Portfolio to Go: 1000+ Reflective Writing Prompts and Provocations for Clinical Learners 9781487510381

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PORTFOLIO TO GO 1000+ REFLECTIVE WRITING PROMPTS AND PROVOCATIONS FOR CLINICAL LEARNERS ALLAN D. PETERKIN, MD

Preparing a learning portfolio has become a mandatory part of the course work in most clinical professions: we all need to be able to communicate clearly as we work with our colleagues, students, and those we care for. However, students and educators alike sometimes complain that these mandatory assignments become repetitive and uninspired. In Portfolio to Go, Allan D. Peterkin emphasizes that reflective capacity, critical thinking, creative expression, and narrative competence are attributes that should be developed in every health professional – regardless of the discipline or specialty. The book offers more than 1000 prompts organized under themes highly relevant to students and educators, including those not formally addressed in class, such as coping with uncertainty and ambiguity, team conflict, and resilience through good self-care. Practical tips for writing effectively and for discussing and evaluating narratives in a helpful, respective manner are provided throughout. Written by a pioneer in emphasizing patient-centered, humanistic care, Portfolio to Go will help to train and develop more reflective practitioners. is Professor of Psychiatry and Family Medicine at the University of Toronto where he heads the Program in Health, Arts and Humanities. He is the author of 14 books for adults and children including Staying Human during Residency Training, now in its sixth edition.

ALLAN D. PETERKIN

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PORTFOLIO TO GO 1000+ REFLECTIVE WRITING PROMPTS AND PROVOCATIONS FOR CLINICAL LEARNERS

Allan D. Peterkin, MD

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2016 Toronto Buffalo London www.utppublishing.com Printed in the U.S.A. ISBN 978-1-4875-0019-1 (cloth)

ISBN 978-1-4875-2011-3 (paper)

Printed on acid-free, 100% post-consumer recycled paper with vegetable-based inks.

Library and Archives Canada Cataloguing in Publication Peterkin, Allan D., author Portfolio to go : 1000+ reflective writing prompts and provocations for clinical learners / Allan D. Peterkin, MD. Includes bibliographical references. ISBN 978-1-4875-0019-1 (cloth). ISBN 978-1-4875-2011-3 (paper) 1. Clinical medicine – Study and teaching. 2. Medical writing. 3. Critical thinking. 4. Portfolios in education. I. Title. R834.P48 2016

808.06′661

C2016-903961-7

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council, an agency of the Government of Ontario.

Funded by the Financé par le Government gouvernement du Canada of Canada

For my students, who keep me honest

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Contents

Acknowledgments

ix

1 Introduction

3

2 What Can My Reflective Portfolio Be?

16

3 Finding Optimal Conditions to Write and Reflect

21

4 Getting Started: Learning as a Journey – Writing Prompts

23

5 Using Reflective Writing Prompts and Storytelling Skills to Maximize Growth and Reflection

28

6 Communication – Writing Prompts

36

7 Collaboration and Teamwork – Writing Prompts

39

8 Conflict – Writing Prompts

42

9 The Personal Narrative Reflection Tool: Steps for Enhancing Critical Reflection in Your Portfolio Entries

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10 The Patient or Client as a Person – Writing Prompts

49

11 Diversity/Culture/Equity – Writing Prompts

57

12 Social Justice/Advocacy – Writing Prompts

61

13 From Portfolios to Action: Practical Strategies for Practicing Reflective, Narrative-Based Care

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14 Well-Being and the Clinician as a Person – Writing Prompts

68

15 Ambiguity/Uncertainty – Writing Prompts

73

16 Career Satisfaction – Writing Prompts

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17 Battling the Inner Critic: How to Stay Open When You Reflect and Write

78

18 Personal Reflections – Writing Prompts

80

19 Sample Course Guidelines

91

20 The Body – Writing Prompts

96

21 Things to Consider When Forming a Reflective Writing Group

100

22 Professionalism and Ethics – Writing Prompts

102

23 Values, Beliefs, and Assumptions – Writing Prompts

107

24 Toward a More In-Depth Assessment of Reflective Writing Evaluation

111

25 The Hidden Curriculum and Power – Writing Prompts

115

26 Am I a Good Group Member? Positive Characteristics

118

27 Dilemmas and Difficult Stories – Writing Prompts

121

28 Sample Discussion Points When Working with Stories

126

29 For Teachers and Student Group Leaders

129

30 A Sample Narrative Reflection Workshop Evaluation

133

31 Creativity – Writing Prompts

135

32 Graphic Medicine: Reflecting without Words

147

33 Getting Published: Common Themes That Predict Success

151

34 Guidelines for Narrative Accountability When Writing or Publishing about Patients/Clients

154

35 Finding Publishing Opportunities

157

36 A Few Words on Blogging and Social Media

167

37 Other Writing and Healing References

172

Acknowledgments

I first came to appreciate the power of reflective writing from the clinical side. My colleagues Julie Hann, OT, Guy Allen, PhD, and Rex Kay, MD, and I created countless prompts for a model of group therapeutic writing we use at our hospital for people living with chronic illnesses. We called it Narrative Competence Psychotherapy. I owe Julie, Guy, and Rex and all of our patients over the last 18 years a great deal for teaching me to appreciate how writing works as a form of meaning making, healing, and navigating illness. (The results of the study we have published on the efficacy of that clinical model are listed with Other Writing and Healing References at the end of the book.) My journey then took me to training and eventually teaching with Rita Charon and her wonderful colleagues in the Narrative Medicine Program at Columbia University. I came to understand that writing aids reflective capacity, critical thinking, and narrative competence in both learners and clinical practitioners. I also saw how rediscovering and recording personal narratives about why one chose a healing profession in the first place was invigorating and brought a renewed emphasis to purpose and pleasure in our shared work. Stories healed us as well as our patients by helping us avoid burnout. Finally, as a writer myself, I wanted to create a guide for students that honors the craft of writing and does not just view narrative as means to an end. Recurrent complaints from students from all clinical disciplines when evaluating their portfolio courses mention that writing prompts and reflective assignments seem vague, contrived, artificial, repetitive, and unimaginative, or are evaluation-driven rather than formative (emphasizing learner-driven discovery over time).

x

Acknowledgments

I am quite confident that readers will find prompts in this book that have never been used before and that unexpected even transformative stories will emerge. I would like to thank my colleagues in the Portfolio Course at the University of Toronto where I teach, including Ken Locke, Pier Bryden and Michael Roberts. Our own process of course creation has been enriched over time by the work of Shmuel Reis, Louise Aronson, Rebecca Garden, Patricia O’Sullivan, Ronna Bloom, Shelley Wall, and Barbara Sibbald (who kindly allowed me to reprint some of their materials in this book). The Canadian Medical Association Journal, Canadian Family Physician, Patient Education and Counseling, and University of California at San Francisco have kindly allowed reprinted material to be used, as indicated within the text. I’d also like to thank the following people worldwide for sharing their favorite reflective prompts after responding to a “Call for Prompts” I sent out to a number of health humanities websites: Shannon Arntfield, Audrey Shafer, Jacqueline Genovese, Martha StoddardHolmes, Shauna Singh Baldwin, Carol-Ann Courneya, Giskin Day, Josephine Ensign, Deborah Ferraro, Kelly Fiore, Craig Irvine, Monica Kidd, Marilyn McEntyre, Nicole Schafenacker, Maura Spiegel, Caroline Wellbery, and Jielai Zhang. These are woven throughout the text. Please send your personal favorite writing prompts to allan. [email protected] for subsequent editions of this book. Thanks also to the students from our various inter-professional faculties at the University of Toronto who have allowed us to include their own anonymous narratives as samples of reflective writing. Writing and Healing are creative, challenging, fulfilling vocations. It has been tremendous fun imagining and witnessing their many intersections. Allan Peterkin MD, Toronto, 2016

PORTFOLIO TO GO 1000+ REFLECTIVE WRITING PROMPTS AND PROVOCATIONS FOR CLINICAL LEARNERS

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1

Introduction

Some Background on Reflective Capacity Reflection has been defined as “a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation.”1 This means that both thoughts and feelings are honored in the process of learning. The reflective practitioner, then, is one who uses reflection as a tool for “purposeful, deliberative revisiting of an experience to explore and extract the learning offered by that experience.”2 Given the growing complexity of healthcare technologies and interventions, systems and teamwork, it is not surprising that an emerging goal of education in most of the clinical professions worldwide is develop reflective practitioners who can embody competence, compassion, collaboration, and a tolerance for ambiguity in the face of uncertainty. One of the most promising, well-studied methods to assist in this process is the use of reflective writing and close reading of literary texts in health professional curricula.3 Reflective writing undertaken by students helps them to represent, using a language-based narrative, their subjective and objective experiences in the study and practice of caring for patients and clients.4 These meaningful interactions with people living with illness, professional colleagues, and society at large can often be best described in emotional and personal terms, rather than being captured or “embodied” through comparatively dry scientific reporting or brief, fact-based case presentations. Such reflection includes consideration

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of the larger context, the meaning, and the implications of an experience or action, allowing the student practitioner to integrate or rework concepts, skills, and values into their cognitive framework or understanding.5,6 This allows the student to examine how knowledge and practice are invariably shaped by personal outlook, interpersonal exchanges, established conceptual models, and issues of power, politics, and privilege. Practitioners who have developed their reflective abilities through writing can identify and interpret their own emotional responses to those they care for, identifying and acting upon hidden attitudes, biases, or feelings that may hinder communication and then care for their patients or clients with engaged presence, rather than exaggerated detachment. As one’s professional identity is developed, there are aspects of learning that urgently require an understanding of personal beliefs, attitudes, assumptions, and values in the context of those of the professional culture; critical reflection offers an explicit approach to their examination, modification, and integration.7 This book will look specifically at incorporating reflective writing (and other forms of meaning making) into portfolios, which are defined as “a collection of a student’s works which provides evidence of the achievement of knowledge, skills, appropriate attitudes and professional growth through a process of self-reflection over a period of time.”2 Before we delve into what an optimal, creative, student-focused portfolio can be, it might be interesting to review why stories are so important to us as human beings and why working with stories has re-emerged as a vital skill for healers across disciplines.

Why We Write (and How We Can Do It Better)8 Increasingly, doctors, nurses, and other healthcare professionals and students from most healthcare disciplines are being encouraged to write about their personal experiences in clinical and academic

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settings.9 The aim of such exercises is usually stated – that putting something down on paper will lead to reflection about the work we do, which in turn has the potential to foster empathy and improve patient care. There are numerous sections in clinical journals and blogs, new medical literary magazines (such as Ars Medica, which I help to edit), international courses, and workshops, all of which celebrate the promise of a new medical narratology as informed by a growing discipline called Narrative Medicine. Narrative Medicine as described by Rita Charon and her multidisciplinary colleagues at Columbia University emphasizes the close reading of literary texts and the completion of reflective writing exercises based on these texts or ignited by specially created prompts which encourage engaged storytelling.10,11 This approach was first employed by medical practitioners, but is now practiced all over the world by clinicians and students from all disciplines. The usefulness of journaling, assembling portfolios and “parallel charts” (with the compiling of personal thoughts alongside the official chart), and completing in-depth critical incident reports has been demonstrated with clinical students and similar tasks are now being pursued with gusto by trainees in most educational disciplines and settings. Clinicians from all levels of training and types of practice generally take up a pen (or tap on the keyboard) when confronting clinical uncertainty, processing powerful feelings, regrets, and errors, or when they (or a loved one) are facing personal illness. A very few of them become famous in the process, but most of us write to get in touch with what we think and feel about our work. There are of course, other ways to reflect – mindful meditation exercises, Balint groups, coaching and supervision, case conferences with a mentor or a process group, and professional development seminars. Reflection can be structured (as in the portfolio courses we’re about to explore) or unstructured (e.g., personal journaling). It can be experiential, visual and verbal, longitudinal or sporadic, and can occur as an individual activity or in groups. (In my experience, students tend to derive the most benefit

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from sharing their stories with peers, mentored by more senior practitioners.) Writing narratives about specific clinical incidents honors the subjective experiences of both healer and patient/client. This is a welcome counterbalance to evidence-based practice, which emphasizes what is generalizable rather than what is unique, particular, and unpredictable. We all agree that bringing storytelling and reflection back to healthcare is what we and our patients or clients need. Our predecessors knew this and did not have to perform outcome research to prove it. They would sit with those who were ill and listen carefully. The act of diagnosis or even creating a treatment plan abbreviates an illness experience, renders it manageable (or not), but seldom fleshes it out. Diagnosis and treatment can be anti-narrative acts which distil a lifetime into a single word or phrase (that usually leads to some course of “therapeutic activity”). Stories and written reflections, on the other hand, always insist on meaning. As mentioned above, the fostering of reflective capacity within clinical education is recommended to help develop critical thinking skills, inform clinical reasoning, and enhance professionalism.12 It is a form of meta-cognition where our experiences are transformed into meaning making and new insights, knowledge, and practices. Reflection guides critical thought and diagnostic accuracy,13 as well as future behavior, and is deemed an essential characteristic of professionally competent clinical practice.14 More recently, reflective capacity has been described as integral to the promotion of professional and ethical core competencies of medical and other clinical practice. Reflection plays an essential role in fostering mindfulness and a sense of integrity and humanism with which to approach clinical reasoning and patient care dilemmas that may arise. Quite often, learners write about mistakes, conflicts, critical incidents, experiences of being silenced or demeaned, and previously unexamined assumptions and blind spots. The usefulness of a reflective writing modality (a subset of narrative-based medicine and other reflective practices) in teaching and learning is well documented.10,11 Naming

Introduction

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our experiences with words is an important first step in the reflection process. Nonetheless, learning is never a linear process and competence is not a stable or fixed phenomenon. Our colleagues in business remind us that understanding failure can be a vital part of growth, mastery, and innovation. Meaning making is always environment-dependent and socially constructed. Stories recognize (and even celebrate) all those complications. Reflective writing helps students better understand the complexity or “texture” of a patient’s experience of illness (including an applied learning experience of appreciating the social and community context of healthcare) as well as their own experience and style of providing patient care. Cultivating self-awareness is the goal.10 Reflective writing, as Rita Charon reminds us, helps build narrative competence,10 which consists of processes of attending (achieving mindful presence within the patient encounter), representing the experience in the written word to give it meaning (including affective responses), and affiliating with colleagues through shared text, mirroring processes of clinical practice, and potentially extending empathy and effective care.11 It also offers valuable opportunities for transformative professional growth and student well-being. Reflective practitioners, no matter what their clinical discipline, take better care of their patients, clients, and themselves.15 I have written throughout my career, as a student and now as a professor. Most often for myself, as I try to make sense of my work, and sometimes for others, through publication in literary or professional journals. These two goals are very different, as is the motivation behind them. For the last 10 years, I’ve helped to edit Ars Medica (www.ars -medica.ca), a literary/medical humanities magazine, and have read hundreds of submissions by authors from every clinical profession (including trainees). I’ve been forced to reflect on why healthcare students and practitioners write, how and when we do it, and whether there are mistakes we make as we go along. It occurs to me that this new wave of composition is promising but not always

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honest, helpful, or even benign. As learners, educators, policymakers, and clinicians, we should reflect on what writing and sharing stories means to us and how we approach the task, and then contemplate if there are risks to our integrity as professionals. Throughout this book, the emphasis on directing personal reflection toward improving patient-centered care and impacting social justice will be made explicit. These writing-based problems are itemized below,7 and suggested solutions can be found in the many pages that follow.

Five Common Errors I commonly see five errors that healthcare students make when they start writing. These observations begin with elements of craft and narrative competence, but then move into murkier territories of a particular brand of professional narcissism, marked by a hunger for publication and wobbly ethics. I’ll summarize each briefly, then ask a question which I believe we should routinely pose to ourselves and our colleagues whenever we share written stories about our patients or clients. 1. All clinicians have been taught to cut to the chase, so they usually do a lot of “telling” and not enough “showing” when they construct reflections and stories. Their narratives can be terse, pragmatic, and mimic a dry case presentation rather than invite us into a new world. We need sounds, dialogue, color, feelings, scents, and images to enter the story. Readers (and those of us who grade portfolio submissions), like patients and clients, want to know that they are in good hands and that important things are not being missed. In short, good, authentic writing almost always makes for powerful reflection. Question: Why write this story about this particular patient or client and why now? Why do you care so much about this clinical

Introduction

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encounter and why should we (as readers or listeners)? What have you learned? What will you do differently next time? 2. Our culture tends to favor tidy endings, epiphanies, and accounts of patients or clients who exhibit courage and triumph over adversity. (Think of all the war-inspired metaphors in treating cancer, for example, when we use words such as conquer, battle, courage, and hero.) These have become the tropes of illness narratives, but they don’t capture the chaos and suffering of practice or of real life. Readers want to be shaken into reflection and left with a challenge, dilemma, or new insights and that can only happen if your writing is authentic. Clinicians and students sometimes use their writing to pat themselves on the back, celebrate successes, or privilege narratives of people just like themselves. Such selective recounting and editing is seldom fully conscious or intentional. Stories about the disenfranchised, our clinical “failures,” or times when we’ve been afraid to speak up or are shaken by fear or doubt are much more honest and compelling. They are more difficult to write (and lead us to more unsettling reflection), but are more interesting to read, lead to actual behavioral change for the clinician, and leave a lasting impact. Question: What am I trying to accomplish with this story? Is my voice authentic? Does the ending ring true or have I tidied things up for a good grade? 3. Student clinicians may forget whom they’re writing for. Processing a personal dilemma or using writing as a reflective or even therapeutic tool has great value, but that doesn’t make the story comprehensible or even interesting to someone else. I’ve read a lot of journal and portfolio submissions that were spontaneous and raw, but were not ushered through the exigencies of craft to the next level of becoming a critical reflection or real story. There was no engaged reader in mind when the story was constructed; it was written only for the clinician-self (or as one student put it, “whipped into submission” for the portfolio course instructor).

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The piece may contain clichés, medical acronyms, and excessive technical detail and assumes these fully set the stage. On the flipside, some of the most compelling stories I’ve read have been written by professionals and students who had to re-enter and reimagine the medical world they once inhabited after falling ill themselves. Everything becomes new, foreign, and menacing, and seen with new eyes. Readers are taken on a journey. Question: Whom is this story for: myself as a learner with a unique experience and voice? (This is, after all, the primary focus of this book.) For a patient or client I wish to remember and honor? Or (as I develop my craft), for a literary reader who wants to be entertained and transported? 4. Neophyte clinical writers may lack humility and patience. Many practitioners (and some professors) are used to being right, calling the shots, seeing results, and manifesting their authority. Many don’t accept that they are beginners with respect to writing and reflecting and that creative talent (and the muses themselves) simply won’t be rushed. This reminds me of a story which may be apocryphal, but to my knowledge was first told by Margaret Laurence, a Canadian novelist and author of The Diviners. She was at a dinner party, sitting next to a neurosurgeon who, without guile, told her that he planned to write novels once he quit surgery. Without missing a beat, Laurence replied, “What a coincidence – when I stop writing, I plan to take up brain surgery.” Lesson learned! Question: Where am I in my writing process and where do I need to go? Can I accept being a beginner who has a lot to learn about critical reflection, and then work on learning and cultivating a lifelong craft? 5. The final common error is more serious and needs to be viewed through the lenses of ethics and professionalism. Healthcare students and professionals may think that stories heard in their offices, in clinics, or in the hospital belong to them. If they can be shared in case conferences, the thinking goes, they can be

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published as blogs, tweets, memoirs, poetry, essays, or nudged into fiction (with merely the slightest of changes to identifying details). This notion is deeply flawed and suggests a conflict of interest. Stories are always co-constructed in clinical settings and permission from the patient or client or his or her family must be sought out (and documented) if the encounter is to be morphed into a published form. (My own experience is that patients and clients feel honored that their story will be shared and may benefit others. Some write rebuttals or parallel pieces. Some want certain details changed. Seldom do they refuse to have the story appear in print.) Increasingly, clinical journals like the CMAJ insist that writing about a specific patient be kept as an official part of their clinical chart and that permission to publish be documented in that chart. Fiction-writing students, if they are honest with themselves, can usually identify the impetus for a story – a singular image, a facial expression, or a patient’s unique way of saying something. Part of true craft is using that detail as a point of departure, then moving into something entirely new incorporating personal memory and invention. You have to ask yourself, could anybody identify this patient/clinical detail or story/family if they read my piece? If you have doubts that your writer’s hat is taking precedence over your clinical one, then you need to edit, revise, retell, or get the opinion of a trusted teacher, colleague, professional editor, or ethicist. As I tell my nursing and medical students, the stethoscope always trumps the pen! Part of clinical grandiosity involves the rationalization that minor changes suffice to render the tale fictional or the suggestion that “the patient or client will never read this anyway.” Not so in a plugged-in, Internet world. (Not so in a litigious world either – I’ve heard of doctors’ personal reflection notes or parallel charts being subpoenaed as a part of a discovery for litigation.) Check both your faculty’s and clinic’s policy on where and how such notes should be kept, and whether their very existence should be referenced in the chart. I advise students to keep them in a

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personal journal or password-protected e-file that does not identify patients or colleagues by name. Confidentiality guidelines for including these reflections in a mandatory portfolio for submission and evaluation are offered throughout this book. Encouraging (or forcing) the sharing of stories among students and colleagues invites questions about personal and professional boundaries, confidentiality and privacy, respect, and potential stigmatization. Something can’t be untold once it’s out there. Pseudo-therapy is not the goal of this type of collective reflective writing or sharing narratives in portfolio courses, and the potential vulnerabilities of the teller and the maturity of the group must always be respected. (Writing is generally self-dosed in that people tell what they can or what they’re ready for. Forcing premature closure or probing threads not yet conscious to the teller can do damage to both the story and its teller.) Guidelines for sharing student narratives in a safe, confidential, respectful space can be found in chapters 21 and 22. Question: Whose story is this? Finally, I worry that we may come to reflection and to stories as a balm for what ails our various professions. Reflection should be a call to action and change! Band-Aid narratives make us feel good about what we do, especially when we feel thwarted or silenced as students. We submit them (sometimes half-heartedly) for course evaluation. We publish them in faculty or hospital magazines or on student blogs. We placate, have our altar-authoregos stroked, and are placated ourselves. Stories can also be about control (propaganda being the perfect example). Once we pay more attention to patient or client narratives, how will we select, shape, manipulate, and edit them, and to what end? It’s not up to us to determine what they mean or influence how they end, even as we see the plot unfolding. However, surely the goal of reflective writing should always be better patient care, better self-awareness, and better self-care.15 Ongoing reflection – of which writing can be a part, along with other forms of arts-based learning, mindfulness, and counselling – can prevent cynicism and burnout.

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Final question: Writing and sharing stories has made me more reflective and narratively competent. How am I using this new skill? Is patient/client care being served or is this more linked to control, entitlement, and advancement for me as an aspiring author? The book you hold in your hands offers over 1000 prompts (and what I call “provocations”) for you to deepen reflection on the work you do and study as you learn and on your creativity and vocation as both writer and healer. Some are wide-open and ambiguous, others are more directive or specific to challenge certain practice or attitudes. Portfolio course directors ask you to write but they may not be writers themselves or may not provide nuts and bolts instructions on how they define reflection, how to write with an authentic voice, not to mention the subtleties of editing as a form of critical engagement. These pages will suggest when, where, why, and how to write, reflect, edit, and (maybe even) get published. Remember, reflective writing has been demonstrated to deepen critical thinking, improve self-assessment, and enhance understanding of complex and ethically challenging interactions and to enhance professionalism over time. Reflections are most powerful when shared with other students, coaches, mentors, or course directors because your assumptions will be challenged and you will be reminded of both personal and systemic blind spots. We live in an age of inter-professional collaboration, so these writing prompts apply to any clinical learner at any level of training across a dozen or more disciplines. Prompts are organized into modules – key themes around “teamwork,” “wellness,” “communication,” and so on. Don’t be daunted by the sheer number. Pick one at random or go to a section where a recent incident has raised questions for you (like an unprofessional encounter). My experience in teaching is that a prompt will lead you to a story you need to tell in that period of reflection if you are patient and open to what comes. Don’t be afraid to revisit the same prompts over time. This

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will show how your responses to incidents and the actions you take change over time. You may be skeptical at first (and skepticism is a welcome variety of critical thinking), but if you apply your authentic self, you’ll see that reflective practice brings many personal and professional benefits over time. Portfolio to Go seeks to put reflective learning into your hands and to keep it critical, creative, authentic, and exciting. It will hopefully enhance the Portfolio course that already exists at your school by providing new themes to think and write about. If your faculty doesn’t have a Portfolio course yet, it will provide incentive and practical tips for developing one. Suggestions for forming independent reflective writing groups, giving feedback, and maintaining healthy, professional boundaries with colleagues when sharing reflective writing are also provided. Remember that all forms of narrative-based reflection and dialogue can be a valuable part of lifelong learning and your ongoing growth as a clinician and person.16

REFERENCES 1 Boud D. Avoiding the traps: Seeking good practice in the use of selfassessment and reflection in professional course. Soc Work Educ. 1999;18(2):121–32. http://dx.doi.org/10.1080/02615479911220131. 2 Davis MH, Ponnaperuma GG. Portfolio projects. In: Hallock JA, editor. A practical guide for medical teachers. 3rd ed. Edinburgh: Churchill Livingstone; 2009. p. 349–56. 3 Brady DW, Corbie-Smith G, Branch WT. “What’s important to you?” The use of narratives to promote self-reflection and to understand the experiences of medical residents. Ann Intern Med. 2002;137(3):220–3. http:// dx.doi.org/10.7326/0003-4819-137-3-200208060-00025 Medline:12160380 4 Charon R. Reading, writing, and doctoring: literature and medicine. Am J Med Sci. 2000;319(5):285–91. http://dx.doi.org/10.1016/S0002-9629(15) 40754-2 Medline:10830551 5 Moon J. A handbook of reflective and experiential learning. London: Routledge; 2012. 6 Eva, KW, Regehr G. Self-assessment in the health professions: a reformulation of research agenda. Acad Med. 2005;80(10):S 46–54. http://dx.doi.org/ 10.1097/00001888-200510001-00015.

