Reflective Ability Rubric and User Guide

Patricia S. O’Sullivan, EdD

Professor of Medicine and Director of Educational
Research and Faculty Development
Office of Medical Education
School of Medicine
University of California, San Francisco
521 Parnassus Ave Box 0410
San Francisco, CA 94143-0410
(W) 415 514 2281
(F) 415 514 0468
patricia.osullivan@ucsf.edu

Louise Aronson, MD, MFA

Associate Professor of Medicine and Director, Northern
California Geriatric Education Center and UCSF Medical
Humanities Initiative
Division of Geriatrics
3333 California Street, Suite 380
San Francisco, CA 94118
(W) 415 514 3154
(F) 415 514 0702
louise.aronson@ucsf.edu

Eva Chittenden, MD
Assistant Professor of Medicine
Harvard Medical School and
Director of Educational Programs
Palliative Care Service
Massachusetts General Hospital
55 Fruit St. FND 600
Boston, MA 02114
(W) 617-7249197
(F)617-724-8693
echittenden@partners.org

Brian Niehaus, MD
Research Assistant
Office of Medical Education
School of Medicine
University of California, San Francisco
521 Parnassus Ave Box 0410
San Francisco, CA 94143-0410
(W) 415 514 2281
(F) 415 514 0468
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brian.niehaus@ucsf.edu

Lee A. Learman, MD, PhD

Clarence E. Ehrlich Professor & Chair
Department of Obstetrics and Gynecology
Indiana University School of Medicine
(W) 317-948-8609
(F) 317-948-7417
LLearman@IUPUI.EDU
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Table of Contents

1. Background........................................................................................................4

2. Development.......................................................................................................5

3. Psychometric Evidence......................................................................................7

4. Rater Training....................................................................................................8

5. References.........................................................................................................10

6. Appendix A: Reflective Ability Scoring Rubric.............................................12

7. Appendix B: Training Examples.....................................................................13

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1. Background

Over the last decade, numerous organizations (e.g. UK General Medical Council

(General Medical Council, October 23, 2009); CanMEDS (Frank JR, October 29, 2009);

ABIM (ABIM Foundation et al., 2002; ABIM Foundation); ACP-ASIM (ACP-ASIM

Foundation, & European Federation of Internal Medicine, 2002); ACGME (Accreditation

Council for Graduate Medical Education, 1999)) have called for incorporating reflection

and reflective activities into all levels of medical education. In response to this mandate,

educators and accrediting bodies have required trainees and practicing professionals to

complete reflective activities, most of which have taken the form of written exercises

such as critical incident reports, journals, or responses to structured questions (Wald,

Davis, Reis, Monroe, & Borkan, 2009). Reflection, the process of analyzing,

reconsidering and questioning experiences and of making an assessment for the purposes

of learning, is considered an essential skill for self-directed learning and professional

development. It transforms experience into education by helping practitioners identify

gaps in their knowledge and skills and by promoting critical reasoning, self-assessment,

problem-solving and professionalism (Boud & Walker, 1998; K. Mann, Gordon, &

Macleod, 2007). Recent studies suggest reflection may decrease diagnostic errors and

improve clinical performance in complex or uncertain situations (Mamede, Schmidt &

Penaforte, 2008). Studies of reflection in medical education generally focus on

identifying common themes or responding to content issues.

In order to develop and assess reflective competence in trainees and practicing

professionals, a valid measure of reflective skill is required. Few assessment methods

have been developed and those that have are often either qualitative, and hard to
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generalize (Wald et al., 2009), or cumbersome and requiring extensive rater training (Pee,

Woodman, Fry, & Davenport, 2002). Most have studied inter-rater reliability rather than

other validity evidence.

Our objective was to develop and provide psychometric evidence for a rubric that

could be used by others to describe the learner’s level of reflective ability as determined

from a written essay stimulated by a prompt. Prompts vary but generally provide a topic

or focus for the reflection, such as “a patient who taught you the most about treating a

patient with dignity and respect” or “Reflect on a recent clinical or other professional

situation where you made a mistake or didn’t have the necessary knowledge or skills.”

2. Development

The reflective ability scoring rubric was adapted from work done in the Centre for

Medical Education at the University of Dundee (MH Davis, personal communication),

where educators have developed a scoring schema for reflection when considering an

entire learning portfolio. In our case, we adapted their three level schema to a six point

rubric and applied it to individual reflections:

1. Describes procedure/case/setting without mention of lessons learned;

2. States opinions about lessons learned unsupported by examples;

3. Superficial justification of lessons learned citing only one’s own perspective;

4. Reasoned discussion well-supported with examples regarding challenges,

techniques and lessons learned and includes obtaining feedback from others or

other sources;

5. Analyzes the influence of past experience on current behavior; and

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6. Integrates all of the above to draw conclusions about learning, provides strategies

for the future learning or behavior and indicates evidence for determining

effectiveness of those strategies.

A score of zero was given when the exercise was turned in with no description of a

relevant learning event.

The items for the rubric reflect the components of reflection drawn from the

literature (Boud & Walker, 1998; Hatton & Smith, 1995; Mezirow, 1998; Moon, 2004;

Schön, 1983). The rubric is general but each higher level score assumes the level below.

Half point scores are allowed. While various types of rubrics can be developed to allow

the rating of independent elements, we have chosen a single dimension construct,

“reflective ability,” and have built our rubric following theoretical guidance. This

approach is one commonly used in rubric scoring and takes a holistic approach rather

than an analytic one. While the issue of scoring may merit an alternative approach, this

approach essentially requires incorporation of increasing number of elements as

demonstration of reflective ability rather than being rewarded for the ability to do several

aspects well but failing to address the full range of skills needed.

Our guiding principles included the following:

Guiding Principles and Definitions:

1. Focus on reflection: response goes beyond a detailed and colorful description of
the event itself
2. Holistic rubric: gestalt based on reading entire entry, and then matching
performance to scoring guidelines
3. Score given according to preponderance of reflection skill, and not just weak
evidence of a higher level of performance; scoring commensurate with “spirit” of the
level and not each specific detail
4. Score given for reflection on the action under consideration; saying that one
reflected during the experience not sufficient reflection
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5. "Reflection on action" defined as looking back upon performance to identify

lessons learned about own behavior
6. "Reflection in action" defined as mindfulness of the situation and responding in the
moment

The scoring rubric giving brief examples is provided in Appendix A.

