Brief, Real-Time Reflections: An Efficient, Contextual, and Familiar Variation of Narrative Medicine: A Mixed Methods Analysis

Brief, Real-Time Reflections: An Efficient, Contextual, and Familiar Variation of Narrative Medicine: A Mixed Methods Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Brief, Real-Time Reflections: An Efficient, Contextual, and Familiar Variation of Narrative Medicine: A Mixed Methods Analysis Brian Hilgeman, Kevin Kurtz, Mary Hoeschen, Zachary Hovis, Rachele Harrison, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4209623/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Narrative medicine is a widely used pedagogic tool but can be detached from the clinic context and unfamiliar to students. Brief real-time reflections could be a method of narrative medicine that is contextual, familiar, and convenient. Methods : Fourth year medical students completed 280-character reflections immediately after patient interactions while rotating in a primary care clinic serving complex patients. Three researchers used qualitative methods to develop a codebook to describe the reflections and an independent auditor verified codebook application. Student feedback regarding their experience writing reflections was elicited on a Likert scale to understand student perspectives on the tool about ease of use, empathy, and remembering patient interactions. Results : Eighteen students completed 131 reflections during 64 clinics; an average of 2.04 reflections per clinic and spent an average of 4.39 minutes on each reflection. Three codes were elicited to describe the content of reflections: descriptive, emotional, and cognitive. The most frequently identified code was cognitive (n = 84, 41%), with descriptive (n = 69, 33%) and emotional (n = 53, 26%) being less frequent. Reflections could contain one or a combination of codes. The most common reflection was cognitive-only (n = 43, 33%) followed by a combination of descriptive and emotional (n=24; 18%). Most students agreed or strongly agreed that reflections helped them think more deeply about (9/9, 100%) and remember (8/9, 89%) patient interactions and were a good use of their time (7/9, 78%). Conclusions : Brief, real-time reflections are a tool that allow medical students to reflect upon their clinical experiences in a complex and cognitive way and was well-received by students. Narrative medicine reflection pedagogic tool Figures Figure 1 Practice Points Brief, real-time reflections are a narrative tool that can be utilized at the point of care in a manner that is familiar to students and efficient, requiring less than 5 minutes to complete. Qualitative analysis revealed 3 codes: descriptive, emotional, and cognitive to define the content of the reflections with many reflections containing multiple codes. Real time brief reflections appear to have 2 common and distinct methods of use: cognitively processing events that are encountered and emotionally describing the feelings of self or others that occurs during patient care encounters. Students were engaged in the process and responded that the tool helped them to think more deeply about and remember patient interactions and agreed it was a good use of their time Introduction Habitual and purposeful reflection upon our lived experiences has a myriad of benefits including impacts on professional identity formation and empathy among medical learners [1]. These skills have been increasingly focused on in curricular development at medical schools by using reflection to augment established curriculum allowing students to intentionally digest and process their experiences during clinical rotations. Narrative medicine is a well-established curricular tool that allows caregivers the opportunity to “absorb, interpret, and respond to” [2] experiences with the goal of developing physicians who “practice medicine with empathy, reflection, professionalism, and trustworthiness” [2]. The definition of narrative medicine is loosely defined as tools that allow students to “acquire, comprehend, and integrate the different points of view in the illness experience” [3] but in practice, pedagogic and curricular approaches are varied, and outcome analyses are diverse [4]. Professional identity formation is a complex process by which medical students transition from laypersons to physicians [5] by assimilating the characteristics, values, and norms of the medical profession with core values, moral principles, and self-awareness [6]. As a vehicle for professional identity formation, intentional reflection about our experiences enables us to process, make sense of, and more fully understand what we have witnessed [2, 7-9]. This allows us to remember, learn from, and modify our future behavior from past experiences, leading to professional gains in relation to the individual, relationships, and society, key components to professional identity formation and empathy. Empathy and compassion skills are particularly important for students and practitioners of medicine who bear witness to some of humankind’s most emotional and vulnerable experiences. Contrary to this necessity, it has been found the empathy scores decline throughout the clinical years of medical school [10] and practicing physicians often lack the skills needed to sensitively care for their patients [11, 12]. Empathetic care is correlated with improved chronic disease outcomes [13], reduced medical errors [14], reduced potential litigation [15], and diminished burnout among clinicians [16]. Reflective practice helps us to understand, value, and take perspective of those that we interact with, developing more empathetic and compassionate emotions toward our fellow humans [8, 9]. Rita Charon states, “by rendering whole that which they observe and undergo, doctor-writers can reveal transcendent truths, exposed in the course of illness, about ordinary human life” and develop “deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness” [7]. Evidence is strong that narrative curricula foster empathetic concern among health professions students [17-21] by allowing students to develop core skills necessary for empathy, including perspective-taking, valuing others, and humanizing patients [22]. Thus, narrative practice can lead to meaningful gains in professional development by giving students the space to consciously process the gap between the technical knowledge learned in medical school and the tacit knowledge learned through patient interactions and stories [23]. Requirements for long prose or reflective sessions may not be practical or widely adopted in the context of busy curricular and clinical schedules and further degraded by the volume of scientific learning required during medical training. Furthermore, mock clinical scenarios may be detached from clinical or emotional context for students. A more practical, effective, and convenient tool could be brief and occur in real-time, immediately or shortly after patient interactions. This method of narrative medicine has only been studied in the limited context of surgical rotations [24] and has not been studied in other contexts, such as primary care. In this study, a pedagogical tool of brief real-time reflections on patient care experiences was implemented with fourth-year medical students who rotated in a clinic serving patients with high medical and psychosocial complexity. Our analysis aimed to develop a framework to describe what students reflect upon with the pedagogical tool and to understand the practical usability and feasibility of the tool for students through process and student feedback data. Our primary hypothesis was that the content of these reflections would show that students could reflect in a cognitive and emotional manner with this tool. In addition, we hypothesized that the tool would have good uptake and students would find it useful. All of this is intended to build upon the abovementioned research showcasing the benefits of narrative medicine on professional identity formation and empathy among medical learners. Materials and Methods Context: M4 Ambulatory Internal Medicine: The Ambulatory Internal Medicine (AIM) course is a required, one-month clerkship completed during the 4 th year of medical school (M4) that allows students the opportunity to learn about the diagnosis and management of common ambulatory conditions with experiences in primary and specialty care. Students rotate through a variety of ambulatory care clinics during their rotation with anywhere between one and six half days in each clinic per month. The Enhanced Care Program : The Enhanced Care Program (ECP) is one experience available to students in the M4 AIM course. It is an intensive primary care clinic with an interdisciplinary team that is focused on individuals with high health care utilization, caring for patients that often have significant medical and psychosocial conditions. Students who rotate in the ECP complete approximately three to five half-day clinics over four weeks, participating in all clinical activities, including hospital encounters, home visits, and observing the work of the interdisciplinary care team. The Intervention: A didactic presentation about the ECP and the care of high need, high-cost patients was given to every M4 student (N = 49) at the start of the AIM course. Half the students were randomly assigned to rotate in the ECP (n = 18) with a single preceptor. Students assigned to the ECP were prompted to write 3 anonymous reflections about their experiences in patient care per each half-day they spent in the