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7 Epstein RM. Mindful practice. JAMA. 1999;282(9):833–9. http://dx.doi .org/10.1001/jama.282.9.833 Medline:10478689 8 Peterkin A. Why we write (and how we can do it better). CMAJ. 2010;182(15):1650–2. http://dx.doi.org/10.1503/cmaj.101329. Excerpted with permission of CMAJ. 9 Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009;14(4):595–621. http://dx.doi.org/10.1007/s10459-007-9090-2 Medline:18034364 10 Charon R. Narrative medicine – honoring the stories of illness. New York: Oxford University Press; 2006. 11 Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897–902. http://dx.doi.org/10.1001 /jama.286.15.1897 Medline:11597295 12 Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2011;33(3):200–5. Medline:20874014 13 Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 2008;42(5):468–75. http:// dx.doi.org/10.1111/j.1365-2923.2008.03030.x Medline:18412886 14 Wald HS, Borkan JM, Taylor JS, et al. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing. Acad Med. 2012;87(1):41–50. http://dx.doi .org/10.1097/ACM.0b013e31823b55fa Medline:22104060 15 Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. 2013;11(2):75–81. Medline:23967495 16 Greenlagh T, Hurwitz B. Narrative-based medicine: Dialogue and discourse in clinical practice. London: BMJ Books; 1998. Additional references informing the content in subsequent chapters along with other suggested readings can be found at the end of the book.

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What Can My Reflective Portfolio Be?

Your school will have its own procedures and guidelines for creating, maintaining, and evaluating a reflective portfolio (or PF). Review these carefully. You need to pass the course! If there is no course at your school, here are some tips to keep your portfolio or journal fresh, alive, and relevant as a repository for your reflections. You can choose what you submit for formal evaluation, but make the PF your own by including personal artifacts that are important to you. 1. The PF should track your process, progress, creativity, and growth as a clinician and person over time (and ideally throughout your career). It should not just be a journal of dates and events, although you should record meetings with supervisors. Include milestones, turning points, surprises, moments of despair and doubt. You can have personal/private/protected content (for your eyes only) alongside formal assignments to be submitted for assessment. 2. Set specific, realistic learning goals and completion deadlines and break those goals down into specific items and manageable steps. Procrastination is a killer – don’t leave things until the end. Discuss how you will demonstrate and record that you’ve reached those goals with your tutors/mentors/supervisors. 3. Use both sides of your brain in your learning process! You need to provide evidence of new knowledge based on best practices as well as subjective impressions. This may include direct

What Can My Reflective Portfolio Be?

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observation of clinical skills, clinical evaluation reports, write-ups of problem-based learning cases, and clinical exercises. You will likely be asked to document course attendance, completion of new procedural skills, a checklist of requirements for this phase of your training, exam results, and any publications, research projects, or presentations you write or co-write. 4. Decide how you are going to organize your PF – for instance, on an e-platform or on paper in a ring binder with envelope pockets and tabs with headings. (Lots of courses invite both written and electronic content.) Consider designating “chapters” as determined by course blocks or based on course themes, specific rotations, learning milestones, or professional roles (like the CanMEDS professional roles for medical students – see http:// www.royalcollege.ca/portal/page/portal/rc/canmeds.) Be organized from the beginning so you don’t lose valuable content. Track your evolution over time by giving your entries dates and titles. Try to cross-reference previous entries to show how your thinking has changed or deepened. The best portfolios track longitudinal growth throughout your training. Keep evaluating and re-evaluating. Be persistent! Test your conclusions and ask yourself how you’re going to implement them. Sign off each year with a summary and goals for the next term. Update your CV each year and insert it as a marker of achievements. 5. This book emphasizes reflective writing, but if you’re a visual learner, include images, video clips, photos, drawings or paintings, crafted objects, performance extracts, scrapbook extracts, and other multimedia. Jot down seeds of ideas so you can trigger recollection and then flesh them out when you have time to write. 6. Identify personal resistances to keeping a portfolio early on. Is it a question of scheduling and time? Doubt regarding the value of the initiative? Clashes with your personal learning style? Concerns about sharing personal reflections with faculty or other students?

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Problem solve around each obstacle alone or in conversation with other students. Resistance and curricular critique can actually be a terrific impetus for reflection! (I sometimes suggest that students create a bogus piece of reflective writing, based on checklists they imagine their preceptors are looking for and then write a constructive critique of the evaluation process.) 7. Revisit your learning goals and any obstacles to growth in an ongoing fashion. Include strengths and failures. (A whole literature on the value of failure has emerged in the corporate/business literature.) Start articulating career and life goals. (This content can be placed at the end of your portfolio.) 8. Get your money’s worth from the preceptor/mentor/ coach who is evaluating your PF assignment. Ask questions and request feedback and resources. Book face-to-face time with your individual mentor well in advance – three times a year is a good frequency. Group portfolio feedback (which includes peer and faculty discussion) typically occurs monthly. You can use feedback to edit and improve a written reflection for submission and evaluation. Many preceptors actually look for and rate your capacity to hear feedback non-defensively and to incorporate it into your work over time. (As an important aside, the most successful portfolio courses have clear learning goals and summative/formative evaluation techniques and offer ongoing faculty development and support to preceptors. Teachers also need to work on writing and reflection skills, close reading, and reliable assessment methods in order to model ongoing engagement with the process.) 9. You can decide what else goes into your PF: parallel chart patient notes (use their initials, not full names), feedback and evaluations, research questions, case presentations, key research or review articles, correspondence from your professional association, minutes from committees, field notes, creative initiatives and projects, reviews of books and films, newspaper

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clips, printed emails/tweets, write-ups of critical incidents, test scores, personal journal entries, thank you notes from patients, quality improvement projects, OSCE videos or scores, evaluations coming from direct observation, rotation evaluations, evidencebased-practice research projects, course evaluations, “360 degree” evaluations (coming from multiple sources including patients). If you want to become an academic, keeping a portfolio during all stages of training and thereafter will dramatically assist you in preparing a promotions document – an otherwise onerous and time consuming task! 10. Create your own writing or project prompts. Reviewing your association’s core values and professional attributes and requirements can lead you to invent challenging prompts of your own. For example, at the University of Toronto, we created prompts based on the CanMEDS medical professional roles that are used to track learning goals throughout medical education in Canada. An example for advocacy: “Write about a time you did or did not stand up for a patient.” Every clinical profession has in its own professional guidelines – check your licensing body and create prompts from keywords found in those statements, such as communication, scholarship, teamwork, leadership, confidentiality, respect, diversity, equity, etc. … 11. Push the envelope. If you’re primarily a verbal/wordbased reflector, push yourself to incorporate your five senses into your learning and record the results. Include sketches, doodles, stickers, and/or collage pieces to capture the visual. Include the one image from your training that you cannot get out of your mind. Write about smells that evoke memories and associations. Insights that have come to you from your body (when walking, running, doing yoga, working out). What have your own movements, posture, gestures taught you about yourself and others? What about the sounds of your classroom, clinic, hospital, or a unique voice? How good are you at closely listening to the

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stories your fellow students, clients, or patients bring you? What are your tactile observations from examining people’s bodies and touching medical instruments? What about the taste of hospital food or the meal celebrating your graduation? Help your professors create new prompts that honor the multiple ways we all learn and reflect. 12. Keep track of your own wellness and happiness in your PF. Reflective practitioners take better care of their patients and clients and also of themselves. Commit to the process and be authentic. You’ll lose out and will be graded poorly if you just go through the motions. Students can get a bit jaded if they are obliged to “reflect and emote” every year for three to six years. “What’s left to write about?” The many prompts provided here are meant to shake things up and keep your reflective process fresh, relevant, and provocative. Remember that the PF can be a useful tool for your entire career and a part of continuing education and growth. Some practitioners come to see it as a “mission statement” which they reaffirm and/or revise over time.

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Finding Optimal Conditions to Write and Reflect

Reflective writing doesn’t just happen. You need to prioritize it as part of your learning and then find the time, space, and optimal setting and working conditions. Answer the following questions to see what works for you and will allow your reflective practice to become sustainable: WHEN – When are you most likely to have quiet time? When are you most likely to write something down? Determine if morning, afternoon, or evening are best for you to write. How do you handle urgent questions/situations – do you flag them for later or process them immediately? WHERE – Some people need complete quiet to reflect. Others prefer to write in a cafe or restaurant, or with others around. Do you have a study? Do you go to the hospital library? Do you jot things down on the subway? Over a lunch break? WHY – Notice trends in which kind of incidents or situations you write about. Do you write when you feel silenced by authority? When something goes really well (or really badly)? When you’re stumped or experiencing doubt? Your reflective writing may be obligatory in your course, but are you writing honestly for your own learning or are you going through the motions for a grade? HOW – How do you write? Do you prefer pens and notebooks or journals? Typing on your phone or laptop? Jotting short phrases/quotes in your agenda to return to later? Do images,

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sounds, smells, and other sensations trigger your reflecting process? As you write more, do you find you’re drawn to a certain genre? Short memoir pieces? Poems? Dialogue? Twitter feeds or blogs? Lists? Do doodles or drawings accompany your reflections as in a graphic comic strip or novel? Shake things up by trying a new form or style of writing. WHAT – What gets you started? Most people like a prompt, assignment, or trigger to nudge a particular personal story or reflection onto the page (or screen). Try picking one of the prompts in this book randomly. Or, take an assignment and play with the idea so that it fits what you need to express as a self-directed learner.

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Getting Started: Learning as a Journey Writing Prompts

The many years of study you are undertaking will be exciting, challenging, and sometimes daunting. These prompts will help you pay attention to process rather than content learned – to how you are acculturated in and by your profession. (Some educators have dubbed this “cognitive journeymanship.”) There’s no doubt that your training will change you as a person. You have a chance to deepen your resilience and affirm your personal values and humanism, but the risk of cynicism and burnout are very real. Why did you choose to study this profession in the first place? Write about a student who taught you something. Write about a specific encounter with a patient or client that you’ll never forget. Why do you say “patient” versus “client” anyhow, and what does it mean to those around you? Go to YouTube.com and type in your profession/discipline. Watch a random video and write about it. Where I’ve been … Write about a mistake you have made. Write about a mistake you have witnessed. Write about something you learned that has since been shown to be wrong/obsolete.

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Describe something you know now that you wish you knew at the beginning of the year. Reflect on a lesson you were taught by a patient/client. Write a story about a mentor. Turn to page 50 in one of your textbooks. Write out the fifth line on that page as your prompt. Write about a first clinical experience related to a: • Birth/delivery • Death • Serious clinical error • Delivery of bad news • Suture, suctioning, limb manipulation, or some other procedure performed on a person’s body • Family meeting • Other (your choice – pick something unique to your discipline) Write about a leader you admire. Write about a clash of generations in a teaching encounter. “They fell off the pedestal with a thud …” Write about a research experience. Your chief of staff/supervisor “wants to see you right now!” What happens next? Write about a time you were published (or rejected for publication). Write a story about a baby. Write a story about a home visit or house call. Write about a medical test or medical image. Write about a life you helped save. Write about someone you have idealized. Look at a map that shows topographical features (mountains, rivers, forests, etc.), then choose a position on the map that

Learning as a Journey – Writing Prompts

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best corresponds to your current “location” in your student/ practical journey. Next: • Plot a course through the map that shows your journey up to this point; • Discuss any obstacles you have encountered along the way (mountains you climbed; bodies of water you crossed; jungles you hacked through; etc.); • Discuss any sections where the going was easy; • Use a dotted line to project where you anticipate your journey will take you from this point on. Write a postcard to a person who acted as a mentor (formally or without knowing they were fulfilling this role), describing how they inspired you. “Here are five pieces of advice for student in the year behind me.” What is your favorite word or phrase? Write a story based on it. Write about some bad advice that you followed. “This is my _______ year of study. Here’s what I’ve learned so far.” Write three questions you would like to be asked about your work. Write about a deadline that mattered to you. Pick a word and write about it: • X-ray • Prescription • CT or other form of imaging • Syringe/needle • Bandage • Fetal monitor • Electrocardiogram • Lab result What is your work uniform (real or symbolic)? Take five minutes to critically review the last lecture you heard or attended. Use cheeky language. Write it as a tweet.

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Write a story about an instrument or procedure specific to your clinical discipline. Write about a time you’ve procrastinated. Write about a teacher who: • Inspired you • Disillusioned you • Scared you • Harassed or bullied you • Behaved seductively toward you or another student Write about why another student might remember you, based on an incident or encounter you shared. Write about a night on call or night shift. Describe your favorite teacher and what he or she taught you. Write about a time when you enjoyed learning the most. Write about a time you hated learning or where you felt stuck. A “Eureka moment” is defined as “the moment when you suddenly understand something important, have a great idea, or find the answer to a problem” (Oxford Advanced American Dictionary, 2015). Think of a time during your clinical practice when you experienced a “Eureka moment,” and write about: • The conditions under which this occurred; • The particulars of the dilemma; • How your moment of insight brought clarity; • How your perspective on clinical care changed. Write about a transformative encounter or experience. Write a story about an interview. Write about an exam you took/wrote. “I flunked …” Write about a time you actually hid at work or school. “What I missed …”

Learning as a Journey – Writing Prompts

Write about a struggle. Here’s my working definition of: • Empathy • Humanism • Person-Centered Care What I learned from failure.

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5

Using Reflective Writing Prompts and Storytelling Skills to Maximize Growth and Reflection

Most of us hate staring at a blank page. My experience is that students like prompts to get things started (whether they use the original trigger or not). Here’s how to use them. 1. View the prompt as an invitation or launch pad. See if a story comes. Most often, it will! If not, write whatever emerges. • Let yourself reflect on the writing prompt. Work with it if it captures your imagination, or choose something else that really matters to you in the moment. A prompt might lead you to another prompt of your own or to a more urgent story you need to tell. • Choose a time of day and place where you’re not distracted, then write for up to 45 minutes. See chapter 3 for tips on “Finding Optimal Conditions to Write and Reflect.” • Don’t expect too much from the first go – the goal is to get something on the page, not to judge it. It might be one word or image. A list of events. A snippet of dialogue. These can lead to more. 2. Follow your pen (or cursor) and trust where it takes you. You don’t know what will come next, so let yourself be surprised. There’s no right or wrong answer as the story emerges. 3. Most often a story will emerge – see it through as part of your reflective process!

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4. Don’t get hung up on grammar or syntax in your first draft. (But do pay attention to these in your formal course submissions! Your credibility as a communicator and professional will be questioned if you make silly errors in spelling, punctuation, or grammar in your portfolio assignment, and even more so in official chart entries. Brush up on these skills, too, as part of all writing tasks.) 5. Give your piece a date and title and set it aside. You can rework it later, read it in group, or share it with others when you feel ready. 6. You are “writing a story.” Remember to pick an incident or event that mattered to you for your reflection because that will bring it urgency and depth. Shape it by including a beginning, middle, and end. 7. The form will follow – see how the story wants to be told. In the first, second, or third person. As dialogue. A cartoon panel. A Poem. A Rant. A tweet or blog. 8. Be flexible. Stop and start. You may start with one story, but another may impose itself. Go with the one that sticks. Date it and give it a working title. 9. Choose between the terms “observed” or “experienced” to allow yourself to write a personal story that reveals only as much as you are comfortable with. In other words, you can write about something you’ve witnessed rather than something you’ve actually done and still reflect critically on the incident. (e.g., the OT student; “he/she did this” rather than “I did this …”) 10. You may choose to write, then tell or read your story in the third person, but you may actually discuss the story in the first person in a group learning setting. 11. Make sure the story and reflection matter to you. Critical reflection and transformative learning involve taking risks,

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not just going through the motions or scoring a passing grade. Your readers/evaluators will be looking for authenticity in your voice.

Elements of Critical Written Reflection • Describes a situation that truly matters to you, the writer. As the author, you are fully present in the narrative and your voice is personal, lively, and engaged. • Reframes the situation you have described in a new way or demonstrates a breakthrough or personal growth. • Incorporates evidence-based clinical knowledge and reference to the best practices of your profession. • Weaves together past and present experiences you have had. Donald Schon (see References at the end of the book), a pioneer in reflection literature, called this “reflection on action.” This leads to “reflection in action.” • Includes plans for different actions, outcomes, solutions, and new learning that you can pursue in the future. • Incorporates the subjective as well as the objective: your own feelings, emotions, doubts, assumptions, thoughts, and values are explained in order to create an authentic, engaging voice in the narrative. • You as the narrator seek multiple sources of knowledge (colleagues from your own and other disciplines, teachers and supervisors, up-to-date references and resources) to expand your perspective on the incident/situation described. • You demonstrate a new skill, meaning-making perspective, attitude, or knowledge base within the narrative. You show how new lessons were learned in specific (i.e., not vague) terms.

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• You present interpersonal conflict and team interactions (if present in the incident) honestly but fairly. • You provide specifics, particulars, unique factors, and details rather than generalizations or clichés. • Your narrative reflection isn’t vague, plaintive, selfcongratulatory, preachy, or excessively detached. • Your writing is professional and narratively competent – organized, clearly written, grammatically correct – and it responds to all of the assignment requirements. • You can back up claims, conclusions, and new actions with evidence, practice guidelines, or references from the literature.

Make Your Assignment Come Alive – Some Writing and Editing Tips A Portfolio course is not a literature or creative writing class, but keep your mind open to how your reflective writing develops. Reflection deepens when you care about your story and craft it attentively and compellingly for someone else to read (or hear). • Create an incident-based story with a beginning, middle, and end. The incident should matter to you professionally and personally. • Show, don’t tell. Paint a picture with words instead of providing facts in a sequence. Try to write as if you were telling the story aloud to a friend or fellow student in your reflection group. • Locate the reader at the outset of the story, e.g., name “characters” (you may wish to use initials for actual patients or colleagues), specify time, detail surroundings. • Use strong, active, and specific verbs (vs. adverbs) to carry the main meaning. For example, replace “she walked slowly” with “she strolled, wandered, drifted …”

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• Avoid forms of the verb “to be.” For example, replace “she was telling a story” with “she told a story.” • Use dialogue to show, versus describe, characters. Make sure the reader knows who is speaking. • Write the way you naturally speak in your academic/clinical setting. Use honest, direct, and simple language. Avoid the wordy, pompous, and redundant. • Avoid complex or lengthy sentence structure to enhance clarity. • Replace clichés with specific detail. • Discard the passive voice. For example, write “the group took a vote” instead of “a vote was taken by the group.” • Pay attention to structure – is the piece arranged, logical, and held together? • Pace your story. Make the reader want to know what happens next. • Quantity does not equal quality when it comes to reflection. Less can be more in terms of content. • Stories should reflect what you feel about what happened, not just what happened, so that the reader is invited to feel curious and connected. This subjective/affective part of learning does not mean invoking false sentimentality to score points in evaluation. (One critical but very reflective student told me, “The folks who mark our portfolio entries just love it when we say we cried after an encounter with a client.”) • Demonstrate what you’ve learned and what you will do differently from the incident described. Show how you can justify any lessons learned from clinical guidelines/literature. Source: Allan Peterkin and Julie Hann (eds.), Still Here: A PostCocktail AIDS Anthology (Toronto: Life Rattle Press; 2008)

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SUMMARY: Thoughtful, well-crafted writing almost always makes for critical reflection for both the writer and the reader – so make your account come alive! Read this well-crafted narrative reflection by a student:

Scholar: Write about a time when your learning was optimized or hampered. Tying the Knot I’m only 23 and I’ve already tied the knot twice. The first time was with Dr. Plastic, who proposed only moments after we met. “That’s all wrong,” he scoffed as he leaned over my shoulder. “Your patient would have bled out on you by now.” We were in the skills lab, and I was so engaged in my silk thread and latex skin model, that I didn’t notice him approach from behind me. He was tall, middle-aged, and angular. He had big hands, and long plastic surgeon fingers. “Let me show you a better way,” he said. He sat down beside me, pulled the model toward himself, and proceeded to knot-tie in rapid succession. I was mesmerized by the quick action of his long graceful fingers. In fact, I was so distracted that I forgot to pay attention to what he was doing. “Your turn,” he said as he pushed the model back in my direction. I grasped the silk threads tentatively, and used my left hand to begin the motion of typing a knot. “Too bad,” he said, “you’re a south paw. Well, just do the opposite of what I’m doing then.” He took the model and did eight more rapid action knots. I was starting to feel stupid. What’s wrong with me? Why can’t I get it? He made the skill seem so easy, but I was struggling. I tried another clumsy knot. At this point, he turned to my friend sitting beside me,

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who, incidentally, had spent his summer in South America sewing up episiotomies and delivering babies via c-section. “Excellent work,” he said to my friend. “I can see you’re a natural.” Then he turned to look at me. “Wrong. Were you paying attention? I just showed you this.” Another six knots and he pushed the model towards me again. I was starting to sweat. My fingers felt like fat sausages Of course, I did it wrong again. He coughed and rolled his eyes. “You’re not going to be a surgeon are you?” At this point, I was starting to get pissed off. This was day one of my surgery rotation. I knew it was time to end things with Dr. Plastic. I smiled at him, and then went back to my knot tying. I didn’t look up again until he walked away to teach advanced suturing skills to my more gifted peers.

Knot 2 They say the first cut is the deepest, but it was my second one that sealed the deal for me. C was a PGY1 in general surgery. The moment I met her, when we were on call together, I immediately liked her. She told me not to worry when I accidentally eletrocauterized outside of the incision line marked on the patient’s abdomen with a sharpie. She said “great job” after I finished my first 8-minute single-suture on a real patient. She noticed that I looked a little awkward tying knots as we were closing up on an emergency lap appendectomy, so she asked me if I wanted any tips. I was happy to get any guidance I could, as guidance on surgical skills was so hard to come by in the surgery rotation so far. It was midnight, and we found a quiet spot in the main lobby of TGH. She procured a packet of silk thread from the pocket of her scrubs, and pulled out a pen. She tied the thread around the pen and held the pen in place.

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“It’ll be easier if I can watch you first, to try and understand what you’re doing.” She watched me tie a few knots, and then made some suggestions. She had such a gentle way of speaking, and her smile immediately put me at ease. We sat on the bench for an hour, until I was a knot-tying pro. I didn’t sweat once during the whole process, and not once did she mention that I might not be cut out for surgery. Instead, she said “great job,” and reassured me that she too had difficulty with this skill until someone took the time to sit down with her and teach her. I felt relieved. Even more than that, I hoped I would run into Dr. P in the OR, so I could now show him who was or wasn’t cut out to be a super surgeon.