3. Psychometric Evidence

We have done several studies generating psychometric evidence. Learman, Autry

and O’Sullivan (,Learman et al, 2007; Learman et al, 2008) provided validity evidence

using the rubric to study reflective ability in 32 OB/GYN residents. The residents

completed 6 exercises that were scored from 0 (no description of event) to 6 (deep

reflection) using the rubric. Residents completed 183 reflections. Inter-rater reliability with

two trained raters was 0.89. Five exercises had adequate internal consistency reliability as a

set (0.62); systems-based practice did not correlate with the other five. Senior residents

received higher reflection scores than junior residents; the magnitude of difference was not

statistically significant and was similar for other competency measures such as in-training

examination performance and ratings by medical students and nurses. Reflection scores

were correlated with professionalism and communication skill assessments (0.36-0.37,

p<0.01) but not with medical knowledge.

Aronson (Aronson, Robertson, Lindow, & O'Sullivan, 2009) studied third year

medical students who were given a prompt on professionalism about which they were to

write a reflection. The control group (n=37) received no further instruction and the

experimental group (n=78) received guidelines about reflection. The experimental group

scored significantly higher in reflective ability as measured by the rubric (3.6 (sd=1.2) vs
 8

2. (sd=0.8), p<.001, effect size = 1.25). Students with instruction should score higher and

the rubric detected this difference which is evidence of its validity.

Using generalizability theory in these studies we determined that we could

consistently obtain a reliability exceeding 0.85 with two raters using this rubric. In the

course of these analyses, we trained six different raters who scored in various

combinations for different studies, with a total of two or three raters in any one study.

Based on this evidence, we would anticipate that with two trained raters reliability would

remain above 0.8.

4. Rater Training

The training process requires several steps. Appendix A provides examples that

can be used to train raters. These reflections were generated from our experience with

actual examples and have been contrived for the purposes of providing these training

materials. First, the review team must have a discussion of the rubric. Review the guiding

principles and then each level. Discuss interpretations of each level and how one differs

from the preceding and succeeding level. As a group, the raters then discuss one of the

supplied examples and elaborate what score they would give and why and how that

compares to the decision provided along with the example. Continue this process until

there is comfort in applying the rubric. At that point, have raters rate five examples and

calculate the agreement with the provided scores. If agreement is less than .8, review and

discuss. The rater reliability can also be calculated using interclass correlation

coefficients or generalizability statistics. A reliability of at least 0.8 with two raters is

required. In our experience, this process is less successful if attempted as a single

training session than if spread over two in-person sessions, one to achieve comfort with
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the rubric and a second meeting a week or two later to address additional questions which

arise as raters score reflections independently. In general, no more than 15 examples are

needed to prepare raters to consistently use the rubric. It is also advisable initially to

calculate reliability at regular intervals (every 20 or 50 reflections) to assess for drift and

to create opportunities for raters to discuss any reflections they found particularly

challenging to score.
5. References

ABIM Foundation, ACP-ASIM Foundation, & European Federation of Internal

Medicine. (2002). Medical professionalism in the new millennium: A physician

charter. Obstetrics and Gynecology, 100(1), 170-172.

Accreditation Council for Graduate Medical Education. (1999). Outcomes project.

Available at http://www.acgme.org/outcome/Comp/compFull.asp.

Accessed 1/12/2010.

Aronson, L., Robertson, P., Lindow, J., & O'Sullivan, P. (2009). Guidelines for reflective

writing produce higher quality reflections. AAMC Research in Medical Education

presentation, AAMC annual meeting, November.

Boud, D., & Walker, D. (1998). Promoting reflection in professional courses: The

challenge of context. Studies in Higher Education, 23(2), 191-206.

Frank JR. (October 29, 2009). The CanMEDS 2005 physician competency framework.

General Medical Council. (October 23, 2009). Tomorrow’s doctors.

Hatton, N., & Smith, D. (1995). Reflection in teacher education: Towards definition and

implementation. Teaching and Teacher Education, 11(1), 33-49.

Learman LA, O’Sullivan P. Resident physicians’ ability to reflect. Chicago: American

Educational Research Association Annual Meeting, 2007. Contact: Lee Learman

llearman@iupui.edu

Learman LA, Autry AM, O'Sullivan P. (2008). Reliability and validity of reflection

exercises for obstetrics and gynecology residents. Am J Obstet Gynecol,198(4),

461.e1-8.
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Mamede S, Schmidt HG, Penaforte JC. (2008) Effects of reflective practice on the

accuracy of medical diagnoses. Medical Education, May;42(5):468-75

Mann, K., Gordon, J., & Macleod, A. (2007). Reflection and reflective practice in health

professions education: A systematic review. Advances in Health Sciences

Education : Theory and Practice, doi:10.1007/s10459-007-9090-2

Mann, K. V. (2008). Reflection: Understanding its influence on practice. Medical

Education, 42(5), 449-451. doi:10.1111/j.1365-2923.2008.03081.x

Mezirow, J. (1998). On critical reflection. Adult Education Quarterly, 48(3), 185-198.

Moon, J. A. (2004). A handbook of reflective and experiential learning : Theory and

practice. London; New York: RoutledgeFalmer.

Pee, B., Woodman, T., Fry, H., & Davenport, E. S. (2002). Appraising and assessing

reflection in students' writing on a structured worksheet. Medical Education, 36(6),

575-585.

Schön, D. A. (1983). The reflective practitioner : How professionals think in action. New

York: Basic Books.

Wald, H. S., Davis, S. W., Reis, S. P., Monroe, A. D., & Borkan, J. M. (2009). Reflecting

on reflections: Enhancement of medical education curriculum with structured field

notes and guided feedback. Academic Medicine : Journal of the Association of

American Medical Colleges, 84(7), 830-837. doi:10.1097/ACM.0b013e3181a8592f

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6. Appendix A: Reflective Ability Scoring Rubric

 7. Appendix B: Training Examples

The following pages provide 20 examples with scores ranging from 0 to 6. These

examples are derived from real examples. In selecting them, we have tried to preserve the

range of responses, approaches and writing styles (including errors) we encounter but

also to sufficiently modified them so they do not represent unique or identifiable

individuals or situations. While the boxed guidance for Rubric scores 0 and 1 mention

prompts, the prompts are not specified since this approach has been used with a wide

variety of prompts including “Select a clinical situation during this rotation that taught

you the most about demonstrating integrity, respect and responsiveness to the needs of

the patient above your own”, “Critically reflect on your community engagement

experience” and “Reflect on a recent clinical or other professional situation where you

made a mistake or didn’t have the necessary knowledge or skills.” Although these

examples are presented from lowest to highest scores, they should be chosen at random

for training purposes so as not to bias the scoring.

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Rubric Score 0

Applying the guiding principles and rubric, these examples scored ‘0’ since they did not
follow the prompt and/or talked in great generality about broad issues.

