MUSA - Alberta Pharmacy Students' Association

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MUSA As often happens for busy clinician teachers, my schedule precluded my facilitating at the same point in the course two years in a row, so the material discussed differed from one year to the next. Last year I had facilitated a small group after they watched the movie The Doctor (1991) starring William Hurt as a callous surgeon who discovers he has cancer and must become a patient. 2 The experience changes the way he views his patients, his family and his life. Although the film was fictional, it was based on a real-life physician’s memoir. This year I facilitated a group discussion of The Doctors’ Diaries, a condensed version of the Nova documentary series which followed eight Harvard medical students for fifteen years, from the first year of medical school, through residency, and into practice. 3 Facilitating the two groups was very different. With last year’s group, the narratives contained significant insights about the film The Doctor. Topics presented in the students’ reflections included personal experiences of illness, family support, worklife balance, spirituality, and the concept of duty assumed upon entering a caring profession. The students read descriptions of their own doctors, and also the kinds of doctors they wanted to be. Their writing styles and abilities were varied, but they honoured each others’ stories, and the discussion was very rich. Not so with this year’s group. At first, I thought it was because of the material used for this particular session—because it was a documentary, not a story, or perhaps because it was about a prestigious ivy-league school, and not “here”. Yet it was clear from the kinds of questions and comments made during the panel discussion that the students had been emotionally engaged with these real people, and threatened by the very real stresses the Harvard medical students experienced as depicted in the film. There was something else going on in my group’s session. I should have noted it then and put a stop to it because what was done was not what was intended, but I didn’t figure it out until I myself reflected on the process for today’s workshop. This is what happened. The first student took out what I thought was his written narrative, and instead of reading it aloud, he presented his ideas in a casual conversational style as in any other group discussion. When I glanced at his paper, I saw it contained some thoughts scrawled across the page in point format, like speaker’s notes. Not a narrative. The next student, who had written a full narrative, 22 started to read but when she got to a sentence that was similar in its theme to the first student’s, she followed his lead and apologetically abandoned her text to wing it—“Oh, yeah, I sorta felt the same way,” and “I’ll skip that because it was the same as he said,” and so on, essentially stripping her response of her individual writing style and all the personal narrative details—especially the careful selection of WHAT TO SAY. Those two students set the tone of the session, and the other students followed suit. No one read more than a few sentences. Yes, there was a good discussion overall, but the responses became muddled together, and at the end I could not identify one distinctive story. Why had this happened? The groups were the same size and equally varied in their backgrounds and experiences, we’d started with the same introductions process and the students seemed comfortable with each other. The session left me unsatisfied. I felt I had somehow not done my job as facilitator although I wasn’t able to figure out what I had done wrong. I recalled the individual student voices from the year before in their carefully chosen words and phrasing and compared that to the bland “Me, too”-ing of this year’s group. Even one young woman who’d admitted during the introductions to having participated in a poetry—yes, POETRY—group as an undergraduate, became self-conscious of her written attempts to create a voice and left off reading her text for the comfortable, conforming anonymity of chat. Perhaps you now can see why I have chosen to read this narrative script instead of casually discussing my experiences with reflective writing. Writing and oral language are not the same. Oral language, by its speed and spontaneity, is inaccurate. We speak off the cuff and in the moment, trying to communicate with someone who is physically present. This works because we have instantaneous feedback from our communicative partners—in their body language, their attentiveness to the message, the quality of their response. If we’re not making sense, we know it—the listener asks questions to clarify the message, and based on these questions, we change what we are saying—repeating, perhaps paraphrasing, altering word choice, even backtracking or simplifying to arrive at understanding. Speech language pathologists with whom I work call this process “narrative repair.” People who are good communicators don’t wait for the questions from the listener to begin this process. They’re in there at the first frown or lifted eyebrow, when the internal “uh-oh” tells then they’d better go back and fix things, or they’ll lose their audience. They are already starting to pick up the pace before the increasing frequency of yawns tells them that they are being boring. This does not happen with written text. In writing, the repair is in the edits and must be done before the “speaker” ever “speaks” his piece, because any clarifying feedback will be removed in time and space. This forced clarification creates a powerful communication tool. Spontaneous oral language is ephemeral, unless recorded or written down. We as listeners are left with an impression of someone else’s truth. In writing we aim to achieve our own truth. Writing should stand alone. In John Sandars’ 2009 article in Medical Teacher he states that reflection is a metacognitive process. 4 I would add that editing is also a metacognitive process—it requires us to think about language, to deliberate and become deliberate in our approach to a communicative task. The act of writing slows us down. We carefully consider the ways we use words to avoid the possibilities for ambiguity that can ambush the sought-after clarity and ultimate presentation of our personal truth. When we submit our final written draft, we are no longer figuring out what we want to say. We know. We say, “THIS is what I think. THIS is what I feel. THIS is what I believe.” NOT “I’ll say this about that”, but “THIS is what I WANT to say about THAT”. This is the lesson of narrative reflective practice, and should be our focus when we teach this to others: the deliberate consideration of what we think and feel and believe, and the value of communicating these thoughts and feelings and beliefs through the deliberate consideration of the written word. The narrative reflective process was not as effective in my small group this year, at least partially because I let the discussion stray from the written word. Despite the students’ emotional engagement in The Doctor Diaries, the superficial conversations did not capture their individual reflections or link the experience of viewing the film with their own stories. The discussion never reached down to the very deep issues that had arisen from the film. Next year I know what to do. If any of the students wander away from their requested narrative reflection, I am going to stop them and say, “Please read what you wrote, because the words are important.” University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1
