Using Reflective Writing to Teach Empathy

by Rachel Coleman Drury, Pharm.D., PGY2 Ambulatory Care Pharmacy Practice Resident, University of Maryland School of Pharmacy

Can empathy be taught? Some would argue that empathy is an inherent personality trait.  Others believe it’s a developed skill.  The literature suggests that empathy can be cultivated.^1,2 Many health professional schools are incorporating fine arts and empathy building exercises into their curricula to develop well-rounded practitioners.  The Accreditation Council for Pharmacy Education (ACPE) references empathy five times within the Accreditation Standards and Guidelines for the Doctor of Pharmacy Degree.³  Pharmacy practitioners must be empathetic in order to competently deliver effective patient care.³

As a pharmacy resident practicing in the ambulatory care setting, I could not agree with ACPE more.  “They don’t care what you know, until you show them that you care” is something I frequently say to students on rotation. To achieve optimal health outcomes, the provider must first understand the patient’s problems from the patient’s perspective. This is how a trusting relationship is built.  Without empathy, a provider cannot make patient-specific recommendations.

Empathy is a higher-level skill that requires the practitioner to quickly process information from the patient interaction to make a purposeful response that conveys understanding.  Like empathy, reflective writing requires the learner to process information and respond.  Given these similarities, reflective writing has often been used as one method to develop empathy. Universities, residency programs, and even hospital systems have successfully used reflective writing exercises to develop a practitioner’s empathy.¹ At the Cleveland Clinic, participating physicians attended training sessions that included reflective writing and small group discussions. Topics included the patient experience of pain and suffering, empathy across cultural barriers, and empathetic communication. This study found that facilitated small group sessions, which included sharing thoughts from reflective writing exercises, was effective in increasing self-reported empathy.¹

The Columbia University College of Physicians and Surgeons used a similar method of reflective writing to foster empathy development in an elective course that was structured to allow participants to deeply explore their personal experiences of illness. Throughout the course, students were asked to write about the cultural context of the illness as well as how the ill person was perceived by others. Similar to the Cleveland Clinic exercise, students were given the opportunity to share and discuss their reflective writing. Students in the course indicated that they had a better awareness of their own personal illness and this awareness brought them closer to the experiences of patients.²

Shapiro and colleagues proposed a two-stage conceptual model that uses reflective writing to cultivate empathy in health professional students. The first stage is writing and the second is reading and listening.  It is during the writing phase that learners think about the patient’s situation and contemplate their own subjective and personal reactions to the patient.  Learners should also be aware of their voice (or point of view) in the reflective writing – is it the voice of the provider or patient? The learners should also be encouraged to express emotions, use imagination, and think creativity when writing. In this manner students may begin to see the psychological and spiritual dimensions of many clinical dilemmas as well as find creative solutions.⁴  During the writing stage prompts should be given to guide the learner. Prompts may include: thinking about a time when it was challenging to be empathic; reflect on an experience that gave you insight into patient suffering; and reflect on a personal illness.^1,2

During the second stage learners read and listen.  By reading out load and listening to the experiences of others, learners have the opportunity to empathize and sympathize with one another other. Shapiro defines this as witnessing – an act that creates responsibility in those who hear the testimony of suffering to not turn away, but rather to accept and acknowledge. Witnessing allows students to release their own helplessness and fears. Witnessing only occurs through mindfulness — excluding thoughts of past problems or future obligations and accurately and attentively listening and observing.  Sharing personal experiences often makes students feel vulnerable — which in turn allows them to understand their patients’ feeling of vulnerability.⁴  When students share their reflections, ground rules must be established. It is important that students feel safe.  Strict confidentially must be established.  All participants must listen to each other without judgment and offer support.⁴

The scoring of reflective writing can be challenging. Should student’s reflection be “graded” or should the student be awarded points merely for completing the assignment? When evaluating reflective writing, it is important to remember that the exercise is intended to foster and develop empathy. Therefore, any evaluation should ensure that students are truly growing from the experience. One validated evaluation rubric is the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT). The rubric examines several elements of the writing process including spectrum, presence, description of conflict, attending to emotions, and analysis and meaning.  The performance on each element is assessed based the following ratings: habitual action (nonreflective), thoughtful action or introspection, reflection, and critical reflection. In addition, the evaluator rates the narrative as a whole as either transformative reflection and learning or confirmatory learning.⁵

Reflective writing is an effective method to teach and develop empathy in health professional students.  These activities can be easily facilitated and there is a validated grading rubric.  Learners can continue to use reflective writing throughout their careers.   But reflective writing does have some drawbacks.  For learners, reflective writing is difficult and requires considerable time to reflect and compose ones thoughts.  For teachers, there is a lack of evidence confirming its benefits in terms of actually increasing practitioner empathy applied to patient care. None-the-less, the literature shows that reflective writing can be successfully incorporated into any curriculum and formally evaluated.

