Faculty Development Pearls

Encouraging Reflection to Deepen Learning and Combat Burnout-Rebecca Hutchinson, MD

Kolb describes 4 stages of experiential learning, the type of adult learning that forms the cornerstone of medical education.^1,2

Although all of these steps are important, reflection is believed to be particularly important to create deep or lasting learning.³  Reflection is a metacognitive process, or thinking about thinking; this process allows the learner to make connections between new information and prior experiences and knowledge.⁴  Effective reflection results in connections that increase accessibility of the learning, allowing application to relevant subsequent scenarios.  Reflection can be written or oral, there is no evidence to suggest superiority of one method over the other; this MITE tip will discuss methods of facilitating both.⁵

There are many ways that we can incorporate reflection into our education of medical trainees of all levels.  Prior to encounters, we can encourage reflection by explicitly discussing our objectives for the visit using questions such as: “What physical exam maneuvers might be most helpful to determine our management for the day?”  or “What questions should we ask the patient in order to further refine our differential diagnosis?”  This type of reflection will help the learner know what to focus on during the encounter, increasing the yield of the learning experience.  This type of ‘pre-visit’ exercise can help all members of the treatment team maximize their learning from a shared patient encounter even if they are not participating in an active way.  We can also encourage reflection after encounters.  Some examples of questions that could be used to reflect are:  “how did the physical exam compare to what we expected to find in this patient with advanced heart failure?” or “what emotion do you think the patient was having when you explained the plan for the day?”¹

In addition to facilitating deep and lasting learning, reflection has also been shown to be an effective way to improve resiliency and well-being of the clinician as well as increase empathy for patients.^6,7  It is particularly important to help learners take the time to reflect after challenging emotional experiences.  We can do this by having formal or informal debriefing sessions where all members of the care team have the opportunity to share how they are feeling or how the experience is impacting them personally.  We can also encourage reflection through writing, such as through the use of journaling.  Additionally, you could consider having medical students and/or residents do a writing exercise at the end of a month long rotation to encourage reflection.⁵  Some examples of prompts are: writing gratitude letters to patients, writing about a patient who surprised them and explaining why, reflecting on a time when they felt they communicated something difficult in a way that was effective (or not!).  One fun exercise to consider doing as a group to aid in reflection and team bonding is having everyone write a six-word story.  A famous example of this is “For sale: baby shoes, never worn,” attributed to Hemingway.  These writing exercises help our learners, but they can also help us.

References:

1. Maudsley G, Strivens J: Promoting professional knowledge, experiential learning and critical thinking for medical students. Medical education 34:535-544, 2000
2. Kolb DA, Boyatzis RE, Mainemelis C: Experiential learning theory: Previous research and new directions. Perspectives on thinking, learning, and cognitive styles 1:227-247, 2001
3. Mann K, Gordon J, MacLeod A: Reflection and reflective practice in health professions education: a systematic review. Advances in health sciences education 14:595, 2009
4. Sandars J: The use of reflection in medical education: AMEE Guide No. 44. Medical teacher 31:685-695, 2009
5. Aronson L: Twelve tips for teaching reflection at all levels of medical education. Medical teacher 33:200-205, 2011
6. Chen I, Forbes C: Reflective writing and its impact on empathy in medical education: systematic review. Journal of educational evaluation for health professions 11, 2014
7. Zwack J, Schweitzer J: If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine 88:382-389, 2013

Can you really make your brain BIGGER: Using cognitive science to increase your study efficiency and retention by Jason F. Hine, MD-Emergency Medicine SMHC

How are we as clinicians going to keep up with the ever-expanding fund of medical knowledge?

The rapid expanse of medical knowledge is a well-recognized reality creating a daunting circumstance for us as clinicians- trying to keep up with what we need to know.¹ There are several strategies to help the practicing physician keep up. These include:

1. “Peripheral brains” such as smartphone apps and pocket cards
2. Secondary journals- which were discussed in our November Monthly Tips
3. Efficient study techniques

Wouldn’t it be great if you could improve the efficiency with which you study and learn?

Enter cognitive science. While this is a vast field of research covering a range of topics, one area of study has been in the production and retention of memories.  A summation of this field’s findings can be found in the book Make It Stick: the Science of Successful Learning.² Cognitive scientists Henry Roediger and Mark McDaniel teamed up with story teller Peter Brown to outline how we can improve our efficiency in learning and memory retention. In its simplified form, this involves four processes:

• Retrieval Practice (R) – As a medical student you cannot spend 3 grueling hours on acid-base analysis, put the book down and expect to nail an ABG interpretation 4 months later. To solidify a memory into our long-term bank we must practice using it. Quite simply, this is the act of pulling information (a memory) from our memory back. This is retrieval practice.
• Spacing (S) – The idea of spacing is linked to retrieval practice but gives greater detail about when we should be retrieving memories. It is fine to practice retrieving a memory 30 minutes after it is created (ie shortly after you read a new article), but it is more powerful and efficient in creating memory retention when some time has passed. Allowing for a bit of forgetting to occur and making the retrieval effortful leads to greater retention.
• Interleaving (I) – Interestingly, cognitive science has found that when we mix our study of different subject matter we often gain a greater understanding of each. This is thought to be related to pattern recognition across topics, rule generation, and the linking of memories in our brains. By mixing our review of several articles, therefore, we can improve our retention of the take-home from each.
• Generation (G) – The concept of generation is akin to an active rather than passive learner. It explains that in creating from our memory we again reinforce the content and improve retention. Activities such as recollective summaries or content application are much more retention-producing than passive actions such as rereading.

So, after reading an article use these steps to “Make it Stick”:

1. Take a moment to write out the key points of the paper and how they may affect your practice (R, G).
2. Create an alert 1 week later (via smartphone, calendar, post it notes, whichever structure works for you) to remind yourself to do a recollection exercise where you spend two minutes writing all you can remember on the article, then review and correct (R, S, G).
3. Create a notecard with the article title on one side and short summation on the other (S, G).
4. Whenever you sit to read a new article, review the notecard and simply speak aloud the major summative points (R, S, I, G). Once the article and its content become second nature, the notecard can be filed or discarded.

While more effortful than our inherent learning strategies, this method of study based on cognitive science is more time efficient. For most of us, our typical pattern involves reading an article, putting it down, forgetting it, and rereading it months to years later when we realize the content is lost. In the proposed study construct, after the first active reading session the subsequent retrieval activities are quite short, collectively require less time, and are higher yield for actually remembering the topic.

To learn more on the topic of memory retention, please read Make it Stick or use these links to my podcast website for my summary and interview with the author.

References:

1. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
2. Brown P, Roediger H, McDaniel M. Make It Stick : the Science of Successful Learning. Cambridge, Massachusetts :The Belknap Press of Harvard University Press, 2014.

Staying on Top of the Literature by Christopher Turner, MD Pediatric Surgery

When I was preparing for my pediatric surgery boards, I asked an emeritus professor for advice. He recommended what he had done for his boards: read every article ever published in the Journal of Pediatric Surgery. While this may have been feasible in 1979 with thirteen volumes, it was not feasible now with fifty-three. Not only have journals continued to churn out articles, they are doing it more quickly. The number of citations added to MEDLINE per year has almost tripled over the last twenty years from 322,825 in 1996 to 869,666 in 2016. Our ability to produce medical data as a community has exceeded our ability to consume it as individuals. I would like to offer you some strategies and resources to compete.

1.      Primary Journal. Identify the primary journal for your specialty. Commit yourself to reviewing every issue.
   1. Make it a habit. Try to reserve time on your outlook calendar so it does not get skipped. Do it with a peer so you can hold each other accountable. Pair it with a treat (like a molasses cookie at Tandem!).
   2. If you like print, subscribe. If you like digital and free, consider Browzine (com). This is a service supported by our library that allows easy reading of most major journals on your tablet or phone. It also allows you to track individual journals and save articles.

2.     Secondary Journals. There are many services that curate the literature. Here are a few.

2. Read (com/read-by-qxmd) or Case (https://www.casemedicalresearch.com) or Prime (www.unboundmedicine.com/products/prime). These apps send you the most popular articles in selected specialties. I have received a weekly email from Read since fellowship. It often shows me interesting articles that I would not have otherwise. Case allows you to listen to audio transcriptions of abstracts which might be useful for your commute.
3. Journal Watch by the New England Journal of Medicine (org). A good option for medical specialties. It reviews 250 major journals and posts updates by email. The twelve specialties are cardiology, emergency medicine, gastroenterology, general medicine, HIV/AIDS, hospital medicine, infectious diseases, neurology, oncology, pediatrics, psychiatry, and women’s health.
4. Patient Oriented Evidence that Matters (com). This sends email alerts with updates. I have not used it but it looks promising.
5. Uptodate and Dynamed. Both of these review services also offer subscriptions to receive email alerts for “practice changing” updates. I have not used them either
6. TDNet (com). This will send you the table of contents for the journals that you select. I find it clutters my inbox.

3.      Deep Dive. Through myNCBI, it is possible to receive a regular email with all new publications from PubMed that match a particular search term. This can be overwhelming. It works well for very narrow topics and when you don’t want to miss a thing. Consider it for your research projects. Ask library staff to help you set it up.

I am sure many of you have your own habits and suggestions. Please send them to me if you are interested at cturner1@mmc.edu. I will try to post them here as comments.

I would like to thank Dina McKelvy and the library staff for their help compiling these resources and for their frequent kind assistance.