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Communication Writing Prompts

Even if you resist reflective writing at first, you have to agree that speaking clearly and writing well are essential requirements for your clinical discipline, no matter what it is. Your words matter to your clients and patients, perhaps more than you realize. Your chart notes matter (sometimes urgently) to anyone sharing the care of that person. Misunderstandings among colleagues or with patients can happen because of non-verbal cues like demeanor, dress, and facial expressions. As you weave these details into your narratives and reflective pieces, you will come to understand how. Write about a misunderstanding. Write about a miscommunication. Write about a phone call. Write about a conversation you’ve had in the middle of the night. Write a story about criticism. Write a story about a rumor you’ve heard or passed along. Write a story about a patient asking you a personal question. Write a story about gossip you’ve heard in the workplace. Write a story about mixed messages. Write about a time you tried to comfort someone. Write about a time where you were interrupted or where you did the interrupting. Write about an apology.

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Write a story based on a phrase you overheard somewhere at work today. Write about the most difficult conversation you’ve ever had. Write about an encounter with a receptionist or admin person. Write a story about “feedback.” Write about a time you were rude or were treated rudely. Write about someone in your clinical environment you see as fake or phony. Show why. Write about a time you held back information from a patient (or were told to do so.). Write about the last email you sent. Write about a conversation you have overheard on a ward or in a clinic. Write an honest email to your supervisor (but don’t send it). Write about an automated phone call or a message that was left by you or someone else. Write about a time you delivered news (good or bad). Write about the nicest thing anyone has ever said to you in your educational or professional life. Write about a time you offended a patient or colleague without meaning to. Write a thank you note to someone who helped you. Write about a time you gave advice or reassurance. What happened? Dissect and analyze five examples of jargon (acronyms, abbreviations, etc.) from your own clinical profession. What does this “lingo” accomplish? “What I didn’t get to say …” Write about a time when you gave good news. “Don’t be so negative …”

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Write a letter to a patient/client you let down. Pick a medical headline from the news. Interview yourself about your opinion on the matter. Write about your most recent apology. “The last time I got chewed out by a client/patient …” Write down the one question you didn’t get to ask in your last encounter with a patient/client. Write about a time you pretended to know something you didn’t. Write a story about listening. Write a story about silence.

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Collaboration and Teamwork Writing Prompts

We all work in teams – with colleagues from the same or other health professions and disciplines. Teams bring out the best and worst in people. If members can keep in mind that their shared work is to help people get or feel better, they can transcend their own egos and concerns and navigate conflict in ways that deepen trust and enhance team functioning. The minefields are: POWER • PRIVILEGE • SENIORITY • PECKING ORDER • ENVY • MONEY • CONNECTIONS • PERSONAL NARCISSISM • CRONYISM • NEPOTISM (Feel free to add to this list.) Writing stories can help us understand what really happens in teams and sometimes we can share and use those texts (or literary pieces dealing with key themes) as a proxy for collective problem solving rather than finger pointing. Write about an incident you witnessed/experienced on a committee. Explain, in a paragraph, what someone from another discipline on your team really does. Write about being on a team. Write about the disintegration or strengthening of a team that you have been part of. Describe each member of your clinical team (including yourself) in one word. Make a list of how your team members see you. Draw a ladder of hierarchy where you work (including yourself), with notes on roles and attitudes.

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Write about the last piece of advice you received from a colleague. Write an email offering help to a colleague in trouble. Write up your latest team meeting from the perspective of someone with a different job. Describe a tense situation you were in, from the perspective of the allied healthcare professional you were working with. Write a story about leadership. Write about a betrayal. Write about a snitch. Write about a whistleblower (or why you’d like to be one.). Write about the elephant in the room at a team meeting (i.e., what could not be said). “What we all missed …” Write about your relationship to an important authority figure. “Here’s how I manage my day…” Write about an innovation you and your team created or improved together. Write about a time you were blamed unfairly. Write about how competition plays out on your team. Write about a workplace celebration. “The manager/team leader has no idea …” What leadership means to me … Write about a team member who was: lazy, arrogant, incompetent, impaired – or all of the above. Write about a team member who didn’t carry their weight or was missing in action when it mattered. Write about inclusion or exclusion. Write about being lowest man or woman on the power ladder.

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Write a story about being put on the spot. Write about a colleague who was high/drunk/impaired on the job. Make a list of five interview questions for a colleague from another clinical discipline. Write about a time you were micro-managed. “I called the ethicist …” “I called the chaplain …”

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Conflict Writing Prompts

Even well-functioning teams have disagreements. This is the necessary price for collective meaning and decision making. We all become accountable for optimizing care as we discuss things we doubt or don’t like, or that clash with our own professional views, values, assumptions, and blind spots. Students often feel silenced in the context of team conflict or power plays. Writing thoughtfully and sharing stories about these situations can lessen personal distress and helplessness, allow for problem solving, and invite more assertiveness or decisive action the next time something similar happens. Write about a morale-killer on your team (a person or process). Write a story about the last time you were yelled at. Write about a time you felt misunderstood. Write about a time you felt jealous/envious. Write a story about a confrontation. Write about the last time you chewed someone out. Write about a time you felt afraid at work. Write about someone you have disliked in a work context. Show why. Write about an angry encounter. Write about a time you were fired or wanted to fire someone. Write about a rupture or break-up. Compose an email (written by a [fr]enemy) explaining why they don’t like you.

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Write a letter to a teacher or colleagues who hurt you. Be specific about what they did. Write an incident of bullying you witnessed or experienced. Write about a time you felt offended at work. Write about a conflict at work or school. Write out a conflict that happened at work in dialogue only (no description). Write a story about disobedience. Write a rant … let it rip! Write about a time there were mixed messages on your team. “YOU IDIOT!” Write about a time you felt intimidated, harassed, or abused. Write about a “disruptive colleague.” Write a story about biting your tongue. Write a story about exploitation. “The buck stops here.” “Money talks …” “They were just being manipulative …” Write about a conflict that injured a patient/client or compromised their care in some way. Write about a time you reported someone. Write about the most inappropriate thing you have ever observed or experienced at work or school. Read this student story about teamwork and collaboration:

“Push 2 of epi!” Several minutes earlier I had been down in emerg, reviewing with my senior resident about a patient I had just consulted on. Midway through the HPI, her pager had gone off. I had no idea that medicine call meant that we

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were part of the code team. But as I ran down the hall and up five flights of stairs, I realized that we were the first responders to the code blue that was being paged overhead. This would be my first code blue that I would partake in, and the first acute resuscitation I would witness. Monitors were beeping. Blood was being drawn. Orders yelled out. “Jessica! Patch in!” The patient was intubated. A nurse in pink scrubs was up on the bed doing compressions. “Jessica! Patch in!” It took me a minute to realize that I was the Jessica being addressed. A femoral line was started. IVs were put in. I had no idea what I was supposed to being patching. V fib. A Foley was inserted. Adenosine. Another 2 of epi. “Jessica, patch in for CPR.” So that’s what it meant. I patched in for a nurse, this one in blue scrubs. This was the first time I’d come close enough to see the patient. He was a large man, which made it difficult to landmark. CPR was harder than I thought. Several seconds in, and my body ached, my stethescope kept hitting me in the face, and I found myself humming that stupid “staying alive” song. “Jessica, harder. Faster.” I’ve never been more uncomfortable, half standing half squatting on a stool that was too high on a man that was too large for me to make much of a difference. “Uh uh uh, staying alive, staying alive.” What a stupid song. Two minutes have never felt so long. I patched out, removed my stethescope from around my neck and caught my breath, while I waited for my turn to come again. “Clear. Shock. Resume CPR.” More epi, more compressions. Five minutes. I patched back in. V fib. Find a pulse. I patched out. Ten minutes. More epi. More compressions. Thirty minutes later the code was over. I’ve collaborated with colleagues, classmates, physicians, nurses and allied health professionals on a daily basis since beginning my clerkship, but none stands out as a prime

Conflict – Writing Prompts

example of teamwork, cooperation and care delivery like my first code did. There must have been 20 people crammed into this single little room. Orders were being yelled, multiple lines and tubes were being inserted at once, and yet there was an order amongst the chaos. Everyone had their own role, pushing drugs, attaching monitors, ventilating, but everyone was willing to assist each other. Senior staff didn’t seem to mind being told what to do by an R2. I patched in and out with nurses, RTs and senior residents. We were a group of people who prior to this code had never met, and here we were, functioning like a well-oiled machine, as though we had been doing this together all our lives. At times clerkship has felt like a one-man show. There have been instances where no one seems willing to tell me where forms are, I get a lot of attitude for asking questions, people are cranky and I’ve spent many a moment lost in a stairwell. And it’s not just me – I’ve seen the nature of the healthcare hierarchy. I’ve had doctors tell me how stupid nurses are and nurses tell me what assholes doctors are. I’ve witnessed turf wars by different specialities, trying to turf off a patient who’s come into emerg. But I’ve also seen the flip side of this coin – and I’ve come to realize how much more effective a group is when it works as a team instead of individuals, and how much even more effective a group is when it works well together. Imagine an OR without a scrub nurse handing over instruments, or getting an elderly patient back home without the help of PT and OT, or a trauma assessment without the X-ray tech and IV nurse. Sometimes we might have different ideas of what is best, and often we get bogged down by logistics and politics, but in the end I truly believe that we are all in this profession because we want to help others. And there is no better way to witness this sense of connection and demonstration of collaborative performance than in an acute life-or-death situation.

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The patient didn’t make it. The team of anesthetists, nurses, RTs, residents and students filed out, several sticking around to tie up loose ends and contact the patient’s family. I returned to the emerg with team medicine, trying to calm my pumping adrenaline and resume reviewing my consult. In a situation like this, I think you have to measure your success at how well the code went, and not what the end outcome was. We were organized, meticulous and thorough. I didn’t vomit. And next time, I will know right away what it means to patch in.

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The Personal Narrative Reflection Tool Steps for Enhancing Critical Reflection in Your Portfolio Entries

Answer the following questions for selected pieces of reflective writing. This may help you edit the piece for formal PF submission and will allow you to deepen your process.

1. Why did you choose this incident/story? 2. What went well in this situation? 3. What didn’t go well? 4. What would you do differently next time? Be specific about perceptions, attitudes, and behaviors. 5. Summarize learning/teaching points, incorporating evidence for what you have learned. 6. What evidence can you find and document for your decision/ new action in practice guidelines, or other available literature, sources, or resources?

What truly engaged reflection can help you accomplish: • To challenge personal assumptions, biases, blind spots, privileges and vulnerabilities, shortcuts, and old habits in your learning and encounters with others. • To appreciate the sometimes very different perspectives of those around you (including those of patients, clients and their families, professors, classmates).

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• To honor feelings, intuitions, subjective responses, and your five senses as well as your cognitive skills. • To remain open to new learning challenges and personal experiences as you acquire new tools to process and understand them. • To find your own ideal learning strategies through experimenting with various styles/modalities/techniques (i.e., visual vs. verbal reflection exercises). • To question the sources and reliability of knowledge by asking which ideas/practices/policies are justified, well grounded, and evidence-based and which are unexamined, in flux, or obsolete. • To assess the impact of what you say/think/do on yourself and others.

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The Patient or Client as a Person Writing Prompts

All clinical training programs promote the concepts of humanism and person- and family-centered care. There are endless exam questions on these themes, but they don’t flesh out the real story. As you move through your training, you’ll realize that these attitudes (or the absence of them) are best embodied through real experiences and through working these encounters into personal narratives that you can remember and learn from. As already mentioned, reflection “on” (past) actions leads to reflection “in” action in the here-and-now real world. Write down a phrase, word, or image that sticks in your mind from an encounter with a patient or client. Use it to begin a story about that person. His/her last words … Write about a patient who scared you. Write about a patient you were attracted to. Write a description of the last patient/client you saw, providing details from each of your five senses. Write about someone who isn’t getting better. Write a story about a person living with a type of suffering that is invisible to others. Write a story in which a person is cleaning out the house of a recently deceased relative. Write a story, choosing one of the following titles: • My ideal patient/client • My worst patient/client • My favorite patient/client ever

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“Middle age is …” “The treatment was worse than the disease …” Write a story about consent. Ask one of your patients or clients to write a one-page impact statement about their illness for their chart. Discuss it with them. Write “a day in the life” of one of your patients as you imagine it – from the time they wake up to the time they go to bed. Write about a person with depression. Try to show what it’s like. Pick a patient/client. Write about their biggest disappointment. Then, write about their greatest joy. Write about a patient/client whose name you dread seeing on your day sheet or clinic list. Write about a patient/client you have: • Disliked • Liked too much Based on what only you know, write a short obituary for one of your patients who died. You present a case and the patient involved is secretly in the room. Describe what happens next. Write a story about homelessness. Write a story using a word or metaphor or phrase that was unique to a patient. Write up a secret that a patient or client told you. Imagine you have room for one to three lines to record information that might provide some brief but helpful information about a particular patient’s state of mind, circumstances, needs, cultural preferences, etc. What might they be? Thinking of a particular patient, write those sentences. You have three sentences. The first is “I didn't know what to say.” Expand on that for two more sentences, thinking of a

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particular clinical encounter. Then play with your sentences on the page, laying them out like a poem, considering where the line breaks, perhaps a stanza break, might be, changing words if you like, but not over-editing. What you’re doing is not trying to perfect a poem, but to discover a small surprise or two in the process. “A physical description of an eccentric patient.” “What mattered most to them was …” “A parent is only as happy as their least healthy child.” Using words, paint a picture of a sick room or hospital room, incorporating all five senses. Write about a person who came to their appointment loaded with clinical information obtained from the Internet. Describe what you imagine a patient’s home looks like. Write about a patient who reminded you of a family member. Write a full description of yourself (personality and appearance) from the perspective of a patient/client. Pick one word/image that stands out from an encounter with a patient. Write a poem with that word as the title. Write about your last encounter with a patient in their words. Then, rewrite the story in the words of their partner, parent, or child. Write out the day of the parent of a sick child or the spouse of a chronically ill partner as you imagine it. Write about a patient/client who taught you something. Write down what you said to a patient with a broken heart. Step-by-step, moment-by-moment, write about what a blind person, or a person in a wheelchair, experiences when they enter the hospital. Pick a health-related incident from the news. Write what happened in the first person from the perspective of one of the key people in the story.

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Write a story about a sick child. Write a story about adoption. Write a story about twins. Write a story about abuse. “Never judge a book by its cover …” “I was sorry I cut them off …” “Boy, did I miss the boat…” Write five tips on how your patient can best navigate the medical system, from your professional perspective. Write about a patient who reminded you of a family member. “I never asked about their sexual life …” Write an over-the-top stereotype of the following patients. See if any unexamined biases emerge for you personally or within your training context (e.g., the Emergency Room): • A fat person / a smoker / a person with tattoos / a single mother / an alcoholic or addict / a homeless person / a person on welfare or disability benefits / a person with chronic fatigue or fibromyalgia / a “hypochondriac” / an elderly patient / a sexual minority / a person from a cultural group other than your own. Write about a time you avoided a hospital patient (consciously or unconsciously). Write about a time you blamed a client/patient. Write about a time you almost lost a client/patient. Write about a time you did or didn’t tell a patient about an error in their care. Write about a patient who “whines.” “The family of the patient were just impossible …” Nature vs. Nurture – discuss. Mind vs. Brain – discuss.

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“Everything that could go wrong did …” Write about a patient with whom you had to involve “the authorities” (i.e., Children’s Aid, Public Health, the police). Write a story from the perspective of a relative cleaning out a dead person’s home. Write a story as a person with early: • Dementia • Parkinson’s • A disease that scares you “It was a freak accident …” “The patient was right after all …” “The family kept interfering. Now I know why …” “I couldn’t believe how beautiful/unattractive they were …” Choose one patient/client. Write about what you think brings them pleasure and a sense of purpose in their daily lives. “What kept him/her going …” “Side effects” Write a story about a living will (or the absence of one). “The bleeding wouldn’t stop …” Write a story about a fever/infection/obstruction/fracture. “It was a miracle …” Write about a sudden death. Write about a needle-stick or other workplace injury. “I’m pretty sure they were faking it …” Write about a patient who was deemed “incompetent” (incapable). “They left AMA – against medical advice …” Write about a day in the life of a 3-year-old, 17-year-old, 85-yearold (or any age you choose).

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Ask a patient what students should include in a portfolio and write it up for your course director. Take any chart note or specialty consultation note and rewrite it in a letter format and style so that it could be given to the patient as a tool for healing, empowerment, and understanding. Read this story about advocacy and power by a medical student. Write about a time when you did or did not stand up for a patient “Oh a med student. Ohh …… we love you guys,” a nurse in the urgent care department at HSC said, her voice dripping with insincerity after I told her that I was a 3rd-year clerk. Wow, I thought. I guess I have my answer on the utility of medical students in the Emergency Department. It was my first urgent care shift in the last week of my pediatric emergency rotation, and I was working with a family medicine resident, a pediatric fellow and the staff physician for the evening shift. After I was briefly oriented to the department, the charts started coming in and I was instructed to see a minimum of two patients every hour. My second patient was a thirteen year old boy who walked in diffidently with a face mask on. Initially, I thought that this was a deviation in H1N1 protocol, but I quickly realized during the history that the boy was extremely self-conscious about the extensive rash he had all over his face, neck and thorax, and lymph nodes that had coalesced to the size of a golf ball. This boy had been diagnosed with strep throat, without a throat culture, and was treated with amoxicillin, which did not work as his symptoms persisted. He developed extensive bilateral lymphadenopathy, which was worse on the left, had not been vaccinated at all, and the rash came a few days after taking the antibiotic. I evaluated his

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ABCs, the rash and his organs, and noted that he had a tactile fever on exam and his speech was somewhat garbled because of the massive cervical lymph nodes. He looked sick, but he was ambulatory and denied any shortness of breath. After reviewing with my staff, the consensus was that he likely had mononucleosis, but we took a throat swab to r/o a resistant strep variant and decided to send him home until the results came in. I did some counseling on the implications of mononucleosis and what to do if the pruritis from the drug rash he likely had became uncomfortable. My supervisor had mentioned Steven Johnson Syndrome on her differential of worst case scenarios, but it was placed lower on the priority list based on the physical exam, which looked like a textbook drug rash and or pharyngitis/mononucleosis presentation. I was instructed to discharge the patient and let him know that he would be contacted w/ the monospot test results. I walked towards the patient and his mother, who were now waiting in alternate UC waiting area, and did my now well-rehearsed discharge spiel. I noticed that the patient was lying in his mother’s lap, and looked a bit more tired than before. I thought that it was weird at first, but I told myself, don’t judge, children can regress even if they are teenagers when they are sick and he has been waiting here for a while. For some reason, I felt hesitant about leaving, and asked if the patient had any questions for me. He then told me that he was having more difficulty breathing. I felt a surge of adrenaline, but, then again, my internal “freak-out barometer” had been 99.9% wrong in the past three weeks. I thought that if I was going to take this back to my supervisor, I had better have more than “I just had a bad feeling” to explain not carrying through with the discharge. I took his vitals again, and he was full out tachycardic, and tachypnic, although his lungs and throat remained clear. I told the patient to wait there a moment and explained the situation to my staff. She took it seriously, re-examined him and readmitted the patient to UC. I was sent

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to see more patients, but I kept the discharge note for the time being so that I could track him later on. Towards the end of the night, I asked my staff what happened to the patient. It turned out that he had been admitted to the wards b/c of probable SJS. He had been administered an anti-histamine in hopes of reducing the inflammation, but he decompensated and was being worked up for SJS secondary to ampicillin and EBV. I decided that even if the threshold is still too low to be reasonable, perhaps my internal “freak-out” barometer is not so useless after all.

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Diversity/Culture/Equity Writing Prompts

We all come from different places and have different backgrounds. To drive home the point for yourself, write out your own demographic with respect to the following: age; gender; sexual orientation; relationship status and availability of supports; physical build and (un)attractiveness; physical and mental capabilities; challenges; privileges; disabilities; religion; ethnicity; political affiliation; IQ; EQ; socio-economic status; current and family of origin; core values and beliefs; assumptions and blind spots (if conscious); prominent personality traits; coping skills (or lack thereof) ; current opinion on issues such as abortion, euthanasia, same-sex marriage; OTHER (i.e., what got left out?).

My Demographic Now you can appreciate that you have a worldview shaped by all of these attitudes and attributes (many of them given to you by your parents and community) and that it will invariably differ from time to time from that of fellow students, educators, patients, clients, and their families. Once again, writing real stories about values that clash, personal/moral distress, judging or being judged, and being silent around witnessed or experienced discrimination helps form the substance of a true appreciation and acceptance of difference. And, if you are stumped by that difference (or it remains unexamined), how can you be present, engaged, mindful, helpful, and therapeutic to the person in front of you? Write a story where gender or sexual identity really mattered in terms of what happened in the care of a person.

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Write a story about belonging. Write a story about not belonging. Write a story about your mother tongue. Write a story about communication with a client or patient who didn’t speak your language. Write a story about “political correctness” (or incorrectness). Pick a word you really like from a foreign language. Compose a story using that word. Write a story about gossip within a community. Write a story about staring. Of all the different communities you belong to right now, which is the most important to you and why? Write about a situation that felt: • Racist • Sexist • Homophobic or trans-phobic • Disability-insensitive (“able-ist”) Write about a time you were or felt like a foreigner. Write about someone coming out to you. Write about a stranger. Write about a time you felt privileged. Visit a neighborhood you’ve never been to. Write what you see. Describe your cultural background to a stranger. What three things should they know? Describe your own cultural/ethnic identity in 10 lines. “What is still taboo …” Write a story about whispering. Write a story where one of your assumptions was challenged. “On being a woman in that community …” “On being a man in that community …”

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“On being disabled in that community …” “On being LGBTQ in that community …” Make a list of all the pronouns that sexual minorities now endorse and use to identify themselves. “The rich kids in my class have it easy …” “Getting old isn’t for sissies …” Write about a person who was failed by the system because of their perceived difference. “This one person shattered all my stereotypes …” Write a story about micro-racism. Rewrite the Ten Commandments for the twenty-first century. Add three new ones, if you’d like. Pay attention to cultural symbols around you and write about how they make you feel. (E.g., the clinic Christmas tree or Scottish bagpipes at formal events.) My favorite motto/saying/quotation is … I am unapologetic about …

Using a Story and Personal Experience Pick a story (fiction or from a newspaper or magazine) you’ve read about someone who is part of a vulnerable population. Draw on your own personal or professional experience involving the care of, or caring for, a person representing a vulnerable population, and consider any or all of the following, in the context of the story you have selected: What conflict or dilemma was raised/encountered? What attitudes, beliefs, values, and/or assumptions do you bring to such patient care and, if relevant, how have these elements been challenged?

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What was your emotional experience of the story you chose, and/or your own story, and what helps you stay emotionally engaged? How might this reflective exercise impact your work and professional identity? Vulnerable populations are groups that are not well integrated into the healthcare system because of ethnic, cultural, economic, geographic, or health characteristics. This isolation puts members of these groups at risk of not obtaining necessary medical care, and thus constitutes a potential threat to their health. Commonly cited examples of vulnerable populations include racial and ethnic minorities, the rural and urban poor, undocumented immigrants, LGBT, and people with disabilities or multiple chronic conditions. (http://www.urban.org/health_policy/vulnerable_populations/)

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Social Justice/Advocacy Writing Prompts

We touched on inequities/perceived “otherness” in our last set of prompts. It’s important to ask again why we reflect and write about our studies and work in the first place. For personal learning, wellness, and growth. To pass portfolio courses. But more importantly, critical reflection should always be a call to action: What can I do differently for individual patients and clients to enhance their care and bear witness to their suffering? But then you realize, with each client narrative, that beyond your therapeutic dyad, all sorts of social and economic factors determine who gets access to care and who gets well in the first place. The social determinants of health will have been noble concepts or exam questions until you treat a child who dies because his parents couldn’t afford a prescription (or the ambulance/car fare to bring him to the ER). A queer teen who committed suicide because of bullying. A woman who is too ashamed to leave her abusive husband because of what her tightknit religious community might say. The father with high blood pressure who loses his job to offshore manufacturing when his son is supposed to start college in the fall. These details form the real story. They definitely should find their way into your portfolio narratives. Write a story about housing/lack of housing. Write a story about health insurance. “He couldn’t catch a break …” “They were living hand to mouth …”

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Write about a time when you were asked to find resources for a patient. Write a story about going the extra mile. Write about a time where money (too much or too little) complicated a patient’s care. “The insurance company really screwed them over …” “Who made that policy anyhow?” Write about your favorite social cause. Show why. Write a profile of a patient who experiences poverty. Describe in full detail a day in the patient’s life. Write a letter to the editor of your professional journal about something that really bothers you. You have a million dollars to give away. Where does it go? Write about a time you felt small or different than other people. “The patient outcome wasn’t good because of their social status …” Write a catchy slogan about a health condition you would like to prevent. Write a health-related bumper sticker. Write about a time you witnessed/experienced poverty. Write about a time you complained and nothing happened. Write about a time you felt helpless/powerless. You have been appointed or are seeking to be elected Minister of Health (or equivalent government position). Write your fivepoint action plan (or platform), if elected in your jurisdiction. Write a letter to your Minister of Health (or equivalent government position). Use point form to indicate your complaints and suggested solutions. What 10 things make for an inspiring healthcare provider in your field?

