Qualitative Analysis of Family Medicine Residents’ Reflections about Global Aspects of Patient Care

*Learning to See Beneath the SurfaceAshley P. Duggan, PhD, Boston College

Allen Shaughnessy, PharmD, MMedEd, Tufts University School of Medicine, Cambridge Health Alliance

*Reflection in Medical Education*Writing prompts learners to revisit an experience with

the goal of gaining new perspectives and appreciations*Descriptions of events and goal setting gives light to

what draws the attention of the individual*Reflection may encourage deeper approach to learning*In medicine and medical education, a shift to integrated

care and to relationship-centered medicine*SHIFT assumes reciprocity in decisions, which means

different boundaries for information

*Written Reflections of Family Medicine Residents*Family medicine residents (33 residents) were

required to write a reflective entry three times a week for an academic year*Examined 756 private written reflections*Over 140,000 words of data

*Global health themes were systematically and inductively derived from the data

*Interdependence in Patient Roles and Culture*Included noticing how: • Patient roles and

relationships are interconnected to their cultures and international contexts of their everyday lives

“I wonder about this patient’s move from Haiti as connected to nutrition and obesity

and self-image and her connection with

others.”

*Attentiveness to Communication Indicative of Desires

Included better understanding communication for: • Comprehensive

partnership-building

• Relational processes

• Shared decision making

“She was in her 40s, kids grown up, trying to claw

her way out of deep depression. I wonder what

she put aside all those years she was parenting? How can I support these

women so they don't decompensate when it's

finally 'safe' to do so?

*Integrate Health Equity

*Included:• Presupposition that

underlying the formation of the physician is desire to understand and integrate health equity

“This was my first interpreter experience

and was not good. I realized ongoing

challenges that prevent patients from getting the right care, today

because of my limited questioning.”

*Attentiveness to Global Health Concerns*Included:

• Appreciation for opportunities for foster learning communities attentive to global health concerns and primary care innovation across disciplines.

“In understanding the community’s health

needs, I am surprised by teen pregnancy

rates, HIV/AIDS concurrent with suicide rates, and the lack of addressing needs.

*Implications of Reflection

• Connected physician communication to important outcomes

• Recognized potential to support patients beyond biomedical knowledge

Interdependence

• Attentive to patient emotion and aware of missed nonverbal cues

• Better equipped to acknowledge limits in what they see, and to see below the surface

Communication Indicative of Desires

• Moving from simple answers to multi-dimensional complexities that acknowledge competing tensions

Health Equity and Fostering Learning

*Visual Models (i.e. Float model)

*Balanced interconnectedness of organizational and cultural context of family medicine*Explicit and implicit points of communication *Competing realities of patient experiences with

physicians’ professional roles and responsibilities*Limitations

*Enhancing the Quality of Medical Education

Anthropological• Clinical interaction

is inseparable from the humanness of a physician

• Multiple dimensions of medical practice• On the surface

and beneath

Empowerment• Fosters physicians’

abilities to acknowledge strengths and limitations

• Must be addressed in constructive ways to benefit medical practice

*Thank You

*Suggests possibilities for --enhancing international communities for primary care, --facilitating primary care innovation, and --attending to higher-value models of social and health behavior change in global healthcare delivery.