medical reflective writing

medical reflective writing

The Importance of Reflective Writing in Medical Practice

1. Introduction

Reflective writing has been described as a scientific process for learning. To understand the significance of this definition and briefly compare reflection with more familiar concepts of learning consider a modern medical student. The student has been witnessing a teaching session on history taking. At the end of the session, they are requested to commit some facts about history taking to memory. This process can be compared to basic remembering and writing down of facts. Later, the student goes to the hospital and tries history taking for the first time. After the experience, the student realizes how little they actually know about taking a history and going back over the facts, they realize that they cannot actually apply them in a practical situation because they do not understand. This comparison of the two ideas has previously led to confusion over reflective learning and reflective practice. Reflection is not simply thinking back over past experiences and reiterating facts or comments. It is a deeper and more meaningful process. The student has in doing, history taking, actually experienced. Reflection here may occur spontaneously in the form of realization during the event that their guidance from the teaching session was inadequate. This present or past experience is then compared with the knowledge or idea of an ideal situation (in this case effective history taking) and then the significance of this comparison is considered. In our example the student may be a little disappointed that they found their tutor teaching was not so relevant, but still only a change from poor to good history taking. At this point there would be no action in changing the manner of history taking. It is this last stage of reflection which is a conscious effort, normally done at the end of an experience and often written, in today’s context of medical practice and education. This type of reflection is best expressed through descriptive or analytical writing and leads to a change in understanding and potentially a change in how we act, with the aim of providing a better outcome for us or those we are serving.

The General Medical Council in the United Kingdom advises all medical practitioners to engage in reflective practices as part of their professionalism. Reflection is a conscious process of making sense of an experience or idea in order to learn and change from it. It may be done in conversation with others, in written form or within the person’s own head. For the purposes of this paper, we will focus on written reflection and its application in modern medical practice. Reflective writing is not a new concept and has been used by medical practitioners with differing opinions on its utility, writing style and emphasis on reflection, since Hippocrates. This essay aims to discuss the relevance, utility and ways in which a modern medical practitioner could incorporate reflective writing into their professional practice. This will be done using evidence and practice from the literature and our own experience in applying reflection to a range of scenarios.

2. Benefits of Reflective Writing in Medical Practice

Reflectivity is seen as an important trait of professionalism in medicine. Individually, professionals must be able to assess and learn from their experiences. It is through analysis and self-evaluation of our experiences that we can add to our knowledge base and improve our practice. It is a long-term process and often relies on a supportive environment. Becoming a reflective practitioner requires the development of new skills – it is not simply a matter of thinking about an experience, but learning to describe, analyze and evaluate it, and this is best done with the use of a framework or model. Carrying a notebook, writing diary entries or being involved in reflective discussion are all methods used to document reflection. Written reflection, on a one-off basis, or as part of ongoing portfolio building, is being used more widely in medical education and has been seen as a tool to help students and doctors develop their reflective skills. At a time when educators and regulators are looking for ways to enhance and evaluate the reflective process, there is an urgent need to consider exactly how written reflection can be used effectively, and how it should be assessed. Written reflection, on a one-off basis, or as part of ongoing portfolio building, is being used more widely in medical education and has been seen as a tool to help students and doctors develop their reflective skills. At a time when educators and regulators are looking for ways to enhance and evaluate the reflective process, there is an urgent need to consider exactly how written reflection can be used effectively, and how it should be assessed.

3. Techniques for Effective Medical Reflective Writing

Develop insights and learning so that your writing has an impact. Medical writer and editor, Dr. Pippa Shulman, suggests that successful reflective writing leads to change for the better. She explains, “Two common models used when reflecting are Gibbs reflective cycle and Driscoll’s ‘What?’ model of learning and development. These help tease out what happened but also look at the implications of the event and give a structured way to translate the experience into new insights then into action.” Suggestions for Disseminating Reflective Writing and Manager’s Toolkit can help you carry through changes in your practice with the support of others.

“This is really about getting into the clinical scenario,” explains Dr. Daune MacGregor, Lecturer in Adult Nursing. “You want to put yourself back in that situation, think about what you were feeling and what was going through your mind. For every action there’s a reaction, so the patients’ reactions to your care may affect you; it’s important to jot these down as they are often the things you forget.”