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Write about a time when your efforts to help someone were thwarted. Write a story about obstacles. “The patient wasn’t compliant with treatment.” Write up a differential diagnosis of five points explaining why. Write a story about being silenced. “Obese people are …” “Single mothers are …” “OK, I get it. I’m privileged …” Different rules for different people. Make a list of five ways financial status determines health and well-being for one of your current patients/clients. “My definition of stigma is …” “I think the family was taking advantage …” Write a story about a person who was blamed by his/her care provider(s) for being sick, poor, or “non-compliant” with treatment. Write about a patient/client with a secret. Write about a situation where beliefs and values clashed. Write about a role model who taught you what social justice really means. Decide not to spend one cent today and document what it’s like. (You can beg or borrow.) Write about three personal struggles or hardships. Show how they may have affected your clinical practice positively or negatively.

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From Portfolios to Action Practical Strategies for Practicing Reflective, Narrative-Based Care

My own experience in offering narrative workshops to learners from all healthcare disciplines is that they agree about the importance of narrative-based reflection, but wonder how they can realistically incorporate strategies into a busy office or practice “without opening a can of worms.” There are ways to improve your narrative competence – that is, your capacity to receive, interpret, co-construct, and bear witness to the stories your patients and clients bring you. As you develop your own narrative-reflective practice, you’re waiting to apply what you’ve learned. After all, that’s the whole point of narrative medicine and portfolio and humanities classes. Here are some simple, practical strategies to try and then integrate into your work life as a clinician.

Ask open-ended questions. Rita Charon, founder of the Narrative Medicine movement in the United States, starts her first patient visits by asking, “What would like me to know about you?” before jumping into questions about symptoms. Try asking an open-ended question like this in a new assessment. You can allow a few minutes for the patient to present his or her concerns and then move into a more systematic, structured inquiry. If you need to contain the story, you can use your usual time management strategies, but make a point of telling the patient or client that you want to pick up the thread next time. Consider asking, “Did we miss anything today?” That question can be a goldmine and lets your patient/client have the last word.

From Portfolios to Action

Do not interrupt. The average doctor interrupts a patient or client within 15 seconds and other clinicians aren’t much better. Make a point of letting the patient and client finish his or her thought before launching into the next question or comment. Ask patients and clients to write about their illness/condition. Consider asking your patients and clients to write a one-page “Impact of My Illness/Condition” document, which you will read and discuss with them and keep in their charts. This might be the first time your patients were ever asked about the real effects of illness on their daily lives. How did illness change or interrupt the stories they had imagined for themselves? Allow patients and clients to discuss their concerns. How is the person in front of you coping with suffering? You may have a handle on their disease process, but what about their lived experience of their illness? Ask yourself if you have allowed room for patients and clients to talk about their distress, fears, and other real concerns in each visit. Themes of anger, regret, and loss are usually under-explored. Learn your patients’ and clients’ stories. Find out one thing you did not know about your patients’ and clients’ stories in every visit. Who are they when they are not ill? What are their interests, their hobbies, the names of their grandchildren? What matters most to them? Look for a metaphor or key word. Look for a metaphor or key word that emerges in your meetings that is unique to your working alliance. It may be found through a humorous exchange, but it can become a symbol of the story you are constructing together over time. View non-compliance as a blocked narrative, not as patient or client stubbornness. Get the real story (usually it is the “backstory” that long predates you) or find out why your emerging shared story is blocked. It’s a cop-out to “fire” clients or to label patients as “difficult.” Non-compliance/non-adherence to treatment has a differential diagnosis like every other problem in healthcare. You

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are definitely a character in that plot. Spending the time now will build trust and save you and your patient/client time later. Record encounters with patients and clients. The next time you are troubled by a patient or client encounter, take three minutes to write down what happened. Write it the way you would tell a colleague – as a story with a beginning, middle, and end. Writing it down on the page will give you the distance to see how your own story (expectations, time pressures, unresolved grief) has collided with that of your patient or client. Most people are surprised by how much of a story emerges in only three minutes and how it can facilitate personal reflection. Be aware of your body language. In a time of high-tech record keeping, make a point of maintaining eye contact and not typing while the patient or client is speaking. Sit down with the person. Your body language conveys or annuls your receptiveness to a story. Think of other barriers to storytelling in your office; e.g., where or how chairs are placed, whether you answer non-urgent calls (or text ill-advisedly) during appointments. Manners are not the same thing as empathy, but poor manners kill rapport. Change what you can! Examine your assumptions. The next time you feel bored with a patient or client, think about the question you have not asked. Ask yourself what your unexamined assumptions about the patient or client are and revisit the moment in your shared story where the assumption took hold. Examine stereotypes. Regarding assumptions, give yourself a writing prompt. “People with tattoos are …”; “Obese people are …”; “Single mothers are …” Stereotypes are the unexamined stories we tell ourselves without realizing it. Ask “What do you think is going on?” When you are not sure what is going on with a patient or client, ask “What do you think is going on?” This reveals the story he or she is telling internally about his or her symptoms. It might not give you a clue about the cause of the symptoms, but at the very least it will enlighten you about his or her fears and worse-case plot scenarios.

From Portfolios to Action

Ask “How would others describe you?” Patients and clients tell stories differently to their healthcare providers than they do to anyone else. Ask “How would others describe you?” If what they tell you does not match what you are seeing in your visits, then you have missed something important in their stories. Ask “What’s the one thing you haven’t asked or told me?” From time to time, ask your patient or client “What’s the one thing you haven’t asked or told me?” Chances are you will hear the story that matters most. Review your patient’s/client’s chart. Before you see your next patient or client, take a moment with his or her chart. Take a deep breath. Ask yourself, “Where did we leave the thread of our story the last time?” A symptom is not a story. A laboratory result is not a story. These things might be the punctuation. But there is always more to the story and time is of the essence! You can build the story together over time. Reprinted with permission: Peterkin, A. Practical strategies for practising narrative-based medicine. Can Fam Physician. 2012; 58(1):63–4.

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Well-Being and the Clinician as a Person Writing Prompts

We know that reflective practices, including reflective writing, improve patient experience and client-centered care. However, reflective practitioners also take better care of themselves because they are better able to recognize stress points, personal discomfort, blind spots, potential errors, and moral distress. They step back to reflect on their own well-being (and that of their loved ones), their sense of balance, and happiness, and ensure that they build a sense of purpose around their work and pleasure in their day-to-day lives. Write about a time you let a family member down because of work. Write about a desire. Write about a time you ignored your own signals (bodily or emotional) at work. Write up a dream you had about your work. Write your definition of happiness here and now. Identify three “time thieves” that mess up your time management. Think of the last time you perceived yourself as healthy. Describe the feeling and the context using as much rich, descriptive detail as possible. “I wish they understood that …” Write a letter to a child or your own child explaining what you do for a living.

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Write a case for you having more time for yourself. Write your own living will in five lines. Write about sorrow you’ve experienced at work. Take a blank piece of paper and draw an image that reflects where in your body you feel the stress of medical training. Use that image to prompt a written reflection on what steps you are taking to approach a sense of well-being and balance. “My happiest moment so far …” Write about a habit you’d like to break. Write about the most important event in your life. Write about the last time you were upset at work. Write about the last time you had to stay in bed. Write about what makes you unique. Write about the last time you felt romantic. Write about a time you sat in a clinic or hospital waiting room as a patient. Write five things you noticed today on the way to work. Describe your last visit to a doctor’s office or hospital. Make up a list of 10 things that make you angry. Write up your day, hour-by-hour. “If I had the nerve …” Write a note to your doctor about the quality of your last visit. Write a story about your favorite food. Write about a time you felt jealous. Write about the loss of a pet. Review your last five Internet searches and write a biography of yourself based on what those say. Write about a time when you were really stressed and what you did (or didn’t do) to look after yourself.

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“You’ll be dead in six months.” List what you would do differently from this moment on. Write about what circumstances make you feel most alive. Write a story about a time you laughed or cried with a patient. Single or not, write your own personal ad for a dating site. Write about a meal at work. Write about a time you felt lust at work. Write about an experience where you were the patient. Write a letter to your partner exploring what they don’t know/ understand about your work. Write a postcard of encouragement to yourself. What is the first thing you would like your new patient/client to know about you? Write a newspaper headline that describes your life right now. Write about a time you had a health scare. Make a list of 10 unexpected things you learned after a loved one died. “I wish I had been debriefed about what happened …” Write about a time you were: • Hungry • Exhausted • Fed-up • Scared • Disappointed with your own performance Describe your life in one word right now; in two words; in three words. Name one thing you’ve been trying to change and list five obstacles that always get in your way. Write about the last time you cried. What does your garbage (what you throw out) say about you? Write about your addiction, real or metaphysical.

Well-Being and the Clinician as a Person – Writing Prompts

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Write about the last time you felt indignant. What brings you pleasure and a sense of purpose? Write a story about forgiveness. What shames you most about where you came from? Write about what your life looks like when nobody is watching. Write about a time where “you lost it” at work. Write about the last time you moved. Write about a vacation you long to take. List your five favorite things in the world. Write an out-of-office email that describes if/when you’ll be checking email. You put a letter to yourself in a time capsule 10 years ago. What does it say? Turn off all electronic devices for a weekend. Write how it felt in 10 lines. The next time you can’t sleep, list your thoughts. List five pieces of advice for your teenaged self, based on what you know now. Write about an act of kindness. What five questions would you like to be asked by someone in your life? Write about one event that changed your life. What are 10 things you always bring on a trip? Write about your greatest health-related fear. List 10 things you want to do before you die. Write about the last time at work that you: • Cried • Laughed • Blushed • Hugged someone Describe a funeral you’ve attended.

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“My weight …” “I just dreaded it …” “My worst day ever …” Write a story about bad luck. “I’d like to get good at puttering around …” “When I retire …” “How I would simplify my life …” “My New Year’s Resolution …” “I was afraid I’d get infected …” Write about a time you called in sick. Write about hospital food. “I would describe my sex life as …” “On the state of my relationship/marriage …” “On their deathbed, nobody ever says, I wish I’d worked more …” Here are the strengths I possess and here are strengths I look for in colleagues. If I won the lottery I would quit/not quit my studies.

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Ambiguity/Uncertainty Writing Prompts

An engaged clinical life is filled with ambiguities and uncertainties. The course of most illnesses can be unpredictable and people may or may not follow treatment plans (if care teams can even agree on treatment plans). Surprises, tragedies, and miracles (or at least exceptional/unexplainable outcomes) happen every day. As beginning learners, we would like things to be black and white, to follow algorithms and what the evidence-based literature tells us. Some of our professors and preceptors choose rigidity in the face of doubt. As we mature as clinicians, we come to accept ambiguity while rigorously analyzing and making sense of what we do know in that moment of decision. Most importantly, we learn to remain fully present to the people we care for. That does not have to change in the face of clinical uncertainty. Write about a time you doubted yourself. Write about an experience of futility. Write about an expectation. Write a story about apathy observed or experienced. Write about a time you doubted something you were taught. Write about a time you gave a definite answer when you were actually in doubt. Write a 500-word reflection on the theme of ambiguity. Write about a blind spot. Write about a time you felt strange.

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Write about a time when you did or didn’t know what to do or say. Write about a time you felt foolish or were afraid of looking foolish. Write about a time when you had no idea what was going on. Write about a moment of disillusionment, when life did not give what you expected. “I couldn’t find the words …” “The call I don’t want to return …” Write about a time you pretended to know or feel something. Write a story about a clinical hunch or intuition. Write about a time you were anxious at work. Write about the toughest decision you’ve ever made. Write about a time you’ve felt stuck. Write about an important detail you missed. Write about a decision. Write about a time you felt like an imposter. Write about a moment of dread. Write about a time you waited too long. Write about a time you felt undeserving. Write about a time you had to choose. Write about a time you didn’t feel safe at work. Write about a time you procrastinated. Discuss this statement (paraphrasing a famous saying): “Nothing human should be foreign to me.” Write a story about false hope. “It just felt wrong …” Write about a missed deadline or opportunity. Write about something you learned through observation, in the absence of words.

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Career Satisfaction Writing Prompts

It’s never too early to explore what you want from your career and how your profession fits in with other life plans and goals. The students who best avoid burnout and cynicism over time are the ones who actively shape their own learning process. They ask for what they need, affirm their own personal values (and the reasons they have chosen a healing profession), control the parameters that they can (such as scheduling, electives, placements) and build a network of personal supports. Use these prompts to discover what you want in the here and now from your chosen vocation and what you would like to see for your future. Describe a time when you felt really alone at work. “I quit!” “If I had more time …” “A day in my life …” Write your definition of success. I want to give more versus I want to give less. Discuss. Write a story about moving on. What prize/award/promotion do you hope to win? What happened? What would you be doing work-wise if you weren’t doing this? Where would you like to move to? Why? Write about a time you gave up or quit.

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Write up in dialogue form your last argument with a friend or family member as related to work. Describe your first office space using all five senses. Write a story about credit given or stolen. Write a letter of promotion (or dismissal) to yourself. Write about a time you were reprimanded or fired. Write about a time you wanted to escape/run away. Write a letter of reference for yourself to enter the next step of your career. Write about a funny encounter at work. Write about a time you left a job/placement. Write about your work uniform. Write a story about an institution. Write up your own job performance evaluation in 50 words. Write about a time where work made you sick. Where will you be in five years? Be specific. Write a story with the title “Should I Stay or Should I Go?” Write about what made you laugh at work most recently. Write about an incident that felt really unfair. Write a letter to the CEO of your hospital and include five things you like and five things you dislike about your institution. (Do not send it.) Your younger self is about to be offered your first job placement. What would you tell yourself? A young person you know asks if he should go into your profession. Write an email reply. Write about a time you did the right thing but got no thanks or acknowledgment. Write 10 tips of advice for students graduating from your program.

Career Satisfaction – Writing Prompts

List five places you’d rather be right now. “My parents wanted me to pursue this career. Not me. Now what?” In no more than 10 lines, explain why you chose the work you do. Write about a time you shut down emotionally at work. You can retire tomorrow. Would you do it? Write about your second career choice – “the road not taken.” What would a perfect “mental health day” look like for you? Write the worst story you have ever heard about your profession/clinical discipline.

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Battling the Inner Critic How to Stay Open When You Reflect and Write

There’s a difference between harsh criticism and reflective critique (helpful editing). Identify your own analytical/critically reflective style and see how you can be kinder and more helpful to yourself when reflecting on a dilemma or meaningful encounter, when writing about it, and when discussing the piece of writing with other students (or listening closely to theirs).

Criticism is negative • Judges/finds fault • Only finds what’s missing • Is sarcastic or demeaning in tone • Condemns unshared points of view • Attacks the writer • Is vague or all-encompassing • Is power-based (authoritarian) • Is humorless • Invites a fear-based response • Interrupts the flow of creativity and ideas.

Critique emphasizes the positive • Identifies strengths • Points out possibilities to make things more clear

Battling the Inner Critic

• Is honest but kind • Is open to learning • Emphasizes the craft of writing and analyzes what’s on the page (the text at hand) rather than extrapolating to things the author hasn’t shared in the story. • Is specific, concrete, well directed • Is collaborative and facilitates an exchange of ideas • Can be playful and provocative, but is always respectful • Encourages the next step (new directions, actions, possibilities, and/or learning experiments)

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Personal Reflections Writing Prompts

Here’s a list of “off-the-wall,” wide-open prompts I have gathered over the years from colleagues and students, from writing workshops I’ve taken and given, from patients in therapeutic writing groups, and from the many references cited at the back of this book. They may lead you to reflections on your clinical work, or they may lead you to stories you want to tell for pleasure or eventual publication. Describe the hospital corridors at 3:00 a.m. Explain what a hospital is to an extraterrestrial sent to interview you. Tell a story you don’t often tell. Are you a Right Brain or Left Brain person (or both)? Discuss. Write about a time you felt lost. Write about a time someone trusted you. Write about a connection you made that surprised you. Write a story about: • A pet • A job interview • A parent and child • A school experience • A holiday • Traveling • An intimate relationship you have had

Personal Reflections – Writing Prompts

• • • • • • • • • •

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Something you have observed or experienced in the city Medical technology, equipment, or machinery A teacher Something you observed as a child A place A gift A photograph Something that changed A transition A milestone

“What was I thinking?” Write a poem on compassion. Write a story about flowers. Write about a meal. Detachment vs. empathy. Discuss. Write a story about grief. How would you envision your life if there were no limitations on what you could achieve (i.e., if it was not possible to fail)? Imagine that the room you are in right now has been carefully crafted to be exactly how it is in this moment, as if you have stepped into an installation art piece. Look around and, if possible, physically explore the space. • What did you observe? • How did you feel in this exploration? • What thoughts came to mind during your exploration? In 15 minutes, write your life story in 10 points. Put an asterisk next to an event you’d like to develop further. Then spend five minutes more on that particular story. Write about an image that sticks in your mind. “Suddenly I realized …” “About moving into a new country …”

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Pick a favorite quote or aphorism. Explain why it’s your favorite. Write a story about a trip. Write a story about a guilty pleasure. “Lost and Found.” Write a 500-word story. Write about your earliest memory. Why does it matter? Describe your ideal circumstances for reflection (place/time/ familiar objects). In point form (10 points): Describe what you’ve learned so far about human nature. Put yourself in another person’s skin and write a poem using his or her voice. Write an epilogue to the story of your life. “Things could be worse …” Record what is going on for you (thoughts/feelings/behaviors/ bodily sensations) right now and for the next five minutes. Write about a mask. “The best storyteller I ever met …” Take the last note you wrote in a chart and turn it into a poem. Write a story about patience or impatience. Write a letter to your internal critic. Write a thank you letter to someone. Write a story about longing. Write a story about following directions. Write about a special place. Write a story about memory or forgetting. Write a story about going home. Write about a beginning or an ending. Write about something broken. Write about gentleness.

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Write about a favorite feast day or ritual. Write 10 lessons about survival. Write a story about hope. “I was really tempted …” Write about something that makes you feel better. Write a poem titled for your own clinical profession/discipline. “The”: OT / PT / Pharmacist / Chiropractor / Osteopath / Physician Assistant / Chaplain / Bio-Ethicist / Psychologist / Social Worker / Counselor / Doctor / Nurse / Dentist / Veterinarian / Radiation Science Technologist / Speech Pathologist / Specialist (e.g., Psychiatrist) / Health Humanities Professor / Social Scientist / Naturopath / Healthcare Consultant / Healthcare Lawyer / Patient Advocate or Ombudsman. Look up a definition of Emotional Quotient (EQ) online. Now describe/rate your own EQ in a poem. Write about a time you felt inspired. “If I were an animal, I’d be …” Write about stigma you or your family have experienced. “My parents wanted me to do/be X but I wanted to be Y …” “Look at my graduation photo …” “What I no longer believe …” Write about a significant letter you have sent or received. Write a story about your own birth. Write the story of your name. Write about a medical miracle. “Personal vs. Private.” What does freedom mean to you? Write a story about silence. Describe your walk/ride to work in glorious detail.

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Write about your last encounter with nature. Write about a coffee break. If you had seven days to live, write a list of seven things you would do. Describe a moment of joy. What’s the one thing you can’t live without? Write a list of how money matters and financial issues will affect your personal decisions this year. Write about an obsession. What object or thing best describes you. Why? Make a list of 10 family pressures and/or encouragements that brought you to your career as a clinician/healer. You meet a long-lost friend from grade 2. What do you tell them about your life now? List five identifiers that describe you, in order of importance. Write a story where silence played an important role. Write about your favorite place/space in the world. Write about a surprise visit. Write about something you’ve lost. Write about a personal character flaw. Google yourself and write a composite of what you find. What would you change about yourself if you could? List three people who made you what and who you are today. Then, write a three-line statement about each. Write a story beginning with, “If only you knew now …” Where will you be in one year? Describe the face of someone you really love. “What comes next?” Write a story about darkness.

Personal Reflections – Writing Prompts

Write about a change of fortune. Diagnosis is an anti-narrative act. Discuss. Write a love letter to yourself. Write about something hidden or secret. Write about a book you always meant to read but haven’t yet. Whom did you last smile at? What were the circumstances? List five things your inner critic is telling you right now. Write a story that demonstrates that “the road to hell is paved with good intentions.” “You are not special.” Discuss. Write about your own privileges. Write down a joke you remember hearing at work. Write about leaving home. “Where my education fell short …” Make a list of words and images you associate with any of the following themes: • Laughter • Hunger • Sexual desire • Sadness • Beauty • Money Write about a coincidence. “My next dream project is …” Write a story about forgiveness. Look outside. Describe in detail what you see. Write a story starting with “In hindsight …” Write a story about dirtiness. Write a story about coffee.

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Take one panel from a favorite graphic novel and contextualize what’s happening. Write a prayer to God (or the universe). Write unexpected/inspirational/creative instructions on three Post-it notes. Stick them on your refrigerator. Write an advertisement to sell something you want to get rid of. Write about a time you eavesdropped. Write a letter to your antidepressant. Write a letter to any of your medication(s). Write about a surprise. Write a postcard to yourself. Write a story about a pet. Write a story about the street you live on. Write a tweet (140 characters) about your day. Write your own report card for when you were in grade 1, grade 6, grade 12, and now. Write your to-do list for today. Then write an imaginary one. Write about a meal you remember. “Unfinished business” Write about a time you said “NO.” Write a story about being on an airplane. Write about a time you felt: • Jealous • Rejected • Embarrassed • Silenced • Seduced or tricked • Different from others • Thwarted Write your own obituary.

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Find your admission letter into medical/professional school. Write a letter back to yourself, based on what you know now. Write about a time you felt inspired. Write an email to someone you haven’t seen in years about how your priorities have changed since you last met. What do you want for your next birthday? Write a rant in point form about what you dislike intensely at work. Write down five regrets. Write a six-word memoir. Write a tweet about school or work today. Write about your favorite piece of clothing. Write about your favorite possession showing how and why it says something about you. Write about a favorite song, quoting specific lyrics that matter to you. Write about a classmate who stands out in your mind. Show why. Write a story about water. Write about a rescue. Write a letter of gratitude to yourself detailing what you like about your life. Write about a time when intense feelings helped or hindered your encounter with a patient. What do you collect? What does it say about you? Write about a day where you have no phone or computer access. Write about your biggest fear. Write about something you have lost/found. Write about a disappointment.

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You have a magic wand. What would you change about yourself or your situation? Write about the place you feel safest. Write about something you hide at work. Write an epitaph of no more than five lines for a chapter in your life that is now closed. Write about the one thing you would do over if you could. Write a patch of graffiti you would tag if no one was looking. Describe one object in your office that has personal meaning. Write a limerick about something that just happened at work. (“There once was a student named Jack/Jill …”) Write about a time you were kept waiting. Write about losing something precious. List the five most important things that have happened in your life thus far. Write about a secret. Write a first line for your memoir. What song, movie, YouTube clip, poem, or novel sums up your life right now? Write about a problem you wish you could solve. What five things would you want to have with you if you were stranded? Describe your own waiting room and office in clinical detail. Which actor would portray you in a movie about your life? Why? Write about a twist of fate. Write the story of your nickname. Write about a sense of wonder or mystery in your world. Write a haiku about a surprise. Write about a time you tried to show off.