References:

1. Misra-Hebert A, Isaacson JH, Kohn M, et al. Improved empathy of physicians through guided reflective writing. International Journal of Medical Education [Internet]. 2012 Apr 9 [cited 2014 Oct 1]; 3:71-77.
2. DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Academic Medicine [Internet]. 2004 Apr [cited 2014 Oct 1]; 79(4):351-356.
3. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree [Internet]. [Chicago]: Accreditation Council for Pharmacy Education; 2011 Jan 2006 [cited 2014 Oct 1]. 35, ix, xxvi, ps.
4. Shapiro J, Kasman D, Shafer A. Words and wards: a model of reflective writing and its uses in medical education. Journal of Medical Humanities [Internet]. 2006 Sep 26 [Cited 2014 Sep 29]; 27:231-244.
5. Wald HS, Borkan JM, Taylor JS et al. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing. Academic Medicine [Internet]. 2012 Mar [Cited 2014 Oct 4]; 87(3): 355.
6. Peterkin A, Roberts M, Havey T. Narrative means to professional ends. Canadian Family Physician [Internet]. 2012 Oct [Cited 2014 Sep 30]; 58(10): e563-e569.
7. Wald HS, Reis S. Beyond the margins: reflective writing and development of reflective capacity in medical education. Journal of General Internal Medicine [Internet]. 2010 Jul [Cited 2014 Sep 30]; 25(7): 746-749.

Anticipating Difficult Situations in Experiential Learning

by Kaitlin Pruskowski, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Bayview Medical Center

Inevitably, all preceptors will be faced with difficult teaching situations in the experiential learning setting.  Both the teacher’s and the student’s skills and expectations can contribute to these difficult situations.  Lack of motivation, either on the student’s or preceptor’s part, can play a big part in a difficult teaching situation.  In addition, not understanding generational differences and expectations can lead to problems.

Teacher-specific factors that can make teaching difficult include poor teaching skills, lack of experience, and not being well-prepared to supervise students.¹  Student-specific factors include lack of effective communication skills, poor baseline-knowledge, and lack of ‘real world’ skills.  Because students lack real-world experience, they may question a preceptor’s recommendations.  When this occurs, it may be helpful to direct the student toward the evidence on which the recommendation is based.  Additionally, mismatched teaching and learning styles, personal insecurities, and life events may contribute to difficult teaching situations.¹

Lack of motivation may also be a significant contributor.  A student may lack internal motivation and is only motivated by external factors (i.e., grades).  Because the learner may not be interested in the subject matter, she may only be willing to do the minimum work required.  Her actions and body language may reflect this.  The student may be tardy, not prepared, or not willing to participate during patient care rounds or group meetings.  Similarly, a preceptor may not be motivated to teach his student.  The preceptor may not make time to meet with students and may not provide clear instructions about what is required.

Generational differences can also play a role in difficult learning situations.  Today, there can be up to three or four generations sharing a common workplace.²  Each generation has its own unique attitudes with regard to work, work-life balance, and respecting authority.  The ‘Baby Boomers’ tend to be ‘workaholics’ and work until they achieve the goals they have set for themselves.  They usually work to please their managers and coworkers.  Members of ‘Generation X’ tend to be self-reliant and are focused on building their resume.  Most are usually very knowledgeable about technology and how it can be used to improve the workplace.  ‘Generation Y’ value life-long learning and like problems-solving.  They are often dependent on technology and are comfortable participating in virtual meetings and communities.  With all of the technology available to them, they expect their preceptors to be available 24/7 to address questions or concerns.  If a preceptor and learner are of different generations, issues may arise due to these differences in values and expectations.²

So how can you prevent difficult teaching situations?  During the orientation period, teachers need to clearly define their expectations, including rotation schedule, workload, and interactions with the medical team.  The teacher/preceptor should know the school or program’s expectations of its learners; chances are that the learner has already received some instruction about these expectations – but it is up to the teacher to reiterate these to the student or resident, along with any rotation-specific requirements the teacher may have.³

Despite clearly stating the expectations in the beginning of the rotation, teachers may face problems as the rotation progresses.  Be sure to address these issues early! If the teacher ignores them, they will worsen with time.  Ask the student about what is going on.  When talking with the learner, it is important to stay calm and give objective feedback.  Be specific about what was observed and what the student can do to improve.

Hewson and Little conducted a survey of medical residents to see which feedback techniques were the most and least helpful.⁴  Feedback that was non-judgmental and based on observations was found to be significantly more helpful than disparaging comments that were not tied to specific events.  It is important to elicit the learners’ ideas and to offered suggestions for improvement.

Based on their findings, the authors developed a model for giving effective feedback.⁴  First, the learner should be given some ‘warning’ that the teacher like to give some feedback and to schedule a time to talk about it.  Next, the learner should be asked to do a self-assessment.  The student should identify what he does well and the areas in which he should improve.  Then, the teacher/preceptor can give feedback as to what the learner is doing well and what he can do to improve.  As a team, the teacher and learner should develop a plan for improvement.  The session should end with a follow-up plan developed by both the teacher and the student.

After meeting with a student and discussing difficult learning issues, the situation may not improve or may get worse.  When this happens, it is time to contact the school or program director.  Program administrators know that not every student is ‘perfect’ and that the teacher may encounter an especially difficult student from time to time.  The school needs to get involve and they are prepared to help if an especially difficult situation arises.

References

1. Langlois JP and Thach S. Managing the difficult learning situation. Family Medicine. 2000;32:307-309.
2. Ginsburg DB. Teaching across the generations: Challenges and opportunities for preceptors. Presentation given at The University of Texas at Austin College of Pharmacy. Austin, TX.
3. Langlois JP and Thach S. Preventing the difficult learning situation. Family Medicine. 2000;32:232-234.
4. Hewson MG and Little ML. Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med. 1998;13:111-116.