. XXX was able to help her through such a difficult time. It’s powerful, communication, and it’s something we often overlook. I will never underestimate my voice and I will never underestimate the importance of asking a patient what their goals and wishes are. Thank you Dr. XXX for sharing your story.

NARRATIVE (SMALL GROUP)

Summary I had the privilege sitting down with Dr. C to discuss his views on some ethical issues I have

both valued and struggled with in the past. I asked Dr. C to “tell me about a time a physician who followed the highest standards of behavior and refused to violate his/her personal and/or professional code.” He struggled with finding an appropriate example, so I expressed that my reasoning for asking this particular question was rooted in having instances in my own life prior to medicine where “doing the right thing” had put me in harms way. I was curious how he would deal with such situations in medicine. I clarified the details of my story upon his request explaining how I had a call when I was an EMT where my partner was accused of providing inappropriate patient care and management was threatening to fire him. I spent some time researching the problem and spent several hours later proving to my employers that my partner’s actions were in fact justified by both county guidelines and supported by research. Challenging management was not an accepted practice, as this company had a very hierarchical structure that suppressed dissent from employees, and could have hindered my work life there.

Dr. C, now understanding the context of my question proceeded to give me several examples of what he called “clinical grey areas,” where practitioners had to make challenging decisions despite incurring possible consequences to themselves. First he discussed a former psychiatry colleague who happened to have an actress for a girlfriend. His girlfriend referred all of her top flight actor and actress colleagues to him. The caveat was he would have to make house calls to their extravagant mansions to discuss intimate details of these stars broken lives. He found the juxtaposition of immaculate, gorgeous, well kept homes with patients whose lives were anything but to be an extreme obstacle in caring for these patients. Too many of his patients’ chagrin (ultimately losing some of their business), he insisted his patients meet him at his small, quaint office downtown. Although losing some of his client base and irritating many patients who were used to being catered to, he insisted they respect his decision for them to receive the best care he knew how to provide.

The story that resonated with me most was Dr. C’s personal struggle and ultimate decision to leave the academic medicine setting. He was once the IOR for the psychiatry rotation, ran academic inpatient/outpatient services, and loved it for many years. He enjoyed teaching students and specifically focusing on skills that would be pertinent to students going into any field. He was, however, “disenchanted” by his colleagues’ overutilization of pharmacological management as first line treatment instead of developing relationships with patients to address the root of their problems. He expressed this openly to colleagues while still finding ways to give patients the best care he knew how. There were many disagreements in teaching ideology over the years with “higher ups.” I asked him to specifically describe how he dealt with these disagreements, in which he explained he was particularly forward with his ideas, complaints, and irritations with methodology, but always found respectful ways to do this “within the system” confines. After years of this work and a trial at running the Doctoring course, he was frustrated with three limitations of the system that made his work particularly difficult and made him unable to provide the educational opportunities he felt most relevant to students: 1. Not enough people involved 2. Not enough money and 3. Not committed to relationship treatment methods. After years of work in the academic setting, he decided to provide the care he felt patients responded to best by becoming a private practice psychiatrist. As he left, he was particularly vocal about changes he felt that needed to happen in order for patients and students to receive the best possible service from the academic staff. This provided an example of times when despite his best efforts there are some obstacles and settings in which you have to leave to put your energy into something you find will be more fulfilling and useful for both yourself as a person and clinician and your patients and students.

NARRATIVE (SMALL GROUP)