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Write about a photograph. Write a poem based on one of the Seven Deadly Sins. Write about a time a colleague or patient surprised you. Write a poem about your stethoscope. “If I could start over …” Give the movie of your life a title. Write a sales pitch to a Hollywood producer. If I had time, here’s what I would study … If I could change the curriculum, here are three things I’d do. Write about a time you felt hopeless. Discuss the role of play in your life. Here’s what really brings me a sense of purpose and pleasure … Write about something you need to stop/end. Write about being last in line. Inclusion and Exclusion: Remember and describe an experience of being in a physical, social, architectural, psychological, intellectual, or cultural space that made you feel excluded. This space was not designed for you and/or you were not welcome in it. A Kafka Moment: Write about waking up and finding your body radically altered. A Hemingway Moment: Write one true sentence. Then write another. Edit until you have a paragraph built of true sentences. Point of View: Write about an experience of loss (or anger, shame, or any other strong emotion). Now write about the same experience but change one of the following: • point of view (if it was first-person, make it third or even second); • tense (present tense to past tense or even future);

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• proximity (if you described the experience from up close, describe it from a helicopter – think about it like camera distance – zooming vs. long shot vs. bird’s-eye view). Repeat until you feel you have found a satisfying sense of dimensionality in the written experience. A Sensory Memory Set up your notebook and pen so they are nearby. Now close your eyes and get comfortable. Relax systematically from your head to your toes (instructor can guide the students … maybe it double-dips as a quick anatomy review!). Return to a place in the past where you felt x (fill in as needed: joyful; ashamed; confused; focused; confident; etc. I also use this in a metacognitive way to get students to remember feeling satisfied or excited about their writing). Stay there in that remembered moment. Now check in with what’s around you in this past place. What do you smell? What do you hear – up close, and off in the distance? What do you taste? What can you feel beneath your feet, beneath your fingertips, touching your body? What do you see – up close, behind you, in front of you, in the distance? Prompt your mind to recall: I smell … I hear … I taste … I feel … I see … When prompted, slowly open your eyes and quickly capture what you remember in writing. Do not edit; this is a core dump; everything is welcome as is.

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Sample Course Guidelines

Your school may not yet have a Portfolio course or formal offerings in reflective writing. Here are some sample guidelines on reflection from one of the top courses offered by the University of California at San Francisco medical school which can help get the discussion started in your faculty.

“UCSF Leap: Learning from Your Experience as a Professional”: Guidelines for Critical Reflection The University of California at San Francisco has developed a wonderful curriculum to encourage reflective practice and develop ways to deepen that reflection to critical, transformative levels. Their course instructions for LEAP (Learning from Your Experience as a Professional) are among the most accessible, understandable, and user-friendly I have found. For those students who do not have narrative healthcare, humanities, or portfolio courses in their faculties, it might be worth sharing these with your professors to prompt new course, elective, or seminar offerings.

Most people reflect, but the skill health professionals need – Critical Reflection – is different: • Reflection – looking back at something, considering it • Critical reflection – the process of analyzing, reconsidering, and questioning an experience in order to make an assessment of it for the purposes of learning

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Start LEAPing by choosing an experience which triggered questions or concerns for you, such as: 1. a situation where you didn’t have the necessary knowledge or skills; 2. a situation that went well but you’re not entirely sure why; 3. a complex, surprising, or clinically uncertain situation; or 4. a situation in which you felt personally or professionally challenged. Note: This is about your learning, so even if you weren’t the major actor, consider why the experience stands out for you and what you can learn from it that will further your professional development. Remember the acronym SOAP (often used for clinical notes and updates in charts)

S = Subjective Consider the content, processes, and premises of the experience: • Content: What happened? Describe the situation and its context. What was your reaction, intellectually and emotionally? What went well? What would you change? • Process: How did it happen? How did you approach the situation? How did you perform? How did you/others affect the outcome for better and worse? How did your emotions affect your choices? • Premise: Why did it happen? Why did you act/react as you did (consider past experiences and personal characteristics)? Why did you and others make the assumptions you made? What system factors may have contributed to this problem and why is the system set up that way?

Sample Course Guidelines

O = Objective Reconsider the experience from multiple perspectives. Go beyond imagining others’ perspectives to presenting data: What did you learn, formally or informally, from the reactions of patients, families, supervisors, peers, friends, and other professionals? What feedback did you get? What did you learn from the medical literature? What other sources did you consult?

A = Assessment Synthesize your learning: What educational, personal, or professional challenges and/or strengths have you identified? How has this analysis affected how you will approach similar situations in the future? [If you conclude you wouldn’t do anything differently, consider (a) whether you’ve picked an appropriate experience and (b) whether you’ve really reframed the situation with your reflection.]

P = Plan Make a plan to address future similar situations. The plan should be specific, measurable, and attainable in the near future: What will you do next? Where can you get the information or help you need? Who will you check in with and when? How will you know whether your plan is working, or not? (Text above is used with permission from Louise Aronson, MD, MFA, USCF)

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Reflection on Action Rubric (UCSF) Level (points)

Reflection performance

Scoring guidelines

Elaborated guidelines

0

Does not respond to the assignment.

Narrative is submitted but is not responsive to the topic or assignment.

Venting without description of a specific situation. Describing an encounter unrelated to the topic.

1. “Patients in this hospital are challenging to care for.” 2. “You asked about this, but I’d rather tell you about something different.”

1

Describes without reflecting.

Narrative description of encounter but no evidence of reflection on action.

Very detailed story with some insight into behavior in the moment but no further discussion of behavior in retrospect.

“We took care of this patient, considered their needs, addressed their concerns and challenges, and did a good job.”

2

Does not justify lessons learned.

States that lessons were learned but without explicit linkage to supporting evidence.

Vague reference to lessons learned without elaboration. List of lessons learned without linkage to evidence. General platitudes about optimal care without specific linkage to scenario.

“I took care of a Cuban patient and became aware that it is important to consider their cultural background.”

3

Provides limited justification of lessons learned.

Relies on personal assessment of lessons learned.

Personal opinion about lessons learned predominates. Little or no inclusion of external evidence as defined below.

“I felt more confident about my skills and I expect the patient will check her blood sugars more frequently and return for her appointments.”

Examples

Sample Course Guidelines

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Level (points)

Reflection performance

Scoring guidelines

Elaborated guidelines

4

Includes evidence of lessons learned.

Includes external evidence of lessons learned.

External evidence includes detailed feedback from patients or professional associates, objective data on outcomes, and/ or use of the literature.

“I followed up and found that the patient returned to clinic, brought her glucose records, and had better glycemic control.”

5

Analyzes factors from experience.

Explicitly refers to prior experiences and describes how they inform own behavior in current situation.

Reference to prior experience can reinforce successful practices or inform a change in practice. Must meet criteria for level 4: even if analyzes factors from experience, cannot achieve this level without including external evidence of lessons learned.

“In the past, I have approached patients like this by providing them with a monitoring sheet and not evaluating their literacy level. In this case, I established that the patient had limited English proficiency and used levelappropriate materials to inform him.”

6

Integrates previous experience with current events and data to inform further action.

Analysis including external evidence of lessons learned, relation to prior experience and implications for the future.

Must meet criteria for level 5 and also include a specific plan for the future including how success will be monitored.

Examples

Authors: Lee Learman, MD PhD, and Patricia O’Sullivan, EdD, University of California, San Francisco. Used with permission.

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The Body Writing Prompts

We all have bodies. What’s extraordinary is that as health professionals we have complete access to the bodies of complete strangers. We uncover, view, touch, examine, manipulate, probe, and perform procedures on them multiple times a day. This is a privilege, but can be unsettling at times. We find some bodies beautiful and others frightening or repulsive. Things can get “too close to home” when we reflect on our own scars, illnesses, and unique vulnerabilities or traumas. How can you fully honor your own body while serving the bodies of others? Write a story about cancer. Write about a personal health scare. Write a story about someone’s voice. Write about a facial expression you have never forgotten. We are embodied creatures. Healthcare students study the body in anatomy, in physiology, in pathology, and even in pharmacology. • What does it mean to be embodied, and for the body to fail in a variety of ways? • What does it mean to mend? “They were hanging on by a thread …” “They came out without a scratch …” “Will I ever be the same?” “They woke up paralyzed …”

The Body – Writing Prompts

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“The disfigurement was awful …” (Pick one) Write a story about: • Breathing • Eating • Sweating • Drinking • Exercising • Sleeping • Other bodily functions (including sexual ones) “I know I’m not supposed to think this but …” Write about a burn. Write about an amputation. Write about a laceration. Write about an obstruction. “HUNGER” “I’ll never forget that sound …” “They stopped breathing …” “I’ll never forget the smell …” Write about the last time you rolled your eyes or shook your head in a clinical setting. Write about a personal brush with death. “What my body knows …” Write a story about sleep. Write a story about hands. “Illness as metaphor …” “My/his/her face is a map …” Choose any illness that comes to mind and write a poem about it. Write a poem about one of your five senses. Write a story about blood.

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Doodle freely with words and images for 10 minutes on any body-related theme. Describe your favorite part of the human body and explain why. Write about a time when your own body surprised you. Write about how your body and looks have changed over time. Observe a stranger on the street. What’s your diagnosis? “What the patient lost …” Write about a time you inflicted pain at work. Write about a time you almost vomited or did vomit at work. Write about your last injury. Write about a day without access to clean water. Write a story about pregnancy. Describe a time when you were in physical pain. Write a story about birth control. List what’s in your medicine cabinet and create a character composite of yourself based on what you find. Start with one health-related word and write as many words in a list under it as you can in three minutes. Circle three words that move or surprise you. Write a letter to a medication or drug you currently take or prescribe. Write about an encounter with a dead body. Write about a scar. Write a story about something related to sexuality that surprised you. Write a story about alcohol. Write about a death. Describe a time when you thought you had reached your physical limit, only to surpass it.

The Body – Writing Prompts

Write about a funeral. Your reproductive clock is ticking. Write yourself a reminder. Write about a birth. Write a story about a tattoo. Write a story about CPR/resuscitation. What part of your body would you change if you could? After your next long shift, write a letter from your body to yourself. Write a story about sex. Write a story about “body fascism.” Write about an allergy. “The tumor is malignant (or the tumor is benign) …” What three diseases do you think about most? “The operation went horribly wrong …” Write about a physical examination you’ll never forget. “My gut said …” “They were disfigured …” “Their eye contact was kind of funny …” Write a story about palpitations. Write a story about blood. Write about a “code” you attended/ran. Write about an infection. Write about an epidemic you were exposed to or feared.

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Things to Consider When Forming a Reflective Writing Group

Many readers of this book will not have formal portfolio or reflective writing offerings at your schools yet want to build a community around writing. Or maybe you want to start a creative writing group outside of your mandatory Portfolio course. Here are some things to consider if you plan to start a reflective writing group that combines elements of a writing workshop while providing a professional, supportive learning environment that fosters the skills necessary for critical reflection. • In the absence of a faculty member, who will lead the group? If you are initiating the group, do you plan to make it clear that you, and/or another person, will spearhead things? (What about schedule conflicts or night-shifts, etc.? Who will lead if you need to be away?) Will the group eventually vote for officers (i.e., president/vice-president/secretary)? • How will you recruit members: email, bulletin boards, health clinics, word of mouth, referral from current group members, flyer inviting people to contact you by phone or email? • Will your group be inter-professional/multi-disciplinary? With students or faculty only (or mixed)? • Decide how many members you want and how long the group will run (i.e., one and one-half hours weekly for 12 weeks or open-ended). For an open-ended group, are new members allowed in if numbers drop, or will the group be closed for specific periods of time? For brief groups, can people repeat after 12 sessions and if so, how many times?

Forming a Reflective Writing Group

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• Do you want to invite guests – professional writers, writing coaches, or instructors? • Tell potential members about the group format. For example: They will be given a writing prompt each week and will be asked to take turns reading. Members are expected to write week-to-week, even if they don’t read. • Alternatively, members can hand out or email their writings the week before so that more detailed feedback can be given after a piece is read. • Formulate group rules regarding attendance, punctuality, participation, boundaries, and how to give feedback (see chapter 29). As the group gels, how are new decisions going to be made? • How will conflicts be resolved? What if a member repeatedly misses group, is belligerent, monopolizes discussion, makes overly personal or inappropriate comments, and doesn’t write, participate, or offer to read? Do you give a warning? Vote on expulsion? Who delivers the message and is it done privately or in the group itself? • Prepare a handout summarizing the ground rules so that people know what to expect from the very beginning. You may revisit these rules as you go along and modify them based on consensus. • Invite members to revisit personal goals periodically to make sure the group is on track. • As the group draws to a close, consider putting together a booklet of members’ favorite writing, so you all have something to take away.

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Professionalism and Ethics Writing Prompts

Every health profession has official guidelines on professionalism and bioethics. Students can be exposed to the best and worst of what happens in real practice with respect to these standards. Most of us are exposed to unprofessional behavior on a regular basis, but don’t know what to say in the moment or to do right after the incident. It’s important to process such breaches promptly so that they don’t damage your own sense of what your profession can and should be. Also, celebrate those encounters or experiences where care is delivered in an exemplary fashion that fully embodies respect and humanism. Once again, narrative reflection can help inoculate you from cynicism and burnout! Write about a mistake that you or somebody else covered up. My health profession is a job versus a vocation. Discuss. Healing is an art. Healing is a science. Discuss. Write a story where a natural health product or allopathic technique was involved. From what you have seen and heard, what makes a good doctor or health professional in your discipline? Write about an episode of bad behavior (yours or someone else’s). Write a story about a boundary violation. Write a story about something you experienced as unprofessional.

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Describe: “My online presence …” Write about a forced, false, or incomplete consent process. Write about a time you did something dishonest. Write about an example of gallows humor at work. Describe your bedside manner. Write a story about passing the buck. “Primum Non Nocere – First Do No Harm.” “Assisted Suicide – My Thoughts Based on the Story of a Real Patient/Client I Worked with” Write about a serious medical error you’ve made, witnessed, or learned about. Write about an incident of bad/unprofessional behavior that you witnessed recently at work or school. Write a letter to someone you read about who is involved in a health-related scandal. (Do not send it.) A patient asks you to lie to their partner. What do you do? Write about a time you covered up for someone. Write a story about one of the Ten Commandments. Write a story about cheating. Pick a summary of disciplinary action from your college/university newsletter and turn it into a fictional story. Write a story about how money influenced an important decision you or your team made. Write about a lie. “Where they cut corners …” Write about a recent moral dilemma or moment of moral distress at work in 100 words or less. Write about an email you regret sending. Write about a social media indiscretion you or someone you know made.

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Write about an unprofessional situation you experienced or witnessed. Write a story about a role model. Write about a gift (or bribe) from a patient. Write about a personal assumption that got blown out of the water. Write a story about being late. Write about a time you called the hospital chaplain or ethicist. Write a story about false hope or empty reassurance. Write about a time you fudged the truth. Write about the one thing you want expunged from your record. “Money is no object.” What would you charge? Write a story of your profession in 10 points. Write a story about “pulling the plug.” Write your own Professional Oath in 10 lines. A patient asks you out for coffee. Write what you would say as a dialogue between you and him/her. “What I think about drug companies.” “What I think about insurance companies.” “What I think about hospital administrators.” “What I think about my professional college/licensing body.” Write about a faux pas at work or school. Write a story about whistle-blowing. Write about a recent interaction with the pharmaceutical or insurance industry. “There’s no free lunch.” Discuss. Write a story about a conflict of interest situation. “My white coat …” Write a story starting with, “We are all accountable …” “Dress for Success” or “The Costume I Wear to Work”?

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“I was just following orders …” “They fudged the notes on the chart …” “They say the file went missing …” “I never should have pressed SEND …” “It is okay/not okay to give advice to patients and clients by email.” Discuss, and then review your school’s/institution’s policies on social media. “Of course I friend all my patients on Facebook …” You’re dating online. What do you need to consider? “There’s going to be a lawsuit!” “They were pushed to the head of the line …” “I ran out of time …” Think about your profession and ask the three following questions: Who am I? What am I? Where am I? “The paperwork didn’t get done …” Read this story [writing prompt] by a nursing student. Was the encounter professional? What is missing? Patient/Client Autonomy The mother told me she didn’t want her child vaccinated with the MMR. She had read online about links with autism and mentioned that celebrity on TV – Jenny Something – who had started an anti-vaccer campaign. She also mentioned that her cousin’s baby got really sick with fever after taking it last year. The baby gurgled away on her lap – a beautiful little girl. I asked if she had discussed it with the doctor? She said yes, but that he had dismissed her concerns as unscientific and told her to check in with me for the shot before she left.

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Although I was new in this clinic placement, I knew the doctor in question. He’s always rushed and it didn’t surprise me one bit. He also didn’t tell me about the mother’s concern, which annoyed me. I agreed with the mother that she shouldn’t proceed until her concerns had been properly addressed with the physician ordering the injection. She seemed pleased with my advice. I documented, “Declined MMR injection for baby today. Instructed her to discuss with Dr X.” I’m not sure if she ever booked another appointment.

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Values, Beliefs, and Assumptions Writing Prompts

As you’ve already seen, writing about real encounters with patients/ clients, with other students and faculty, and with yourself as you reflect can help you to uncover biases, assumptions, and blind spots, while helping you affirm what your core beliefs and values are. Many years into my clinical practice and teaching, I can guarantee that there will always be surprises, things you’ve missed or taken for granted, no matter how experienced you are. It’s worth writing about surprises because you can always learn from them. Write about an incident where your personal values clashed with what was expected of you. Write about hearing about something sexual at work that made you uncomfortable. Write a story about a stereotype. Write a scenario where your politics clashed with your job. Take one fact from your life. Now prove it’s true beyond a shadow of a doubt. Write about cultivating compassion. Write about a commitment. “What inspires me most …” Write a story about making a difference. “I promised myself I’d never …” “Where I find wisdom …” Write about “A Good Death.”

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Write a poem about what you think happens after death. Write about a test of faith. Write about something you’re sure of. “Skinny vs. Fat …” Write your definition of “Humanism in clinical care …” Write a prayer or tribute for a sick patient. “Patients should be stoical. Not complaining is a virtue.” Discuss. Write a story using your favorite or least favorite swear word. Write about a charity you support. Explain why. “Healthcare has to be earned. You shouldn’t drive a Porsche if you can only afford a bicycle.” Discuss. List five ways power or status has changed you. Write a story about someone fat. Write a story about hope. “Messy vs. Tidy.” Discuss. What’s the most expensive thing you own? What was it like to buy it? What does it say about you? “Religion was/was not important in my family …” Describe your social class. What clues do you work at giving in speech, behavior, grooming, or dress to reinforce your status? Pick a forbidden word and write your association to it. Write a story about a prayer. Write about a time you said a prayer at work. Explain death to a four-year-old. Write a story about a patient you judged or misjudged. Write a story about a person whose beliefs you think are crazy or ignorant. Whom do you copy nowadays in terms of style/mannerisms/ speech? Explain why.

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Write about a superstition. Write a story about beliefs or values colliding. Write about a time you rationalized about a situation. “What the chaplain said …” Pick a patient or client. Write a reflection starting with “My view on their quality of life …” Here is what I believe: 1. 2. 3. 4. 5. “Here is what I hold sacred …” “Suck it up, buttercup …” “Smile and the world smiles with you …” “Nobody should ever raise their voice …” “Violence is never justified.” Yea or nay? “Suffering in silence is a virtue.” Or choose another a culturebased trope. Discuss. Using dialogue, write about a disagreement you’ve had at home, work, or school regarding one of the following: • Gun control • Immigration • The election • Racism • Colonization/colonialism • Sexism • The rights of sexual minorities (including marriage) • Affordable healthcare • Welfare/Social Security • Liberals vs. conservatives

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• • • • • • • • •

Tax cuts Strikes by healthcare workers Indigenous/Aboriginal rights Unions Global warming Abortion Medically assisted death Legalization of marijuana “All unemployment is voluntary.”

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Toward a More In-Depth Assessment of Reflective Writing Evaluation

You need to find out how your portfolio will be assessed with respect to stated learning goals. In many courses, peer assessment of reflective writing is being built into PF courses. Questions to consider: Is assessment formative, summative, or both? Are faculty mentors evaluating your submissions or are other faculty? (Some schools assess portfolios as a committee.) How do they grade them? Is it a Pass/Fail system or other? Are rubrics/scoring systems used for writing assignments or is feedback more narrative? Are you rated for class/group participation? Is there a procedure for appealing grades? How will you receive, use, and incorporate feedback as you go along to demonstrate growth? Here are helpful steps that thoughtful faculty use when reading and evaluating student writing. You’ll see that the best response to narrative is more “narrative” – a form of written or spoken dialogue. Educators can use these guidelines, but so can students when assessing their own writing or when assessing another student’s narratives in a study group. We’re seeing more peer feedback being incorporated in courses around reflective content written by fellow students, so these thoughtful tips will be helpful. 1. Read the entry from start to finish without making notes, keeping in mind the SOAP guidelines from UCSF (chapter 19). Look for evidence of the subjective (thoughts/feelings/an authentic voice) as well as the objective (theory/data/exposition). 2. As you read, consider whether the entry answers these questions: • Why did you choose this story/content? • Could anything have been done differently by you/others?

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• What questions does this story raise for you? • What are the learning points? 3. Highlight any keywords, themes, anchor points, or terms suggesting insight and reflection for each entry and make a list of these. 4. Making notes, rate each entry separately using the LEAP Reflection on Action Rubric. Score each entry from 1 to 6 using LEAP definitions of reflexivity. 5. When formulating written feedback, consider the following acronym used at the University of Toronto. Feedback should be: • Balanced – points out strengths as well as weaknesses/gaps. • Explains what other options/resources/actions might have been possible. • Specific. • Timely – don’t delay giving feedback. Strike while the iron is hot! Use details, metaphors, words, images, surprises, and questions raised by the students themselves.

BEGAN The Brown Educational Guide to the Analysis of Narrative Here are more helpful tips for crafting peer feedback on student reflective writing pieces. They invite deep reflection on the part of the reader/assessor (whether a faculty member or student) and help complete a circle of mutual, shared meaning making. Context: Consider the setting, student’s identity and background, stage of training, assignment/prompt, if available, and your knowledge of student’s previous reflective skills. Step 1: Read carefully from beginning to end without pen or keyboard (overall undifferentiated gut impressions and reactions to the learner’s written expression).

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Step 2: Record initial impressions triggered by the learner’s written expression (overall impressions and reactions, as well as your clinical and/or personal experiences, views, and biases). Step 3: Reread and analyze the text – use a pen or keyboard to make notes: a) Underline learner’s salient quotes and key concepts, expressed emotions (e.g., verbs such as “surprised,” “scared”), and reflections. b) Extract key themes, categories, and patterns. c) Extract the lessons learned – consider both what the learner expresses and what you see as learning opportunities. d) Additional consideration (see below). Step 4: Craft feedback using key themes and lessons learned, reflection-inviting questions (see below), and concrete recommendations. Filter and prioritize what is educationally valuable to the learner and look for opportunities to provide positive feedback. Defend your impressions with actual text. Use coaching rather than evaluative language. Step 5: Critique feedback – pause and edit before pressing SEND (e.g., be concise – remember sometimes “less is more,” make your relevant beliefs and biases transparent). Additional consideration for Analysis of Student Narratives: Step 3d. I. Close reading approach: How is the story or writing framed (what is inside and outside the border?) Is there an Introduction? Is Plot (storyline) being evoked? Plot thickening/complexity? Subplots? Ironic turns in plot? Ironic reversal? Pivot point(s)? Conflict in the plot? Time line/temporality? (analogy: chief complaint, HPI, social history, diagnosis). First person? Characters entering the story/interrelation of characters? Conflicts in characters? Humor (derives from improbability of circumstances)? How detailed? (Could it be more forceful?) Metaphor, imagery, symbolic content. Does

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the end of the narrative cast new light on the beginning? Resolution (sense of conclusiveness)? Defend your impressions with the actual text. Step 3d. II. Reflection-inviting questions: For the patient encounter/observation described, how are both the patient’s (when attending to an encounter) and student’s explanatory model informed by culture, belief, gender, family structure, personal and familial illness history, life experiences? Why are you doing it? (Action taken, words spoken.) How did your actions influence the outcome? What were you feeling? (From what you’ve written, I interpret you may have felt X. If you’re comfortable answering, is that true?) What assumptions did you make about this situation? What else might be affecting this situation? Might there be alternative explanations? What could they be? (Fostering multiple perspectives.) Consider what may be puzzling, inadequately explained, or inconsistent with your expectations. What skills did you learn? What new insights did you derive? How would you apply what you learned in your future work? How might you do things differently if you had a chance to repeat this situation? What could be an action plan for improvement? What valuable insights gained and/or anything uncomfortable about community mentor’s clinical encounter with a patient. Reis SP, et al. Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative) – A framework for enhancing impact of faculty feedback of students’ reflective writing. Patient Educ Couns. 2010 Aug;80(2) 253–9 (used with permission).

