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.

You Can Get All A’s and Still Flunk Life

by Christine Puschak, PharmD, PGY2 Cardiology Pharmacy Practice Resident, University of Maryland School of Pharmacy

        

Take a moment to think about what is required to lead a “successful” life. Is it knowledge, luck, hard work? How about self-awareness and relationships?¹  Success in life often requires all these.  It is our job, as educators, to help students achieve success: in the classroom, in the program, and in their lives. Many of us focus on teaching content-specific material to increase students’ factual knowledge and problem solving skills. However, have you ever thought about increasing students’ self-awareness and relationship management skills?

Emotional Intelligence^1,2

Daniel Goleman describes emotional intelligence (EI) as a flexible, intangible concept.² EI is comprised of four major cornerstones: self-awareness, self-management, social awareness, and relationship management (see Table 1). The four cornerstones allow us to work through a situation by evaluating ourselves and effectively interacting with those around us. These skills focus on recognition and regulation of emotions. EI helps build stronger relationships and success at work by empowering others and leading change. It is a skill required by health care workers as they need to effectively communicate with patients and create a plan that meets a patient’s goals. Healthcare providers must be attuned to the emotions and motivations of their patients and co-workers as they address complex issues. Empathy helps providers understand their patients in a way that improves decision-making.

TABLE 1 – The Cornerstones of Emotional Intelligence

	Self	Social
Recognition	Self-Awareness ·  Emotional self-awareness ·  Accurate self-assessment ·  Self-confidence	Social-Awareness ·  Empathy ·  Organizational awareness ·  Service orientation
Regulation	Self-Management ·  Self-control ·  Transparency ·  Adaptability ·  Achievement drive ·  Initiative	Relationship Management ·  Inspirational leadership ·  Developing others ·  Influence ·  Change catalyst ·  Conflict management ·  Building bonds ·  Teamwork & collaboration

Most of us acquire these skills through experience and practice, but how do we teach learners to be emotionally intelligent?  Can it even be taught?

Measurement¹

Before we can teach EI, we have to determine if there is a way to measure these skills. Drs. Bradberry and Greaves developed the EI Appraisal questionnaire  — a survey to quickly and accurately assess one’s emotional intelligence quotient (EQ).¹ This assessment tool is based on the four major cornerstones of EI. It has shown strong reliability through validation studies. In addition to this test, there are currently nine other assessment tools to determine a person’s EQ, all varying in complexity and utility. The details of each assessment can be found at http://www.eiconsortium.org.

Can I Improve my EQ?¹

While our intelligence quotient (IQ) is considered to be rigid and remains relatively unchanged throughout life, EQ often increases with age and experience. Improving your EQ is something that you work on regularly. A change can often be seen within a few months with a measurable difference in EQ score often occurring in three to six months. The key to successful developing your EQ is to start small and work on it incrementally. A person should choose one of the four cornerstones and work to improve that area before moving to another. It is beneficial to first identify which cornerstone requires the most development. The EI surveys and assessments can help one identifying these areas. To increase EQ, it requires self-management and a specific action plans. Ultimately, the responsibility is the learner’s.  Personal growth requires a conscious effort and constant practice.

How Do I Teach EI?

To help learners improve their EQ, a teacher must be aware and cognizant of the skills required for emotional intelligence. If teachers are not aware of or do not understand EI, they can not effectively nurture the development of EI skills in their learners. EI can be built through self-reflection and relationships with others. Thus, teachers must first build their own EQ! Once mastered, there are numerous ways of incorporating the skills into your instruction. Activities to raise awareness of the cornerstones of EI are available in print and electronic media.⁴

EI skill development exercises increase EQ scores.  In one study, third year medical students were assigned to a seven month EI training program which included individual reflections and group activities.⁵  A second group of medical students who participate in the study did NOT participate in the EI training program.  The group assigned to the EI program had a substantial increase in mean EQ over time while the comparator group actually had a slight decrease. Although an increase in EQ was observed, the benefits remain unclear. The study reported only changes in the EQ score, which is merely a surrogate marker, and did not follow-up with participant over time.   It would useful to know if the EI program participants did better during their 4^th year practice experiences, more likely to match with the first preference for residency training, and if their patients and co-workers believed their were more competent (when compared to those who did not complete the EI program). Clearly we need more data to document the impact of EI training on outcomes.

