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The hidden (informal) curriculum is blamed for its negative effects on students’ humanism and professional development. To combat this, educational initiatives employing mentored reflective practice, faculty role-modeling, and feedback have been advocated.
Promote reflection on professional development using collaborative, web-based technology.
Four-week basic medicine clerkship rotation at an academic institution over a one-year period.
Students were asked to contribute two reflective postings to a class web log (blog) during their rotation. They were able to read each other’s postings and leave feedback in a comment section. An instructor provided feedback on entries, aimed to stimulate further reflection. Students could choose anonymous names if desired.
Ninety-one students wrote 177 posts. One-third of students left feedback comments. The majority of students enjoyed the activity and found the instructor’s feedback helpful. Assessment of the posts revealed reflections on experience, heavily concerned with behavior and affect. A minority were not reflective. In some cases, the instructor’s feedback stimulated additional reflection. Certain posts provided insight to the hidden curriculum.
We have discovered that blogs can promote reflection, uncover elements of the hidden curriculum, and provide opportunities to promote professional development.
Medical educators are challenged with teaching students humanistic care and professionalism 1,2. Medical schools have developed programs to address psychosocial aspects of care, however, their overall potency has been questioned 3,4. Exposure to the hidden (informal) curriculum of the clinical wards is partially to blame 5,6. The interplay, and often conflict, between the explicit curriculum and hidden curriculum can result in cynicism, erosion of morality, and the adoption of negative professional behavior 7–9. To combat this, educational initiatives employing mentored reflective practice, faculty role-modeling, and feedback have been advocated 4,7,10,11.
Reflection is a well-accepted practice for helping to integrate theory with experience and is a key to learning 12–14. There is growing use and appreciation of reflection in medical education in order to promote professional development and encourage humanistic qualities 15–18.
Concurrently, Internet-based tools are creating a revolution in medical education 19,20. They can contribute to personalized learning, collaborative learning, and transformation of the teacher role 20. Web-based portfolios 18 and online reflective journaling 21 have facilitated tracking, accessibility, and mentorship of reflective assignments.
This article describes the use of a faculty facilitated web log (“blog”) to integrate reflective writing into the clinical clerkship.
The purpose of this study was to promote reflection on professional development using collaborative, Web-based technology.
The study took place in a 4-week medicine clerkship rotation from December 2006 through November 2007 at an academic teaching institution.
A password-protected blog was created on a commercial hosting site. Students “posted” their writing, with posts displayed in reverse chronological order. They shared feedback through a comments section following every posting.
Students were given these instructions:
Requirement: A minimum of two reflective posts per 4-week rotation, with the first post within the first 2 weeks to ensure classmates have a chance to read and respond to your writing. There is no length or subject requirement, but the posts must be reflective, that is, not just telling a story but reflecting upon how this experience affects you or changes the way you think about something. Commenting on other classmates’ posts is encouraged. The facilitator will read every post and give feedback in the form of comments. Participation is required but not graded.
One instructor with formal training in adult learning theory (K.C.) and guided by Mezirow’s descriptions of reflectivity served as the blog facilitator 22. Further reflection was encouraged through directed questioning (i.e., How has this changed the way you approach patients?). Comments were given with a supportive tone, often sharing personal experiences to encourage additional reflection. While students were allowed to use anonymous names in posting, the instructor knew students’ identities for tracking purposes.
Students were sent email reminders to post at mid-rotation and near the rotation end.
This study was exempted from IRB oversight.
Descriptive data, a student satisfaction survey and qualitative analysis of blog themes were used to evaluate the program.
Over the year, 91 students participated, writing 177 posts. Approximately one-third of students (31/91) left comments, either on other students’ posts (21/91) and/or responding to feedback on their own (13/91). The majority of students did not respond to instructor feedback in writing. Few students posted more than two posts; half (53%) chose an anonymous username.
Table 1 summarizes the results of the anonymous survey of students’ experience with the blog.
The content of the posts was analyzed for common themes. A non-clinical educator (E.G.) as well as the instructor (K.C.) analyzed all posts independently, following a modified version of the Moustakas method 23. Mezirow’s descriptions of reflectivity were used to determine if posts contained reflection at all and whether these were simply on experiences or at a deeper level concerning the student’s own awareness of their attitudes or beliefs 22. The few coding discrepancies were resolved through discussion.
Each reviewer developed a set of 7–12 themes to describe the data. Initially there were three overlapping themes. An additional three were derived through discussion. These are defined in Text Box 1 with representative examples.
*Three posts were coded with two themes.
