Fischer Melissa A, Harrell Heather E, Haley Heather-Lyn, Cifu Adam S, Alper Eric, Johnson Krista M, Hatem David
University of Massachusetts Medical School, Worcester, MA, USA.
J Gen Intern Med. 2008 Jul;23(7):958-63. doi: 10.1007/s11606-008-0508-1.
Recent changes in healthcare system and training mandates have altered the clinical learning environment. We incorporated reflective writing into Internal Medicine clerkships (IMcs) in multiple institutions so students could consider the impact of clerkship experiences on their personal and professional development. We analyzed student reflections to inform curricula and support learning.
We qualitatively analyzed the reflections of students at 3 US medical schools during IMcs (N = 292) to identify themes, tone, and reflective quality using an iterative approach. Chi-square tests assessed differences between these factors and across institutions.
Students openly described powerful experiences. Major themes focused on 4 categories: personal issues (PI), professional development (PD), relational issues (RI), and medical care (MC). Each major theme was represented at each institution, although with significant variability between institutions in many of the subcategories including student role (PI), development-as-a-physician (PD), professionalism (PD) (p < 0.001). Students used positive tones to describe student role, development-as-a-physician and physician-patient relationship (PD) (p < 0.01-0.001), and negative tones for quality and safety (MC) (p < 0.05). Only 4% of writings coded as professionalism had a positive tone. Students employed a "reporting" voice in writing about clinical problem-solving, healthcare systems, and quality/safety (MC).
Reflection is considered important to professional development. Our analysis suggests that students at 3 institutions reflect on similar experiences. Theme variability across institutions implies curricula should be tailored to local culture. Reflective quality analysis suggests students are better equipped to reflect on certain experiences over others, which may impact learning. Student reflections can function as a mirror for our organizations, offer institutional feedback for support and improvement, and inform curricula for learners and faculty.
医疗保健系统和培训要求的近期变化改变了临床学习环境。我们在多个机构的内科实习（IMc）中纳入了反思性写作，以便学生能够思考实习经历对其个人和职业发展的影响。我们分析了学生的反思内容，以为课程提供参考并支持学习。
我们采用迭代方法对美国3所医学院的学生在IMc期间的反思（N = 292）进行了定性分析，以确定主题、语气和反思质量。卡方检验评估了这些因素之间以及不同机构之间的差异。
学生们公开描述了深刻的经历。主要主题集中在4个类别：个人问题（PI）、职业发展（PD）、人际关系问题（RI）和医疗护理（MC）。每个主要主题在每个机构中都有体现，尽管在许多子类别中机构之间存在显著差异，包括学生角色（PI）、作为医生的发展（PD）、专业精神（PD）（p < 0.001）。学生使用积极的语气来描述学生角色、作为医生的发展和医患关系（PD）（p < 0.01 - 0.001），而对质量和安全（MC）使用消极的语气（p < 0.05）。在编码为专业精神的写作中，只有4%的内容具有积极的语气。学生在撰写关于临床问题解决、医疗保健系统和质量/安全（MC）的内容时采用了“报告”的口吻。
反思被认为对职业发展很重要。我们的分析表明，3所机构的学生反思的是类似的经历。机构之间主题的差异意味着课程应根据当地文化进行调整。反思质量分析表明，学生更有能力反思某些经历而非其他经历，这可能会影响学习。学生的反思可以成为我们机构的一面镜子，提供机构反馈以支持和改进，并为学习者和教师的课程提供参考。