Example 1:
Note: I chose this as a topic to focus on, because I found a general “reflection” too
broad, and needed a way to focus my thoughts.
I do not underestimate the challenge of teaching medicine, and I appreciate how
hard it is to meet everyone’s individual needs, and to connect with people with such
different backgrounds and interests. I have found the third year of medical school in
regards to teaching and mentorship to be a huge disappointment.
For example, on my first clerkship I didn’t have continuity with any attending for
longer than two weeks. The only sort of continuity I had was with one resident for one
month. Given these brief periods of time, I don’t see how you can learn a field like
medicine that relies on an apprenticeship model, with this reality. Once you find a good
teacher you don’t get any time to establish a relationship with them
Now teaching is much different than mentorship. Having only two weeks with
someone does not allow you to establish this type of relationship either. Worse, even if a
structured mentorship program existed where I was assigned a mentor this would not be a
fair substitute. Mentorship cannot be forced or facilitated with any curriculum because it
has to be established by finding someone that is a good fit and let it evolve naturally. You
need a large milieu of people and adequate time.
Lastly, I am disappointed that so much of our education is based in the classroom
for the first two years. Most of what I have learned this year has been either from
patients, or a good clinician who can teach at the bedside. You cannot recreate those
experiences in a lecture hall with a forced cased-based PowerPoint presentation. I
wonder why we cannot get the clinical experiences much early on, and this troubles me.

Discussion: This reflection earned a ‘0’ because instead of focusing on a single clinical
experience that had an emotional impact on the learner as the prompt outlined, the
student decided to talk about third year of medical school in general. That alone would
give it a zero, but it also is unclear whether the student learned anything from the
exercise. It seems more likely that this is just venting of opinions which haven’t been
explored or discussed with others in a constructive or reflective way.

Example 2:
One of the most interesting experiences I have had was this lecture on evidenced
based physical exam techniques. I found out that unless you are a heart specialist you
can probably do more harm that good when it comes to cardiac auscultation. The
majority of doctors are wasting time and money by doing this part of the exam because
very few of us can diagnose cardiac abnormalities effectively using cardiac auscultation.
You should have seen how animated the class was when they learned this information and
quickly the room became divided as to what this research meant. Should we stop
listening to the heart? Shouldn’t this inform our future practice in medicine? What was
 15

interesting is that you would think a study like this would lead to a renewed interest in
teaching cardiac auscultation, but I guess not. I still am unsure how to process this
information other than to keep it in the back of my head should I miss a murmur or two.

Discussion: This student describes a particular experience but mostly recounts events
and then concludes that s/he doesn’t really know what to make of it. Depending on the
prompt, this reflection might earn a 1 or 1.5. In this case, however, this reflection earned
a ‘0’ because the prompt asked for reflection on a clinical experience and the student
discussed a didactic lecture instead.
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Rubric Score 1

Applying the guiding principles and rubric, these examples scored ‘1’ because although
they followed the prompt, there was no evidence of any lessons learned and they consist
simply of storytelling or venting. Reflections are also given a 1 when they focus on many
examples with scattered thoughts or lessons.

Example 1:
I was in a meeting in the ED with my attending to discuss our research project
when all of a sudden a code blue was called on the overhead. The attending and I ran to
the opposite side of the hospital, and it made me understand this is a sprint and not a jog.
When we arrived to the scene, I was completely out of breath and all I saw was chaos.
My attending went to the head of the bed and I just stood there nervous, out of breath,
and not knowing what to do. Then the attending started ordering me to get supplies that
he needed and I went in search of these items. I couldn’t find all of the items I needed
and it took me way more time than it should have because I had to ask numerous people
where the supplies were. I realized that I was totally unprepared and felt guilty for not
knowing where all these things were.
I saw that when running a code communication is important and everyone needs
to understand what to do. I realized that not having any information about this patient
made it very difficult to know what is wrong. Only a femoral pulse could be found, and
they couldn’t get in an arterial line. This meant we had to interpret venous blood gas
results, something I knew nothing about.
As the patient, now resuscitated, was being wheeled into the ICU it was my job to
keep one hand on the bed and one hand on the IV post. As we were approaching the
doors of the ICU my hand slipped on the IV post and it almost hit the patient in the head,
but luckily someone caught it as it was falling. If this would have happened the patient
would have needed a head CT scan. I felt bad, and I still feel bad. What if the pole had
hit the patient in the head?!?

Discussion: This reflection earned a ‘1’ because although the student told an interesting
story about a code in the hospital, there is no evidence of even low level reflection, i.e.
that any lesson was learned in the writing of this assignment.

Example 2:
My first clinical rotation made me question my own motives and the workings of
medical care teams. I have heard that the “borderlines” are the most difficult patients to
care for because they generate negative feelings towards themselves and cause conflict in
medical teams. Knowing that and experiencing it first hand are totally different. A
patient came into the unit after being picked up by police. This had been her third
admission in this week, and I knew we had our hands full.
I knew from the chart that the patient had bipolar, and was in AA, and was a full
time cat-sitter. I expected to see a manic patient acting out, and needing sedation.
 17

However, when I interview the patient, there was no pressured speech, flight of ideas,
grandiosity or delusions. Instead, she was very angry that she was here and felt wronged
by what had happened to bring her here, which seemed entirely appropriate. She then
started getting allies within the team, and her story started changing every time we talked
to her.
Then something weird happened because of the police involvement, if she was
discharged she would go to county jail. She told one of the team members that she now
wanted to be in the hospital because she wanted her own room and the food was better.
She said she had only been in this dispute because of a small street fire she made to keep
her warm that didn’t do any harm. We then learned that the fire was actually set in a
school and the charge was being raised to a felony. The patient then starts smearing her
feces on the walls. We didn’t know what to do, and we felt like we have been enabling
the patient. Then in response, a resident starts a “bland diet” and we restrict all of her
privileges so she will agree to go to jail. But then the nurses say this is unethical and
stopped our intervention. Then the nursing staff and the doctors seem to be fighting over
this patient’s care and I leave for a different rotation the next day feeling like I
contributed to unethical behavior.
I plan to gain more experience so one day so I can feel secure about the quality
my decisions.

Discussion: Like the example above, this reflection earned a ‘1’ because although the
student told an interesting story about a single clinical experience, there is no evidence
that any lesson was learned in the writing of this assignment.

Example 3:
At my outpatient medicine clinic, I was given the task of taking histories and
physicals in one room while my attending saw patients in another room. She only gave
me 15 minutes to do an H&P, which is kind of impossible since I didn’t know any of
these follow-up patients at all. After each 15 minute H&P I had to present my assessment
and plan, which seemed like a daunting task since I do not know very much. She would
say to me, “You can’t say you’re not sure or you don’t know.” I was so embarrassed
because I felt I was letting the patient down due to my apparent lack of clinical reasoning.
Later that day, I had an experience that stands out to me. When I walked in a room
with my preceptor, and saw a female patient with two black eyes and bruises all over. I
was in total shock that someone would do that to a woman. I mentioned to my attending
that I was grateful for his presence because I could not have done that interview, and
didn’t feel comfortable talking about violence. The patient wanted to know if the attacker
would have to pay for the medical bills, and the attending didn’t know, but I did. We had
learned about a program that helps woman pay medical bills in these circumstances. This
gave me confidence that I can be useful.