Of the 177 posts, eight were identified as not reflective. In some cases, the instructor’s feedback stimulated additional reflection, evidenced by subsequent comments by the student or classmates (Text Box 2). The posts almost exclusively concerned reflection on experiences rather than deeper level reflections on awareness 22. The few reflections on awareness involved changes in assumptions being used in treating patients. For example:
“...they’re making me a better observer and interviewer. I don’t find myself jumping to conclusions or making assumptions about my patients’ condition or situation only because my mind has no reference to fall back on. So just because my patient is over 75 doesn’t mean I don’t ask about street-drug use...and just because my patient is homeless doesn’t mean we can’t compare notes on our favorite playwrights while waiting for a CT scan.”
Certain posts provided insight to the hidden curriculum. Three students on one team wrote on matters of professionalism, stemming from their interaction with one highly dissatisfied resident. One student wrote about his changing definition of professionalism:
We talk a lot about professionalism in medical school; it’s usually a tedious talk about “looking the part” and being punctual; it’s sometimes a talk about professional responsibility and honesty. This man has made me think a lot about attitude—patient attitudes toward health care, doctors’ attitudes toward nurses, our own attitudes toward our patients. In such a large group of people working toward the same goal, everyone’s attitude matters and affects everything and everyone; I can understand why doctors get frustrated with nurses, I can understand why patients feel discouraged by our health care system, and I can understand that patients themselves are very frustrating. I think this is really what professionalism is all about: a good doctor is one who can acknowledge all those difficult attitudes and can honestly and sincerely negotiate a solution through them without holding grudges.
A second student wrote about the value of listening and trying to understand patient’s refusals of tests instead of labeling a patient as “noncompliant”:
Mr T’s current admission ended with the abrupt change of mind and refusal of prostate biopsy. This was the last straw for his intern, who threw her hands up with the lack of willingness to follow medical advice, and bid farewell to her pt. As i tried to pry into the mind of a pt refusing such a blatantly necessary procedure, i found a scared man, unwilling to admit he needed support by his side (of which he has little). I learned that he was put off by his intern, who he knew was concerned, but felt to be ‘demanding,’
Finally, a third student reflected on the process of becoming more cynical with training:
I understand that many people have had justified frustrations with the [system] and with patients... Sometimes I wonder if this is what makes an eager med student into a “jaded” physician later on?
The fact that all three students independently decided to write about these issues reflects both the impact a single house officer can have on students’ professional development and the potential value of a faculty facilitated discussion to help students put this negative role-modeling into perspective.
We have found that blogs when structured with theory driven faculty-facilitation have the potential to promote reflection, uncover elements of the hidden curriculum, and provide opportunities to support student professional development. Other medical student reflective writing studies report themes similar to those we describe but we found a higher incidence of reflectivity in our students’ writing than previously reported 17.
Key advantages of the use of computer technology include: the option for anonymity; the ability to receive timely feedback and support from peers and instructors when critical events occur; and the dynamic interaction between students and instructor. This interaction has the potential to lead to deeper reflections and is a critical component of the development of expertise. Importantly, we have seen how this technology can efficiently extend the reach of one faculty role-model to many students.
Our study has several limitations. Students choosing anonymity could be de-identified by references to identifiable house officers or patients. True student anonymity might have resulted in more genuine responses, but would sacrifice the ability to follow-up specific concerns. Because students were not required to formally respond to feedback, there is little evidence for the direct impact of the faculty facilitation on the development of students’ ability to reflect. And of course, the study occurred at a single institution which may limit generalizability.
We have learned a number of practical lessons through the experience of implementing this blog. Getting each cohort of students signed up with their personal blog accounts took more time than anticipated. Some students tended to put off posting until the end of the rotation, limiting potential for peer interaction. Some students put little effort into writing. Commenting on classmates’ posts varied by cohort; some groups were more active than others. Further work needs to be done to identify ways to make this activity meaningful and educational for a larger proportion of students.
After some discussion, the house officer, who was being a poor role model for students, was brought to the attention of the residency program director and anonymous feedback was filed to the house officer’s evaluation.
Security of the blog should be considered. The blog was password-protected and by invitation only, yet any Internet-based tool is never completely secure. As additional safeguards, students were prohibited from using identifying patient information. Firewalled in-house servers may afford additional security. Many public medical blogs are currently struggling with similar issues of privacy, anonymity, and reflection upon the profession 24. This area warrants further exploration.
We believe the supportive, personal nature of faculty feedback was important for encouraging participation. Indeed, students’ reflections covered sensitive topics including questioning attendings’ bedside manners, negative examples of professionalism, and frank reactions to patient encounters. Instructors need to be educated in the provision of appropriate feedback which facilitates deep reflection.
Future studies of this type of reflective writing should formally assess the level of reflection achieved through blog entries versus other methods of reflection. Longitudinal blogging experiences throughout the four years of medical school may provide us with a deeper understanding of the professional development of medical students and provide insight into how to best structure training to buttress that development in the face of the inevitable challenges of real world medical practice.
We are indebted to the 91 student bloggers.
This research was not funded.
Conflict of Interest None disclosed.
Presented in part at SGIM 30th Annual Meeting, 2007, Toronto