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The Hidden Curriculum and Power Writing Prompts

We all know what the official course syllabi say about content and learning goals and outcomes. But what content gets left out? Who actually created that knowledge base and standards? Who gets left out in decision making? What about behavioral inconsistences from those in power? (“Do as I say, not as I do!”) Who creates the pecking order in my institution? How is dissent dealt with? What happens if someone powerful misbehaves? How do money and power determine what is seen as important in my faculty/school/curriculum? If you start to ask these questions, you are outing and naming what has been called the Hidden Curriculum (HC) – all the systemic assumptions, biases, and privileges which seem invisible but which powerfully shape policy and practice. Use these prompts to uncover how the HC plays out where you are. Write about a time you questioned authority. Write about a time you disagreed with an authority figure. Write a story about jumping the queue. Write a story about a workplace bully. Write about a VIP patient. Write a story about dealing with an insurance company. “I kept my mouth shut …” “They said the cuts were good for the institution …” Write your boss’s to-do list today. “The Portfolio is another example of faculty control and surveillance.” Discuss.

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To whom do you defer nowadays and why? Write about an incident where you came off as arrogant. “Whistleblowing.” What information would you like to leak if there were no consequences for you? “(S)he still gets away with it. Here’s why …” “What a hypocrite!” “We all saw what happened. Nobody dared speak up …” “They talk the talk. But that’s about it …” Write about an incident where you felt intimidated. “My boss was impossible to please …” Write about pleasing an authority figure. Write a letter to your boss/supervisor/instructor, saying all the things you would never dare to say to his/her face. (Do not send it.) Write about a time you said “NO.” Write a story about pulling strings. Write about a time you were forced to do something you didn’t want to do. Write about a time you disobeyed orders. Write a story that typifies arrogance. “The senior colleague …” Write about a time you used your title/status to get something. Write about someone whose approval matters to you. You are the janitor on your floor at work. What do you see? Write about a secret in the institution where you work that nobody talks about. Write a story about power differences. Write a story about an encounter with the police. “Profit seemed to come before care …”

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“Money talks …” “Here’s what really happens with our evaluations …” Write about a time someone with real power disappointed you. Write a story about “sucking up” to authority. “It’s all about who you know …” Give an example of Groupthink.

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Am I a Good Group Member? Positive Characteristics

The literature on Portfolio course success emphasizes that sharing reflections in a safe, respectful environment deepens learning and may even be as important as the writing itself. Listening and communication skills can be enhanced in group learning as discussion and shared meaning making around stories takes place. Here is an assessment rubric for student performance in small group meetings, used at the University of Toronto in a course that uses prompts based on the CanMEDS medical professional roles (http://www.royalcollege.ca/portal/page/portal/rc/canmeds).

You will be graded not only on submitted written reflections but on how engaged/active/respectful you are in group learning within the Portfolio course. Here’s a sample grid along with tips on how to be a top-notch participant in discussions of other students’ writing. Score

Insufficient

Adequate

Superior

Preparation

Student did not show evidence of having prepared for the discussion; e.g., no sense of the CanMEDS role, no organization of personal story.

Student prepared with a basic understanding of the CanMEDS roles that organized a personal story that could be presented.

Student had a highly developed personal story that showed evidence of in-depth understanding of the CanMEDS.

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Presentation

Student could not present their story in any depth; superficial reporting of events with no personal reflection.

Student told their story clearly, giving listeners insight into the personal significance of the event reported.

Student presented their story with high impact; listeners are left with a strong sense of the student’s personalized view of the CanMEDS role.

Attentiveness

Student did not appear interested or attentive to the presentation of others; this would include non-engagement or disruptive behavior.

Student showed interest in other students’ presentations and made an effort to understand their stories.

Student was highly engaged throughout meeting; showed ability to grasp the subtleties of other students’ views of themselves.

Feedback

Student did not offer any more than cursory feedback; no appreciative elements; had a negative reaction (e.g., cynicism, mockery, dismissiveness).

Student gave feedback that recognized the strengths of some other students’ presentations, provided with some probing questions to assist others in developing their stories.

Student gave highly personal and relevant feedback that assisted the presenter in developing new insights; showed a knack for reaching out to the presenter.

Positive Characteristics of Reflective Writing Group Members Here’s how you can participate fully and professionally in a reflective writing group/class. Try to: • Respect the confidentiality of all members and health-related stories, by holding stories in confidence; • Give and receive feedback in a constructive, non-threatening or non-defensive manner;

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• Be eager to learn about telling and sharing stories, whether experienced in writing or not; • Work with others and to take an interest in their work; • Attend regularly and on time, and commit to the group process; • Share feelings about your own writing process and about pieces read in the group; • Share floor time with other members (so as not to monopolize the discussion); • Write every week, even when it’s not your turn to read; • Be flexible and open with respect to listening to other points of view; be able to comment respectfully on a member’s writing even if you disagree with its content, and to redirect conflict back to the writing; • Redirect comments to writing and the specific piece read in the group, rather than emphasize unrelated content or concerns; • Keep comments specific and concise, and to emphasize strengths of a piece; • Respect other people’s boundaries; you can ask questions, but it’s up to other members to decide how much they say about their own work; • Assist in problem solving around difficult stories or clinical dilemmas (including directing the author to references, guidelines, and/or resources).

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Dilemmas and Difficult Stories Writing Prompts

Sometimes things go wrong and become tinged with shame, blame, guilt, humiliation, despair, regret, irrationality, retribution, even degradation. The difference between resilience and burnout is that you can learn from your failures (because they will be inevitable in a long, complex healing career), then bounce back and renew your sense of purpose. Business schools are already emphasizing how “failures” lead to new questions, solutions, and successes. Use these prompts to help process disappointments, disillusionments, and failures as they come up (or even to process a story you’ve been carrying around for a long time). Write about an incident that feels un-metabolized/unresolved. Write a story about telling a patient about an error. Write about a time you got passed over or rejected for something you wanted. Write about the most tragic case of your career. What motivates/compels you to work in healthcare? What do you think are the biggest potential sources of professional burnout, and what can you do to mitigate these? How do you know when you’re getting too close to a patient or community issue? Write a story about war. Write about something that broke. What are the unspoken truths you long to say to someone, but can’t? Explain why.

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Write about a problem situation. List the plot as a series of factual events. Write a cartoon balloon beside each event containing what you were thinking/feeling. Write the story from work that you’ve carried for a long time but never told. Write a story about a medication or procedure that harmed rather than helped. Write about an experience that caused your “fight or flight” response to kick in. Did you fight or flee? Write a story about jumping to conclusions. Write about a patient’s suicide or suicidal attempt. Write about someone who cuts/self-harms. “Suddenly it all went sour …” Write a story about revenge (real or imagined). Write about a time when you could not meet the expectations of someone very close to you. Write about an epidemic. Write a story about terrible luck. “It was definitely harassment …” “The whole thing felt abusive …” Write a story about a loss of innocence. Write about an image you can’t shake from your mind. Write about your greatest fear, health-wise. “I felt desire/revulsion. I’m not supposed to …” “In the end, it was all unnecessary.” “I totally misinterpreted what they said/meant …” Write a story about being blamed for something. Write about something that happened at work that you’re ashamed of.

Dilemmas and Difficult Stories – Writing Prompts

Write a story about separation or divorce. Write about an accident. Write about a debt. Write about your worst experience at work. Write about the most frightening thing that ever happened to you. Write about an assault or murder. Write about a time you felt stupid. “Something was wrong …” Write about a time you felt you had to hide. Write about a time your hands were shaking. Write about your worst decision. Write a story about street drugs. Write a story about overreacting. Write a story about sudden death. Write a story about forgetting something important. Write a story about someone who was flirtatious or hostile at work. Write about a mistake you have made or observed. Write about a time you lacked money or resources. “I kept my head down …” Write about a time you asked for help. Write about a message you regret delivering. Write a story about losing something. Write a story about a gun. Write about a time you felt threatened. “Fuck off!” Write about an error in patient care. What happened?

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Write about a rejection. Write about a time you became angry with a patient or client. Write about a clinical situation where you doubted yourself. Write about a time you felt insulted. Write about a clinical outcome that surprised you. Write about a situation that made you feel hopeless. Write about a time you got lost. Write up a nightmare you’ve had recently. Write about an encounter with violence. Write about a time where you froze. Write about a mistake. Write about the worst thing you ever witnessed or experienced. Write about a close call. Write about a clinical situation you couldn’t explain. Write about a betrayal. Write about a time you felt disgust for a patient or colleague. Write about a time you had to look away. “It was traumatic …” Write about a failure. “They acted like the victim …” Write about a time you felt guilty at work. Write about a time a patient or client said or did something inappropriate in your office. Write a story about a lawsuit. Write about a time you felt unsafe at work. Write a story about blame. Write about a time you got hung out to dry. Write about a family conflict you have observed at the hospital or clinic.

Dilemmas and Difficult Stories – Writing Prompts

Write about a patient/client who stopped coming to see you. Write about a time you “fired” a patient or client (or they “fired” you). Write about a time you witnessed or experienced violence. Write about an act of meanness or spite. Write a 10-line rant on the subject of your choice. Write about being late or sleeping in. Write about a time you were unprepared. Write about a time you couldn’t sleep. Write about a time you feared failing. Write about a time you were completely exhausted at work. Write about a time you did or didn’t listen to your gut. Write about a bad choice.

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Sample Discussion Points When Working with Stories

As your reflective writing group gels, you can become more and more helpful to one another. Reiterate the importance of respect, confidentiality, and professional boundaries when discussing stories that may be about patients, colleagues, or professors. Here are some helpful questions that participants can consider when discussing reflective pieces shared in a group. They will also be helpful to any of you who want to form a creative writing group or to craft your piece further for publication: • What did you like about this piece? What are its strengths? • How did hearing it make you feel? • Can you relate to this story? • How does the author let us know he or she cares about what happened? • Who in the story do you like or dislike? • What really happened? • Does any word or image catch your attention? • What was left out? • What keeps us wanting more? • Did anything confuse you in the piece? • What’s the main conflict or tension in the piece? • What’s unique about the language in this piece? • Why is the group so animated or angry after hearing this piece? What in the writing got us there?

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• How do you know where we are in the piece? • Which of our five senses did the story capture? • What makes this story edgy, funny, suspenseful, or scary? • Is there a central metaphor in this story? • What pictures or images came to mind after you heard the piece? • Who is the narrator? Why does first/second/third person work so well there? • How does the author succeed in showing us what happened rather than telling us? • Is this a hopeful piece? • What about the pacing keeps us wanting to hear more? • What stance is the author taking? • What’s the theme or message of the piece? • Any suggestions to make things clearer or more emotionally powerful? • What about possibilities – where could this story go next?

Reflective Questions for the Author You can encourage reflection about a shared piece, but you should never force it. Respect where the author/reader is in the process of their own insight and understanding. (Sometimes their reflective piece can be ahead of where they are in terms of their ability to discuss it aloud. Other times, what is shared may be raw and unprocessed.) Remember – this is not a therapy group. These are your student peers and colleagues (and professors who are evaluating you). Once something is revealed, it cannot be unsaid. These questions can be helpful in deepening reflection to a critical, even transformative level. You can ask some of them. But keep in mind that the reader/

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author may choose to answer these or not. Respect their boundaries. The story is always in the hands of the teller. Always work with the text they actually provide you. Be ready to jump in to stop intrusive or personal questions and then reassert the ground rules for discussing a colleague’s written narrative. (More tips on sharing and discussing writing respectively follow in the next chapter.) • How did it feel to read this piece aloud? • How did you feel after you wrote it? • Did anything surprise you during the writing of this piece? • Are you the narrator or have you kept a distance? • Is there anything you left out? • What held you back from going deeper or further? • What was your inner critic saying as you wrote this? • Can you imagine sharing this piece with family or friends? • Have you tried to write about this before? • What was most difficult about writing this? • Have you softened things for the group or have you been as honest as you can be? • When did this incident happen? How have your views changed? • Have you ever told this before to anyone? • Can you see yourself reworking/expanding this story? • Were you silenced in the encounter you described in the piece?

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For Teachers and Student Group Leaders

Once again, you may not have portfolio or reflective writing courses at your school. Share these tried and true start-up strategies with faculty (or senior students) so that they entertain the possibility of providing new learning opportunities. They emphasize safety, respect, confidentiality, and healthy professional boundaries in the sharing of student narratives. Make your case for changes to your curriculum by reminding them that reflective writing honors both the subjective and objective facets of experience and learning and allows students to document their evolution as human beings and as healers over time.

Using Reflective Writing with Students Safely and Respectfully: Ten Practical Tips for Getting Started Clinical educators and senior residents/grad students are increasingly asking students to use writing as a tool for enhancing selfawareness and reflective capacity. As we’ve seen, critical incident reports, parallel charts, portfolio entries, and journaling have all been used with success in facilities across North America and are an example of successfully incorporating the humanities into curricula. Generally, a writing prompt is provided and students either write onsite (for 5 to 20 minutes) or take the prompts home

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and bring their writings for small group discussion and feedback to the next meeting. We have been using writing prompts based on CanMEDS professional roles in a new writing elective for clinical clerks at the University of Toronto. The following guidelines derived from that experience may be helpful for educators wishing to use reflective writing in a small group teaching context. 1. Establish ground rules for the group. Emphasize confidentiality. Some of these stories may be self-revelatory or based on encounters with patients and colleagues. “What’s told in the group stays in the group.” Define boundaries. This is not a psychotherapy group. If a student reads a piece, they should be in control of what they wish to reveal at all times. When making comments, group members should concentrate on the text provided or read. As mentioned above, they may ask questions about the story, but it’s always up to the volunteering reader whether they answer or reveal more. 2. Create a safe space for learning and exploration. Tips for giving helpful, constructive feedback on writing should be provided. Each reading should be voluntary. Strengths of the piece should always be discussed first – what was moving, powerful, and resonant. Students may make helpful suggestions on the piece, but the goal is to be constructive and supportive. Even if readers disagree with the sentiment or viewpoint of the piece, their goal is to work with the text itself rather than challenge the author personally. 3. Suggest that fellow students write about real life, personal incidents – something specific that actually happened. Invite them to write the story as if they were telling a friend and not to worry about grammar, spelling, or syntax in their first draft. Encourage them to structure the story with a beginning, middle, and end, and to include how they felt about the incident (not just the facts).

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4. Provide short, simple writing prompts that capture the imagination, rather than eliciting intellectualized content or formal essays, like “Write about a good-bye.” You have a thousand to choose from in this book! Remind students that prompts are merely a suggested launching pad and that they are always free to write about whatever they like. 5. When a student reads a piece to the group, ask them to read the story as written from start to finish (no apologies, explanation, or preamble). Ask them to remain silent during the feedback from the other students so that they can take it all in. Then invite them to rejoin the discussion. They may be surprised by some of the interpretations of their piece, and answering questions or commencing right after reading could short-circuit that process. 6. Ask respectful questions to deepen reflection: “Why did you write this piece?” or “Why did you choose that incident?” “Did anything surprise you in the writing it?” “Would you do anything differently?” “What do you like about your piece?” “What did you struggle with?” “How does it relate to other things you’ve written?” “Do any learning points emerge for you?” 7. Even though other students may not read to the group every week, encourage them to write every week even if just for themselves. We suggest taking up to 45 minutes for writing a piece, so that the task doesn’t feel onerous or overly time consuming. Students can take longer if they like. 8. When fellow students write about patients, remind them that clinical stories are always co-constructed and do not belong to the physician writer alone. They can be shared in a respectful manner or for learning and reflection (as in case presentations), but permission should be obtained from the patient if the piece is to be published (including, of course, posted to a blog). 9. Teachers or senior students supervising groups should be ready to intervene if a student reveals distressing content (i.e., issues related to abuse, self-harm, or professional boundary violations).

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A private discussion at the end of the teaching session should be offered and appropriate resources for help provided. 10. After the class is finished, encourage your colleagues to continue writing and journaling throughout their career as an ongoing form of personal reflection. Tell them to keep track of all their “firsts” in medical training – their first delivery, the first death of a patient, their first mistake, their first attempt at a new procedure. Remind them to keep their pieces together so that nothing is lost. Consider using the course evaluation provided in the next chapter. Adapted from Peterkin, A. Using Reflective Writing with Students: Ten Tips. CAME Newsletter, May 2010.

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A Sample Narrative Reflection Workshop Evaluation

Once you or faculty create new reflective writing learning opportunities, it’s a good idea to evaluate so that you can fine-tune or modify what you’ve done to create maximal student buy-in and participation. (If their participation is elective/voluntary, ask, “Why did you join this workshop and what did you expect to learn or gain from being a participant?”) For obligatory/existing portfolio courses, ask the following: 1. Were your expectations met in this course? Please elaborate. 2. Were there any surprises from the workshop? 3. What part of the experience was the most valuable and what was the least valuable? 4. As a clinician, how will you use this experience of discussion and writing in a group with patients and caregivers improve your professional practice? 5. Would you like to see this workshop continue for other students? 6. What changes do you propose for the workshop? Were there logistic concerns (regarding, for example, submitting narratives, posting comments, or completing course evaluations)? 7. Did you feel you were in a safe environment, free to express yourself in honest, open conversation and to share your personal writing?

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8. Did any specific CanMEDS or other professional/ethical role(s) as outlined by your discipline’s college/professional body become clearer for you? Please elaborate. 9. Are there any roles or duties you are still confused about? Please elaborate. 10. How do you see yourself using reflective writing during your training? 11. Did writing in the group help you to process any specific incident(s)? If yes, please explain. 12. How has this process helped you to navigate the clerkship/ internship/placement experience? 13. Any other thoughts, comments, or suggestions about the workshop?

Overall Course Evaluation (Circle One) Excellent

Good

Fair

Poor

Content

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Presentation

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Readings

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Exercises

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Coaches

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Size of group

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Location

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Time

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Food

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Overall evaluation

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Creativity Writing Prompts

In my experience, the most gifted clinicians and healers I have encountered over the years have viewed creativity as essential in their professional and personal lives. They managed to remain curious, flexible, and unthreatened by change. (As the saying goes, Change is inevitable. Growth is optional.) They looked for novel solutions to problems while maintaining humility and joy in their daily work. Many had an artistic outlet – literary, visual, or musical – that sustained, recharged, and inspired them. Do not let anyone tell you that there is no room for play in a clinical life! Write about PLAY. Write a story in which each sentence starts with the next letter of the alphabet, starting with A and ending with Z. Write a haiku that works as an autobiography. What can you tell the world about yourself in 17 syllables? Watch a young couple interact in the hospital but remain out of earshot. Based on visual clues alone, write the conversation the couple is having. Pick a photo (personal or commercial) and write about it. Write the funniest story you’ve heard. Describe a time when your creativity was really flowing and you were having a pleasant experience. Take a line from a favorite poem as a first line of a story. Write about building something.

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Write about a cure you long to see. Explain why. How would you redecorate your clinic/office/hospital, if you had the freedom to do so? Be specific and draw a sketch. In a team of five people, ask each person to write down five words and then write a collective poem incorporating all those words. Write anything you like for three minutes. Read what you’ve written and circle one word or theme you’d like to pursue further. Mind map: Choose one health-related word that strikes you and place in a circle in the middle of a blank page. Draw six lines and add a new word to the end of each in a circle. Create six to 12 new lines, each with a new word. Circle these words. Look for patterns, themes, concepts, and surprises. What emerges? Write a story about your favorite color. Write a Table of Contents of your life based on key events. If you had a tattoo or wanted a new one, what would it be? Why? Working with a patient currently under your care, ask the patient to show or tell you about three personal objects (e.g., an old typewriter, a sports shoe, a decorative ornament), and then choose one: • Compose a biographical sketch or portrait of the person/ patient evoked by those objects; • Write a brief journal entry for the person/patient which includes mention of those objects; • Explain three things you have in common with the patient based on those objects. What pill would you like to discover? What would you call it? Pick a letter from the alphabet. Think of a word that starts with that letter and use it as a title for a story. Write about a color that stood out in your work day. Write about a discovery.

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Pick a movie, play, or book that really moved you and explain why in a tweet (140 characters). Write about someone or something that got away. Describe your day at work by listing sounds only. Write a 50-word synopsis for a horror movie or comedy set in your workplace. Write about something that happened in an elevator. Doodle for five minutes, without lifting your pen off the page. Open up the dictionary and put your finger on a word. Now write a story with that word as the title. Pick a professional journal article. Select three words from it and write a poem. Write a story using any of these words: • Promise • Metabolism • Gun shot • Vaccination • Orderly • Tribute placebo • STDs/STIs • Incubator • Pus • Aspirin • Waiting • Midwife • Monogamy • Rash • Psychosomatic • Melodrama • Surgeon • Sutures • Dressing/bandage • The misfit

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• • • • • • • • •

Skin Widow(er) Lullabies Assault Fever Hair Plague Diva Coward

For 215 billion (!) opening lines to get you writing stories, visit www.thestorystarter.com.

Conduct Your Own Media Interview (with Yourself!) Time to put it all together. How would you answer these questions as a person, not just a health professional? If you can’t answer some of them, why not? Is something missing in your life? At the very least, they’ll make you more interesting at the next dinner party you attend! When were you happiest? What’s your greatest fear? What’s your earliest memory? Which person (living or deceased) do you admire the most? What trait in yourself do you deplore? In others? What is your most prized possession? Where would you most like to live? If you could have a super-power, what would it be? What do you like/dislike most about your appearance? Who (or what) is the love of your life?

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What extinct species would you bring back to life? What is your favorite smell/taste/sound? What is your favorite saying or phrase? What do you owe your parents? What is the worst thing anyone ever said to you? To whom would you most like to apologize? Whom would you most like to invite to a dinner party? (Include celebrities, historic figures, as well as people you know.) Which words do you overuse? What was your worst job/placement/assignment ever? What is your biggest disappointment? What is one thing you wish you could change? If you could go back in time, when and where would you go? When did you last cry? Why? How do you relax? What one thing would improve your life? What brings you a sense of pleasure and purpose? Name your greatest achievement. How would you like to be remembered? What is the most important lesson life has taught you so far? (Questions inspired by columns in The Guardian newspaper – www.theguardian.com)

Literary Readings and Writing Prompts Many colleagues across North America shared their writing prompts based on selected literary readings. They have provided links to access the poems, short stories, and articles along with the prompt they created. You and fellow students can read and even discuss

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the suggested reading first and then write a personal narrative. Or, you can use the prompt to write your own material and then read the poem/fiction/piece afterward (alone or in a group setting) to deepen reflection. Following are some recommended readings along with prompts for each piece: Read and discuss the poem “Torn,” by C. Dale Young: http:// www.vqronline.org/torn. • Prompt: “Write about a time you were torn.” Read and discuss the poem “A Green Crab’s Shell,” by Mark Doty: https://www.poets.org/poetsorg/poem/green-crabs-shell • Prompt: “Write about an inner chamber.” Read and discuss the Hippocratic Oath (for medicine) or Nightingale Pledge (for nursing): http://www.britannica.com/ topic/Hippocratic-oath; http://www.nursingworld.org/ FlorenceNightingalePledge • Prompt: Write a short (500–750 words) post-modern textual critique on its language and rhetoric. Read and discuss the short story “Girl,” by Jamaica Kincaid: http://www.newyorker.com/magazine/1978/06/26/girl • Prompt: Write instructions to yourself. • Prompt: In Jamaica Kincaid’s style, write instructions you received growing up. Read and discuss the poem “Kitchenette Building,” by Gwendolyn Brooks: http://www.poetryfoundation.org/learning/ poem/172080 • Prompt: Write about protecting a dream. Read and discuss the poem “What the Doctor Said,” by Raymond Carver: http://writersalmanac.publicradio.org/index. php?date=2014/07/24 • Prompt: Write about a time you wish you’d said more to a patient.