References 1. Brett-MacLean PJ, Cave MT, Yiu V, Kelner D, Ross D. Film as a means to introduce narrative reflective practice in medicine and dentistry: A beginning story presented in three parts. Reflective Practice. 2010;11(4):499-516. 2. Haines R. The Doctor [Motion Picture]. Burbank (CA): Touchstone Pictures; 1991. It all began with a cup of tea: Introducing narrative reflective practice into undergraduate and postgraduate medical education at the University of Alberta 3. Barnes M. Doctors’ Diaries [Documentary]. Boston (MA): WGBH-TV; 2009. 4. Sandars, J. The use of reflection in medical education: AMEE Guide No. 44, Medical Teacher. 2009;31(8):685-695. Marie-Therese Cave, MSc, P.G Dip Couns. Cert. Ed. Assistant Professor, Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada D. Jean Clandinin, PhD Professor and Director, Centre for Research for Teacher Education and Development, University of Alberta, Edmonton, Canada Correspondence to Marie-Therese Cave: Email: marie.cave@ualberta.ca Abstract Marie Cave and Jean Clandinin describe their experience of bringing narrative reflective practice into medical education at the University of Alberta. In this account they discuss their experiences with the process of curriculum change, as well as some of the unique characteristics of narrative reflective practice in medical education. Marie-Thérèse Cave: There are certain moments that turn out to have important consequences. Except for flashes of intuitive prescience, rarely is one able to predict which events will turn out to be the momentous ones. Only in retrospect can one appreciate the significance of the beginning points, turning points, and contingencies that characterize the introduction of a curricular innovation in medicine. This is the way it was for the individuals in the story that follows. I suppose I should be the person to begin the story. However, for me, it didn’t begin with the cup of tea. It began weeks before, one morning, when I walked into my office in the Department of Family Medicine to find a journal on my desk. The journal was the latest edition of Reflective Practice: International and Multidisciplinary Perspectives. The title itself was enough: This was the first journal to address the work in which I had been involved for more than ten years. My own education in how to be a reflective practitioner, and how to facilitate reflection, began in Liverpool, during my undergraduate work in education. At the time I was also personally engaged in exploratory learning through the work of John Dewey, and his accounts of how learning takes place. My self-education included Donald Schon’s writings and also that of more local reflective practitioners, like Hawkins and Shohet, in nearby Bath. My education continued later, in Bristol, in my second career as a counselor and then as a supervisor of counselors and therapists. My clinical work began with educating and supervising the practice of counselors and therapists in Bristol, England. My practice then expanded to involve physicians, mostly family doctors, who were seeking a way to reflect upon the challenge of delivering optimal care to patients and patients’ families, and themselves. As a practitioner, my interest grew from trying to understand how students learn to understand, to how I, and my peers, made meaning of our experiences with clients. When I came to the University of Alberta I was able to continue some of this work, as the College of Family Physicians of Canada had recently announced their expectation that residency programs develop curricula in behavioural medicine. This was to be a curriculum that included “opportunities for reflective practice with skilled and sensitive teachers of family medicine.” As the Behavioural Medicine coordinator within the family medicine residency program, I incorporated a “reflective practice” pedagogy into the curriculum. In the 15 years that followed, I continued listening to physician stories, trying to help resident physicians make meaning of their experiences. Some of the medical educators I met shared my interest in reflective practice, but much of the work in which we were involved together focused on developing curricula in communication skills and the practice of patient-centered care. I opened the new journal eagerly. I was keen to discover if it was a place in which I could share my interest in reflective practice, and read of others in the midst of similar work in medicine. An immediate scan revealed interesting work being done in several of the “helping professions” – in nursing, education, and also, surprisingly, in business – but none of the articles focused on medicine. I then read the list of those on the international editorial board, and I was surprised to see the name of a professor at the University of Alberta, in the Faculty of Education. Instinctively I picked up the university directory and made a call. “Dr. Jean Clandinin is in Taiwan,” responded her secretary, and then she added “you can leave a message if you like.” So I did. d. Jean Clandinin The message from Marie Cave came in the fall of 2003 while I was in the midst of planning what eventually became the Handbook of Narrative Inquiry: Mapping a Methodology. 1 The handbook was to be interdisciplinary and inter-professional, and I had a lot to learn. While I knew editing a research methodology handbook for a major international publishing house University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 23 MUSA
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Page 3 and 4: Contents Editorial Commentary OSCE:
Page 5 and 6: University of Alberta Summer Studen
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Page 13 and 14: antipsychotic. Of these patients, 4
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Page 17 and 18: Embryonic Stem Cell Transplantation
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Page 23: creative, and actually produce some
Page 27 and 28: The arts and Humanities in Medicine
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Page 37 and 38: he was acknowledged with Canada and
Page 39 and 40: Thank you The UAHSJ wishes to thank

MUSA - Alberta Pharmacy Students' Association

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