Reflective Rounds in a Surgery Clerkship

1. Reflective Rounds in a Surgery Clerkship Mary T. White Boonshoft School of Medicine Dayton, Ohio

2. Why? • Attention to spirituality has long been recognized as an essential component of effective palliative care. • Today, growing effort to integrate spirituality into medical school curriculum. • Typically, course content, electives, are delivered in B1, vary widely, and inconsistentlyaddress spirituality as part of students’ personal and/or professional development. • 2009 Competencies in Spirituality for Medical Education were developed, emphasizing core knowledge, communication skills, and more. • 2011-2012 George Washington University and Templeton Foundation partnered to develop curriculum for clinical years: the G-TRR Reflective Rounds

3. G-T Reflective Rounds: Goals • Through exploration of spirituality, to • Affirm the call to service. • Prevent burnout, improve well-being. • Promote patient-centered clinical care. • Focus on personal and professional formation, to: • “Embed spirituality in the clinical years with a replicable sustainable model” based on defined competencies. • Provide an educational forum for exploration of spirituality and self- and patient care. • Use the outcomes as an evidence base to sustain the spirituality competencies in medical education. • Monitor efficacy and disseminate findings.

4. Characteristics of Medical Education • Long on content, short on reflection • Little attention to emotional impact of clinical experiences • Expectations of positive emotional availability (empathy, compassion, etc.) without evident emotional support. • Can lead to burnout, cynicism, feelings of isolation, stress, depression; loss of purpose/sense of meaning in medicine.

5. Reflective Rounds • Provide a supportive forum for discussion of students’ experiences, emotional reactions, beliefs, values, and personal challenges. • Encourage habits of reflection, emotional self-awareness, meta-cognition. • Focus on four general topic areas: • Sources of meaning in medicine • Suffering • Boundaries • Finding fulfillment and self care

6. Spirituality defined as: • That which gives meaning and purpose to life, recognizing that every person makes decisions about when and whether life has meaning and value that extends beyond life, self, and death.

7. Structure • Two hours/week for four weeks in rotations 2-5 of Surgery Clerkship. (Sessions 1 and 6 are control groups for research.) • Met in groups of nine students or less (we needed two sessions each week to reach all students). • Jointly facilitated by an ethicist or physician and a hospital chaplain. • I (MW) adapted the materials provided to fit within our four-week time frame, adhering to the prescribed format as closely as possible.

8. Safe Space • Coffee, snacks, etc. made students feel welcome. • Facilitators had no role in clerkship evaluation. • First session included explanation of what the goals of reflection rounds were, that the focus was on students’ needs and thoughts, and set ground rules (chiefly that confidentiality was to be maintained).

9. Practiced Reflective Listening • The belief that the capacity for self-insight, problem solving, and growth resides primarily in the speaker. • The listener’s role is to think about how the person see’s himself/herself and situation, not to solve problems. • Listen more than talk. • Respond to the speakers’ frame of reference, rather than abstract concepts. • Restate/clarify what is heard, don’t solve problem. • Tryto discern and respond to emotional and spiritual content, rather than facts/ideas. • Respond with empathy and unconditional acceptance, not objectivity or detachment. • Facilitators speak minimally, chiefly to clarify or direct.

10. Opening/closing rituals • Begin by asking students, in silence, to recall an experience with a patient or staff member related to the theme of the day. Notes/verbatim encouraged if helpful. • Handout provided with standard and theme-specific questions. • Sessions ended with another moment of silence, to bridge the transition back to students’ didactic sessions and clinical responsibilities.

11. Discussion • Begin by asking all students to state briefly what experience they thought of and why. • Students then chose which stories they wanted to hear more about; the discussion moved on from there. • Standard questions provided for reflection included: • Why this particular patient? • What was your emotional response to this patient? • What did you learn from this encounter?

12. Weekly topics • Session 1 • Where do you find meaning in medicine? • What is it like to be a medical student? • How does personal faith or belief come up in patient care? • Session 2 • What is suffering? • When do you (and don’t you) notice suffering? • How do you respond to suffering? • Session 3 • What are some different kinds of boundaries? • How do boundaries contribute to/detract from effective relationships with patients? • What boundaries are most challenging? • Session 4 • When are you most fulfilled in medicine? • What keeps you from feeling fulfilled? • How do you take care of yourself? • What makes your heart sing?

13. What we found • Students readily, eagerly, responded. Evaluations highly positive. • Concept of “spirituality” too loaded to use easily; “meaning in medicine” was more effective and brought rich, humanistic responses. • “Suffering” elicited insightful responses to a wide variety of experiences. • “Boundary” issues were largely identifiable to all but a few. • Final discussion: of sources of fulfillment and self-care strategies was the weakest in terms of content.

14. What we talked about • Experience of being powerless, the lowest rung of a hierarchy • The satisfaction of meaningful connections with patients, of feeling valued • The privilege of being invited into intimate moments in patients’ lives • Anger at difficult patients who “cause their own suffering” • The need to act professionally despite feelings about some patients or physicians. • Emotional reactions to acute suffering and death • Fear of making mistakes. • The need for emotional boundaries; compassion can be burdensome. • Reactions to offensive behaviors or poor patient care by residents and preceptors; the impulse to align with patients or vice versa • The desire to be liked; awareness of attraction to some patients and need for boundaries • Sources of boundaries: family, beliefs, profession • Experience of gender differences in medicine • The joy of learning, of developing skills and working effectively with teams • Coping (or not) with stress, exhaustion, burnout • Use of prayer, writing, and talk as coping strategies • Increased respect for classmates

15. G-TRR Research • Control groups – first and last rotations (1& 6) • Each rotation: • Assessed extent of teaching on spirituality and reflection at medical school • Malasch Burnout inventory • Center for Epidemiologic Studies Depression Scale (CES-D) • Functional Assessment of Chronic Illness Therapy Spirituality (FACIT) • Patient-Practitioner Orientation Scale (PPOS) • Program survey • Qualitative survey