Reflection

The appreciative inquiry assignment gave me an excellent excuse to snag one of my mentors for an hour session, picking his brain on a valuable topic – sticking to your moral/professional/personal guns. I was very thankful to have this opportunity and felt I could glean some useful information as I fine tune my professional moral compass. Dr. C has been my doctoring facilitator for the last two years. I have learned he is excellent at stripping problems to their most basic unit, picking up on nearly imperceptible body language, teaching students how to step-wise build these skills of understanding and perception honing them to best care for patients, and using strategically chosen language to express minority opinions in groups. I am incredibly thankful to have learned from these skills and I believe they all show through in each example he discussed during the AI assignment. The stories Dr. C told all taught a common message, major internal conflicts in medicine arise when your view of how to best to care for a patient does not match the reality of the situation. This was true in the conflict with the psychiatrist struggling to care for actors in their homes, and Dr. C both dealing with “excess medical care” with the wealthy woman and leaving academic medicine. Identifying these problems and acknowledging that there are some instances when your ideal way of practicing will not match what you are actually doing is the first step to making a change. There were also a set of skills used by Dr. C to best address these times. The first skill is choosing language in times of conflict very carefully. When I probed deeper into how Dr. C dealt with academic medicines approach not meeting his personal goals, he often said he was outspoken about his opinions, but always argued within the constructs of the system. I believe what he is suggesting is there are effective language, timing, and negotiating skills that are necessary to encourage systems to better reflect your ideals of care. What Dr. C does very well is determining other people’s conflicting ideas on the subject, addressing them aloud with the group, and directly stating an alternative that either meets and exceeds the root issue or provides what he deems a better alternative and explains his reasoning. I will incorporate these skills of identifying problems, considering my language and timing, and identifying root conflicts and suggesting alternatives into my approach. I believe these skills will be particularly helpful with conflicts that arise between other medical practitioners and me. I have had issues with superiors outside of medicine that, if I had utilized these skills may have gone much more smoothly. Also keeping in mind the goal of adjusting the way things are run, I will better implement identifying people with different ideas or goals to better understand where our true conflicts lie to best address the crux of the problem. Additionally, I believe these skills will be very effective in the microcosm of a patient encounter, especially with those patients who seem quite difficult. It seems to me, if you can identify the root cause of their frustrations, addressing them with effective language and timing can make a world of difference.

Furthermore I learned the need for support and identified common ideals between teams of physicians. I am also developing a better sense of when to walk away from conflicts, spending energy on something more fruitful. Dr. C’s struggles to fight against treatment ideals exemplified how doing the right things by your patients and standing by your own ideals sometimes means giving up on one fight to begin anew is sometimes a viable, necessary option. I have a habit of fighting within the system even if the fight is futile. I hope to better recognize these situations when time and effort may be better spent on other avenues to practice by my own ideals of best caring for patients. And when struggles do exist, I will enlist the support of colleagues for support and guidance to identify areas of common ideals.

EXTRA NARRATIVES A and B

NARRATIVE A (Imani Clinic) Summary

“Tell me a story about a time when you felt most involved in, most excited about, or most satisfied with your practice in medicine.” Jennifer noted an opportunity not in the hospital, but in the Imani free clinic, a free clinic that attempts to serve the Black population of Sacramento. During her 1st year of medical school, she had volunteered at Imani free clinic many times, with her volunteer opportunities declining over time, due to less free weekend time. But she decided during her 4th year to volunteer with me at Imani for an afternoon. It was also my first time attending free clinic during medical school. That afternoon, we saw a good number of diverse patients and I was exposed to primary care for the first time. I shadowed her multiple times and seeing her comfort level with patients and preceptors inspired me to be that much better. I was forever changed that day. I mentioned this to Jennifer, and she said something shocking: that this was the most rewarding moment that she had had in medical school to this point. Jennifer had a very difficult time during medical school, experiencing many emotional tugs and pulls throughout the time. And for her to say that to me after all she had been through made me feel so connected with her on an entirely different level.

Reflection

Speaking to my role model is always an inspiring time. It gives me the motivation to continue through the rigors of third year. Talking with her about my first clinic experience helped me to remember that not all memories of medicine have to be negative. What this story taught me about being professional: I learned that in order to be a professional, it is a progressive process. Even with the heavily calculated plan medical school sets out for us, the time it takes for us to feel like we are medicine professionals varies with each person. It also showed me that perseverance is crucial in order to make it through all tough times. Jennifer always inspired me to do better as a medical student. She also taught me to live life to the fullest, even while being in medical school. How you plan on changing/adapting your approach or attitude as a result of this experience I’m not sure how much I plan on adjusting my approach. I do always try to incorporate Jennifer’s bedside manner with my patient encounters. I will attempt to allow this to be a more passive reflex. But otherwise, I will try to stick with what has been working since the third year of medical school has started, and that’s being empathetic to patients, and taking in as much knowledge as I can with each encounter.