ECP. Students did not complete reflections while rotating in other clinics. Students were provided the following phrase: “Please write a reflection about your experience with this patient. Limit 280 characters. Do not include any identifying patient information.” The prompt was kept intentionally broad to allow students to adapt to the patient care context at hand. Students were reminded by the preceptor frequently to complete their reflections throughout the month. Students completed their reflections via Qualtrics, an IRB-approved data gathering service. All reflections were anonymous, only the date and timestamp of the reflections were recorded. Additionally, precepting faculty did not have access to the reflections while students were on rotation. Data was collected from March 2019 through October 2019. The study was reviewed and approved by the institutions Institutional Review Board. During the intervention, the tool was referred to as tweets aligning with current utilization of social media platforms for students. The tool has been re-named brief, real-time reflections to highlight the uniqueness and privacy of the tool and pivot away from the current business model changes at Twitter. Analysis: Grounded theory methods were strictly followed to allow for robust and un-biased analysis according to established principles of framework analysis [25]. Three coders collaborated to develop the codebook. One of the coders (BH), was the primary investigator and clinician preceptor involved in the intervention. The other two coders (LM and KK) were not involved in the design and implementation of the pedagogic tool. LM is a learning scientist and educational researcher who has extensive experience implementing qualitative methods, including grounded theory. LM led the analysis and ensured the team strictly adhered to qualitative methods quality criteria. Inductive coding was used to develop the codebook (Table 1) following rigorous qualitative methods [25-27]. The process was iterative and involved frequent refinements of the codes and definitions between the coders. As new codes emerged through the inductive process, previous codes and reflections were reviewed to ensure accuracy and clarity. Care was taken to ensure all reflections were reviewed by at least 2 coders and inter-coder agreement was found to be 82% once the codebook was complete. An independent auditor was educated on qualitative methods. Her role and duties as auditor were explained by the coding team led by LM. The auditor was given a random sample of 20% of the reflections from the dataset along with the developed codebook. The auditor (MH) was not involved in the design of the study or clinical care with the students and had no knowledge of the clinical scenarios that were reflected upon. Example reflections for each code were included in the codebook to further illustrate the definition of each code. Initial inter-coder agreement between the auditor and research team was 61%. The group met and discussed disagreements and refined code definitions as a team. All disagreements were resolved, and inter-coder agreement was 100% at the end of analysis. In addition, a survey was sent out to students after the rotation to garner feedback on the tool. Survey questions aimed to understand the students’ perceptions of the tool including impacts on empathy, use of time, empathetic responses, and remembering and thinking deeply about patient encounters (Figure 2) aligned with understanding impact on the study hypotheses. A Likert-type scale was used, with 1 being strongly disagree, 3 being neutral and 5 being strongly agree. Frequency counts for each response choice and the averages of each response were calculated. A score of 4 (agree) or 5 (strongly agree) was considered a positive response and reported as such in the results. Results Eighteen M4 students participated in the study, completing a total of 64 half-day clinics over 5 months. The students generated 131 reflections with an average of 2.05 reflections per half-day session in the ECP. The average time spent on each reflection was 4.39 minutes after nine outliers were removed where students spent over 25 minutes reflecting. This cutoff was determined as it most likely indicated the student was not actively engaged in reflection but had left their browser open. Three codes were generated: descriptive, emotional, and cognitive (Table 1). The descriptive code described a reflection, or portion of a reflection, that focused on the retelling of the events and details of the patient encounter. Emotional code described a reflection, or portion of a reflection, that highlighted the emotions of either the patient, the student, the caregiver, or a combination of individuals during the encounter. Cognitive codes described a reflection, or portion of a reflection, that displayed active and intentional cognitive processing including reflection on thought process or learnings regarding a patient encounter. The most utilized code was cognitive (n = 84, 41%), with descriptive (n = 69, 33%) and emotional (n = 53, 26%) codes being slightly less frequent (Table 1). Table 1: Codebook: Codes, Frequency of Use, and Definitions to Categorize Real-Time Brief Reflections in Primary Care Code Frequency of Use (absolute/%) Definition Descriptive Reflection 69/33% Reflection contains a descriptive narrative about a patient encounter or experience Emotional Reflection 53/26% Reflection demonstrates a student recognizing their own, patient, or caregiver emotions surrounding the patient encounter Cognitive Reflection 84/41% Reflection shows active and intentional cognitive processing including reflection on thought process or learnings. Reflections could be coded with one or a combination of codes. The most common reflection code was cognitive-only (n = 43, 33%), followed by a combination of descriptive and emotional codes (n=24; 18%), and descriptive and cognitive codes (n = 19, 15%). Emotional-only was the least common reflection type (n = 7, 5%) (Table 2). Table 2: Reflection Code Combinations Coded in Brief, Real-Time Reflections in Primary Care Code Frequency of Use (absolute/%) Definition Example quotation Descriptive Only 16/12% Reflection only contains descriptive code “I saw a patient with lupus and she described the depression she had due to her chronic disease because it was limiting the things she does in her life. She described it so well – chronic disease is challenging. #depression” Emotional Only 7/5% Reflection only contains emotional code “It was frustrating to hear this patient tearfully speak about the horrors of interfacing with the medical system (specifically providers). She’d been traumatized by going to doctors who didn’t believe her and talked down to her so much that she refused care at times.” Cognitive Only 43/33% Reflection only contains cognitive code “I don’t know exactly how stable housing factors into health care outcomes, but I would imagine that it is very important. It is nice to have social work as a part of the care team to address housing concerns that patients may have #stablehousing” Descriptive & Emotional Reflection 24/18% Reflection reflects both the descriptive and emotional codes “This patient came in looking for a prescription for a scooter. When she was told that we weren’t going to go there just yet, she became disengaged, started asking for tramadol, and was refusing to follow up with other recommendations we had. It was frustrating.” Descriptive & Cognitive Reflection 19/15% Reflection reflects both the descriptive and cognitive codes “Met with a patient who had chronic knee pain that was only mildly responsive to opioids. Due to other comorbidities, she couldn’t have NSAIDs or Tylenol. It showed the difficulty of caring for patients with complex problems while balancing the use of opioids.” Emotional & Cognitive Reflection 12/9% Reflection reflects both the emotional and cognitive codes “This patient was very irritable. I found myself also becoming impatient because he wouldn’t even let me examine him. Reflecting on this helped me better recognize that some patients are distrustful of the medical system and may have good reason.” Descriptive, Emotional, & Cognitive Reflection 10/8% Reflection reflects all three codes “A middle-aged woman with a variety of chronic illnesses came in with a cold. She was jovial and made a lot of jokes, many self-deprecating which made me empathize with her more. I guess humor is my main way of connecting with people.” Descriptive-only reflections contained a pure descriptive recollection of an encounter without emotional or cognitive elements. For instance, a student shared, “ Mr. L came to clinic not just for medical management but also for inquiring about losing his license. This visit was mostly a social visit which required the physician to be gentle and listen to the patient’s concerns about his license. After the visit Mr. L was more open. ” Another student reflected, “ Frightening when a patient started hav[ing] exacerbation of chest tightness and breathing difficulties during the patient interview. Thankfully symptoms improved after albuterol administration. One of the first times such an acute event has happened during one of my interviews .” These two examples provide a direct account of what occurred during a patient encounter, but do not provide additional evidence for emotional or cognitive reflection. These reflections may contain emotions such as “frightening,” but they are not explicitly recognized by the student during the reflection, nor do they contain