Discussion: This reflection earned a ‘1’ because there are actually two anecdotes here,
they are not explicitly linked, and there is no evidence that any lesson or take home
message was learned in the writing of this assignment over and above what was learned
during the experiences.
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Rubric Score 2

Applying the guiding principles and rubric, these examples scored ‘2’ because they
demonstrated a very general sense of lessons learned with little elaboration.

Example 1:
There was an elderly male patient who had suffered from an MI, and now had a
new diagnosis of a brain tumor. I would have thought that these two medical conditions
would have been his primary concerns, but I was incorrect. He was most worried about
his financial situation and the future of his social support system. As a future physician,
hearing about his concerns brought to light the importance of taking a detailed social
history and assessment of insurance coverage.
Although his family lived outside the city, he had friends who lived in his
apartment complex. Presumably, these social interactions improved his mental and
physical health. But he felt like a burden to his friends and felt guilty relying on them for
transportation to and from his hospital visits. People who are capable of driving and have
more financial resources would not have this problem. Hearing about these concerns
made me think about what transportation services are available to the elderly.
His finances were a daily concern as he was on a fixed monthly income that
needed to pay groceries, medications and rent. Although he would prefer buying
healthier foods, the cost of his medications made it difficult for him to do this. He also
took costly supplements, many of which I didn’t know whether they were useful or not.
Perhaps a physician who knew about these could help trim some monthly costs.
In conclusion, the home visit taught me about the patient’s activities of daily
living, and how meaningful patient education about lifestyle can be.

Discussion: This reflection earned a ‘2’ because although the student showed that they
learned from this experience, the conclusions are vague, not well linked to the experience
and insufficiently focused to provide the student with discrete lessons for future clinical
experiences.

Example 2:
Being the only medical student on the team made this rotation a lot different than
my other rotations. I finally felt almost like an intern, and I relished this opportunity for
more responsibility. After a week, I got very comfortable to the daily routine of pre-
rounding, getting collateral information, and order writing. I was on cloud nine.
This all changed one morning during my second week when I got hit in the face
with a harsh reality check. While looking at all of my patient’s charts to see if the night
resident had written any new orders on my patients, I saw in large block red ink under my
NPH insulin order from the previous day, “ORDER CANCELLED, WRONG
PATIENT!!!!” Yesterday, in my mad dash at the end of the day to get my orders co-
signed, I had accidentally mixed up the charts of two patients, one needing insulin and
the other needing a blood draw for liver studies. Thank god the nurse had caught the
mistake, and prevented me from harming this unsuspecting patient. I had a rush of
 19

conflicting emotions running through me: panic, shame, fear, but a huge relief that the
only harm done was one patient getting unnecessary labs drawn.
My attending walked in and I knew I would have to explain this mishap. When I
told him he was very understanding, but I still felt like such a huge failure. The rest of
the rotation went well, but my confidence never came back to what it was before the
mistake happened. I guess that is the price to pay for such a valuable lesson.

Discussion: This reflection earned a ‘2’ because although the student showed that they
learned from their medication error, they did not explore in detail what to take away from
this experience to use in the future. In this sort of superficial reflection, the lessons are so
general that it is often apparent that the learner has missed learning opportunities and/or
come to erroneous, too broad or too narrow conclusions.

Example 3:
My first day in outpatient clinic, I saw a patient who complained of recurrent
stomach pains and headaches. I had never been to this hospital before and I found it
difficult to locate her past visits and past medical history either in the computer or in the
chart. Even more difficult, she was Spanish speaking and I was forced to use an
interpreter. I decided to use the interpreter for the history and then have him explain the
steps of the physical exam before asking the interpreter to leave. When I presented the
case to my attending, he wanted a rectal exam because of her stomach pains. We both
entered the room and he told the patient in Spanish that we needed to do a rectal exam,
and then proceeded to do the exam, and then had me repeat the exam. We then left the
room to discuss the plan and when we entered the room the patient was crying
hysterically. Her affect changed strikingly and she only responded in short answers to
our follow-up questions. My preceptor began probing to why she seemed upset and she
said it was because of unspoken problems at home. My preceptor stepped out to get a lab
sheet, and I took this opportunity to delve further into the sudden change in behavior.
When I asked if she was upset about the rectal exam, she completely broke down but
didn’t say anything. I wasn’t sure why.
I was very upset knowing that I had been the reason a patient was so distraught
and felt that she must have felt physically violated. I was angry at the situation because I
thought it was my attending’s fault for not carefully explaining the rectal exam, and why
we needed to do this. I wonder if she will ever return to clinic after such an experience.
As a medical student, I need to be an advocate for my patients in these situations
where my attendings are not in tune with the wishes of the patient. Before the patient left
I told her that it was her right to request a female provider, but I felt guilty telling her this
behind my attending’s back.

Discussion: This student told mainly a story, but in the last paragraph there is some
evidence of some vague and not specific lessons that the student took away from this
experience earning it a ‘2’. It is not a ‘3’ because the lessons are not concrete enough,
fully reasoned or clearly linked to the anecdote.
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Rubric Score 3

Applying the guiding principles and rubric, these examples scored ‘3’ because they listed
concrete lessons learned, but they failed to bring in any outside evidence or feedback into
the situation to help provide context and insight about the situation.

Example 1:
I was taking care of a paraplegic during my rotation in the hospital. He became
that way from a gunshot wound, and now came to the hospital needing bilateral below the
knee amputations secondary to osteomyelitis. On the team we needed to “buff him up”
for surgery, which meant improving his nutritional status. In reality this meant he had to
just sit around all day waiting for another day to pass for him to get surgery.
He was very angry about his diagnosis and upcoming surgery and even more
angry about having to sit in the hospital all day. Every time anyone from the team would
walk into his room he would yell, call people names, and accuse us of doing experiments
on him. This was very disturbing to me, and I noticed that people were visiting him less
often because he was so difficult to be around.
Something strange happened when the new set of interns came on service. The
new intern was initially greeted with the same yelling and name calling, but he took the
opposite approach with the patient. He spent a great deal of time with the patient
allowing the patient to vent and be heard. This went on for a few days, and suddenly the
patient stopped yelling when the team came by to visit the patient each day. We found
out that he wanted to be able to go outside everyday so we arranged for someone to take
him outside in his wheelchair and let him get some fresh air. Suddenly, this difficult
patient became one of the favorite patients to visit on the team.
This experience reminded me of the importance of taking extra time for any
patient who needs it, and this may mean spending more time with patients that are less
likeable. Often people are rude because they are suffering and it is our job to help find
the best ways to relieve that suffering even if it is just an ear for them to talk to.

