1. The Value of Critical Reflection Groups: Teaching Medical Students Critical Reflection In and On Practice Randall Longenecker, M.D. Assistant Dean Rural and Underserved Programs Sharon Reynolds, Ed.D. Office of Rural and Underserved Programs Elizabeth Beverly, Ph.D Assistant Professor of Social Medicine Heritage College of Osteopathic Medicine Ohio University, Athens, Ohio FMEC Annual Conference October 24 - 26, 2014

2. Overview Process of Clinical Jazz Research Questions Research Methodology Research Results Discussion

3. “Good clinical practice should be performed like good jazz, with the physician blending the structure of evidence-based medicine with the appropriate improvisation of clinical experience.” Shaughnessy, Slawson, Becker, 1998

4. Reflection-on-action…in-action Reflection: A Continuum …toward-action

5. The Jotter Wallet

6. Logistics Meet monthly for 90 minutes in a small group with 2 faculty facilitators, at a regular time in a regular place Intentionally create a diverse group (multiple levels of students and residents, faculty, and even other professions) so as to bring multiple perspectives Minimal structure and simple rules of engagement

7. The Jotter Assignment Jot things down during the month, and come to Jazz prepared to: Present a case Draw a picture Pose a question – something that happened in the provider-patient relationship (or an inter-professional relationship) this month that continues to intrigue, surprise, frustrate, puzzle, or “eat at” them

9. Minimal structure Bring a case with a question that matters Draw it in context and tell the story The group then clarifies the case and the question, refines the question into a useful one, interacts around the question from multiple perspectives, and in the end comes up with an actionable clinical pearl, specific to the question but also generalizable to future practice

10. What’s new? Intentional diversity – year of training, professional role, other; including a physician and a non-physician participant-facilitator Content arising out of daily practice Focus on reframing the question into a “useful” one Emphasis on actionable solutions to specific clinical questions in pursuit of generalizable “clinical pearls”

11. Research Questions 1.Does the Clinical Jazz model contribute to the development of critical thinking in medical students and residents? 2.How do medical students and faculty facilitators value the Clinical Jazz process? 3.What facilitator factors/actions/characteristics contribute to the success of the Clinical Jazz? 4.What general content emerges with regard to behavioral health, communication, and relationship- centered care? 5.What osteopathic core competencies and reflective practice competencies are addressed by Clinical Jazz? 6.What elements of the “hidden curriculum” emerge from Clinical Jazz?

12. Research Questions 1.Does the Clinical Jazz model contribute to the development of critical thinking in medical students and residents? 2.How do medical students and faculty facilitators value the Clinical Jazz process? 3.What facilitator factors/actions/characteristics contribute to the success of the Clinical Jazz? 4.What general content emerges with regard to behavioral health, communication, and relationship- centered care? 5.What osteopathic core competencies and reflective practice competencies are addressed by Clinical Jazz? 6.What elements of the “hidden curriculum” emerge from Clinical Jazz? How do medical students and faculty facilitators value the Clinical Jazz process?

13. Sample Medical students in the RUSP program at Heritage College of Osteopathic Medicine (n=21) RUSP Faculty Facilitators (n=5) CJ Observers (n=2)

14. Methodology: Nominal Group Process 1.Introduction 2.Silent Generation of Ideas in Writing 3.Round Robin of Ideas – Flip Charting 4.Break 5.Ranking Elements 6.Discussion of Vote 7.Re-ranking and Rating Priorities 8.Conclusion Van de Ven & Delbecq, 1972

15. Methodology Students and faculty individually wrote five answers to the question, “What do you value about Clinical Jazz?” Participants worked in groups to cluster the responses. Viewed clustered responses and assigned value by placing one or more “dots” on any one cluster.