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Other Exercises Linked To Readings 1. Embodiment We are embodied creatures. Medical students study the body in anatomy, in physiology, in pathology, and even in pharmacology. What does it mean to be embodied, and for the body to fail in a variety of ways? And what does it mean to mend? “homage to my hips” by Lucille Clifton, in Good Woman (BOA Editions, Ltd., 1987) “Cadaver, Speak” by Marianne Boruch, in Cadaver, Speak (Copper Canyon Press, 2014) 2. Writing Exercise: Bad Behavior Writing that intrigues the reader frequently records or implies conflict and tension. Writing about bad behavior provides a platform for readers’ emotional and critical response, that is, for engagement with the work – is it bad behavior? – how bad? – in whose opinion? – what will be the consequences? – why did they do it? In this exercise, describe a scene with bad behavior. Any genre can work. “My Lie” by Jen McClanaghan, The New Yorker, 9 January 2012 3. What Do Medical Students Do? What is it that med students do – what is the dailiness, the range of behaviors, and activities, the motivations behind what med students do? What do you do? What is different for you now? Perhaps there is some other aspect of your life you would like to explore. What do runners do, what do writers do, what do daughters or sons do? What do friends do? This exercise is a way to think about the reasons we do what we do: when, where, how, and, in the particulars, to discover why. “What the Living Do” by Marie Howe, in What the Living Do (W.W. Norton, 1998)

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More Literary Texts for Close Reading and Discussion Students at the University of Toronto have created a Companion Curriculum that matches short pieces of fiction, poetry, memoir, and journalism to every lecture topic/theme/learning block of their four years of medical-school studies. Themes are broad enough to be relevant to all clinical disciplines. You can access these student-selected pieces at www.utmedhumanities. wordpress.com.

Using a Poem for Reflection – A Sample Exercise in Detail Ronna Bloom, poet-in-residence at Mount Sinai Hospital in Toronto, uses a poem she wrote called “A Blessing for Ben’s Ears.” This poem and the writing prompts that follow offer a way to close a reflective session in a gesture of self-care. She asks: “Is there a recurring frustration or a block that keeps throwing itself at you?” Students are asked to “write into the block.” The aim is not to try to change anything, simply to open it widely and penetrate it with awareness and the pen. “Just as scientists magnify the cells they are trying to eliminate to see what they are, we get to see what limits us in detail. To know something, you must look at it. Then it may be possible to interrupt the process.” Ronna suggests that students read her poem at the end of their writing session to offer them a place to rest, assimilate, or simply have an experience of self-compassion about the block they have described. Afterwards Ronna suggests that students “write a blessing for a part of you that needs a blessing.”

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A Blessing for Ben’s Ears

May they be open, the tiny trumpets, instruments for taking in sound, may they be open to the songs of animals: the caterwauling cat and his deeper purr, the wordless chirp of bird and bark of dog, the harkening, sharp call of crow. May you hear words, language with its carriage of meaning, each word like a person bearing a message. May the words be carried on the air to your ears and you hear, and not just hearing, but with consideration, listen. Listen in silence too. May you have the gift of hearing the silence of your own company, your own presence. May you hear yourself speaking in your own voice, that you know to recognize it when it speaks and pay attention when it knows something. Your ears right now so small and fine – may they be treated well – and like last week when we walked down the Danforth and the screech of the siren assailed us, I covered your ears. May your ears always be protected from pain and for those sounds we can’t prevent may you make your own sound in response loud or soft, a cry of anger or of joy. May you hear yourself, as you hear others, the loud, the whispered, the flutter of eyelashes or wings beside your ear, the beating of hearts, the rhythm of prayers and chants that comfort. May you hear them and be soothed. And hear in things other things, so that your world becomes large and rich.

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For sometimes the whistling kettle sounds like the shofar blowing and sometimes it sounds like the trumpet call for a hot drink. May your ears bring you pleasure and information, bring you to others through hearing their presence and to yourself hearing your own. May we celebrate this instrument of connection and offer this blessing together. May I ask for approval from all those present with the chant and the chorus: Hear! Hear! (Poem used by permission of the author)

Five Ideas about Creative Editing Your imagination is vital in the editing stage of the creative process. Characters and their stories are reshaped many times in fine writing and the process invariably involves editing. Trying using the mnemonic “DRAFT”: 1. D: Deconstruct for better construction This is about the story. As a storyteller you have to keep your reader’s attention and build the tension: Have you told the story in the best manner possible? As you read your article, you’ll notice scenes that are defined by a change in time, scene, and/or characters. Each of these is a succinct bit, or a “glob” (as Douglas Glover would call them). Take these and move them around. Build tension. Lose the clunky segues, disperse the back story, tighten and focus. • The idea is to write true scenes, then weave these together into a story. As T.S. Eliot says, “The artist’s job is to bring disparate fragments of the already-made together to creative a quilt-work of something original.”

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2. R: Reader Find a critical reader who is not a friend or relative, but is someone who is well read, passionate about literature; an outsider who will be honest with you. Ask them to read your piece and assess it for: • Comprehension (does it make sense?) • Reaction to characters; their gut feelings • Narrative flow, continuity (Is the reader drawn through toward more understanding?) • Language (is it cliché, over the top, labored or transparent?) • Point of view – is it right? • Structure: does point of view work? • How is time treated in the story; with chronology/ flashbacks? Does it function well? 3. A: Aloud – read it. • Call on your ear’s experience with language. Tape yourself reading the piece, then listen; this is a good way to grasp the rhythm. • If you stumble over a word or passage as you read, put a tick mark beside it and change it later. • Look for things that crackle, irritate, or puzzle and excite you, including images, certain words, and cadences. Look for overall unity and content you need to cut or expand. • Read it aloud before you go to sleep, allowing it to resonate in your mind as you dream. The next morning revise on hard copy, away from the mechanics of your computer. 4. F: Cut the Fat Pay attention to the sentences, the music of the language. It is a lifelong process of learning to use language well. The Canadian short story writer Mavis Gallant likened writing and

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editing to sculpting. “You remove, you eliminate in order to make the work visible.” Even those pages you remove can somehow remain in the telling of the story. The goal is to achieve a more powerful whole, all of whose parts are dependent upon one another and necessary for the desired effect. “Kill your darlings,” as William Faulkner said. Get rid of the stuff that doesn’t work in the story. BUT: save what you’ve deleted elsewhere. You never know when you can reuse leftovers! And: • Get rid of the passive voice – Not: There were two men stumbling down the street, But: Two men stumbled down the street. • Beware of multiple adverbs and adjectives. Choose the right one. • Lose the clichés, the belabored metaphor or simile. • Watch out for unnecessary “weasel words”: • Just = often a qualifier, weakens the work • That = a fattener, unnecessary most of the time • It = vague • Others include: about, actually, almost, already, even, exactly, finally, here, kind of, nearly, now, really, seems, somehow, somewhat, sort of, suddenly, then, there, truly When in doubt, cut it out! 5. T: Toss the last paragraph This advice was given to Irwin Shaw by editors at The New Yorker and it often makes the piece tighter and more thought provoking. (Often the last paragraph summarizes or rehashes content). (Used with permission of Barbara Sibbald, Editor, News and Humanities, CMAJ)

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Graphic Medicine Reflecting without Words

Not all students are verbal learners. Many are visually oriented and reflect/learn based on images. At the University of Toronto, we encourage students to complete art projects and submit drawings, sketches, cartoons, doodles, paintings, photographs, and short films to their portfolios. Even if you are a verbal learner, it can be a good challenge to try your hand at drawing (even if you use stick figures) as a way of honing your eye for detail and overall visual literacy. So many cues our patients and clients give us are unspoken. Below are ten visual reflection prompts followed by some information on the exciting and growing field of graphic medicine. Professor Shelley Wall, illustrator-in-residence at University of Toronto’s Faculty of Medicine, has provided the exercises that follow.

Ten Prompts for Reflecting without Words 1. Draw an image representing a dilemma you currently face. 2. Draw a pie with four slices representing love (relationships), work (study and practice), play (creativity, athletics, what you enjoy), and meaning (beliefs, spirituality, values). There’s no correct version of how the slices should be apportioned for you, but ask yourself: “Do I see the balance I want to see in my life?” 3. Draw or sketch what’s right in front of you now. 4. Sketch an image from a recent dream.

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5. Draw an image related to a time you were left speechless. 6. Draw something from a clinical experience that you will never forget. 7. Sketch a visual detail that really mattered in the care of one of your patients/clients. 8. Draw your work or study space as it appears. Now add what you would like to see there! 9. Draw a facial expression that stood out for you in a recent patient/client encounter. 10. Draw a self-portrait from a time you felt stressed or bewildered. Graphic Medicine is an exciting new discipline that takes comics and cartoons seriously as a way of telling the stories of patients, their families, and healthcare workers across disciplines. These images are especially powerful because the narrative is captured in words and pictures. For more information and a list of the best graphic novels/memoirs dealing with health and illness, go to www.graphicmedicine.org. Here are a couple of drawing prompts from workshops offered by Professor Shelley Wall (used with permission).

Thought Bubbles Participants are provided with copies of the following material: Courtney Angermeier and Jeff Benham, Peoplings: Autism, Education, and the Savage of Aveyron (Albuquerque, NM: Belmondo Tomato, 2011), 55–9. 1. Using the comic convention of “thought bubbles,” participants take 10 minutes individually to fill in the thoughts of the characters in the scene – parents, healthcare professional, and child.

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2. The group then reads through the scene together page by page and participants are invited to share the inner dialogue they’ve come up with, and discuss what it is about the scene and the imagery that suggests how the characters are feeling and what they’re thinking. The discussion can be quite open-ended, but one of the main topics that emerges is how page layout (e.g., scattered, swirling panels), typography (e.g., dissolving text when the “autism” diagnosis is spoken), and subjective point-of-view (e.g., the doctor’s hand presenting the upside-down pamphlet) can be profoundly meaningful in representing emotional states.

Transitions Participants are provided with copies of the following material: Jessica Abel and Matt Madden, Drawing Words & Writing Pictures (New York: First Second, 2008), 7–8; and Scott McCloud, Understanding Comics: The Invisible Art (New York: HarperCollins, 1993), 66–7, 70–2. 1. The exercise begins with a brief discussion of the Abel and Madden handout that covers the basic anatomy of a comic: panels, word balloons, thought balloons, etc., so the group has a common vocabulary for discussing the parts of a comic. 2. Participants receive a blank three-panel comic template and are asked to think of an incident that has happened to them recently that has a beginning, middle, and end. The incident can be anything at all – anything that has struck them in some way. They then take 10 minutes to represent that incident in three panels. The quality of the drawing is not a concern here: it’s about telling a story. 3. The group shares their stories.

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4. Participants then receive a handout (McCloud) that enumerates different kinds of panel-to-panel transitions that are common in comics (as an analogy, think of the different kinds of “cuts” in movies: from one location to another, from one moment to another, from a shot of one person speaking to a shot of their interlocutor replying, etc.). Transitions affect the pacing and focus of a visual narrative. As a group, participants look at their three-panel comics again, and talk about what kind of transitions they’ve used. 5. Participants are asked to retell their same stories from the first step of the exercise, but using completely different transitions. Once these are done, the group looks at them and discusses them, and usually discovers that changing the types of transitions is a way to discover different dimensions of a story, and to see the same incident in a quite different light.

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Getting Published Common Themes That Predict Success

After you’ve edited and crafted a reflective piece, you may wish to submit it for publication in a professional journal in your field. Over 50 literary and academic journals publish student reflections about their training and clinical work. Here are common themes/key ingredients identified for success in such pieces from a survey of 14 primary care journals that publish clinician reflections:

Question

Themes identified

Definition of reflective papers Tells a story Based on personal experience/personal opinion Purposes of reflective papers Inform/challenge Provide insight/meaning Instill empathy/foster understanding Stimulate reflection Entertain Present humanistic side of medicine Effective reflective papers – Writing style

Well-written, concise, focused, engaging, avoids jargon, from the heart, tells a good story

– Topic

Based on real doctor–patient interactions: topical, relevant to readership, addresses important issues

– Reader response

Increased self-awareness, insight, empathy, appreciation for multiple perspectives, emotional connection with story (Continued)

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Question

Themes identified

Poor reflective papers – Writing style

Poorly written, poor English, rambling, unclear, dull, trite, cranky, poorly told story

– Topic

Not credible, doesn’t add any new ideas, not fresh or novel, trivial topic, use of patient’s story without consent, too specialized

– Reader response

Moralistic, judgmental, simplistic, author doesn’t reveal enough to engage reader, doesn’t share personal connection, impact of story?

Results: Mean Ratings of Attributes of Reflective Papers Survey question: To what extent should a reflective paper:

Mean score*

Emotionally engage the reader?

4.3

Stimulate reflection in the reader?

4.17

Provide a lesson applicable to patient care or professional development?

4.0

Stimulate discussion with colleagues and/or use with learners?

3.83

* Likert scale 1–5 From Walling A, Shapiro J, Ast T. What Makes a Good Reflective Paper? Fam Med. 2013 Jan;45(1):7–12.

Next Steps as a Writer in Healthcare Who Wants to Get Published: Remain Accountable! If you have indeed crafted a reflective piece further and would like to submit a polished/reworked version for publication in a clinical journal, here are some guidelines on how to do so ethically and professionally, so as to avoid any breaches of confidentiality or a conflict-of-interest situation. Keep in mind that our clients and patients would simply not tell us certain things if they knew we would be writing and publishing the information. The encounter belongs to the person we are helping first, even though we are present and help construct it over time. Your professional responsibility must always trump your desire to pick up the pen! Nonetheless, there are ways you can write about encounters that remain

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confidential, respectful, and fully accountable. The following chapter provides guiding principles for assessing accountability in the stories we elicit, read, tell, write, and publish about the work we do as we all further develop this exciting field of reflective writing and narrative-based clinical care.

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Guidelines for Narrative Accountability When Writing or Publishing about Patients/Clients

Two Basic Rules 1. Ensure that the sharing of clinical stories should somehow lead to improved patient/client care (which implies reflection and action or behavioral change by the clinician). 2. Ensure that it furthers the goals of all health professions being held fully accountable to the individuals they serve.

Reflecting More Deeply Each of the accompanying questions is linked to two fundamental principles of narrative accountability. What’s going on for the clinician or student in this story? Intention: Why was this story written/published/read? To instruct or improve care (the fully accountable “gold standards” of narrative construction) or for personal reflection, “self-therapy,” career advancement, financial gain? Is the writer fully conscious of the message the writing delivers about work with patients and colleagues, or is the insight expressed limited or superficial? Are some physician narratives better left unshared on the page or in small group learning?

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Projection: How might the writer of this text have projected personal views, wishes, and beliefs onto the patient or client experience? How conscious is this process? Would the patient or client be surprised or hurt by this betrayal? What’s going on for the patient or client in this story? Consent: Could the patient or client in this narrative have provided fully informed, unhampered consent for the publication, posting, or sharing of this story? Why or why not? Power: How is the power relationship inherent to the providerpatient or provider-client contract reflected or not reflected in this story? Is the trust a patient or client has in the provider enhanced or obscured? Has this story been misappropriated or is its co-construction fully acknowledged? Is patient permission fully documented? Culture and community: Apart from the clinician-patient or provider-client dyad, under what pressure is this patient’s or client’s story with respect to gender, culture, community, race, socio-economic status? What are the unseen forces that shape what is told? Does the teller expect heroics on the part of the patient or client and resolution/restitution of the story? If the story is fictional, what cultural tropes inform its form and message? Perspective of time: Does the story convey that the account is a time-specific snapshot of a clinician’s or patient’s or client’s experience with illness and of their working relationship? Or does it “encase” what has happened as a permanent, limiting representation in which a patient’s or client’s growth and mastery are not acknowledged?

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What’s the impact of this narrative exchange? Relationship with the patient/client: How might the publication (or other sharing) of this story affect the working relationship with this patient or client? Will it help or hinder trust, or will it lead to boundary dissolution and complications in care? The profession: Has the writer of this text remained “professional,” as defined by his/her clinical discipline? Have they used respectful language and tone, and a competent style? If a provider-patient or provider-client (or collegial) conflict is being presented or humor is being used, has it been done in a respectful fashion? Is the health profession being called to account? On the other hand, are “problematic narratives” being systematically screened out or not published? What message is the author sending about the work a healer does? Change: Is this story an act of self-placation or self-congratulation for the writer? Is it a vehicle for personal reflection without keeping the needs of the patient or client in mind? Or is it a call to action for improved care, social responsibility, and professional accountability to individuals and their communities? On documenting permission: Review the policies on obtaining permission to write about a patient or client in the journal in which you hope to publish your piece. Most will require that you document written permission from the patient (or a family member) and that they have had a chance to read/discuss the submission. Some journals like the CMAJ insist that any published writing about a real patient becomes a part of their official medical chart.

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Finding Publishing Opportunities

The field of narrative reflection in healthcare continues to burgeon worldwide. Proof of this is the sheer number of literary and academic clinical journals that publish student and clinician narratives/reflections about their work. A partial list follows. If you don’t find your own discipline’s professional journal here, check their website for submission guidelines. (New humanities/literary sections are cropping up all the time.) Write to them and suggest a new section of practitioner stories and reflections if there isn’t one already!

Journals Accepting Clinician Reflections and Creative Writing Here is a list of journals which publish reflective and creative pieces by students and clinicians from multiple clinical disciplines. The genres published include personal reflections and narratives, case reports, fiction, poetry, creative non-fiction, memoir, journalistic and opinion pieces, and artwork; some hold contests for student writers. Check journal websites for current submission guidelines (some limit submissions to local students, faculty, or staff), publication deadlines, and editorial staff. • Abaton: https://www.dmu.edu/abaton – Des Moines University’s student-produced literary journal; publishes poetry, essays, art, and photography that explores aspects of healthcare that often elude academic disciplines. Annually awards the Selzer Prize to one

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student (from any institution) for an outstanding submission of literary writing about the field of medicine • Academic Medicine: www.academicmedicine.org – The journal’s Medicine and the Arts (MATA) column runs on two facing pages; the left-hand page features an excerpt from literature, a poem, a photograph, etc. Literature excerpts generally run no more than 700 words and may include a brief introduction as needed. On the right-hand page is a commentary of about 900 words that explores the relevance of the artwork to the teaching and/or practice of medicine. • AMA Journal of Ethics: http://journalofethics.ama-assn.org/ – Formerly known as Virtual Mentor, the AMA Journal of Ethics publishes articles on medical education, literature, medicine and society, and history of medicine as well as first-person medical narratives and other pieces that explore bioethics in different ways. The journal is home to the John Conley Ethics Essay Contest for medical students. • American Family Physician: http://www.aafp.org/journals/ afp.html • American Journal of Hospice & Palliative Medicine: http://ajh .sagepub.com. – Publishes poetry. • American Journal of Kidney Disease: http://www.journals elsevier.com/american-journal-of-kidney-diseases – “In a Few Words” section features creative nonfiction that gives voice to the personal experiences and stories that define kidney disease. • American Journal of Medical Genetics: http://onlinelibrary.wiley .com/journal/10.1002/(ISSN)1096-8628 – “Frameshifts,” a narrative medicine column, features articles, poetry, and creative nonfiction by patients, parents (caregivers), and physicians (healthcare providers)

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• American Journal of Nursing: http://journals.lww.com/ajnonline/ pages/default.aspx – Welcomes submissions by nurses of narratives, commentaries, photography, artwork, and poetry. • American Nurse Today: http://www.americannursetoday.com – Accepts nonfiction narrative and poetry by nurses • Anesthesiology: http://anesthesiology.pubs.asahq.org/journal .aspx – “Mind to Mind” section publishes poems, essays, and humor that creatively reflect unique perspectives on our public work and our private lives. • Annals of Internal Medicine: http://annals.org/ – Publishes narrative nonfiction pieces from the physician’s perspective (“On Being a Doctor”) and patient’s (“On Being a Patient”). Also accepts photography for the cover (“Personae”), history of medicine pieces, and poetry. • Ars Medica: www.ars-medica.ca – A biannual literary journal that explores the interface between the arts and healing, and examines what makes medicine an art. Its content includes narratives from patients and healthcare workers, medical history, fiction, creative nonfiction, poetry, and visual art. • Atrium: www.bioethics.northwestern.edu/atrium/index .html – Published annually by Northwestern University’s Center for Bioethics and Medical Humanities, each issue focuses on a different theme related to these disciplines, with each contributor exploring the theme in different, thought-provoking ways. • Bellevue Literary Review: http://blr.med.nyu.edu – A literary magazine that examines human existence through the prism of health and healing, illness and disease. Each issue is filled with high-quality, easily

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accessible poetry, short stories, and essays that appeal to a wide audience of readers. • Blood and Thunder (University of Oklahoma, College of Medicine): http://www.ouhsc.edu/bloodandthunder – Publishes healthcare-related literary and artistic works • Cambridge Quarterly of Healthcare Ethics (CQ): http://journals .cambridge.org/action/displayJournal?jid=CQH – The new “Voices of Illness” section features original work on pathographies – i.e., (auto)biographical accounts of disease, illness, and disability – that provides narrative inquiry relating to the personal, existential, psychological, social, cultural, spiritual, political, and moral meanings of individual experience. Analysis of various genres (e.g., memoir, biography, short story, novel, poetry, film) is welcome, as are various perspectives (e.g., patient, healthcare professional, family member, advocate) and disciplinary orientations (e.g., philosophical, psychological, literary, sociological, and theological). • Canadian Family Physician: http://www.cfpc.ca/Canadian FamilyPhysician • Canadian Medical Association Journal: http://www.cmaj.ca/ – The Humanities section includes discussions on medicine and society, profiles of biomedical and health practitioners, and narratives written by patients and health practitioners reflecting on their experiences of illness or medicine. • Connective Tissue: http://texashumanities.org/connective_ tissue – Publishes creative writing and personal reflections by University of Texas–Galveston med students • Daedalus (Journal of the American Academy of Arts & Sciences): https://www.amacad.org/

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– Contributors are fellows of the American Academy of Arts & Sciences. Each issue addresses a theme with original, authoritative essays on a current topic like happiness, human nature, and imperialism. • The Examined Life Journal: http://theexaminedlifejournal .blogspot.com – A literary journal of the University of Iowa Carver College of Medicine. They accept fiction, poetry, and non-fiction. • International Journal of the Creative Arts in Interdisciplinary Practice (IJCAIP): http://www.ijcaip.com – An international and interdisciplinary peer-reviewed open-access journal which publishes information, research, and knowledge about the creative arts in health and interdisciplinary practice • Family Medicine: http://www.stfm.org/NewsJournals/ FamilyMedicine – Publishes narrative essays, including stories or poems from clinical practice or educational settings • Gold – Hope Tang, MD Humanism in Medicine Essay Contest: http://www.gold-foundation.org/programs/ student-opportunities/essay-contest/ • The Healing Muse: http://www.upstate.edu/bioethics/ thehealingmuse – The annual journal of literary and visual art published by the SUNY Upstate Medical University’s Center for Bioethics and Humanities. It welcomes fiction, poetry, narratives, essays, memoirs, and visual art, particularly but not exclusively focusing on themes of medicine, illness, disability, and healing. • Health Affairs: http://www.healthaffairs.org – “Narrative Matters” presents first-person accounts that connect to policy.

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• Hektoen International: A Journal of Medical Humanities: http:// www.hektoeninternational.org – An online humanities journal that publishes illustrations, photography, narrative fiction and non-fiction, essays, and scholarly articles. Runs the Hektoen Grand Prix Essay Competition. • Hospital Drive: https://news.med.virginia.edu/hospitaldrive/ – Online literary and humanities journal of the University of Virginia School of Medicine. Publishes original literature and art on themes of health, illness, and healing. Poems, short fiction, essays, visual arts, and audio and video art are considered. • The Human Factor (University of Missouri–Kansas City Medical School): http://med.umkc.edu – Publishes visual and textual reflections on healthcare. • Human Pathology: http://www.humanpathol.com – Features essays, narratives, and poetry on the humanistic aspects of medicine. • Inside Stories: http://in-training.org/inside-stories – An oral narratives project which invites medical students to share their experiences in medical school in the form of brief podcasts published and archived on in-Training. • Intima: A Journal of Narrative Medicine: www.theintima.org – Online literary journal dedicated to promoting the theory and practice of Narrative Medicine • IRIS: https://www.med.unc.edu/iris – University of North Carolina School of Medicine Art and Literary Journal • JAMA: http://jama.jamanetwork.com/journal.aspx – Publishes “A Piece of My Mind” essays – personal vignettes (i.e., exploring the dynamics of the patient-physician relationship) taken from wide-ranging experiences in medicine;

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occasional pieces express views and opinions on the myriad issues that affect the profession. • Journal for Learning through the Arts (JLTA): http:// escholarship.org/uc/class_lta – An online journal published by e-Scholarship University of California. While its focus is primarily on use of the arts in K–12 education, it includes a regular section on Literature and the Arts in Medical Education, with 1–2 articles • Journal of General Internal Medicine (JGIM): http://www .jgim.org/ – The journal’s “Text and Context” feature consists of excerpts from literature (novels, short stories, poetry, plays, or creative non-fiction) of 200–800 words and an accompanying essay of up to 1000 words discussing the meaning of the work and linking it to the clinical or medical education literature. • Journal of Medical Humanities: www.springer.com/journal/ 10912 • The Lancet: http://www.thelancet.com/journals/lancet/ issue/current – Holds the annual Wakley Prize for an essay on the topic of health and healthcare. Submissions are usually due by October. • leaflet: http://leaflet.thepermanentepress.org/ • Literature and Medicine: https://www.press.jhu.edu/journals/ literature_and_medicine/ • The Lumen: https://issuu.com/thelumen – Welcomes submissions of new prose, poetry, and art from healthcare professionals, patients, students of all healthcare professions, and writers of all disciplines and backgrounds. Error! Hyperlink reference not valid.

