Cultivating the Inner Life of a Physician Through Written Reflection

Andrea Vicini; Allen F. Shaughnessy; Ashley P. Duggan

doi:10.1370/afm.2091

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The Examined Life: Reflective Writing for Personal and Professional Flourishing in Medical Residency Education
Hedy S. Wald, PhD

Published on: 25 August 2017

Published on: (25 August 2017)
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The Examined Life: Reflective Writing for Personal and Professional Flourishing in Medical Residency Education
Hedy S. Wald, PhD, Clinical Professor of Family Medicine
The being and the doing the work of a physician.[1] Attitudes, values, beliefs. Scientific knowledge, clinical skills, technical expertise. All key elements of the becoming of a physician; their development essential within professional competency. Reflection supports this transformative, dynamic process of emerging professional identity formation.[2] Professional formation "mirrors" the process of formation in clergy tr...
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The being and the doing the work of a physician.[1] Attitudes, values, beliefs. Scientific knowledge, clinical skills, technical expertise. All key elements of the becoming of a physician; their development essential within professional competency. Reflection supports this transformative, dynamic process of emerging professional identity formation.[2] Professional formation "mirrors" the process of formation in clergy training, preparing an individual to serve a spiritual calling.[3] Vicini and colleagues' use of reflective writing pedagogy during medical residency training [4] embodies this process which includes "attention to one's inner life, reflection on experience and growth in self-knowledge" along with "growth in expertise and intense mentoring."[3 pg.230, 5,6] Within a medical residency curriculum jam packed with clinical mastery imperatives, it's reassuring to see educators walking this talk. With the power of the pen.
The value of "slowing down when you should" is highlighted in surgical education[7] and germane to medical education in general. Get off the treadmill of do, do, do and reflect on all you are doing and becoming as an emerging reflective practitioner.[8] Writing can help us do just that. "I write because I don't know what I think until I read what I say," Flannery O'Connor wrote.[9] And "what I feel," I would propose based on Vicini and colleagues' work with written reflections that allows space for exploration of emotions (and beliefs) which can include tolerating uncertainty and other challenging emotions as well as ethical and spiritual development.[4] Indeed, clinical training and practice should encompass this and must. Emotions can affect both the quality of medical care and the physician's own sense of well-being[10] and cultivating moral character and ethical vigilance within medical practice is integral to medical education.[11] Reflective writing-enhanced reflective habits of mind, heart, and practice[12] can help with identifying professional dilemmas[13] as well as the ethical reasoning for addressing those dilemmas.[14]
I'm a believer, based on my own experiences with reading and providing feedback to medical students' reflective writings on formative experiences within emerging professional persona.[2] Furthermore, the need for resilience and wellbeing promotion has been identified within a developmental PIF process that can indeed be both "adventure-wonder and adventure-ordeal."[15] Both the content of Vicini and colleagues' residents' reflective writings (within opportunities for sharing within a community of practice) and their focus group outcomes are compelling evidence for the value of adding protected time for written reflection that can "foster the more realized person as physician, a better doctor."[4] Their work with reflective writing for personal and professional flourishing within PIF [16] complements the work of narrative reflective practice with internal medicine and obstetrics-gynecology residents.[17,18] Reflective writing-enhanced self-awareness, emotional processing, and empathy as well as self-compassion may help prevent "physician distress, disengagement, burnout, and even poor judgment" which may be associated with unexamined emotions.[11 pg.3007] As such, reflective writing pedagogy within supportive mentorship and peer collaborative reflection can help foster both emotional and moral resilience[19] and be a vehicle for expanding the Triple Aim toward realizing a Quadruple Aim with inclusion of caring for the practitioner, enhancing wellbeing, and bringing joy to medicine.[20] Nurturing one's inner life in this way with spiritual exploration and meaning-making can ideally enhance one's focus outward and help preserve empathic, humanistic clinical practice. Further research on long-term impact of cultivating the inner life of a physician on humanistic patient care and practitioner wellbeing will be of interest.
References
1. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: Integrating identity formation into the medical education discourse. Acad Med. 2012;87:1185-90.
2. Wald, HS. Professional Identity (Trans)Formation: Reflection, Relationships, Resilience. Acad Med. 90(6): 701-706.
3. Nothnagle, M. Reis S, Goldman RE, Anandarajah G. Fostering Professional Formation in Residency: Development and Evaluation of the "Forum" Seminar Series. Teach Learn Med. 26:3, 230-238.
4. Vicini A, Shaughnessy AF, Duggan AP. Cultivating the Inner Life of a Physician Through Written Reflection. Ann Fam Med. 2017; 15(4): 379-381.
5. Daaleman TP, Kinghorn WA, Newton WP, Meador KG. Rethinking professionalism in medical education through formation. Fam Med. 2011;43:325-9.
6. Rabow MW, Remen RN, Parmelee DX, Inui TM. Professional formation: Extending medicine's lineage of service into the next century. Acad Med. 2010; 85:310-7.
7. Moulton CE, Regehr G, Mylopoulos M, MacRae HM. Slowing Down When You Should: A New Model of Expert Judgment. Acad Med. 2007; 82(10): S109- S116.
8. Wald, HS. Refining a definition of reflection for the being as well as doing the work of a physician. Med Teacher. 2015; 37(7): 696-699.
9. Flannery O'Connor. http://oconnorflannery.blogspot.com/ Accessed August 6, 2017.
10. Meier DE, Back AL, Morrison RS. The Inner Life of Physicians and Care of the Seriously Ill. JAMA 2001; 286(23): 3007-3014.
11. Reis SP, Wald HS. Contemplating Medicine During the Third Reich: Scaffolding Professional Identity Formation for Medical Students. Acad Med. 2015; 90(6): 770-773.
12. Shulman, L. Signature pedagogies in the professions. Daedalus. Summer 2005; 134:52-59.
13. Wald HS, Borkan JM, Taylor JS, Anthony D, Reis SP. Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Acad Med. 2012; 87(1): 41 -50.
14. Margaret Moon M, Taylor HA, McDonald EL, Hughes MT, Beach MC, Carrese JA. Analyzing Reflective Narratives to Assess the Ethical Reasoning of Pediatric Residents. Narr Inquiry Bioethics. 2013; 3(2): 165- 174.
15. Madill A, Sullivan P. Medical training as adventure-wonder and adventure-ordeal: A dialogical analysis of affect-laden pedagogy. Soc Sci Med. 2010; 71:2195-2203.
16. Wald HS. Insights into professional identity formation in medicine: Memoirs and poetry. Eur Leg Towar New Paradig. 2011; 16:377-384.
17. Levine RB, Kern De, Wright SM. The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ. 2008; 13: 723-33.
18. Learman LA, Autry AM, O'Sullivan P. Reliability and validity of reflection exercises for obstetrics and gynecology residents. Am J Obstet Gynecol. 2008;198:461.e1-461.e10.
19. Wald HS, Anthony D, Hutchinson TA, Liben S, Smilovitch M, Donato AA. Professional Identity Formation in Medical Education for Humanistic, Resilient Physicians: Pedagogic Strategies for Bridging Theory to Practice. Acad Med. 2015; 90(6): 753-760.
20. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014; 12(6):573-6.
Competing interests: None declared
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Competing Interests: None declared.