Discussion: In the last paragraph, the student showed evidence of a specific concrete
lesson that can be applied to future situations with patients that are not “likeable”. It is
not a ‘4’ because they did not bring in any outside evidence (literature or a team
member’s thought process of the situation) to deepen or reframe their understanding of
the situation.

Example 2:
In came trauma echo, a 17 year old male who came in with a fractured femur
from a gunshot wound. I found out that trauma patients get fake names to disguise their
identity to protect them. At the time I assumed this must mean the patient must be in
some sort of gang given the fake name and being involved in a drive by shooting.
The patient for the first few days after surgery was very somnolent due to the
many narcotics he was on. This made it very difficult to establish rapport. Assuming he
liked feeling “high” with the PCA and other narcotics it made me suspect that he used
 21

recreational drugs. My perception was proved totally wrong as the chart showed that he
barely used the PCA at all for pain, and took less pain medication than was expected. My
first real conversation with the patient informed me that he was being shot at because his
girlfriend was wearing red, and he pushed her out of the way and got shot in the process.
Later his high school counselor came by and was shocked at what had happened, and told
me that the school was so surprised when they heard about this. I found out the patient
was an excellent student, and was in many advanced placement classes. My impressions
of him suddenly totally changed. It made me wonder whether I would have acted
towards him the same way had I not heard about these new details about the patient. This
has taught me that I will have to be conscious of how my pre-judgments change the way I
treat patients in the future because all patients deserve the same level of care regardless of
circumstance.
After getting to know the patient for awhile I learned how much his social status
will impact his future health. He had poor family support. He also had to walk up many
flights of stairs to get to his house, and that was going to be a big problem since it was
not handicap accessible. It made me realize just how little we can do to help patients in
their social situations. I am not sure if a social worker can get him a room with an
elevator until he gets better.

Discussion: This student clearly shows in depth lessons learned from this experience.
Although the student incorporated two outside perspectives, the patient and the school
counselor, this evidence came from the student’s normal role of following the patient not
from active pursuit of additional information for the purposes of reflection and deeper
learning. Hence, it received a ‘3’. Had the student discussed his/her misconceptions
with his/her team or the social worker to ask how they managed their own prejudices
and/or used the reflection as an opportunity to investigate what social supports are
available for this sort of patient or even how to find out about social supports, this would
have received a ‘4’ since it would have shown that the student sought out outside
perspective that helped formulate the lessons learned.

Example 3:
I cared for a patient that affected me deeply during my first rotation. He was in
the hospital before I came on service and stayed there after I left. When I said goodbye to
him he told me I helped him more than I would ever know. After getting to know him, I
wished he hadn’t have had to suffer through this illness. He was rapidly declining due to
a progressive disease and his doctors didn’t quite understand what was happening to him.
Every test that was done came back negative. What made things more frustrating is that
every test was getting more and more invasive for the patient with lots of time in between
each test. We both shared a feeling that the powers that be were not paying proper
attention to his worsening condition and didn’t take enough time to understand what was
happening to him. I didn’t share my agreement explicitly with him, but he could tell that
I felt like he did.
This whole process made me feel so distraught. What could I do for this patient
just being a student? Worse, everyday he would vent to me about how slow things were
 22

moving and I could not give him any answers. I then begin to wish this rotation would
just end just so I didn’t have to be overwhelmed with these feelings everyday.
I learned quite a few things from this experience. In the future, I will not be so
reluctant to share my feelings with my team. I also learned that I tend to get too
emotionally involved with my patients, and this negatively impacts my work. I am not
sure what I can do about it, but maybe I should talk to someone to learn about strategies
for how to create some boundaries between me and my patients.

Discussion: Similar to the example above, this student had clear lessons learned that
could be applied to future clinical encounters. Hence, it earned a ‘3’. Although the
student incorporated the patient’s perspective, it did not count as outside evidence
because these discussions happened in the defined clinical role of the student. Had the
student, as mentioned in the last sentence, talked to a mentor about the situation, the
reflection would have earned a ‘4’.
 23

Rubric Score 4

Applying the guiding principles and rubric, these examples scored ‘4’ because they
demonstrated concrete lessons learned and included additional perspectives and/or
outside evidence about the situation.

Example 1:
As I have learned since starting on my clerkships many diseases can be prevented
from ever occurring in the first place. Prior to this, I had thought of illness purely as a
chance event and that doctors dealt with just the end result. I was sent to an Indian
reservation as part of my family medicine rotation and as we drove through the
reservation I was shocked at the low standards of living there. Despite being surrounded
with nature’s gifts, there were close together makeshift houses with empty beer cans piled
up outside, and the whole town was filled with dirt roads. There were no grocery stores,
medical facilities, streetlights, and this was totally foreign to me. How is this community
just two hours away from 4 star hotels and well-staffed hospitals?
The patients we saw in clinic that day suffered from pretty much the same
diseases: obesity, hypertension, and diabetes. While most of the patients had prescriptions
for their illnesses, hardly any were adequately controlled. How can you explain this
epidemic? Was it all based on genetics? However, we did discover that they lived very
sedentary lifestyles and their diets were mainly red meat, soda, snacks, and lots of
alcohol, tobacco and drug abuse.
I thought of how hard it would be to change the lifestyles of these patients. They
grew up in an environment where they are surrounded by people eating poor diets, using
illegal substances, and probably have bad genetics to begin with. Perhaps our efforts
should be spent in the neighborhood schools. Would this stop the cycle I was seeing in
this town?
I talked to a local activist about this experience and to many of the patients about
how they thought primary prevention could impact their community. They reaffirmed my
ideas that performing interventions focused on the youth and focused on behavioral
modifications would be helpful to the community. And while doctors come into the
reservation for clinic visits, I found out from patients that this community really needed
dieticians, therapists and social workers. This experience may have a profound effect on
my future career choice.

Discussion: Notice in contrast to the examples that received a‘3’, in the last paragraph
the student incorporated both the patient’s and an activist’s thoughts into their reflection.
This resulted in lessons learned that were informed by outside perspectives. Because this
evidence was obtained outside the defined student clinical role, it received a ‘4’.

