Students’ Narrative Journals: What can we learn? Maria C. Clay, PhD Janice E. Daugherty, MD Patrick A. Merricks, EdD

Journals, Journals everywhere… Since late 1990s, M3 students on FM Clerkship complete –Patient demographic encounter logs –Total encounter tallies –Narrative journal entries [8-week required clerkship, two 4-week blocks] Informal reading by EdD or clerkship director

One way to “skin the cat….”

Section 1- Encounter Record

Section 3: Daily Patient Count

Why Journal? Student benefits include: –Encourages students to reflect on the events they experience –Promotes a sense of accomplishment –Gives a perspective on the types of health care problems prevalent in a community –Allows tracking of experience in comparison to learning objectives

Why Journal? LCME wants the type of information journaling can provide. ED-2. “…clerkships will monitor and verify, by appropriate means, the number and variety of patient encounters in which students participate, so that adjustments can be made to ensure that all students have the desired clinical experiences.” ED-8. “…each course or clerkship must identify any core experiences needed to achieve its objectives, and assure that students received sufficient exposure to such experiences…”

Why Journal? Program benefits include: –Tells us what patient problems students are seeing –Allows tracking of procedures performed –Gives information about what students are thinking –Allows comparison across various sites –Flags potential problems with preceptors or sites

Looking for information different than encounter tallies…

What information do we have? 576 journals Chose 10% to study ‘first pass’ –Random stratified sampling technique Began with student #3 and selected every 10 th book Sample size : 54 journals Half were completed for ‘home’ site rotation, half for community rotation sites

Journal ‘narrative’ characteristics 3 basic writing styles: 1.Repetition of the list of patients seen with no narrative (7/54), or blank (2/54) 2.Mixture of patient log with minimal narrative 3.Narratives rich with information that captured important aspects of the clerkship experience (2+3=45/54)

Student characteristics for selected journals: 23 females –7 minority 31 males –8 minority Fairly representative of demographics of Brody SOM classes

What have we learned from student narrative comments? Clinical content- –Diseases they were seeing for the first time –New skills they were learning –Areas in which they felt unprepared –Areas they knew but realized a need for more practice –Affective comments about clinical content

More things we have learned from student narratives Insights about their own professional development –Helping their preceptors with EBM, etc –Their speed / proficiency at the physical exam –How the EHR was helping them learn particular clinical skills –What they like to do –What they don’t like to do or see

More affect from student narratives Gratitude statements toward patients and preceptors Affirming one’s own ‘gut’ feelings as valuable to heed Understanding of patients’ needs to be heard Statements of fears, both realized and unrealized Humor!

What have we done in response? First systematic reading of narratives From informal scanning we noted (examples): –Discomfort with geriatric patients, so added a session with healthy elderly –Appreciation of anecdotal home visit experience, so added a required home visit and specific reflection assignment for all students –Discomfort with some clinical skills, so added specific skills sessions –Notes about religious or social concerns, so added Beliefs and Values session

What else can we learn from student narratives?

Dr. Rita Charon Narrative Medicine program Columbia University, NY Students complete a “parallel chart” with patient stories and their own experiences

Why? Dr. Rita Charon: “I wanted to find a way to help the students focus on what they themselves were going through, and a way to focus on what their patients had to endure in the course of being ill. It's a tremendous cauldron of experience, and I wanted to have a way to let them reflect, consider, think about what they themselves were going through. “

Dr. Rita Charon “I told them, there are things that are critical to the care of your patient that don't belong in the hospital chart, but they have to be written somewhere. And I would say, if you're taking care of an elderly gentleman who has prostate cancer, and he reminds you of your grandfather who died of that disease, every time you go in his room, you weep. You weep for your loss, you weep for your grandfather. I said, you can't write that in the hospital chart. I won't let you. And yet, it has to be written. Because this is the deep part of what you yourself are undergoing in becoming a doctor. Only when you write do you know what you think. And there is no way to know what you think, or even what you experience, without letting your thoughts achieve the status of language. And writing is better than talking.”

So, what is really in these narratives?