1. Reflective Writing as Professional and Personal Development Dean A. Seehusen, MD, MPH, FAAFP Program Director NCC – Family Medicine Residency dean.a.seehusen.mil@health.mil

2. Objectives Describe the benefits of reflective writing for medical professionals and educators List the 2 most important features of reflective writing List the 3 key tasks of the reflective writer Name at least 5 venues for publishing reflective writing Generate ideas for potential reflective writings

3. Agenda Introductions Define reflective writing Identify features of reflective writing Identify key tasks of reflective writer Discuss publishing ***Interspersed audience tasks***

4. Introduction Who is in the audience?

5. Introduction Who is in the audience? Who am I?

6. Introduction Who is in the audience? Who am I? Why did I begin publishing?

7. Introduction Who is in the audience? Who am I? Why did I begin publishing? Why do I continue to publish?

8. Reflective Writing A practice in which the writer describes a real or imagined scene, event, interaction, passing thought, memory, form, adding a personal reflection on the meaning of the item or incident, thought, feeling, emotion, or situation in his or her life.

9. “But I don’t see patients” You will still have professional topics that inspire passion for you and others Your work –Impacts you personally –Impacts patients –Impacts the scientific literature –Has the ability to stimulate reflection

10. Professional Benefits Validating professional identity Develop critical thinking skills Challenge assumptions Connection with peers Potential for publication Develop insight into profession Improve patient care skills Shapiro J. Fam Med 2012;44:309-11

11. Personal Benefits Catharsis Acknowledge emotions Self-assessment Self-understanding Values clarification Prevent cynicism and disillusionment Offsetting burnout Shapiro J. Fam Med 2012;44:309-11

12. Getting Started An audience participation event

13. Who is YOUR Audience? Yourself –Memoir –Personal satisfaction –Therapy Small group of colleagues –Department –Military only –Professional society Publication

14. Who is YOUR Audience? Yourself –Memoir –Personal satisfaction –Therapy Small group of colleagues –Department –Military only –Professional society Publication

15. Audience Task #1 List 3-5 events or episodes from your professional life that elicit significant emotion from you (could be a concept) They may also have some significant overlap with your personal or social life, but should connect to your professional life in some way You will NOT be coerced into sharing anything you do not wish to

16. Two Indispensible Features A story that is: –Heart wrenching, fascinating, tear jerking, hilarious, one-of-a-kind, mesmerizing, paradoxical, awe-inspiring A concept that is: –Fundamental to your profession, frequently forgotten, controversial, heretical, dogmatic, in need of revision, outdated, timeless

17. Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and pain in her back. Then a chest X-ray showed her left lung had collapsed, and her chest was filled with fluid. -Letting Go Atul Gawande in The New Yorker

18. This is the point in Sara’s story that poses a fundamental question for everyone living In the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic cancer – or, for that matter, a similarly advanced case of emphysema or congestive heart failure – what would you want your doctors to do? -Letting Go Atul Gawande in The New Yorker

19. Three Tasks Tell the story exceptionally well Lucidly describe the concept Convincingly relate the story to the concept

20. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s okay” or “I’m sorry” or “I love you.” -Letting Go Atul Gawande in The New Yorker

21. “Her father and her sister still thought that she might rally. But when the others had stepped out of the room, Rich knelt down weeping beside Sara and whispered in her ear. “It’s okay to let go,” he said. “You don’t have to fight anymore. I will see you soon.” -Letting Go Atul Gawande in The New Yorker

22. Audience Task #2 Pick 1-2 of the events or episodes from the list you developed before If you are having a hard time picking, pick the ones that elicit the most emotion in you List the major emotions these elicit in you and why

23. Two Broad Categories Confirmatory –Reaffirm beliefs –Validating professional and personal values Transformative –Challenge norms –Altering world view Shapiro J. Fam Med 2012;44:309-11

24. Confirmatory These reflective writings leave you feeling re-energized and thankful Show the value of your work Remind you why you do what you do Make you proud of what you do

25. Transformative These reflective writings make you re- assess about what you believe to be true Special circumstances that led to you act in a way you normally would not have Expose an additional way of looking at a problem An experience that will alter the way you think or act in the future

26. Possible Structures Two course meal Sandwich Layer cake

27. The Two Course Meal StoryConcept StoryConcept OR

28. The Sandwich StoryConcept StoryConcept OR StoryConcept

29. The Layer Cake OR Story Concept Story Concept Story Concept Story

30. Audience Task #3 Narrow your list down to just one If you are having trouble, pick one that you think other professionals: –would relate to –could learn from –might be emotionally stirred by Take 5 minutes to write the story in an outline fashion or as a single paragraph

31. Places to Publish Top Tier –JAMA: “A Piece of My Mind” –Annals of Internal Medicine: “On Being a Doctor” –BMJ: “Fillers” Other –Family Medicine: “Narrative Essays” –Medical Encounter: “Narratives & Health” –Pulse: http://www.pulsemagazine.org –Letters to the Editor

32. Obligations to Others How does the story reflect on others? –Colleagues –Family –Patients Confidentiality Consider requesting permission Shapiro J. Fam Med 2012;44:309-11

33. Reflection and Education Excellent way for learners to process the new experiences they are having May actually lead to increased resiliency Proposed as a method for teaching empathy For residents, addresses ICS and PBLI Impact on professionalism? Wald HS, Reis SP. J Gen Intern Med. 2010;25(7):746-9.

34. Audience Task #4 Write a paragraph about what message you think this event/episode/concept reveals. Potential questions to ask yourself: –What could other professionals learn from this? –What larger truth about your profession does it reveal? –What does it say about human nature? –What weakness of downside of your profession does it expose?

35. A Personal Example “Going Home” published in November 2008 Email from medical student who had read the essay and felt the same way Letter to the Editor published in April 2009

36. University of Wisconsin MS3 I would just like to take the time to thank you for writing your essay “Going Home”…. I can’t convey how much I appreciate your essay…I have a copy that I keep in my white coat on the wards as a reminder to follow the “milk prices” as it is a great proxy for how the farmers of north central Wisconsin are doing in such a tenuous time…

38. Outcomes of “Going Home” Personal catharsis Publication in the peer-reviewed literature Personal impact on a medical learner Publication for that learner Suggests a possible scholarly question that is amenable to research through relatively simple methods

39. Bibliography Shapiro J. Narrative Medicine and Narrative Writing. Fam Med. 2012;44:309-11. Bolton G. Reflective Practice: Writing and Professional Development. London: Paul Chapman Publishers; 2001. Roy R. Teaching cultural sensitivity through literature and reflective writing. Virtual Mentor. 2007;9(8):543-546. Shapiro J, Kasman D, Shafer A. Words and wards: a model of reflective writing and its uses in medical education. J Med Humanit. 2006;227:231- 244. Wald HS, Reis SP. Beyond the margins: reflective writing and development of reflective capacity in medical education. J Gen Intern Med. 2010;25(7):746-9. Charon R, Hermann N. A sense of story, or why teach reflective writing? Acad Med 2012;87(1):5-7.

40. Questions? Comments?