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).