EXTRA NARRATIVES A and B

NARRATIVE B (Dr. Verghese) Summary For this assignment I interviewed Dr. T, who works as a Pediatrician at KEG. He went to University of Wisconsin for medical school, and did his residency at Loma Linda. I have worked with Dr. T extensively for the past 3 weeks and he was happy to sit down with me to talk. I asked Dr. T the question “Tell me about a time when you witnessed a physician who followed the highest standards of behavior and refused to violate his/her personal code.” As it turns out, the weekend prior Dr. T had attended a meeting of KEG doctors where Dr. Abraham Verghese spoke. Dr. Verghese is the author of several popular books including the national bestseller Cutting for Stone. Dr. T told me the story of Dr. Verghese. He had completed medical school in his native Ethipoia and traveled to Tennessee for residency in Infectious Disease in the early 1980’s. It was during this time that the AIDS epidemic began to take hold. Apparently none of the pulmonologists working with Dr. Verghese agreed to take any AIDS patient for fear that they would somehow contract the virus themselves. This forced Dr. Verghese to go back to obtain a fellowship in pulmonology so that he would be qualified to handle the many respiratory complications of AIDS. Dr. T found this action to be of the highest standard and regards Dr. Verghese as an intensely brave man who is willing to make huge sacrifices for his patients, in this case giving up his practice to go back to training. Dr. T said he did not know of many doctors who would be willing to do this themselves, if any at all. Reflection

I interviewed Dr. T, one of my preceptors on my outpatient block for this assignment. He told me the story of Dr. Abraham Verghese, the author of Cutting for Stone. The story focused on the sacrifice Dr. Verghese made for the benefit of treating his patients. The theme of sacrifice is nothing new to medicine or medical education. Even the process of applying to medical school involves a lot of sacrifices. However, the sacrifice Dr. Verghese made was not to better himself, but to better the treatment of his patients at great personal cost. Not only did Dr. Vergehse give up his practice and attending physician’s salary, but he also divorced his wife during this time because they had grown so far apart. I don’t know anyone who would make that same decision. Sure, we all want to say will do anything to help our patients and tell ourselves we are so humble, but the truth is almost all of us would balk at such a choice. We would say things like “I am already helping my patients” or “I have a family to support.” I think Dr. T realized this and is why he expressed such admiration for Dr. Verghese and his choice. Something else we discussed, which is almost in stark contrast to the first point, is the need for physicians to take care of themselves. The concept that “a doctor cannot concurrently be a patient” came up, and was discussed in relation to Dr. Verghese. Both Dr. T and myself agreed that family is hugely important in our lives, and sacrificing family in pursuit of medicine is just not an option. A balance must be found where sufficient attention may be paid to both fields. This balancing point is different for everyone, and once one finds it, the real trick is maintaining it.

CRITICAL REFLECTION EVALUATIONS SMALL GROUP NARRATIVE (Dr. C)

LEVEL



Thoughtful Action

Reflection

Critical Reflection

No problem or question

↓ ↓ ↓ ↓


Distant, indifferent

↓ ↓ ↓ ↓

Deep personal struggle, full engagement

No alternate views

↓ ↓ ↓

↓ Multiple, meta‐perspective

No reconsideration of perspective, no future plan

↓ ↓ ↓ ↓

Change/transformation, commitment to growth

NARRATIVE A (Imani Clinic)

LEVEL



Thoughtful Action

Reflection

Critical Reflection


↓ ↓ ↓ ↓



↓ ↓ ↓ ↓


No alternate views

↓ ↓ ↓



↓ ↓ ↓ ↓


NARRATIVE B (Dr. Verghese)

LEVEL



Thoughtful Action

Reflection

Critical Reflection


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FEEDBACK SUGGESTIONS: SMALL GROUP NARRATIVE, NARRATIVE A, NARRATIVE B SMALL GROUP NARRATIVE (Dr. C): (Validation and personal connection) Thanks you for that very powerful and insightful reflection....your stories bring to mind 2 aspects of professionalism - humanism (including respect-towards everyone) and accountability (to society, to patients and to the profession). Your discussion regarding negotiation strategies and techniques and conflict management styles also resonated with me; being an intuitive personality type, I love theoretical models and try to fit life into such models. One such model that I like a lot is the Nyquist-Lattore Diamond model of leadership (I've attached 2 diagrams showing the model) that talks about how to move from one's 'current state' to one's 'future vision'- using skills (the doing part of things) and values (the being part of things)-both existing skills and values and developing new skills and values. In the center of the 'diamond' are the forces of 'love-trust' and 'fear-courage.' Trust refers to trusting yourself and the 'system' and also developing relationships such that others trust in you. If however, in spite of one's efforts, the system doesn't respect us or we feel that we can no longer trust the system nor embrace (love) it, it is best to move on, much like Dr C did. I did have two questions for you, though (Area of feedback –Comparative perspective) 1) you yourself acknowledge that people can have differences of opinion in how best to address issues/treat patients (including patients themselves). How does one know when differences are more a 'stylistic' issue, or true differences in opinion knowing how nebulous the medical literature can be on so many things, and when they should be of 'concern' to us to make us want to speak out? After all, in today's era, there is so much 'knowledge' out there, isn't it possible that others know more about something..perhaps even more than us? And that our reaction may be more ego-based? & 2) what professional 'value' did the psychiatrist who refused to go to the homes of the rich uphold? Aren't house calls the wave of the future, and a way to become more patient centered? Shouldn't we try to empower our patients and families and so if they feel more comfortable in their own homes, what harm in that? What is this was a poor woman? Would that make a difference? Why? Would love to hear your thoughts on these…. Take care