16. Data Analysis Summed cluster scores Coded clusters Categorized Clusters 32 initial codes 9 categories 42 clusters

17. Results

18. Sample Clustered Responses Getting to know ways to handle non- traditional situations in clinical settings; learning and sharing the more subtle lessons and skills of medical school and in the medical profession - this you cant learn in lecture or in a textbook Introspection; reflection on situation; thoughtful reflection; a concentration of experiential learning Student-led; "open-mic"; style was non- judgmental and invited original ideas and questions

19. Faculty Group Promotes empathy and perspective-taking It gives the students time to process situations in a structured safe environment Helps with my own processing of difficult situations Discuss topics that are not often addressed

20. Categories The aspects of CJ valued most by students and faculty and ranked in descending order Problem-solving (79) Diversity of perspective (73) Relationship building (55) Safe space (50) Thoughtful reflection (35) Clinical application (32) Informal curriculum (20) Interpersonal and communication skills (20) Convenience(10)

21. Results Categories

22. Problem-Solving Learning a more organized, cohesive problem-solving strategy Gave us solutions to common topics and problems we will face during med school and beyond CJ allows for problem-solving of personal/professional matter that would otherwise be left undiscussed

23. Problem-Solving CJ allows for the internalization and reflection of others clinical pearls - allows me to see myself in my peers and gives me creative solutions/seeing things from a different angle.

24. Diversity of Perspective Opportunity to get a diverse spread of opinions and input that otherwise we would not typically get Understanding we are all the same yet different; Getting to know and understand others; Gives me creative solutions/seeing things from a different angle.

25. Relationship Building Understanding we are all the same yet different Getting to know and understand others CJ allows for building of rapport among peers Friendships formed as a result of CRG

26. Safe Space The facilitators create an atmosphere of safety and everyone feels respected (at least I do); CJ allows for the sharing of vulnerable truths. Reassurance that some of my questions were shared by others

27. Thoughtful Reflection Introspection Reflection on situation Thoughtful reflection A concentration of experiential learning

28. Clinical Application Getting to know ways to handle non- traditional situations in clinical setting Learning and sharing the more subtle lessons and skills of medical school and in the medical profession - things you can’t learn in lecture or in a textbook. Hearing some clinical stories from the facilitators(usually after we were done)

29. Informal Curriculum Learning and sharing the more subtle lessons and skills of medical school and in the medical profession - this you can’t learn in lecture or in a textbook

30. Interpersonal and Communication Skills Practicing more intentional and effective communication Develop patient-doctor relationship knowledge

31. Convenience The timing and locations were perfect Runs opposite of academic calendar

32. Conclusions This process is relevant. Students valued problem solving and clinical application. Diversity of thought is important. Students valued hearing a variety of solutions to challenges There seems to be reassurance in knowing others struggle with similar issues.

33. Conclusions Interpersonal skill development and relational aspects were less valued. Faculty facilitators valued different aspects of the process including relational aspects and exposing students to a variety of diverse perspectives

34. Questions?

35. Contact Info Randall Longenecker, MD Heritage College of Osteopathic Medicine Grosvenor Hall 255 Athens OH 45701 740.597-3058 longenec@ohio.edu Sharon Reynolds, Ed.D Heritage College of Osteopathic Medicine Irvine 340 Athens OH 45701 740.593-2257 reynols1@ohio.edu

36. Bibliography Dobbie A; Rhodes M; Tysinger JW; Freeman J. “Using a Modified Nominal Group Technique As a Curriculum Evaluation Tool,” Fam Med 2004; 36(6):402-6. Haidet P. Jazz and the ‘Art’ of Medicine: Improvisation in the Medical Encounter, Ann Fam Med 2007; 5:164-169. Longenecker R. The Jotter Wallet: invoking reflective practice in a family practice residency program. Reflective Practice 2002; 3(2):219-24. J Am Soc Inf. Sci. 1997;48:484–95. Longenecker R. “Curricular Design: A Place-Based Strategy for Rural Medical Education,” in Bell E; Zimmitat C; Merritt J Eds. Rural Medical Education: Practical Strategies, New York: Nova Science, 2011. Shaughnessy AF; Slawson DC; Becker L. Clinical Jazz: Harmonizing Clinical Experience and Evidence-Based Medicine, JFP 1998; 47(6):425-8.