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.