FEEDBACK SUGGESTIONS: SMALL GROUP NARRATIVE, NARRATIVE A, NARRATIVE B NARRATIVE A (Imani Clinic): (Validation) Thanks for sharing your reflection..as I read your reflection, I am reminded of one of the 4 main pillars of 'professionalism' that you have highlighted, that of 'accountability'-towards society, patients and the health care profession as a whole-by serving those who are in need, without a profit consideration. The volunteer clinics serve just that purpose and are a perfect example of how the profession can and should give back to the community. The other 3 pillars are altruism (putting others' needs ahead of ours), humanism and excellence/competence (including an attitude of life long learning and maintenance of competence). (Area of feedback #1- cynicism, lack of personal engagement)

I was also struck by one overarching sentiment/emotion as I read your paper and also, perhaps based on some of our brief conversations and interactions, that seems to be perhaps hidden between the lines. Your statements such as " not all memories of medicine have to be negative" "the heavily calculated plan medical school sets out for us" "perseverance is crucial in order to make it through all tough times" and "live life to the fullest, even while being in medical school'....give me the sense that perhaps your previous experiences in medical school have creating a challenging environment for you, such that you may not be giving your 'all' to the profession and at the same time reaping the enormous rewards this profession can bestow upon those to choose to embrace it wholeheartedly. I don’t want to over read your reflection but I want to make sure that there hasn't crept into you a sense of 'negativism' 'cynicism' or 'doubt' towards the medical profession and medical school. I was wondering if you are aware of this at a conscious level and/or have given some thought to exploring the source of these emotions/feelings? While this may be only be a perception of mine, perceptions often have a greater impact on patient and peer satisfaction, than what one's true intent/meaning might be. (Area of feedback #2- poor focus and description, and also motion)

I would also like you to flesh out your assignment a bit more by addressing some of the following 1) Why is Jennifer a role model of yours? What made the Imani clinic experience with her such a 'fond memory'? 2) What specific 'bedside manner' of Jennifer's resonated with you? 3) Jennifer mentioned how her working with you was a positive experience. How can you ensure that you set yourself up for such similar rewarding experiences in the future and at the same time convey the sense of joy and accomplishment that Jennifer felt, to others when you work with them so that you yourself can inspire them? (Validation and personal ‘touch’ to feedback)

Having a specific commitment to change has helped me set the direction for self growth and

improvement...and we all have areas that we struggle with and can/need to improve. The day that we feel we are perfect is the day we have lost our drive to keep doing better. Any thoughts on that? I'd be happy to talk to you in person too, if that would help.

FEEDBACK SUGGESTIONS: SMALL GROUP NARRATIVE, NARRATIVE A, NARRATIVE B NARRATIVE B (Dr. Verghese): (Validation) Thank you for your wonderful reflection that touches on so many critical areas: work-life balance and the need/importance for health care workers (not just doctors, I would argue) to be there for our patients who, by virtue of their 'role' as patients, are inherently in a state of 'powerlessness' and so extremely vulnerable. (Area of feedback –Motion) You raise a very important and a difficult question-when (if ever) do we stop becoming 'health care providers' and become 'people' who have their own needs and lives, just like our patients do? How do we create a world where we can stop being torn between these 2 realities? Could you ponder over these and share your thoughts with us. Specifically how will you use this experience to achieve better ‘balance’ in your life? (Validation and personal connection) I wait eagerly to get reflections such as yours..for a very selfish reason too ! They make us all slow down and pause-pause to grapple with challenging yet critically important issues such as you have raised. Looking forward to hearing back from you.

Documents

CRITICAL REFLECTION - APPD€¦ · Promoting Critical Reflection and Using Feedback to Stimulate Reflective Capacity APPD March 28, 2012 Lavjay Butani, MD Michele Long, MD Objectives