active or intentional processing of an encounter. Emotional-only reflections only commented on emotions of the patient, student, and/or caregiver without descriptive or cognitive codes. For example, one student shared their frustration about a patient encounter, “ Speaking with the patient about his COPD, I struggled to put myself in the patient’s shoes as he told me about his living conditions and how this was negatively affecting his condition. It was frustrating for me as I felt I had a lack of understanding of his complete disease .” This reflection does not provide a description of the encounter but focuses on the student’s emotions and feelings they experienced. The student noted their frustration and their inability to “put myself in the patient’s shoes,” which, according to the student, limited their understanding of the patient’s disease. The following reflection shows a student providing a complex emotional assessment of an encounter, reflecting upon their frustration for a patient that had many negative experiences in the health system: “ It was frustrating to hear this patient tearfully speak about the horrors of interfacing with the medical system (specifically providers). She'd been traumatized by going to doctors who didn't believe her and talked down to her so much that she refused care at times.” Cognitive-only reflections contained elements of cognition, one student reflected, “ I wonder when we ask patients ‘tell me about yourself,’ how their given story in clinic compares to their true story, ” and another shared, “ It was enlightening to think that this patient’s nonadherence to medication and therapy may be significantly influenced by depression through a lack of motivation and feeling overwhelmed with other aspects of her life. Must consider broad reasons for non-compliance .” These two examples illustrate students’ deeper processing of a patient encounter beyond a mere re-telling of what happened or recognizing what they were feeling at the time. The reflections demonstrate that the encounter influenced their perspective and thinking regarding patient care. Sixty-five reflections had components of two or all three codes. One student reflected, “ An older lady was coming to terms with not being able to take care of the house that she has lived in for a long time. I felt for her and for how hard it must be to make that decision. To balance personal safety with leaving everything that brings you comfort and nostalgia .” The student provided a brief description of the encounter, then shared their emotions surrounding the encounter, and finally the student included a cognitive reflection regarding the patient’s decision making. In another example of this complex narrative was on display when a student wrote: “ She lies in bed with ulcers on her upper legs, the kind that make you wince. ‘ it was either come to the hospital or jump out the window. You guys can't understand this pain.’ We hear this kind of thing often, but I believe her. Maybe I can't feel her pain, but I can believe it.” The description in this reflection leads to a very complex emotional reflection on their patient’s illness experience. Cognitive and emotional reflections also exhibited clear and intentional processing of emotions of themselves, patients, or caregivers that were quite nuanced and complex. One student shared, “ Having an unruly patient made me slightly uncomfortable. I noticed that his agitation made it difficult for me to concentrate on his health problems as his behavior was quite distracting. I realized that I needed to do my best to ignore that and just focus on his diabetes .” This cognitive and emotional reflection displayed how a student recognized their discomfort with an “unruly” patient which led them to a cognitive reflection on what are their priorities in a patient encounter and the technical task at hand. Another student commented in a manner that was also nuanced and complex involving the cognitive processing of emptions: “ Patient was resistant because of possible admit for fluid overload. Once asked about her husband's health, she became engaged and excited. She wasn't resisting medical advice, she just cared so much for her husband's health that she was prioritizing his well-being over hers.” Another student reflected, “ His body's rejecting his new liver and he's on the list for a kidney. Genetic disorders make you feel so lucky to be average. This guy would kill to be average. He's not been out of prison long. Maybe he was acting out against a world and a life that screwed him over, I wonder .” Additional reflections regarding pairs of codes can be found in Table 1. Nine of the 18 students completed the post-survey (50%). Students responded with agree or strongly agree to questions about whether the reflections allowed them to think deeply about patient interactions (n=9/9, 100%) and remember patient encounters (n=8/9, 89%) and were a good use of their time (n=7/9, 78%). Perceived impacts on empathy were lower (n=4/9, 44%) for developing empathetic responses and (n=3/9, 33%) for impact on empathy (Figure). Discussion This study used brief, real-time reflections as a pedagogic tool for narrative patient reflection in the context of an intensive primary care clinic. The goal was to utilize qualitative analysis to understand the content of these reflections and analyze process data and student feedback to understand the utility of the tool as a familiar, contextual, and efficient pedagogic variant of narrative medicine. The developed codebook showcases that with real time brief reflections, students reflect on experiences in two distinct ways. First, students commonly reflected in a cognitive manner displaying their active thought processes and learning about patient care. These components are key tenants of professional identity formation, a focus for narrative medicine. Conversely, reflections that were descriptive and emotional were the second most common type of reflection. These reflections seem to express a separate use of the tool to describe and process the emotions of either themselves, their patients, their caregivers, or a combination of these individuals. This type of emotional reflection, understanding the perspective and emotions of others is an antecedent to the development of empathy [22, 28]. Future research includes further analysis to understand the nuances of these findings and the impact of this tool directly upon quantitative measures of professional identity formation and empathy. It is clear from this study that, despite its short, 280-character limit, students can use this platform to reflect in a complex and emotional manner based on the above qualitative analysis. Further, student post-rotation survey responses illustrate they feel that reflections allow them to think deeply about patient interactions and remember the interactions better, which likely add to the complexity of their reflections and impact of the tool on their long-term professional growth [29]. One intended goal of the tool was to develop a product that was familiar to modern students. Given the dynamic nature of medical education, modern educational tools need to deploy modern strategies to engage students. Twenty-first century students prefer and desire tools that mimic social media platforms they commonly use in their everyday lives as methods for medical education. These tools have been cited to be effective in a myriad of capacities and can serve a role to flatten hierarchies in medical education and improve communication [30] but pose a risk to erode professionalism and lead to misinformation [31]. However, if the tools are deployed in a controlled and intentional manner, the risks can be mitigated. This pedagogic tool was designed to mimic these platforms by designing something that could be utilized on mobile devices and the way students use Twitter (Now X) along with other social media platforms such as Facebook and Instagram in brief posts. The evidence for impact of this goal is the high uptake and generally positive feedback received from the students on the tool. Efficiency was a second goal of the intervention. Given the competing demands on clinical year students between busy clinical expectations and a myriad of curricular requirements, students often feel stretched thin with these competing demands. By distilling down an important curricular method, narrative medicine, into a tool that is quick and efficient, we hoped to improve adoptability and acceptability of our intervention to students. The impact in this realm is evidenced by high uptake of the tool in the clinical atmosphere along with correspondingly short time requirements to reflect (less than 5 minutes). The third goal was to form a tool that was contextual. By allowing students to reflect in the moment, when memories and thoughts are fresh, it was postulated that our tool would allow for deeper and more complex reflections. Although not directly proven, this may be an underlying mechanism for the above-mentioned cognitive complexity noted in the codebook. In addition, student perspective that this method allowed them to think deeply and remember patient interactions may be reflective of this goal. Further research is needed to clearly elicit a direct correlation of these entities. Owning to the tool’s contextual focus as well as open-ended prompting, the tool allowed students to reflect in an adaptable manner based on a real-time story. As clinical care and experiences are so varied throughout the course of training, developing a tool that can