Engage with the emotions experienced at the time.

4. Case Studies: Real-Life Examples of Reflective Writing in Medicine

This is a good example of the interplay between prescribing practice and the doctor-patient relationship and the subsequent impact on dealing with drug seeking behaviour. I saw a gentleman in his twenties who had terrible back pain from a prolapsed disc. An MRI scan confirmed its severity and he was very keen for a neurosurgical opinion. The merits of referral for spinal surgery are a topic in its own right but I opted to try a mix of physiotherapy, NSAIDs, simple co-codamol, and a neuropathic pain agent. Unfortunately, his unscheduled return several weeks later revealed that he was now taking high doses of co-codamol and ibuprofen bought over the counter from the local pharmacy. He was getting modest benefit at best and was experiencing gastric discomfort from the NSAID. I had failed to appreciate his history of recreational drug use and his friends were now advising him to try or buy some heroin as this was more likely to help his mood and cause fewer gastric side effects. I was shocked and explained the risks of addiction and the unlikelihood of achieving long-term pain relief, but he left the surgery disillusioned with NHS pain management and with no intention of reducing his analgesia. This case led to much contemplation of the feasibility of avoiding opioid drugs in certain groups of patients and the need to monitor prescribing of strong analgesia more closely. I had to address my frustration at wanting to ‘solve the problem’ by referring to another consultant when sometimes the best management is damage limitation. The closure came some months later with agreement between myself and the patient that he would request a referral back to the local specialist addiction service that he had previously engaged with. He tried to abstain from strong opiates but unfortunately relapsed several times and the disc problem continued to blight his life over the following years. I still wonder if I could have done more.

13th Apr 2011

Morezeib prescribing painkillers to an addict

5. Conclusion: Embracing Reflective Writing for Personal and Professional Growth

Reflection has the ability to change the way a person thinks and acts. It is argued that early reflective practice for medical students and junior doctors can influence development of professionalism at the outset, guiding individuals to learn the internal standards of practice and organize their clinical knowledge towards the benefit of patients. This could have significant effects, making the newer generations of doctors more reliable and possibly decreasing the high rate of medical errors. It is evident that reflective writing in medical practice has substantial benefits that impact further than the individual healthcare professional.

In today’s society, patients are more diverse and have complex needs, thus it is essential that doctors develop good communication skills because it underpins a trusting doctor-patient relationship and is a central component of the clinical interview. The link between reflective writing and communication skills was illustrated by a study of pediatric residents. It was found that those with greater reflection wrote more elaborate and insightful comments on their patient-physician interactions, and these sessions were then rated higher by the supervisors. Thus, a higher level of reflection has the potential to improve the quality of communication which is so imperative in this day and age.

In an ever-evolving world, lifelong learning in the medical profession is an imperative. Medical schools and junior doctors have recognized that the early practice of writing personal medical narratives of clinical experiences is a way to start development of professionalism and improve patient-centered care. Medical humanities programs have been implemented to further develop the attitudes and skills of medical undergraduates through reflective writing and arts-based modules. Data from the study of self-awareness in UK doctors has shown that the development of self-awareness leads to learning on an emotional level and the improved ability to understand other people’s feelings, and this is correlated with promoting patient-centered care and empathy. The ability to understand and empathize with someone is not only comforting for the patient, but studies have shown that it improves clinical outcomes.

Reflective writing in medical practice is an important process that cannot be overlooked. The experiences and knowledge gained through reflective writing are essential in helping a medical professional to grow and develop into a better practitioner. This essay has explored and contrasted the different forms of reflective writing in medical practice as well as the ways in which it facilitates professional development. Gibbs Reflective Cycle helped to clearly identify the diversity in deeper thought and increased awareness of cultural insights. It has helped to pinpoint a targeted area for remedial action and the likely changes that will result. Missing in the other forms, Gibbs clearly will improve the overall care for the patient. His cycle forces one to think systematically gathering all facts and events and consider the significant factors thus preventing a common rush to judgment.