Example 2:
I was at the hospital doing my anesthesia rotation, and the nurse anesthetist told
me about the patient we were about to see. She said it would have been a great case for
me to see, but the patient said that they didn’t want any medical students or residents
 24

involved in her care. She told me to go and study while the case was going. I came back
a few hours later hoping to help with the next case, but I saw that the surgery was still
going on. She then came out and told me to come into the OR room with her. I felt very
weird about entering the room because of the patient’s preference to not want students in
the room. If I say, “sorry, I do not feel comfortable going into the room,” I felt this would
affect my evaluation. I ended up staying and preparing some IV drugs for her in the OR.
As I thought about this situation I felt enormous guilt for knowingly violating a
patient’s wishes. I ended up talking to the site director about the situation and he too was
unsure about what the best response should have been. He did say that I should feel
comfortable speaking up if something is bothering me to the extent that it did. I also
discussed the situation with my research mentor who said she thought I needed to think
both about what I valued most (good grades or being true to my beliefs) as similar
situations might come up again and more important, that I should work on my
communication skills so I can say things so that people don’t get insulted or mad. She
gave me some examples of strategies I could use.
I later learned that the patient was sexually abused many times and had many
psychiatric issues. The patient never found out I was in the room, and this fact has made
me feel ashamed of myself. I feel that I did a disservice to my own professionalism. I
should have stood behind my own belief even if it would affect my evaluation. Overall,
this incident taught me a lesson that sometimes, the right thing to do is not the easiest
thing to do. I should have talked with someone sooner than I did, and at least voiced my
concerns before violating a patient’s wishes.

Discussion: Again, in contrast with the ‘3’ examples, this student reality tests his/her
perceptions of the situation with the site director and mentor which helped reinforce
lessons learned for future similar situations. Hence it received a ‘4’.

Example 3:
A recent clinical experience had a large impact on me. I was following an 18 year
old-woman at 38 weeks gestational age in the hospital. When I talked to her about her
pregnancy she seemed to talk about her fetus in a very negative light. She kept calling
her fetus “it” with a weird tone, and focused on how mad she was about the pain “it” was
causing her. As her labor progressed she kept rudely screaming at the midwife and I for
more pain meds. I responded by paging the anesthesiologist to bolus her epidural and
helping her with the pushing process during the delivery. However, I did not like being
yelled at and coupled with her negative comments about her future child, I was having
trouble controlling my emotions. I noticed that the midwife was also frustrated and
seemed to ignore the patient’s screams for more pain control. When her baby was born
she did not want to hold it, and said she was too tired. As I think back on this I wish I
could have been a more compassionate presence given this circumstance rather than
taking the patient’s screaming personally. Perhaps she was in so much pain, she couldn’t
think straight and that I misinterpreted her attitudes about her baby. Perhaps, her being a
single teenage mom affected my perceptions about her from the beginning. I could have
asked her more questions about this baby to try to understand what the true issues were,
 25

but at the time, I was happy leaving the room because the patient was so frustrating to
me.
Later that day I felt bad about the whole situation and decided to talk to the
resident and the midwife about what had happened. I also wanted to discuss whether
they perceived the mother to have negative attitude towards her birth and new baby. We
discussed the ways in which teenage mothers can have more difficulty adjusting to
becoming a mother and tend to have complicated social situations surrounding their
pregnancy. I then decided to look up teen mother resources so that I could provide
teenage patients with appropriate support and information.
This situation taught me that I had many unfounded assumptions about teen
mothers and mothers in general who didn’t like the birthing process. I now realize how
having these perceptions affects your care, and can be a barrier to building rapport. I
think I should read more about the psychological impact of pain, and birth and try to
explore why I was so quick to judge this teenage mother. I also need to be more aware
that people in pain may yell at you but I shouldn’t take it personally and that when people
are behaving in surprising ways there may be reasons I don’t know about.

Discussion: In the second to last paragraph, the student discussed the event with the
resident and midwife. Had the next few sentences not been there, it would not have been
a ‘4’ since telling superiors about the patient is part of routine clinical work. This
student sought the resident’s and midwife’s thoughts and feelings and in addition
incorporated outside literature in looking up teen mother resources. If this were a 3, the
student might have felt badly, recognized that pain can affect behavior and come to some
of the same conclusions in the final paragraph. Because s/he went beyond that, seeking
outside input which reframed his/her views of teenage mothers, the reflection received a
‘4’.
 26

Rubric Score 5

Applying the guiding principles and rubric, these examples scored ‘5’ because in addition
to having concrete lessons learned and bringing in outside evidence, they incorporated
the relationship between past experiences and the current situation.

Example 1:
On my first rotation, the first patient I took care of passed away. He was a nice
elderly man with many chronic health conditions. He seemed to be improving and was
going to be discharged the next day when he suddenly had an arrhythmia that set off a
cascade of events leading to his death. Luckily his family was there and he had enough
time to say goodbye to his family.
I was overwhelmed with emotions. I had never experienced a patient dying and I
was in a state of shock. I didn’t understand how a patient about to be discharged could
suddenly die so fast. I was grateful that we were able to make his death peaceful and
according to his wishes. I saw how great the team was with the patient’s family and
letting them know we were there to help them. I also was wondering if I could ever be
the person leading that discussion with the family as I couldn’t control my own emotions
of sadness.
I reflected on my own family and how similar this family seemed to mine. Like
with my grandfather’s passing two years ago, the family was surrounding the bed, all
crying about the family patriarch. This resonated with me and contributed to making this
a difficult situation.
I talked at length to various members of the team about this experience and I
wanted to learn how they approached death and dying. They all reassured me that it is
normal to have this reaction when you experience a patient death and especially my first
one. They also gave me tips on how to approach situations in the future such as telling
the family how sad I am and then refocusing on their needs. I realized that feeling sad is
normal, but I need to recognize that we are also there to give the family comfort and
solidarity when the family is in such pain.
This experience highlighted my inexperience with death and dying. It was a
blessing to be able to learn from such good role models on my team about how to handle
these situations. It also allowed me to confront my own emotions, and realize that most
people react as I did to some degree and that maybe I reacted more because I was still sad
about my own grandfather’s passing. I was proud of our team’s role in assisting this
family in such a time of crisis. I hope one day I will be able to lead that discussion with
the family under similar situation. Hopefully then I will be able to control my own
emotions.