be flexible to this need is important. The breadth and variety of codes employed shows the flexibility of the tool. In one scenario, a student may describe a new experience. In another scenario, a student may comment on the emotions of an encounter. In yet another, the student may cognitively process something new they have learned. The adaptability of the tool may allow the flexibility to be deployed more widely among the health professions. This study is an initial exploration of student reflections in an intensive primary care setting. The sample from a single M4 rotation with one primary preceptor at one institution in an ambulatory medicine rotation is a limitation of the study. The impact of this tool in other institutions, with different preceptors, and in different clinical settings remains to be studied. In addition to the above analyses, the research team is seeking to understand the correlation of these reflections with professional identity formation as well as empathy through additional qualitative and quantitative analyses. To understand its utility in other contexts, the research team is working to expand to other rotations, practice sites, and other health care professional training programs. Further research exploration surrounding the utility of the tool to facilitate teachable moments by sharing with preceptors and the impact of additional prompting of the reflection on the content of reflection. Conclusion Brief, real-time reflections are a pedagogic narrative tool that have been found to allow medical students to reflect upon patient encounters in a contextual, familiar, and efficient manner while rotating in an intensive primary care program. Further research is planned to understand the impact more broadly in the curriculum and directly on empathy and professional identity formation. Declarations This study was approved by the local institutional review board (IRB) for human subjects’ protection at the Medical College of Wisconsin. All participants consented to participate in the study via an informational letter as mandated by the IRB. All data is presented in the manuscript and raw data is available upon request from the corresponding author. 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Dressler, J.A., et al., “Tweet”-Format writing is an effective tool for medical student reflection. Journal of Surgical Education, 2018. 75 (5): p. 1206-1210. Klingberg, S., R.E. Stalmeijer, and L. Varpio, Using framework analysis methods for qualitative research: AMEE Guide No. 164. Med Teach, 2023: p. 1-8. Miles, M.B., A.M. Huberman, and J. Saldaña, Qualitative data analysis: A methods sourcebook . 2018: Sage publications. Saldaña, J., The coding manual for qualitative researchers. The coding manual for qualitative researchers, 2021: p. 1-440. Batson, C.D., These things called empathy: Eight related but distinct phenomena , in The social neuroscience of empathy. 2009, MIT Press: Cambridge, MA, US. p. 3-15. DasGupta, S. and R. Charon, Personal illness narratives: using reflective writing to teach empathy. Acad Med, 2004. 79 (4): p. 351-6. Guckian, J., et al., Social media in undergraduate medical education: A systematic review. Med Educ, 2021. 55 (11): p. 1227-1241. D'Souza, F., et al., Social media: medical education's double-edged sword. Future Healthc J, 2021. 8 (2): p. e307-e310. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4209623","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288601629,"identity":"e792a643-5d25-4efd-bd95-32539d905bc3","order_by":0,"name":"Brian Hilgeman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACAwnGxgNgFnsDmGJsIEJLA0QLzwGitTAwQNRKJBCpxVy6ueHgl4pt8uaSrxM/8zDYyG44QECL5ZyDDYdlztw23Dk7d7M0D0OaMUEtBjcSGw5Ltt1m3HA7dxtzDsPhRCK1/Lttv+HmWZCW/8RpOfix4Xbihhu8IC0HCGuxnAG0heHY7eQNZ4B++WOQbDyTkBZzifSHD3/U3LbdcPzsxo8zKuxk+whpAQFmHoQ7iVAOAow/iFQ4CkbBKBgFIxQAAAV1UF6/0kEEAAAAAElFTkSuQmCC","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":true,"prefix":"","firstName":"Brian","middleName":"","lastName":"Hilgeman","suffix":""},{"id":288601630,"identity":"2ffdff02-9652-41af-b11a-5c784aec912a","order_by":1,"name":"Kevin Kurtz","email":"","orcid":"","institution":"Medical College of Wisconsin Medical School","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Kurtz","suffix":""},{"id":288601631,"identity":"5af9afc2-e806-4b83-82b3-3fda61d87c8c","order_by":2,"name":"Mary Hoeschen","email":"","orcid":"","institution":"Medical College of Wisconsin","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Hoeschen","suffix":""},{"id":288601632,"identity":"8b3ae685-7ee8-4851-8e1e-5f536169622a","order_by":3,"name":"Zachary Hovis","email":"","orcid":"","institution":"Medical College of Wisconsin School of Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"","lastName":"Hovis","suffix":""},{"id":288601633,"identity":"d8ab72f9-94e5-4826-a818-b6c6ab944013","order_by":4,"name":"Rachele Harrison","email":"","orcid":"","institution":"Medical College of Wisconsin School of Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Rachele","middleName":"","lastName":"Harrison","suffix":""},{"id":288601634,"identity":"858dcad2-5683-45be-9382-7d940ec8d436","order_by":5,"name":"Lana Minshew","email":"","orcid":"","institution":"Medical College of Wisconsin School of Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Lana","middleName":"","lastName":"Minshew","suffix":""}],"badges":[],"createdAt":"2024-04-03 03:29:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4209623/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4209623/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54519246,"identity":"d1fde241-877b-465e-a176-772dd345d035","added_by":"auto","created_at":"2024-04-11 17:42:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43888,"visible":true,"origin":"","legend":"\u003cp\u003eStudent Feedback (n=9, except question #1 n=14) on brief real-time reflections. Students rated each statement on a scale of 1 to 5 with 1 being strongly disagree, 3 being neutral, and 5 being strongly agree.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4209623/v1/59e82bfc419712b577b7350e.png"},{"id":63928461,"identity":"45382b0e-5cbf-405a-957a-4b10ba62245e","added_by":"auto","created_at":"2024-09-04 00:35:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":362100,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4209623/v1/a27b097c-6e01-42a9-9ce0-863e2068b03c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Brief, Real-Time Reflections: An Efficient, Contextual, and Familiar Variation of Narrative Medicine: A Mixed Methods Analysis","fulltext":[{"header":"Practice Points","content":"\u003cul\u003e\n \u003cli\u003eBrief, real-time reflections are a\u0026nbsp;narrative tool that can be utilized at the point of care in a manner that is familiar to students and efficient, requiring less than 5 minutes to complete. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eQualitative analysis revealed 3 codes: descriptive, emotional, and cognitive to define the content of the reflections with many reflections containing multiple codes.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReal time brief reflections appear to have 2 common and distinct methods of use: cognitively processing events that are encountered and emotionally describing the feelings of self or others that occurs during patient care encounters. \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStudents were engaged in the process and responded that the tool helped them to think more deeply about and remember patient interactions and agreed it was a good use of their time\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eHabitual and purposeful reflection upon our lived experiences has a myriad of benefits including impacts on professional identity formation and empathy among medical learners\u0026nbsp;[1]. \u0026nbsp;These skills have been increasingly focused on in curricular development at medical schools by using reflection to augment established curriculum allowing students to intentionally digest and process their experiences during clinical rotations.\u003c/p\u003e\n\u003cp\u003eNarrative medicine is a well-established curricular tool that allows caregivers the opportunity to \u0026ldquo;absorb, interpret, and respond to\u0026rdquo;\u0026nbsp;[2]\u0026nbsp;experiences with the goal of developing physicians who \u0026ldquo;practice medicine with empathy, reflection, professionalism, and trustworthiness\u0026rdquo;\u0026nbsp;[2]. The definition of narrative medicine is loosely defined as tools that allow students to \u0026ldquo;acquire, comprehend, and integrate the different points of view in the illness experience\u0026rdquo;\u0026nbsp;[3]\u0026nbsp;but in practice, pedagogic and curricular approaches are varied, and outcome analyses are diverse\u0026nbsp;[4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessional identity formation is a complex process by which medical students transition from laypersons to physicians\u0026nbsp;[5]\u0026nbsp;by assimilating the characteristics, values, and norms of the medical profession with core values, moral principles, and self-awareness\u0026nbsp;[6]. As a vehicle for professional identity formation, intentional reflection about our experiences enables us to process, make sense of, and more fully understand what we have witnessed\u0026nbsp;[2, 7-9]. This allows us to remember, learn from, and modify our future behavior from past experiences, leading to professional gains in relation to the individual, relationships, and society, key components to professional identity formation and empathy. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmpathy and compassion skills are particularly important for students and practitioners of medicine who bear witness to some of humankind\u0026rsquo;s most emotional and vulnerable experiences. Contrary to this necessity, it has been found the empathy scores decline throughout the clinical years of medical school\u0026nbsp;[10]\u0026nbsp;and practicing physicians often lack the skills needed to sensitively care for their patients\u0026nbsp;[11, 12]. \u0026nbsp;Empathetic care is correlated with improved chronic disease outcomes\u0026nbsp;[13], reduced medical errors\u0026nbsp;[14], reduced potential litigation\u0026nbsp;[15], \u0026nbsp;and diminished burnout among clinicians\u0026nbsp;[16].\u003c/p\u003e\n\u003cp\u003eReflective practice helps us to understand, value, and take perspective of those that we interact with, developing more empathetic and compassionate emotions toward our fellow humans\u0026nbsp;[8, 9]. Rita Charon states, \u0026ldquo;by rendering whole that which they observe and undergo, doctor-writers can reveal transcendent truths, exposed in the course of illness, about ordinary human life\u0026rdquo; and develop \u0026ldquo;deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness\u0026rdquo;\u0026nbsp;[7]. \u0026nbsp;Evidence is strong that narrative curricula foster empathetic concern among health professions students\u0026nbsp;[17-21]\u0026nbsp;by allowing students to develop core skills necessary for empathy, including perspective-taking, valuing others, and humanizing patients\u0026nbsp;[22]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThus, narrative practice can lead to meaningful gains in professional development by giving students the space to consciously process the gap between the technical knowledge learned in medical school and the tacit knowledge learned through patient interactions and stories [23]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRequirements for long prose or reflective sessions may not be practical or widely adopted in the context of busy curricular and clinical schedules and further degraded by the volume of scientific learning required during medical training. Furthermore, mock clinical scenarios may be detached from clinical or emotional context for students. \u0026nbsp;A more practical, effective, and convenient tool could be brief and occur in real-time, immediately or shortly after patient interactions. This method of narrative medicine has only been studied in the limited context of surgical rotations [24] and has not been studied in other contexts, such as primary care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, a pedagogical tool of brief real-time reflections on patient care experiences was implemented with fourth-year medical students who rotated in a clinic serving patients with high medical and psychosocial complexity. Our analysis aimed to develop a framework to describe what students reflect upon with the pedagogical tool and to understand the practical usability and feasibility of the tool for students through process and student feedback data. \u0026nbsp;Our primary hypothesis was that the content of these reflections would show that students could reflect in a cognitive and emotional manner with this tool. In addition, we hypothesized that the tool would have good uptake and students would find it useful. \u0026nbsp;All of this is intended to build upon the abovementioned research showcasing the benefits of narrative medicine on professional identity formation and empathy among medical learners. \u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eContext: M4 Ambulatory Internal Medicine:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Ambulatory Internal Medicine (AIM) course is a required, one-month clerkship completed during the 4\u003csup\u003eth\u003c/sup\u003e year of medical school (M4) that allows students the opportunity to learn about the diagnosis and management of common ambulatory conditions with experiences in primary and specialty care. Students rotate through a variety of ambulatory care clinics during their rotation with anywhere between one and six half days in each clinic per month. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Enhanced Care Program\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003eThe Enhanced Care Program (ECP) is one experience available to students in the M4 AIM course. It is an intensive primary care clinic with an interdisciplinary team that is focused on individuals with high health care utilization, caring for patients that often have significant medical and psychosocial conditions. Students who rotate in the ECP complete approximately three to five half-day clinics over four weeks, participating in all clinical activities, including hospital encounters, home visits, and observing the work of the interdisciplinary care team. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Intervention:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA didactic presentation about the ECP and the care of high need, high-cost patients was given to every M4 student (N = 49) at the start of the AIM course. Half the students were randomly assigned to rotate in the ECP (n = 18) with a single preceptor. Students assigned to the ECP were prompted to write 3 anonymous reflections about their experiences in patient care per each half-day they spent in the ECP. Students did not complete reflections while rotating in other clinics. Students were provided the following phrase: \u0026ldquo;Please write a reflection about your experience with this patient. Limit 280 characters. Do not include any identifying patient information.\u0026rdquo; The prompt was kept intentionally broad to allow students to adapt to the patient care context at hand. Students were reminded by the preceptor frequently to complete their reflections throughout the month. Students completed their reflections via Qualtrics, an IRB-approved data gathering service. All reflections were anonymous, only the date and timestamp of the reflections were recorded. Additionally, precepting faculty did not have access to the reflections while students were on rotation. Data was collected from March 2019 through October 2019. The study was reviewed and approved by the institutions Institutional Review Board. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the intervention, the tool was referred to as tweets aligning with current utilization of social media platforms for students. The tool has been re-named brief, real-time reflections to highlight the uniqueness and privacy of the tool and pivot away from the current business model changes at Twitter. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalysis:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGrounded theory methods were strictly followed to allow for robust and un-biased analysis according to established principles of framework analysis\u0026nbsp;[25]. Three coders collaborated to develop the codebook. One of the coders (BH), was the primary investigator and clinician preceptor involved in the intervention. The other two coders (LM and KK) were not involved in the design and implementation of the pedagogic tool. LM is a learning scientist and educational researcher who has extensive experience implementing qualitative methods, including grounded theory. LM led the analysis and ensured the team strictly adhered to qualitative methods quality criteria. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInductive coding was used to develop the codebook (Table 1) following rigorous qualitative methods\u0026nbsp;[25-27]. The process was iterative and involved frequent refinements of the codes and definitions between the coders. As new codes emerged through the inductive process, previous codes and reflections were reviewed to ensure accuracy and clarity.\u0026nbsp;Care was taken to ensure all reflections were reviewed by at least 2 coders and inter-coder agreement was found to be 82% once the codebook was complete. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn independent auditor was educated on qualitative methods. Her role and duties as auditor were explained by the coding team led by LM. The auditor was given a random sample of 20% of the reflections from the dataset along with the developed codebook. The auditor (MH) was not involved in the design of the study or clinical care with the students and had no knowledge of the clinical scenarios that were reflected upon. Example reflections for each code were included in the codebook to further illustrate the definition of each code. Initial inter-coder agreement between the auditor and research team was 61%. The group met and discussed disagreements and refined code definitions as a team. All disagreements were resolved, and inter-coder agreement was 100% at the end of analysis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, a survey was sent out to students after the rotation to garner feedback on the tool. Survey questions aimed to understand the students\u0026rsquo; perceptions of the tool including impacts on empathy, use of time, empathetic responses, and remembering and thinking deeply about patient encounters (Figure 2) aligned with understanding impact on the study hypotheses. A Likert-type scale was used, with 1 being strongly disagree, 3 being neutral and 5 being strongly agree. Frequency counts for each response choice and the averages of each response were calculated. A score of 4 (agree) or 5 (strongly agree) was considered a positive response and reported as such in the results.