Theoretically, all health professions, including pharmacists, would benefit from EI skill development and a higher EQ.  Health professional interact with patients and these interactions require trust and effective communication.  I believe that EI skills are best taught through communication-type labs. By making the students aware of their EQ score prior to lab, learners can improve their EI skills by developing self-awareness and working through various patient case scenarios and healthcare situations. Reflective exercises related to uncomfortable interactions — such as an angry patient or a competitive classmate  — may also help learners develop their EQ.  These exercises are intended to help them to acknowledge their thoughts, control their emotions, and think about others. These exercises may help to decrease school-related stress as they learn to assess and adjust their emotions.  EI exercise can also help learners work more effectively with others in the classroom and beyond.

EI is not a skill that can be developed overnight. With the encouragement of emotionally intelligent teachers, students can hone their skills and improve their own EQ, which may enhance their chances of success, both personally and professionally.

References:

1. Bradberry T and Greaves J. The emotional intelligencequick book: everything you need to know to put your EQ to work. New York: Fireside; 2005.
2. Goleman D. Emotional intelligence: why it can matter morethan IQ. New York: Bantam Books; 1997.
3. Daniel Goleman’s five components of emotional intelligence [Internet]. 2009 Feb 9. [cited 2014 Sept 22].
4. Lynn AB. The emotional intelligence activity book: 50activities for promoting EQ at work. New York: Amacom; 2002.
5. Fletcher I, Leadbetter P, Curran, et al. A pilot study assessing emotional intelligence training and communication skills with third year medical students. Patient Education and Counseling. 2009;76:376-9.

Mobile Devices in the Classroom: What’s Your Policy?

by Benjamin Laliberte, Pharm.D., PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

Ten years ago, the Boston Globe reported that less than 5% of colleges across the United States required students to purchase personal computers.¹  In 2014, things have changed dramatically — 67% of students have two to four mobile devices connected to their campus wireless network.² In the classroom, 94% of students are now utilizing some sort of mobile technology!

From one perspective, the push to use wireless technology in the classroom is due, in part, to the increasing use of computers and technology in our everyday lives, coupled with the need to provide students the skills to succeed in a “technology-dependent” world.^1,2 Moreover, teachers are simply responding to changes in social norms. When companies like Apple, HP, and Samsung roll out new gadgets, everyone seems to jump in line to purchase the latest invention! The integration of classwork with technology can produce interactive, hands-on learning that increases student engagement.  And it provides opportunities for educators to introduce innovative teaching techniques.^1-3 On the other hand, it may just be an easier way to deliver content and go (or not to go) to class.

Numerous studies have evaluated the benefits of laptop use in the classroom. One study was conducted at the United States Military Academy in West Point with 527 college freshmen enrolled in ten general psychology classes.³  Six classes served as a control group that did not use laptops and four classes incorporated laptops into classroom activities.  Students used laptops to prepared presentations and share information using a first generation Dropbox. After seven exams, students in the laptop classes had significantly higher scores when compared to the no laptop group (86.8% vs. 83.5%; p<0 .05)

Similarly, a recent study at the University of Michigan, involving nearly 600 students, examined the benefits of a homegrown, web-based software called LectureTools.  Half of the students were given access to LectureTools on their laptops and half were not.⁴ This interactive program allowed students to ask questions during lectures, take notes, draw on PowerPoint slides, quickly rate the professor’s slides, and review the lecture again after class. At the conclusion of the semester-long study, survey results demonstrated that students in the LectureTools group had self-reported increases in attentiveness (37% vs. 25%), engagement (60% vs. 39%), and learning (53% vs. 40%) when compared to the students who did not have this tool available to them.