Discussion: This student incorporated their teams’ thoughts and experiences about death
and dying into concrete lessons learned. What gives this reflection a ‘5’ is in the 3rd and
last paragraphs where the student incorporated his/her past experience with death and
dying within his/her own family and applied it to this new encounter. This did not receive
a ‘6’ because the student did not clearly articulate a reasonable and measurable plan for
future similar situations.
 27

Example 2:
The CT scan had been unclear with just a hint of signal in the liver, suggesting a
possible metastasis. It was my second week on surgery and I was just getting used to a
patient being wheeled into the OR, and then being draped for the operation. The
difference for this case is that the plan was not so clear. This patient entered the OR not
knowing whether the cancer had spread or not. Only a few moments into the surgery it
was discovered that in fact there was metastasis present in the abdominal cavity. They
took biopsies and waited for the pathology frozen section results. Then a delicate
conversation between the attending and chief resident about what to do next began.
Should we close the patient up and start chemotherapy and radiation or should we remove
some of the tumor now? Would the patient want this? The family and the surgeons had
discussed the possibilities beforehand and still how to proceed was not an obvious choice.
They ended up diverting the bowel giving the patient an ileostomy.
I felt the heaviness in the room as they literally had this patient’s life in their
hands. I had read a lot about this patient and considered his life leading up to this
because like the patient, I too had ulcerative colitis. I could not help to think about my
own risk for cancer, and for a second I considered that I was actually the patient on the
OR table. As the patient woke up from anesthesia, it became very difficult for me to
make eye contact, because I was scared for him.
I went and talked with one of the senior members of the team about what it is like
to see a patient with the same disease you have and how that effects your ability to be the
patient’s doctor. I realized I needed to think about whether sharing something in common
with a patient is a positive or negative. The senior helped me see that it can be positive or
negative or both and that my job and responsibility is to figure out which and to decide if
I’m the right provider for that patient.
I learned quite a lot from this experience. I was grateful to be in a team that so
compassionately considered the patient’s wishes when they decided what to do in the OR.
I saw how they did not panic and made sure they considered every option without
proceeding. I realized that it is very difficult to connect with a patient without allowing
emotions to cloud your clinical judgment. I look forward to facing this challenge when it
is my responsibility to make the decision.

Discussion: Like the example above, this student incorporated his past experience of
being a patient with the same disease into this reflection and further sought the
perspective of a senior resident. It earned a ‘5’ and not a ‘6’ because there is no outline
of a plan for future similar situations.

Example 3:
Ms. X was a 36 year old woman at 36 weeks gestational age who came in for an
evaluation for a high blood pressure reading taken in the OB clinic. She was on the floor
for one week before I came to know her, and at this time there was massive turnover of
the residents. Ms. X became an intimate member of the labor and delivery floor, while
the staff around her constantly changed. Ms. X hated that the doctors, nurses and social
workers were constantly changing and she felt that she had to repeat herself over and
 28

over again. Soon Ms. X became very irritable and began demanding to only work with
certain staff.
One of the doctors, Dr. Y, was the only doctor that seemed to have any type of
rapport with Ms. X. Dr. Y was revered by the whole department and I was lucky enough
to get assigned to work with her. I was so excited. However, watching Dr. Y with Ms. X
was horrifying. From the point of view of the team caring for her, Dr. Y was a saint, the
patient agreed to invasive monitoring, and that was decided in a completely paternalistic
way. When Ms. X started raising her voice over something, Dr. Y talked over her. It was
if I was watching a mother scolding her teenage daughter. The daily plans were told to
the patient and she didn’t have any say in the matter it seemed. There was no open-
ended questions, no understanding the patient’s ideas about their illness. I reflected back
on everything I learned in our doctoring course during the first two years of medical
school. The way the attending was talking to the patient was unprofessional, and the
antithesis of my own idealism of what makes a doctor-patient relationship. I really could
not believe my eyes about what I was seeing. This was the revered doctor in the
department?
I spoke to my mentor about the situation to make sure I understood this situation
clearly. She helped me realize that I was only seeing a snapshot of what was happening
between Dr.Y and Ms. X. I was not with the attending at every moment, so I do not
know how their relationship was. Plus, I do not know the history between the two and
perhaps the attending discovered how the patient likes to be treated. My mentor told me
that sometimes a stern doctor is needed in certain situations, and maybe this was one of
them. It was very useful to run my experience by someone else because sometimes you
don’t know how to process what you are witnessing. I wish I had talked to the attending
to find out how their relationship evolved in that matter. Maybe that would have affected
my evaluation though. In the end I learned that although I was right to question the
doctor’s actions, I must not judge the situation without talking to other people involved in
the case. I wish I would have talked to Dr. Y about it.

Discussion: This student both sought out a mentor to reality test his/her experience, and
used his/her past experience in the doctoring course in pre-clerkship years to help frame
and explain his/her initial response to this experience. Notice, if not for the reality-
testing step, this student could have had a far different take home message. Again, it
received a ‘5’ instead of a ‘6’ because a well thought plan for future similar situations
was not outlined.
 29

Rubric Score 6

Applying the guiding principles and rubric, these examples scored ‘6’ because in addition
to having concrete lessons learned, bringing in outside evidence and linking past to
present experience, they came up with a plan of action that was realistic and measurable.

Example 1:
I was on the first day of my family medicine rotation when I met the resident I
would be working with. He briefly greeted me, gave me a disclaimer that he just came
off night float, handed me a chart, gave me a quick synopsis of the patient, and directed
me to the patient’s room. I entered the room to find a pleasant woman who did not seem
to mind that I was just a medical student. I did a full interview and physical and then
excused myself from the patient’s room to discuss the patient with the resident. When I
presented the patient to my resident, we returned to see the patient together. Afterwards,
we discussed the patient’s case. The resident agreed with most of my presentation but
told me I forgot to mention that we needed to order a rheumatoid factor lab test. Based
on my understanding, this seemed totally wrong, but I deferred to the resident and didn’t
argue with him. I did not feel I was in the position to contest the clinical reasoning of a
second year resident on my first day.
After we talked, we had to present the case to the attending. When I presented to
the attending I added the part about checking for a rheumatoid factor. I went on to say
why we needed to test for rheumatoid factor using what the resident had told me. The
attending then stopped me in mid-sentence, and grilled me on how I could possibly think
to check that lab? The attending went on for about 5 minutes about the signs and
symptoms of rheumatoid arthritis as if I had no idea what it was. I knew what it was, and
I knew the lab test was not needed in this case. What made this even more frustrating
was that the resident was right next to me during all of this and didn’t say anything. I just
felt the resident should have said something and not thrown me under the bus like that.
I spoke to a mentor about the situation later that day, but I didn’t get any meaningful
feedback. People empathized with me but basically said, “it happens”. After talking to
my classmates about it I realized that perhaps I was having an out of proportion response
to a trivial incident.
In the past, I have been in an educational system in which you demonstrate your
knowledge via assignments and tests. I am starting to realize that clinical medicine is
education on a whole different level. I do not have as much control on how and when I
am assessed. Further, I have to learn and be constantly evaluated at the same time, which
is very different than I am used to. Also, this is more about how to be a team member,
obey social cues, and learn the politics of the trade. I find dealing with uncertainty
challenging.
When addressing a similar situation, I plan to be more assertive and question my
resident’s reasoning in a non-threatening way when I do not understand his or her
thinking. Perhaps, I can phrase the question as I am trying to learn rather than trying to
challenge their authority. If I find that a resident is not being supportive, and makes me
look bad in front of the attending, I will try to approach them directly about the situation
so it doesn’t become a bigger issue. Also, I realize that if this happens again I will be
 30

stressed out about it, so I should talk to the site director as soon as possible to get some
perspective on the situation.