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEighteen M4 students participated in the study, completing a total of 64 half-day clinics over 5 months. The students generated 131 reflections with an average of 2.05 reflections per half-day session in the ECP. The average time spent on each reflection was 4.39 minutes after nine outliers were removed where students spent over 25 minutes reflecting. \u0026nbsp;This cutoff was determined as it most likely indicated the student was not actively engaged in reflection but had left their browser open. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree codes were generated: descriptive, emotional, and cognitive (Table 1). The descriptive code described a reflection, or portion of a reflection, that focused on the retelling of the events and details of the patient encounter. Emotional code described a reflection, or portion of a reflection, that highlighted the emotions of either the patient, the student, the caregiver, or a combination of individuals during the encounter. Cognitive codes described a reflection, or portion of a reflection, that displayed active and intentional cognitive processing including reflection on thought process or learnings regarding a patient encounter. The most utilized code was cognitive (n = 84, 41%), with descriptive (n = 69, 33%) and emotional (n = 53, 26%) codes being slightly less frequent (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Codebook: Codes, Frequency of Use, and Definitions to Categorize Real-Time Brief Reflections in Primary Care\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"635\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eCode\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.062992125984252%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency of Use (absolute/%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"68.03149606299213%\" valign=\"top\"\u003e\n \u003cp\u003eDefinition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eDescriptive Reflection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.062992125984252%\" valign=\"top\"\u003e\n \u003cp\u003e69/33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"68.03149606299213%\" valign=\"top\"\u003e\n \u003cp\u003eReflection contains a descriptive narrative about a patient encounter or experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional Reflection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.062992125984252%\" valign=\"top\"\u003e\n \u003cp\u003e53/26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"68.03149606299213%\" valign=\"top\"\u003e\n \u003cp\u003eReflection demonstrates a student recognizing their own, patient, or caregiver emotions surrounding the patient encounter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eCognitive Reflection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.062992125984252%\" valign=\"top\"\u003e\n \u003cp\u003e84/41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"68.03149606299213%\" valign=\"top\"\u003e\n \u003cp\u003eReflection shows active and intentional cognitive processing including reflection on thought process or learnings. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eReflections could be coded with one or a combination of codes. The most common reflection code was cognitive-only (n = 43, 33%), followed by a combination of descriptive and emotional codes (n=24; 18%), and descriptive and cognitive codes (n = 19, 15%). Emotional-only was the least common reflection type (n = 7, 5%) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eReflection Code Combinations Coded in Brief, Real-Time Reflections in Primary Care\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"635\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eCode\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency of Use (absolute/%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eDefinition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003eExample quotation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eDescriptive Only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e16/12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection only contains descriptive code\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I saw a patient with lupus and she described the depression she had due to her chronic disease because it was limiting the things she does in her life. She described it so well \u0026ndash; chronic disease is challenging. #depression\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional Only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e7/5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection only contains emotional code\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It was frustrating to hear this patient tearfully speak about the horrors of interfacing with the medical system (specifically providers). She\u0026rsquo;d been traumatized by going to doctors who didn\u0026rsquo;t believe her and talked down to her so much that she refused care at times.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eCognitive Only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e43/33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection only contains cognitive code\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know exactly how stable housing factors into health care outcomes, but I would imagine that it is very important. It is nice to have social work as a part of the care team to address housing concerns that patients may have #stablehousing\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eDescriptive \u0026amp; Emotional Reflection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e24/18%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection reflects both the descriptive and emotional codes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;This patient came in looking for a prescription for a scooter. When she was told that we weren\u0026rsquo;t going to go there just yet, she became disengaged, started asking for tramadol, and was refusing to follow up with other recommendations we had. It was frustrating.\u0026rdquo; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eDescriptive \u0026amp; Cognitive Reflection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e19/15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection reflects both the descriptive and cognitive codes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Met with a patient who had chronic knee pain that was only mildly responsive to opioids. Due to other comorbidities, she couldn\u0026rsquo;t have NSAIDs or Tylenol. It showed the difficulty of caring for patients with complex problems while balancing the use of opioids.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eEmotional \u0026amp; Cognitive Reflection \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e12/9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection reflects both the emotional and cognitive codes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;This patient was very irritable. I found myself also becoming impatient because he wouldn\u0026rsquo;t even let me examine him. Reflecting on this helped me better recognize that some patients are distrustful of the medical system and may have good reason.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.905511811023622%\" valign=\"top\"\u003e\n \u003cp\u003eDescriptive, Emotional, \u0026amp; Cognitive Reflection \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.228346456692913%\" valign=\"top\"\u003e\n \u003cp\u003e10/8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.291338582677167%\" valign=\"top\"\u003e\n \u003cp\u003eReflection reflects all three codes \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.574803149606296%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;A middle-aged woman with a variety of chronic illnesses came in with a cold. She was jovial and made a lot of jokes, many self-deprecating which made me empathize with her more. I guess humor is my main way of connecting with people.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDescriptive-only reflections contained a pure descriptive recollection of an encounter without emotional or cognitive elements. For instance, a student shared, \u0026ldquo;\u003cem\u003eMr. L came to clinic not just for medical management but also for inquiring about losing his license. This visit was mostly a social visit which required the physician to be gentle and listen to the patient\u0026rsquo;s concerns about his license. After the visit Mr. L was more open.\u003c/em\u003e\u0026rdquo; Another student reflected, \u0026ldquo;\u003cem\u003eFrightening when a patient started hav[ing] exacerbation of chest tightness and breathing difficulties during the patient interview. Thankfully symptoms improved after albuterol administration. One of the first times such an acute event has happened during one of my interviews\u003c/em\u003e.\u0026rdquo; These two examples provide a direct account of what occurred during a patient encounter, but do not provide additional evidence for emotional or cognitive reflection. These reflections may contain emotions such as \u0026ldquo;frightening,\u0026rdquo; but they are not explicitly recognized by the student during the reflection, nor do they contain active or intentional processing of an encounter. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmotional-only reflections only commented on emotions of the patient, student, and/or caregiver without descriptive or cognitive codes. For example, one student shared their frustration about a patient encounter, \u0026ldquo;\u003cem\u003eSpeaking with the patient about his COPD, I struggled to put myself in the patient\u0026rsquo;s shoes as he told me about his living conditions and how this was negatively affecting his condition. It was frustrating for me as I felt I had a lack of understanding of his complete disease\u003c/em\u003e.\u0026rdquo; This reflection does not provide a description of the encounter but focuses on the student\u0026rsquo;s emotions and feelings they experienced. The student noted their frustration and their inability to \u0026ldquo;put myself in the patient\u0026rsquo;s shoes,\u0026rdquo; which, according to the student, limited their understanding of the patient\u0026rsquo;s disease. The following reflection shows a student providing a complex emotional assessment of an encounter, reflecting upon their frustration for a patient that had many negative experiences in the health system: \u0026ldquo;\u003cem\u003eIt was frustrating to hear this patient tearfully speak about the horrors of interfacing with the medical system (specifically providers). She\u0026apos;d been traumatized by going to doctors who didn\u0026apos;t believe her and talked down to her so much that she refused care at times.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCognitive-only reflections contained elements of cognition, one student reflected, \u0026ldquo;\u003cem\u003eI wonder when we ask patients \u0026lsquo;tell me about yourself,\u0026rsquo; how their given story in clinic compares to their true story,\u003c/em\u003e\u0026rdquo; and another shared, \u0026ldquo;\u003cem\u003eIt was enlightening to think that this patient\u0026rsquo;s nonadherence to medication and therapy may be significantly influenced by depression through a lack of motivation and feeling overwhelmed with other aspects of her life. Must consider broad reasons for non-compliance\u003c/em\u003e.\u0026rdquo; These two examples illustrate students\u0026rsquo; deeper processing of a patient encounter beyond a mere re-telling of what happened or recognizing what they were feeling at the time. The reflections demonstrate that the encounter influenced their perspective and thinking regarding patient care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSixty-five reflections had components of two or all three codes. One student reflected, \u0026ldquo;\u003cem\u003eAn older lady was coming to terms with not being able to take care of the house that she has lived in for a long time. I felt for her and for how hard it must be to make that decision. To balance personal safety with leaving everything that brings you comfort and nostalgia\u003c/em\u003e.\u0026rdquo; The student provided a brief description of the encounter, then shared their emotions surrounding the encounter, and finally the student included a cognitive reflection regarding the patient\u0026rsquo;s decision making. In another example of this complex narrative was on display when a student wrote: \u0026ldquo;\u003cem\u003eShe lies in bed with ulcers on her upper legs, the kind that make you wince.\u003c/em\u003e\u0026nbsp; \u0026lsquo;\u003cem\u003eit was either come to the hospital or jump out the window. You guys can\u0026apos;t understand this pain.\u0026rsquo; We hear this kind of thing often, but I believe her. Maybe I can\u0026apos;t feel her pain, but I can believe it.\u0026rdquo;\u0026nbsp;\u003c/em\u003eThe description in this reflection leads to a very complex emotional reflection on their patient\u0026rsquo;s illness experience. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCognitive and emotional reflections also exhibited clear and intentional processing of emotions of themselves, patients, or caregivers that were quite nuanced and complex. \u0026nbsp;One student shared, \u0026ldquo;\u003cem\u003eHaving an unruly patient made me slightly uncomfortable. I noticed that his agitation made it difficult for me to concentrate on his health problems as his behavior was quite distracting. I realized that I needed to do my best to ignore that and just focus on his diabetes\u003c/em\u003e.\u0026rdquo; This cognitive and emotional reflection displayed how a student recognized their discomfort with an \u0026ldquo;unruly\u0026rdquo; patient which led them to a cognitive reflection on what are their priorities in a patient encounter and the technical task at hand. Another student commented in a manner that was also nuanced and complex involving the cognitive processing of emptions: \u0026ldquo;\u003cem\u003ePatient was resistant because of possible admit for fluid overload. Once asked about her husband\u0026apos;s health, she became engaged and excited. She wasn\u0026apos;t resisting medical advice, she just cared so much for her husband\u0026apos;s health that she was prioritizing his well-being over hers.\u0026rdquo;\u0026nbsp;\u003c/em\u003eAnother student reflected, \u0026ldquo;\u003cem\u003eHis body\u0026apos;s rejecting his new liver and he\u0026apos;s on the list for a kidney. Genetic disorders make you feel so lucky to be average. This guy would kill to be average. He\u0026apos;s not been out of prison long. Maybe he was acting out against a world and a life that screwed him over, I wonder\u003c/em\u003e.\u0026rdquo; \u0026nbsp;Additional reflections regarding pairs of codes can be found in Table 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNine of the 18 students completed the post-survey (50%). \u0026nbsp;Students responded with agree or strongly agree to questions about whether the reflections allowed them to think deeply about patient interactions (n=9/9, 100%) and remember patient encounters (n=8/9, 89%) and were a good use of their time (n=7/9, 78%). Perceived impacts on empathy were lower (n=4/9, 44%) for developing empathetic responses and (n=3/9, 33%) for impact on empathy (Figure).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study used brief, real-time reflections as a pedagogic tool for narrative patient reflection in the context of an intensive primary care clinic. The goal was to utilize qualitative analysis to understand the content of these reflections and analyze process data and student feedback to understand the utility of the tool as a familiar, contextual, and efficient pedagogic variant of narrative medicine. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe developed codebook showcases that with real time brief reflections, students reflect on experiences in two distinct ways. First, students commonly reflected in a cognitive manner displaying their active thought processes and learning about patient care. These components are key tenants of professional identity formation, a focus for narrative medicine. Conversely, reflections that were descriptive and emotional were the second most common type of reflection. These reflections seem to express a separate use of the tool to describe and process the emotions of either themselves, their patients, their caregivers, or a combination of these individuals. This type of emotional reflection, understanding the perspective and emotions of others is an antecedent to the development of empathy\u0026nbsp;[22, 28]. Future research includes further analysis to understand the nuances of these findings and the impact of this tool directly upon quantitative measures of professional identity formation and empathy. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is clear from this study that, despite its short, 280-character limit, students can use this platform to reflect in a complex and emotional manner based on the above qualitative analysis. Further, student post-rotation survey responses illustrate they feel that reflections allow them to think deeply about patient interactions and remember the interactions better, which likely add to the complexity of their reflections and impact of the tool on their long-term professional growth\u0026nbsp;[29]. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne intended goal of the tool was to develop a product that was familiar to modern students. Given the dynamic nature of medical education, modern educational tools need to deploy modern strategies to engage students. Twenty-first century students prefer and desire tools that mimic social media platforms they commonly use in their everyday lives as methods for medical education. These tools have been cited to be effective in a myriad of capacities and can serve a role to flatten hierarchies in medical education and improve communication\u0026nbsp;[30]\u0026nbsp;but pose a risk to erode professionalism and lead to misinformation\u0026nbsp;[31]. However, if the tools are deployed in a controlled and intentional manner, the risks can be mitigated. This pedagogic tool was designed to mimic these platforms by designing something that could be utilized on mobile devices and the way students use Twitter (Now X) along with other social media platforms such as Facebook and Instagram in brief posts. The evidence for impact of this goal is the high uptake and generally positive feedback received from the students on the tool. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEfficiency was a second goal of the intervention. Given the competing demands on clinical year students between busy clinical expectations and a myriad of curricular requirements, students often feel stretched thin with these competing demands. By distilling down an important curricular method, narrative medicine, into a tool that is quick and efficient, we hoped to improve adoptability and acceptability of our intervention to students. The impact in this realm is evidenced by high uptake of the tool in the clinical atmosphere along with correspondingly short time requirements to reflect (less than 5 minutes). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe third goal was to form a tool that was contextual. By allowing students to reflect in the moment, when memories and thoughts are fresh, it was postulated that our tool would allow for deeper and more complex reflections. Although not directly proven, this may be an underlying mechanism for the above-mentioned cognitive complexity noted in the codebook. \u0026nbsp;In addition, student perspective that this method allowed them to think deeply and remember patient interactions may be reflective of this goal. Further research is needed to clearly elicit a direct correlation of these entities. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOwning to the tool\u0026rsquo;s contextual focus as well as open-ended prompting, the tool allowed students to reflect in an adaptable manner based on a real-time story. As clinical care and experiences are so varied throughout the course of training, developing a tool that can be flexible to this need is important. The breadth and variety of codes employed shows the flexibility of the tool. In one scenario, a student may describe a new experience. In another scenario, a student may comment on the emotions of an encounter. In yet another, the student may cognitively process something new they have learned. The adaptability of the tool may allow the flexibility to be deployed more widely among the health professions. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study is an initial exploration of student reflections in an intensive primary care setting. The sample from a single M4 rotation with one primary preceptor at one institution in an ambulatory medicine rotation is a limitation of the study. The impact of this tool in other institutions, with different preceptors, and in different clinical settings remains to be studied. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to the above analyses, the research team is seeking to understand the correlation of these reflections with professional identity formation as well as empathy through additional qualitative and quantitative analyses. To understand its utility in other contexts, the research team is working to expand to other rotations, practice sites, and other health care professional training programs. Further research exploration surrounding the utility of the tool to facilitate teachable moments by sharing with preceptors and the impact of additional prompting of the reflection on the content of reflection. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBrief, real-time reflections are a pedagogic narrative tool that have been found to allow medical students to reflect upon patient encounters in a contextual, familiar, and efficient manner while rotating in an intensive primary care program. Further research is planned to understand the impact more broadly in the curriculum and directly on empathy and professional identity formation. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was approved by the local institutional review board (IRB) for human subjects\u0026rsquo; protection at the Medical College of Wisconsin. \u0026nbsp;All participants consented to participate in the study via an informational letter as mandated by the IRB. \u0026nbsp;All data is presented in the manuscript and raw data is available upon request from the corresponding author. \u0026nbsp;This research study did not receive any funding. \u0026nbsp;All authors have no financial or conflicting interests with this manuscript. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWald, H.S., \u003cem\u003eProfessional identity (trans)formation in medical education: reflection, relationship, resilience.\u003c/em\u003e Acad Med, 2015. \u003cstrong\u003e90\u003c/strong\u003e(6): p. 701-6.\u003c/li\u003e\n\u003cli\u003eCharon, R., \u003cem\u003eThe patient-physician relationship. 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Forbes, \u003cem\u003eReflective writing and its impact on empathy in medical education: systematic review.\u003c/em\u003e J Educ Eval Health Prof, 2014. \u003cstrong\u003e11\u003c/strong\u003e: p. 20.\u003c/li\u003e\n\u003cli\u003eBatson, C.D., et al., \u003cem\u003eAn additional antecedent of empathic concern: valuing the welfare of the person in need.\u003c/em\u003e Journal of personality and social psychology, 2007. \u003cstrong\u003e93\u003c/strong\u003e(1): p. 65.\u003c/li\u003e\n\u003cli\u003eGreenhalgh, T., \u003cem\u003eNarrative based medicine: narrative based medicine in an evidence based world.\u003c/em\u003e BMJ, 1999. \u003cstrong\u003e318\u003c/strong\u003e(7179): p. 323-5.\u003c/li\u003e\n\u003cli\u003eDressler, J.A., et al., \u003cem\u003e\u0026ldquo;Tweet\u0026rdquo;-Format writing is an effective tool for medical student reflection.\u003c/em\u003e Journal of Surgical Education, 2018. \u003cstrong\u003e75\u003c/strong\u003e(5): p. 1206-1210.\u003c/li\u003e\n\u003cli\u003eKlingberg, S., R.E. Stalmeijer, and L. Varpio, \u003cem\u003eUsing framework analysis methods for qualitative research: AMEE Guide No. 164.\u003c/em\u003e Med Teach, 2023: p. 1-8.\u003c/li\u003e\n\u003cli\u003eMiles, M.B., A.M. Huberman, and J. Salda\u0026ntilde;a, \u003cem\u003eQualitative data analysis: A methods sourcebook\u003c/em\u003e. 2018: Sage publications.\u003c/li\u003e\n\u003cli\u003eSalda\u0026ntilde;a, J., \u003cem\u003eThe coding manual for qualitative researchers.\u003c/em\u003e The coding manual for qualitative researchers, 2021: p. 1-440.\u003c/li\u003e\n\u003cli\u003eBatson, C.D., \u003cem\u003eThese things called empathy: Eight related but distinct phenomena\u003c/em\u003e, in \u003cem\u003eThe social neuroscience of empathy.\u003c/em\u003e 2009, MIT Press: Cambridge, MA, US. p. 3-15.\u003c/li\u003e\n\u003cli\u003eDasGupta, S. and R. Charon, \u003cem\u003ePersonal illness narratives: using reflective writing to teach empathy.\u003c/em\u003e Acad Med, 2004. \u003cstrong\u003e79\u003c/strong\u003e(4): p. 351-6.\u003c/li\u003e\n\u003cli\u003eGuckian, J., et al., \u003cem\u003eSocial media in undergraduate medical education: A systematic review.\u003c/em\u003e Med Educ, 2021. \u003cstrong\u003e55\u003c/strong\u003e(11): p. 1227-1241.\u003c/li\u003e\n\u003cli\u003eD\u0026apos;Souza, F., et al., \u003cem\u003eSocial media: medical education\u0026apos;s double-edged sword.\u003c/em\u003e Future Healthc J, 2021. \u003cstrong\u003e8\u003c/strong\u003e(2): p. e307-e310.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Narrative medicine, reflection, pedagogic tool","lastPublishedDoi":"10.21203/rs.3.rs-4209623/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4209623/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eBackground\u003c/u\u003e: Narrative medicine is a widely used pedagogic tool but can be detached from the clinic context and unfamiliar to students. Brief real-time reflections could be a method of narrative medicine that is contextual, familiar, and convenient.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e: Fourth year medical students completed 280-character reflections immediately after patient interactions while rotating in a primary care clinic serving complex patients. Three researchers used qualitative methods to develop a codebook to describe the reflections and an independent auditor verified codebook application. Student feedback regarding their experience writing reflections was elicited on a Likert scale to understand student perspectives on the tool about ease of use, empathy, and remembering patient interactions.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003c/u\u003e: Eighteen students completed 131 reflections during 64 clinics; an average of 2.04 reflections per clinic and spent an average of 4.39 minutes on each reflection. Three codes were elicited to describe the content of reflections: descriptive, emotional, and cognitive. The most frequently identified code was cognitive (n = 84, 41%), with descriptive (n = 69, 33%) and emotional (n = 53, 26%) being less frequent. Reflections could contain one or a combination of codes. The most common reflection was cognitive-only (n = 43, 33%) followed by a combination of descriptive and emotional (n=24; 18%). Most students agreed or strongly agreed that reflections helped them think more deeply about (9/9, 100%) and remember (8/9, 89%) patient interactions and were a good use of their time (7/9, 78%).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusions\u003c/u\u003e: Brief, real-time reflections are a tool that allow medical students to reflect upon their clinical experiences in a complex and cognitive way and was well-received by students.\u003c/p\u003e","manuscriptTitle":"Brief, Real-Time Reflections: An Efficient, Contextual, and Familiar Variation of Narrative Medicine: A Mixed Methods Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-11 17:41:58","doi":"10.21203/rs.3.rs-4209623/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e40c81a4-e817-4a8b-82bb-80261ef7d900","owner":[],"postedDate":"April 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-04T00:27:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-11 17:41:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4209623","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4209623","identity":"rs-4209623","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}