Sackler Faculty of Medicine, Department of Medical Education, Tel Aviv University, Tel Aviv, Israel.
Department of Family Medicine, Clalit Health Services, Dan-Petah Tikva District, Israel.
Med Educ. 2018 May;52(5):497-512. doi: 10.1111/medu.13582.
Breaking bad news (BBN) is a challenge that requires multiple professional competencies. BBN teaching often includes didactic and group role-playing sessions. Both are useful and important, but exclude another critical component of students' learning: day-to-day role-model observation in the clinics. Given the importance of observation and the potential benefit of reflective writing in teaching, we have incorporated reflective writing into our BBN course. The aim of this study was to enhance our understanding of the learning potential in reflective writing about BBN encounters and the ability to identify components that inhibit this learning.
This was a systematic qualitative immersion/crystallization analysis of 166 randomly selected BBN narratives written by 83 senior medical students. We analysed the narratives in an iterative consensus-building process to identify the issues discussed, the lessons learned and the enhanced understanding of BBN.
Having previously been unaware of, not invited to or having avoided BBN encounters, the mandatory assignment led students to search for or ask their mentors to join them in BBN encounters. Observation and reflective writing enhanced students' awareness that 'bad news' is relative and subjective, while shedding light on patients', families', physicians' and their own experiences and needs, revealing the importance of the different components of the BBN protocol. We identified diversity among the narratives and the extent of students' learning.
Narrative writing provided students with an opportunity for a deliberative learning process. This led to deeper understanding of BBN encounters, of how to apply the newly taught protocol, or of the need for it. This process connected the formal and informal or hidden curricula. To maximise learning through reflective writing, students should be encouraged to write in detail about a recent observed encounter, analyse it according to the protocol, address different participants' behaviours and emotions, and identify dilemmas and clear lessons learned.
传递坏消息（BBN）是一项需要多项专业能力的挑战。BBN 教学通常包括理论教学和小组角色扮演。这两种方法都很有用且重要，但都排除了学生学习的另一个关键部分：在临床实践中日常观察榜样。鉴于观察的重要性以及反思性写作在教学中的潜在益处，我们将反思性写作纳入了我们的 BBN 课程。本研究的目的是增强我们对 BBN 体验反思性写作学习潜力的理解，并识别出阻碍这种学习的因素。
这是一项对 83 名高年级医学生随机选择的 166 篇 BBN 叙事的系统定性沉浸式/结晶分析。我们在一个共识建立的迭代过程中分析了这些叙事，以确定讨论的问题、吸取的教训以及对 BBN 的理解的提高。
由于之前对 BBN 一无所知、未被邀请或回避 BBN ，强制性作业促使学生寻找或邀请导师与他们一起参与 BBN。观察和反思性写作提高了学生对“坏消息”是相对和主观的认识，同时也揭示了患者、家属、医生以及他们自己的经历和需求的重要性，凸显了 BBN 协议不同组成部分的重要性。我们发现叙事之间存在多样性，以及学生学习的程度。
叙事写作为学生提供了一个深思熟虑的学习过程的机会。这导致了对 BBN 体验的更深入理解，对如何应用新教授的协议的理解，或者对其必要性的理解。这个过程连接了正式和非正式或隐性课程。为了通过反思性写作最大化学习，应鼓励学生详细描述最近观察到的一次经历，根据协议对其进行分析，解决不同参与者的行为和情绪，并识别出困境和明显的经验教训。
