Qualitative Analysis of Family Medicine Residents’ Reflections about Global Aspects of Patient Care Ashley P. Duggan, PhD, Boston College Allen Shaughnessy, PharmD, MMedEd, Tufts University School of Medicine, Cambridge Health Alliance

* Writing prompts learners to revisit an experience with the goal of gaining new perspectives and appreciations * Descriptions of events and goal setting gives light to what draws the attention of the individual * Reflection may encourage deeper approach to learning * In medicine and medical education, a shift to integrated care and to relationship-centered medicine * SHIFT assumes reciprocity in decisions, which means different boundaries for information

* Family medicine residents (33 residents) were required to write a reflective entry three times a week for an academic year * Examined 756 private written reflections * Over 140,000 words of data * Global health themes were systematically and inductively derived from the data

* Included noticing how: Patient roles and relationships are interconnected to their cultures and international contexts of their everyday lives “I wonder about this patient’s move from Haiti as connected to nutrition and obesity and self- image and her connection with others.”

Included better understanding communication for: Comprehensive partnership-building Relational processes Shared decision making “She was in her 40s, kids grown up, trying to claw her way out of deep depression. I wonder what she put aside all those years she was parenting? How can I support these women so they don't decompensate when it's finally 'safe' to do so?

* Included: Presupposition that underlying the formation of the physician is desire to understand and integrate health equity “This was my first interpreter experience and was not good. I realized ongoing challenges that prevent patients from getting the right care, today because of my limited questioning.”

* Included: Appreciation for opportunities for foster learning communities attentive to global health concerns and primary care innovation across disciplines. “In understanding the community’s health needs, I am surprised by teen pregnancy rates, HIV/AIDS concurrent with suicide rates, and the lack of addressing needs.

Connected physician communication to important outcomes Recognized potential to support patients beyond biomedical knowledge Interdependence Attentive to patient emotion and aware of missed nonverbal cues Better equipped to acknowledge limits in what they see, and to see below the surface Communication Indicative of Desires Moving from simple answers to multi-dimensional complexities that acknowledge competing tensions Health Equity and Fostering Learning

* Balanced interconnectedness of organizational and cultural context of family medicine * Explicit and implicit points of communication * Competing realities of patient experiences with physicians’ professional roles and responsibilities * Limitations

Anthropological Clinical interaction is inseparable from the humanness of a physician Multiple dimensions of medical practice On the surface and beneath Empowerment Fosters physicians’ abilities to acknowledge strengths and limitations Must be addressed in constructive ways to benefit medical practice

* Suggests possibilities for --enhancing international communities for primary care, --facilitating primary care innovation, and --attending to higher-value models of social and health behavior change in global healthcare delivery.