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• Medical Education: http://onlinelibrary.wiley.com/journal/ 10.1111/(ISSN)1365-2923 • Medical Encounter: http://www.aachonline.org/dnn/ Resources/Medical-Encounter – A publication of the American Academy on Communication in Healthcare, it accepts poetry, essays, etc. about doctors and patients. • Medical Humanities: www.mh.bmj.com/ • The Medical Muse (University of New Mexico): http://hsc.unm .edu/medmuse • Michael E. DeBakey Medical Student Poetry Awards: https:// www.bcm.edu/news/awards-honors-college/13th-annualdebakey-student-poetry-awards – Only original poetry (one poem, not to exceed two pages) on a medical subject and by undergraduates currently enrolled in accredited United States medical schools is eligible. Annual. • Narrative Inquiry in Bioethics: A Journal of Qualitative Research: https://www.press.jhu.edu/journals/narrative_inquiry_ in_bioethics/ – Narrative symposia may be invited or proposals may be submitted for review. Symposia will consist of six or more personal stories with two commentary articles. • New England Journal of Medicine: http://www.nejm.org/ – “Perspective” section features pieces on the intersection of medicine and society; NEJM also publishes photographs. • The New Physician: http://www.amsa.org/publications/ the-new-physician/ – Bi-monthly magazine of the American Medical Student Association. Publishes original peer-reviewed articles from across the United States and around the world, as well as artwork and reflection

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• Patient Education and Counseling: http://www.pec-journal.com/ – The “Reflective Practice” section includes papers about personal or professional experiences that provide a lesson applicable to caring, humanism, and relationship in healthcare. • The Perch (Yale School of Medicine): http://medicine.yale. edu/psychiatry/prch/the_perch/index.aspx – Online arts and literary magazine, a publication of the Yale University Program for Recovery and Community Health (PRCH); aims to present a wide range of voices on mental health and recovery – both from established writers and from new, emerging authors and artists. • Perspectives in Biology and Medicine: https://www.press.jhu .edu/journals/perspectives_in_biology_and_medicine/ • The Pharos: http://www.alphaomegaalpha.org/the_pharos .html – This quarterly journal publishes scholarly essays of Alpha Omega Alpha society members, covering a wide array of nontechnical medical subjects, including medical history, ethics, and medical-related literature, art, ethics, economics, health policy, and profiles of prominent persons. It also publishes scholarly nonfiction on a medical subject, poetry and poetry/photography combinations, and personal essays. • Philosophy, Ethics, and Humanities in Medicine: www.peh-med .com • Plexus (UC Irvine): http://www.uciplexus.com • Pulse: Voices from the Heart of Medicine: www.pulsevoices.org – One narrative, essay, or poem telling a personal story of healthcare is delivered to each subscriber’s inbox each Friday. • Reflexions (Columbia University): http://psclub.columbia .edu/clubs-organizations/reflexions

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• Touch: The Journal of Healing: http://thelivesyoutouch.com/ touchjournal/Home/ – Accepts poetry, prose, artwork/graphics related to health, healing, and spirituality and gender issues • Veritas, University of Virginia School of Medicine: https:// med.virginia.edu/biomedical-ethics/resources/publications/ veritas/ • Voices in Bioethics: http://voicesinbioethics.org • Wild Onions: http://www2.med.psu.edu/humanities/ wild-onions – Annual publication funded by The Doctors Kienle Center for Humanistic Medicine, Pennsylvania State University College of Medicine. A journal of poetry, prose, and visual art. List of journals used and updated with permission of Rebecca Garden, PhD, SUNY.

36

A Few Words on Blogging and Social Media

One way students may process and record a learning experience, and then share it, is by blogging. Following are the blog moderation guidelines we use for our student-run health humanities blog at the University of Toronto, called ArtBeat (www.utmedhumanities.wordpress.com).

ARTBEAT The University of Toronto UGME Arts and Humanities Blog The purpose for this moderated blog is to promote a safe environment for creative expression and a respectful exchange of ideas in our learning communities about medical training and the role of the arts and health humanities in improving the care of patients and their families. For comprehensive details, please refer to policies listed under the “Appropriate Use of Information and Communication Technology” at the University of Toronto Office of the Vice-President and Provost website, http://www.provost.utoronto.ca/policy/use.htm. In summary, the following aspects of these policies govern the moderation of blogs:

The University of Toronto is committed to maintaining respect for the core values of freedom of speech, academic freedom, and freedom of research. In matters of freedom

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of speech versus responsible speech, it should be noted that speech using information and communications technology (ICT) is not intrinsically different from speech that does not use ICT. While the University does not censor information on its networks and servers, it will act on allegations about the distribution of unlawful material, about the use of its information technology to direct abusive, threatening or harassing communication at any individual or about any other inappropriate use. When exercising free speech using the University’s ICT resources, such as when posting information to a publicly accessible file or web page, personal opinions must be identified as such, so that the reader understands the author is not speaking for the University. However, simply identifying an opinion as personal does not exempt it from the constraints of the law or the University’s policies and codes.

In addition, the following blog guidelines may be useful for moderators (from the BBC’s moderation guidelines for blogs): 1. Each commentator must log in with a unique name, and post as an individual Names may be failed if they … • Contain website or email addresses • Contain contact information (i.e., phone numbers, zip/ postal codes, etc.) • Appear to impersonate someone else • Contain swear words or are otherwise objectionable 2. Comments provided by individuals on blogs may be failed (or removed) for the following reasons: • Are considered likely to disrupt, provoke, attack, or offend others; statements considered threatening or abusive will not be tolerated

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• Are racist, sexist, homophobic, sexually explicit, abusive, or otherwise objectionable • Contain slander or libel (malicious or false claims about corporations or individuals) • Contain swear words or other language likely to offend • Break the law or condone or encourage unlawful activity. This includes breach of copyright, defamation, and contempt of court. • Advertise products or services for profit or gain • Are seen to impersonate someone else • Include contact details such as phone numbers, postal, or email addresses • Contain links to other websites which break our Editorial Guidelines • Describe or encourage activities which could endanger the safety or well-being of others • Are considered to be “spam,” that is posts containing the same, or similar, content posted multiple times • Are considered to be off-topic for the blog discussion

And, here are some additional guidelines from the Canadian Medical Association about the use of social media, in general. They are written primarily for doctors, but are applicable to all health professions. Check your own faculty/professional college website for rules about using social media ethically and appropriately.

Rules of engagement • Understand the technology and your audience. • The many social media platforms work in different ways and often have different goals. Even broad types of social media, such as social networking sites, have different terms and

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conditions under which they operate. Some social networking sites, for example Facebook, are intended for use by everyone, but you set your own network of people you know. Others, like Twitter, are designed for interacting with people you might not know at all. And others still, such as Asklepios, are intended for peer-to-peer interaction between Canadian physicians only. In order to use social media effectively, it is necessary to have a good understanding of how they work and who your intended audience will be before using them.

Be transparent • Identify clearly who you are and any potential conflicts of interest you may have in association with information you are providing. Being transparent encourages more honest interaction with others and a more productive outcome. If you are discussing medical or health issues, it is probably beneficial to identify yourself as a physician/ health professional. If you are employed by an institution or organization, you should state either that you are reflecting corporate policies or that the views expressed are yours alone and not those of your employer. • When participating on a social network site such as Facebook that may include patients/clients in your practice, you should avoid communicating personal or private information. It is possible to establish a professional page where you can post information about your practice and general health information and links.

Respect others • If you are posting information created by somebody else, proper permission should be obtained and acknowledgment

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given. Most social media sites have their own sets of rules, guidelines, and etiquette, and these should be followed. If uncertain of how a specific site operates, spend more time listening and reading prior to engaging in active dialogue. Always respect the principle of patient confidentiality.

Focus on areas of expertise • As a health professional you can often bring most value to a forum or conversation by discussion issues on which you have a particular expertise. Sharing this information – as long as it does not contravene individual patient confidentiality – raises the level of discourse on social media sites and is likely to be viewed favorably by other participants. • You should anticipate that the information you provide on social media may be challenged by both other physicians and non-physicians. Remember to keep the tenor of the debate at a civilized level and do not be unnecessarily offended if your viewpoint is rejected, even if you do feel it is based on best available evidence. • If you choose to use your website to communicate to a non-medical audience about medical or health issues, you should include a terms of use agreement to advise users that information is intended for local residents and that individual health queries will not be addressed. Source: www.cma.ca/En/Pages/social-media-use.asp

37

Other Writing and Healing References

I am grateful to the following authors for deepening my understanding of reflective writing and how portfolios work. Many of the prompts in this book were inspired by their articles and books. Please let us know if we have inadvertently missed any original sources or attributions. Albert SW. Writing from life: telling your soul’s story. New York: Tarcher; 1996. Anderson C, editor. Writing & healing toward an informed practice. Urbana: NCTE; 2000. Aronie NS. Writing from the heart: tapping the power of your inner voice. New York: Hyperion; 1998. Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2010;33(3):200–5. http://dx.doi.org/10.3109/0142159X .2010.507714 Medline:20874014 Aukes LC, Geertsma J, Cohen-Schotanus J, et al. The development of a scale to measure personal reflection in medical practice and education. Med Teach. 2007;29(2–3):177–82. http://dx.doi.org/10.1080/01421590701299272 Medline:17701630 Bennett HZ. Write from the heart: unleashing the power of your creativity. 2nd rev. ed. Novato, CA: New World; 2001. Bolton G, editor. Writing cures: an introductory handbook of writing in counselling & therapy. New York: Brunner Routledge; 2004. Boud D, Keogh R, Walker D, editors. Reflection: turning experience into learning. London: Kogan Page; 1985. Brady DW, Corbie-Smith G, Branch WT. “What’s important to you?” The use of narratives to promote self-reflection and to understand the experiences of medical residents. Ann Intern Med. 2002;137(3):220–3. http://dx.doi .org/10.7326/0003-4819-137-3-200208060-00025 Medline:12160380

Other Writing and Healing References

173

Branch WT Jr. The road to professionalism: reflective practice and reflective learning. Patient Educ Couns. 2010;80(3):327–32. http://dx.doi.org/ 10.1016/j.pec.2010.04.022 Medline:20570461 Bronson P and San Francisco Writers’ Grotto. 642 things to write about. San Francisco: Chronicle Books; 2011. Buckley S, Coleman J, Davidson I, et al. The educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Med Teach. 2009;31(4):282–98. http://dx.doi.org/10.1080/01421590902889897 Medline:19404891 Cameron J. The artist’s way: a spiritual path to higher creativity. New York: Tarcher; 1992. Chabon S, Lee-Wilkerson D. Use of journal writing in the assessment of CSD students’ learning about diversity. Comm Disord Q. 2006;27(3):146–58. http://dx.doi.org/10.1177/15257401060270030301. Charon R. Narrative medicine: honoring the stories of illness. Oxford, UK, New York: Oxford University Press; 2006. Charon R. Narrative and medicine. N Engl J Med. 2004;350(9):862–4. http:// dx.doi.org/10.1056/NEJMp038249 Medline:14985483 Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897–902. http://dx.doi.org/10.1001/ jama.286.15.1897 Medline:11597295 Charon R . Reading, writing, and doctoring: literature and medicine. Am J Med Sci. 2000;319(5):285–91. http://dx.doi.org/10.1016/S0002 -9629(15)40754-2 Medline:10830551 Chretien KC, Chheda SG, Torre D, et al. Reflective writing in the internal medicine clerkship: a national survey of clerkship directors in internal medicine. Teach Learn Med. 2012;24(1):42–8. http://dx.doi.org/10.1080/ 10401334.2012.641486 Medline:22250935 Colbert CY, Ownby AR, Butler PM. A review of portfolio use in residency programs and considerations before implementation. Teach Learn Med. 2008;20(4):340–5. http://dx.doi.org/10.1080/10401330802384912 Medline:18855239 Crawley J. At the deep end. a survival guide for teachers in post-compulsory education. Abingdon, UK: David Fulton Publishers; 2005. Cruess SR, Cruess RL, Steinert Y. Role modeling – making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718–21. http://dx.doi .org/10.1136/bmj.39503.757847.BE Medline:18369229 Daniel L. How to write your own life story. 3rd ed. Chicago: Chicago Review Press; 1991.

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Denzin NK, Lincoln YS. Introduction: entering the field of qualitative research. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. Thousand Oaks, CA: Sage; 1994. p. 1–17. DeSalvo L. Writing as a way of healing: How telling our stories transforms our lives. Boston: Beacon Press; 2000. Driessen E, Tartwijk J, Dornan T. The self critical doctor: helping students become more reflective. BMJ. 2008;336(7648):827–30. http://dx.doi.org/ 10.1136/bmj.39503.608032.AD Medline:18403547 Driessen E, van Tartwijk J, van der Vleuten C, et al. Portfolios in medical education: why do they meet with mixed success? A systematic review. Med Educ. 2007;41(12):1224–33. http://dx.doi.org/10.1111/j.1365-2923 .2007.02944.x Medline:18045373 Dunfee H, Rindflesh A, Driscoll M, et al. Assessing reflection and higher-order thinking in the clinical setting using electronic discussion threads. J Phys Ther Educ. 2008;22(2):60–7. Epstein RM. Reflection, perception and the acquisition of wisdom. Med Educ. 2008;42(11):1048–50.http://dx.doi.org/10.1111/j.1365-2923.2008.03181.x Medline:19141004 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–35. http://dx.doi.org/10.1001/jama.287.2.226 Medline:11779266 Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 Suppl):S46–54. Medline:16199457 Farmer P. An anthropology of structural violence. Curr Anthropol. 2004;45(3):305–25. http://dx.doi.org/10.1086/382250. Fidler D, Trumbull D, Ballon B, et al. Vignettes for teaching psychiatry with the arts. Acad Psychiatry. 2011;35(5):293–7. http://dx.doi.org/10.1176/appi. ap.35.5.293 Medline:22007084 Files M. Writing from life: turning your experience into compelling stories. Cincinnati: Writer & Digest Books; 2002. Fox J. Finding what you didn’t lose: expressing your truth and creativity through poem-making. New York: Putnam; 1995. Geller E, Foley GM. Expanding the “ports of entry” for speech-language pathologists: a relational and reflective model for clinical practice. Am J Speech Lang Pathol. 2009;18(1):4–21. http://dx.doi.org/10.1044/1058-0360 (2008/07-0054) Medline:18845696 Gibbs T, Durning S, Van Der Vleuten C. Theories in medical education: towards creating a union between educational practice and research traditions. Med Teach. 2011;33(3):183–7. http://dx.doi.org/10.3109/0142159X.2011.551680 Medline:21345058

Other Writing and Healing References

175

Gofton W, Regehr G. What we don’t know we are teaching: unveiling the hidden curriculum. Clin Orthop Relat Res. 2006;449:20–7. http://dx.doi .org/10.1097/01.blo.0000224024.96034.b2 Medline:16735868 Greenlagh T, Hurwitz B. Narrative based medicine. London, UK: BMJ Books; 1986. Guillemin M, McDougall R, Gillam L. Developing “ethical mindfulness” in continuing professional development in healthcare: use of a personal narrative approach. Camb Q Healthc Ethics. 2009;18(2):197–208. http://dx.doi. org/10.1017/S096318010909032X Medline:19250570 Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403–7. http://dx.doi.org/10.1097/ 00001888-199804000-00013 Medline:9580717 Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Educ Couns. 2004;54(3):251–3. http://dx.doi.org/10.1016/ S0738-3991(04)00237-X Medline:15481124 Hill AE, Davidson BJ, Theodoros DG. Reflections on clinical learning in novice speech-language therapy students. Int J Lang Commun Disord. 2012;47(4):413–26. http://dx.doi.org/10.1111/j.1460-6984.2012.00154.x Medline:22788227 Huddle TS, and the Accreditation Council for Graduate Medical Education (ACGME). Viewpoint. Teaching professionalism: is medical morality a competency? Acad Med. 2005;80(10):885–91. http://dx.doi.org/10.1097/ 00001888-200510000-00002 Medline:16186603 Kember D, Leung, Jones A, et al. Development of a Questionnaire to Measure the Level of Reflective Thinking. Assess Eval High Educ. 2000;25(4):381–95. http://dx.doi.org/10.1080/713611442. Kennison MM, Misselwitz S. Evaluating reflective writing for appropriateness, fairness, and consistency. Nurs Educ Perspect. 2002;23(5):238–42. Medline:12483814 Kind T, Everett VR, Ottolini M. Learning to connect: students’ reflections on doctor–patient interactions. Patient Educ Couns. 2009;75(2):149–54. http:// dx.doi.org/10.1016/j.pec.2008.09.011 Medline:19013048 Klauses HA. With pen in hand: the healing power of writing. Cambridge, MA: Perseus Publishing; 2003. Kumagai AK. A conceptual framework for the use of illness narratives in medical education. Acad Med. 2008;83(7):653–8. http://dx.doi.org/10.1097/ ACM.0b013e3181782e17 Medline:18580082 Learman LA, Autry AM, O’Sullivan P. Reliability and validity of reflection exercises for obstetrics and gynecology residents. Am J Obstet Gynecol. 2008;198(4):461.e1–e10. http://dx.doi.org/10.1016/j.ajog.2007.12.021 Medline:18395041

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Lepore S, Smyth JM., eds. The writing cure: how expressive writing promotes emotional health and wellbeing. Washington, DC: APA Press; 2002. http:// dx.doi.org/10.1037/10451-000. Levine RB, Kern DE, Wright SM. The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ Theory Pract. 2008;13(5):723–33. http://dx.doi.org/10.1007/s10459 -007-9079-x Medline:17899421 MacCurdy M. From trauma to writing: a theoretical model for practical use. In: Anderson CM and MacCurdy M. Writing and healing: towards an informed practice. Urbana, IL: National Council of Teachers of English; 2000. Mamede S, Schmidt HG, Penaforte JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ. 2008;42(5):468–75. http://dx.doi .org/10.1111/j.1365-2923.2008.03030.x Medline:18412886 Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009;14(4):595–621.http://dx.doi.org/10.1007/s10459-007-9090-2 Medline:18034364 Martin D, McKneally M. Qualitative research. In: Troidl H, Spitzer W, McKneally M, et al., editors. Principles and practice of research: strategies for surgeon investigators. New York: Springer; 1988. p. 235–41. Mezirow J. Transformative dimensions of adult learning. San Francisco: Jossey-Bass; 1991. Pennebaker J. Words that heal. Enumclaw, WA: Idyll Arbor; 2014. Pennebaker JW. Telling stories: the health benefits of narrative. Lit Med. 2000;19(1):3–18. http://dx.doi.org/10.1353/lm.2000.0011 Medline: 10824309 Peterkin A. Medical humanities for what ails us. CMAJ. 2008;178(5):648. http://dx.doi.org/10.1503/cmaj.071851 Medline:18299558 Peterkin A. Narrative competence psychotherapy for people with HIV. Focus: A Guide to HIV Research and Counseling (USCF). 2006;21(2). Peterkin A. Practical strategies for practising narrative-based medicine. Can Fam Physician. 2012;58(1):63–4. Medline:22267625 Peterkin A. Primum non nocere: on accountability in narrative-based medicine. Lit Med. 2011;29(2):396–411. http://dx.doi.org/10.1353/lm.2011.0322 Medline:22428372 Peterkin A. Staying human during residency training: how to survive and thrive after medical school. 6th ed., fully revised. Toronto: University of Toronto Press; 2016. Peterkin A. Therapeutic writing for people living with HIV. Lapidus Quarterly. 2007;Autumn.

Other Writing and Healing References

177

Peterkin A. White coat ceremonies: not so white (or black)? Atrium: Report of the Northwestern Medical Humanities and Bioethics Program. 2011;9(Spring). Peterkin A. Why we write (and how we can do it better). CMAJ. 2010;182(15):1650–2. http://dx.doi.org/10.1503/cmaj.101329. Peterkin A, Benigno T. Revisiting written submissions as part of the medical school application: paying attention to narrative competence in admissions policies. Intima, A journal of narrative medicine. 2013;Spring. Peterkin A, Esplen, MJ, Hann J. A pilot study of a narrative competence group to enhance coping and quality of life in patients with HIV. Arts & Health: An International Journal. 2013;5(1):5–18. http://dx.doi.org/10.1080/175330 15.2012.693513. Peterkin A, Hann J. Still here: a post-cocktail AIDS anthology. Toronto: Life Rattle Press; 2008. Peterkin AD, Prettyman AA. Finding a voice: revisiting the history of therapeutic writing. Med Humanit. 2009;35(2):80–8.http://dx.doi.org/10.1136/ jmh.2009.001636 Medline:23674701 Peterkin A, Roberts M, Kavanagh L, Havey, J. Narrative means to professional ends: new strategies for teaching CanMEDS roles in Canadian medical schools. Can Fam Physician. 2012;58(10):e563–9. Medline:23064935 Plack MM, Driscoll M, Blissett S, et al. A method for assessing reflective journal writing. J Allied Health. 2005;34(4):199–208. Medline:16529182 Plack M, Dunfee H, Rindflesh A, Driscoll M. Virtual Action Learning Sets: a model for facilitating reflection in the clinical setting. J Phys Ther Educ. 2008;22(3):33–42. Plack MM, Greenberg L. The reflective practitioner: reaching for excellence in practice. Pediatrics. 2005;116(6):1546–52.http://dx.doi.org/10.1542/ peds.2005-0209 Medline:16322184 Pollard A. Reflective teaching. 2nd ed. London, UK: Continuum; 2005. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42–5. http://dx.doi.org/10.1136/bmj.311.6996.42 Medline:7613329 Regehr G, Hodges B, Tiberius R, et al. Measuring self-assessment skills: an innovative relative ranking model. Acad Med. 1996;71(10 Suppl):S52–4. http://dx.doi.org/10.1097/00001888-199610000-00043 Medline:8940934 Reis S. 2008. Personal communication. Reis SP, Wald HS, Monroe AD. Begin the BEGAN (The Brown educational guide to the analysis of narrative) – a framework for enhancing educational impact of faculty feedback to students’ reflective writing. Patient Educ

178

Portfolio to Go

Couns. 2010;80(2):253–9.http://dx.doi.org/10.1016/j.pec.2009.11.014 Medline:20056370 Sandars J. The use of reflection in medical education. AMEE Guide no. 44. Med Teach. 2009;31(8):685–95.http://dx.doi.org/10.1080/01421590903050374 Medline:19811204 Schön D. The reflective practitioner: how professionals think in action. New York, NY: Basic Books Inc; 1983. Slavin S, Galanti GA, Kuo A. The 4 C’s of culture: a mnemonic for health care professionals. Available at http://gagalanti.com/articles/The4CsofCulture.pdf Smedley AM. Becoming and being a preceptor: a phenomenological study. J Contin Educ Nurs. 2008;39(4):185–91.http://dx.doi.org/10.3928/0022012420080401-08 Medline:18429373 Stern DT, Papadakis M. The developing physician – becoming a professional. N Engl J Med. 2006;355(17):1794–9.http://dx.doi.org/10.1056/NEJMra054783 Medline:17065641 Wald HS, Davis SW, Reis SP, et al. Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med. 2009;84(7):830–7. http://dx.doi.org/10.1097/ ACM.0b013e3181a8592f Medline:19550172 Wald HS, Reis SP. Beyond the margins: reflective writing and development of reflective capacity in medical education. J Gen Intern Med. 2010;25(7): 746–9. http://dx.doi.org/10.1007/s11606-010-1347-4 Medline:20407840 Wright JG, McKeever P. Qualitative research: its role in clinical research. Annals R. Coll. Phys. Surg. Canada. 2000;33(5):275–80. Zugar A. Doctors who wield the pen to heal the profession. New York Times. 2007 May 15.