Despite these promising results and the increased use of classroom-based technology, it is common for students to become distracted and wander into cyberspace.^1-4  In the University of Michigan study, 75% of students in both groups used their laptops for non-course-related tasks, including 35% for social networking and email.⁴ A survey of law students at three institutions located at geographical diverse areas of the country found that 96% of respondents used their laptops for note taking, but 71% were simultaneously surfing the internet during class.⁵ While many students take advantage of the available internet access to supplement classroom material, others are abusing the privilege, which can be distracting to those around them.^4,5

A 2006 study observed 137 college students in one college general psychology class that permitted laptop use.⁶  Sixty four percent of the students used their laptop during at least one class period. During class, 81% of the students admitted to checking their email, 43% browsed the Internet, and 25% reported playing games on their computer.  Not surprisingly, there was a negative association between student performance in the class and laptop use (p=0.024). Not only were the students who reported using their laptop in class performing poorer on exams, there was a self-reported decreased attention to lectures (p<0 .01)

Pharmacists and other health care providers often pride themselves in being effective multitaskers. But did you know self-proclaimed multitaskers may actually be worse at multitasking?^7,8  One study found that self-proclaimed multitaskers, such those students who actively using laptops during class, performed worse on cognitive memory tasks than students who preferred to focus on a single assignment.⁶  According to a paper on work-memory capabilities, human ability to multitask and “juggle facts” is limited to seven units. There appears to be a “switching time cost” that occurs when changing your attention, say, back and forth between facebook and a professor giving a lecture.⁷ Whereas it would normally take two seconds to repeat a single task, balancing two such tasks at the same time may actually take upwards of twenty seconds! Remember that all-nighter in college? Fatigue, in addition to anxiety and other emotional disturbances lessen our ability to multitask and process information efficiently.

Technology is here to stay. It has been shown that laptops can have a positive effect on attention and learning, if used appropriately.^1,3,4,9  Our job as instructors is to ensure laptops and other mobile computing devices are not a barrier to our students’ learning.¹ Successful teachers will be able to merge effective teaching methods with technology and social media to enhance student learning and comprehension. How? Well, here are a few tips:⁸

• Develop a technology use policy. This is a syllabus “must have” so students know your classroom etiquette rules. Are students with laptops and tablet devices allowed to sit in the front two rows?  Or do you have a “laptop/tablet free” zone?
• Develop in-class activities for students to accomplish using their laptops, tablets, and smartphones. Small group activities, such as patient cases or database research are great ways to engage students.
• Transforming technology into “audience response systems.” This may include tools like LectureTools or social media such as Twitter for students to ask in-class questions and share articles.  In doing so, you have a better shot at limiting technology use to course-related tasks.

References:

1. Russell J. Laptops required at 3 state colleges. The Boston Globe. 30 Aug. 2004.
2. Weldon D. BYOD now a fact of life for majority of college students. FierceMobileIT. 8 May 2014.
3. Efaw J, Hampton S, Martinez S, Smith S. Miracle or Menace: Teaching and Learning with Laptop Computers in the Classroom. Educause Quarterly. 2004;3:10-18.
4. Zhu E, Kaplan M, Dershimer RC, Bergom I. Use of Laptops in the Classroom: Research and Best Practices. CRLT Occasional Paper. 2011;30:1-6.
5. Mazzie LA. Is a Laptop-Free Zone the Answer to the Laptop Debate? Marquette University Law School Faculty Blog. 27 Oct. 2008.
6. Fried CB. In-class laptop use and its effects on student learning. Computers & education. 2008;50(3):906-914.
7. Glenn, D. Divided Attention. The Chronicle of Higher Education. 28 Feb. 2010.
8. Research on In-Class Use of Laptops and Other Devices: Effects on Students’ Learning and Attention. The Teaching Center Journal. 23 Apr. 2013.
9. Penuel WR. Implementation and Effects Of One-to-One Computing Initiatives: A Research Synthesis. Journal of Research on Technology in Education. 2006;38(3):329-348.