Discussion: This student received a ‘6’ on this reflection. The student incorporated
outside perspectives from peers and a mentor. They also compared their experiences as a
learner in a different learning environment to help them learn why this situation was
different. Finally, the student in the last paragraph outlined a clear and reasonable plan
for the future.

Example 2:
As an EMT we frequently went on calls that were considered to be non-medical in
nature, and these patients were referred to as “frequent flyers”. One particular call I
received recently has stuck in my mind. The 911 call was made by a homeless
transgender man who has been known to repeatedly call from the same pay phone every
time. The person I was working with that night was a paramedic who had a reputation
for not being the most compassionate EMT with patients. As we arrived on the scene, he
instantly started being very rude to the patient, being dismissive of her, and became
visibly angry that we had to take care of her. He started with a physical exam before a
history and didn’t want to hear much of what she had to say. I am very inexperienced as
an EMT and my partner has been doing this for many years. I was shocked at what was
happening. No human being, let alone a patient we were supposed to be taking care of
should be treated like that.
After we left the scene I talked to my partner about the way he behaved. I tried to
be very gentle with my questioning and understood that he would probably be annoyed
with me. His answers were very brief, and dismissive and basically said, “we had more
important things to do than waste time with that malingerer.” The system factors that
contributed to this problem were hierarchy and seniority. Like my experience in the
military you do not have the right to challenge a superior unless you are prepared to deal
with the consequences. My mentor didn’t, however, suggested that I needed to consider
not just how I was dealing with my partner but also what that meant about how I was
treating the patient by letting my partner take control.
The situation taught me that I have a lot of growing up to do in order for me to
feel comfortable sticking to my ideals and professionalism in tough situations. While I
did talk to my partner about it, I allowed him to dismiss me. Worse, I didn’t defend the
patient, the real victim in this situation. I thought back to similar situations involving
difficult EMT’s I had to work with and forgot a tactic I used in the past. I would just
forcefully offer to do the patient care duties for that patient, to avoid the problem. This
might have worked in this situation, but this is still a band-aid to the problem. I should be
questioning why I don’t feel comfortable either discussing things more forcefully with
my partner or, if that doesn’t work, reporting him to my supervisor for his actions.
If I was faced with a similar situation, I would be more comfortable advocating
for the patient in the moment. I will try to make sure that the patient’s needs get met first
and foremost. After the situation, I would bring it up with my partner and not let him/her
dismiss me. If they didn’t want to talk about it with me, I would tell my supervisor what
 31

had happened so he is aware that this is happening. Also, I would seek multiple opinions
from other people about strategies for working with difficult partners.
Discussion: This student received a ‘6’ on this reflection. The student sought outside
perspectives from a a mentor and used his/her past experience in the military to help
guide this reflection. Finally, in the last paragraph a clear and reasonable plan for
future was outlined.

Example 3:
I was on my surgery rotation and we were rounding on an elderly patient who was
being admitted for diverticulitis. He had been “bounced” from medicine team to the
surgery after seeing many teams of medicine doctors about his new diagnosis. The
surgical team rounded on him very quickly since he was not a surgical candidate. The
attending quickly asked the patient if he had any bowel movements or gas overnight,
what his pain number was, and whether he has gotten out of bed. The resident and I
pushed on his belly quickly and then we turned to leave the room. As we were leaving
the patient looked anxious and said “why cannot anyone tell me what is going on inside
of me?” The team just kept marching along perhaps pretending that they didn’t hear the
patient. I was shocked and angry that the team seemed to be so dismissive of this elderly
patient. It seemed as if no one talked to him about what is going on with him.
After rounds I asked the resident if I could look up some information about
diverticulitis and then present the information to the patient. I figured I could satisfy the
patient’s needs as well as learn something at the same time. I felt bad for the patient and
wanted to do anything I could do to help. After I learned about the disease, I told the
resident my findings and he was receptive to me telling the patient about it. After
spending time with the resident I felt like I knew most of the relevant information related
to the patient’s case. When I entered the patient’s room, he was still annoyed with what
had happened earlier. I smiled at him, and acknowledged how frustrating it is to be in the
hospital. I told him I was just a student but I tried to learn everything I could about what
is happening to him. He seemed grateful for me being there and asked me some
questions I didn’t know the answer to. I told him I would look them up and get back to
him. As I was leaving he smiled at me and told me that he really appreciated the time I
gave to him. This experience reminded me why I wanted to be a doctor in the first place.
Although I didn’t really do anything medically, I felt like I helped more than I had in the
previous three weeks on the service.
I think what helped me connect with the patient was that I was only a few weeks
into third year of medical school, so I was closer to a lay person than anyone else. I
remember what it is like to be confused and scared and feel like no one is talking to you.
When I was a child I was hospitalized for a couple of months and I remember feeling just
like him, lonely, scared, and wondering why the doctors would not talk to me. Patients
don’t always have an advocate in the hospital, but have large teams with different people
sharing the responsibility.
I talked to the resident about my experience and how I felt about what had
happened on rounds earlier that day. Unfortunately, he did not give me much feedback
other than a pat on the back. The patient’s feedback however was extremely helpful in
validating my actions for the day. He told me that he doesn’t like to go to doctors
 32

because he finds them hard to approach. He wished he had a primary care doctor like me
because he could tell that I really cared about him.
I am glad I had the time to research about diverticulitis and sit down with the
patient and teach him about the disease. More importantly, I am glad I was able to be a
human being to a man in distress. I know in the future I will be under more time
constraints, but I will never forget this experience as a reminder that I will never be too
busy to listen to my patients.
My plan in the future is to figure out how I can make each patient’s stay at the
hospital more pleasant, especially on rounds in the morning. This means I will listen to
my patients and try to either address their needs, or find someone who can. If I am too
busy right then to help, I will assure them that I or someone else will be back and make
sure that really happens. I hope to continue to advocate for my patients, and try to help
the most I can. I want to continue to solicit feedback from patients about this satisfaction
with their stay, and continue to find creative ways to bring up to the team when I feel like
a patient was neglected. When I am a resident, I will try to model this approach and also
try to teach another medical student the same lesson I learned with this patient.

Discussion: This student received a ‘6’ on this reflection. The student sought outside
perspectives from the resident and patient that went above the clinical responsibilities of
the student. The student further used his/her experience as a child to help understand the
patient’s perspective. Finally, the student in the last paragraph outlined a clear and
reasonable plan for future similar situations.