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May 2017 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Vicini, A., Shaughnessy, A. F. and Duggan, A. "On the inner life of physicians: analysis of family medicine residents' written reflections." Journal of religion and Health 56, no. 4 (August 2017): 1191-1200. [This article was originally featured ahead-of-print.]


SUMMARY and COMMENT: This month's article may be for many chaplains a somewhat unusual turn through the spirituality & health literature, providing insights into the "nuances of the inner life" [p. 1192] of family medicine residents. The observations from this qualitative study of physicians' reflections could be especially useful to CPE students, to compare and contrast the findings with their own deepening self-understanding of their "inner lives" in light of their pastoral caregiving. The article may also raise some debatable points about the conceptualization of spirituality vis-ŕ-vis "inner life" and the purview of chaplains' practice.

The authors are Andrea Vicini, S.J., M.D., S.T.L., S.T.D., Ph.D., at Boston College's School of Theology and Ministry; Allen F. Shaughnessy, Pharm.D., M.Med.Ed., at Tufts University's School of Medicine; and Ashley Duggan, Ph.D., at Boston College's Communication Department. The study sample consists of 33 physicians in the Tufts University Family Medicine Residency at Cambridge Health Alliance. Participants completed a written reflection (without any imposed prompts) three times a week for one year, regarding their experiences as a resident. They were allotted 15 minutes for the exercises, and all entries were handled confidentially unless the resident opted to share them publicly. A total of 756 entries were collected. "The current analysis only includes reflections that have an inner life reference" [p. 1194].

"Inner life" here "refers to one's inspiration, reverence, awe, search for meaning and purpose, even in people who do not believe in God..., who are not members of an established religion or who do not practice their faith in any religious context" [p. 1192]. The authors go on to state: "We define 'inner life' in a broad and inclusive way that is shaped by emotions, perceptions, reflections, past and present experiences, professional competence and expertise, beliefs, personal and communal contexts" [p. 1192].

Thematic analysis of the reflections is presented along two lines:

First, their written reflections focused on their emotions/affective experiences and expressed their longings, desires, struggles, frustrations, doubts, sense of helplessness, awareness of personal growth, joys, and gratitude.... [p. 1195] ...Second, in their written reflections, the physicians addressed their responses to daily professional events and their experiences with emotional responses by relying on prayer, stepping back, hope, and personal questioning. [p. 1196]
Each theme is illustrated with a quote, creating a rich core to the article. For example:

  • Longing (n = 32 written reflections): "Thought I was an adult but often feel like an infant knowing how to walk yet crawling at times. Is this what it is like, to a smaller magnitude, to be in rehab after a debilitating accident? To know what is possible but to have it just out of reach? Competence? Longing for competence in the midst of insurmountable paper work and phone calls. Time to read. I read voraciously before medical school. Now I try valiantly but there is life to be lived. At the end of an 80 h work week's full days perhaps all the learning and practicing will spontaneously coalesce......perhaps when I re-emerge as the adult that I am the confidence will be there (again) and I will blossom." [p. 1195]

  • Struggles (n = 11 written reflections): "Work is work and I can't expect that it won't be challenging, but I do want to love what I do. Thinking back to the weeks before vacation, I remember crying too often from exhaustion and feeling burnt out. I don't want to feel rushed and stressed and drained all the time." [p. 1195]

  • Prayer (n = 34 written reflections): "I want a daily prayer/meditation practice. Challenges are like labor -- either go through it in fear, go through it and numb it, or walk and breath through it." [p. 1196]
The authors go on to observe differences between individual physicians in their reflections, like level of awareness of one's inner life or ability to describe one's inner life [--see a listing on p. 1197]. They further note:
These differences in journaling about one's inner life lead us to identify two characteristic dimensions.... First, the "human." Physicians manifest their humanity (i.e., who they are and what they experience). By manifesting their humanity, and by reacting in human ways to what happened to them (e.g., by expressing struggles, wondering, being puzzled, being grateful, etc.), they express their whole being by paying attention to their inner self. The "human" includes the longing for transcendence that is associated with more explicit spiritual discourse.... Hence, what is human and what is spiritual are not separated. [p. 1197]. ...Second, the "religiously-explicit." Some physicians have the ability to articulate their reactions and to express their inner lives by relying on explicit religious language and concepts. Prayer is an example. ...In a figurative way, two circles express these two dimensions. The human is the wider circle. It is the foundational dimension. It includes the other. The religiously explicit circle can be included within the human circle; it can also overlap in diverse ways in different persons. The variations in overlap depend on one's ability in relying on explicit religious language and categories. [p. 1198]
In spite of the observation about a "religiously-explicit" dimension in the reflections, the researchers write: "[W]e notice one constant element: the lack of any explicit reference to their religious membership, as to suggest that one's inner life is not fully comprised by what pertains to established religions (e.g., practices, beliefs, and rituals) and that is best described by what concerns the whole human" [p. 1197]. While one's "inner life" certainly need not be circumscribed by religion, the authors do not address the possibility that the overall culture of the medical school could have in any way discouraged disclosure of religious membership or laid a social expectation bias dynamic onto the reflection exercise.

On a related note, this reader finds striking the authors' sense of the relationship between one's inner life and spirituality or religion:

…[I]nner life should not be associated with a narrow understanding of what is defined as spiritual or religious. The risk is to undermine the pervasiveness of one's inner life in one's human and professional experience and, as a result, to confine what pertains to one's inner life to "specialists" (e.g., chaplains). In doing so, we would reduce our inner life to its religiously explicit expressions that occur in well-defined spiritual forms (e.g., prayer) or within established religions. These restrictions are limiting and ethically problematic because they point to a simplified and reduced view of the human person. [p. 1198]
The point does not appear to acknowledge the very broad and inclusive sense of spirituality prevalent in the healthcare literature (distinct from religion as "associated with the more socially and culturally defined institutional ways of relating to the divine" [p. 1193]), which would seem to have similarity to the breadth of the authors' definition of "inner life" [--for more on the definition of spirituality, see Items of Related Interest, §I, below]. Also, this reader would comment that just because chaplains may be "specialists," the domain of chaplains shouldn't be seen as less than the widest understanding of spirituality nor self-understanding of one's "inner life" less than a proper personal focus for non-chaplains. (In another place the authors also note: "In healthcare settings, one’s inner life might be considered the domain of chaplains," and "While we appreciate established religions and chaplains, we believe that more foundational attention to the inner life of physicians is also needed" [p. 1192]. Mention of chaplains in the context of the picture of the "inner life" could invite some interesting debate in pastoral circles.

Finally, the article offers a description of how physicians' attention to the "inner life" is "an important component in their personal life and in their healthcare practice" [p. 1197].

First, the attention given by physicians to their inner dimension allows them to recognize, identify, and rely on an inner "place" where their emotional responses to daily events can be expressed, addressed, and "sorted out." …Second, by being present to the state of their inner life, physicians can formulate and express fundamental human questions that concern: (a) troubling human experiences (e.g., suffering, death, luck, destiny, and death); (b) questions that surface in practicing their profession; (c) spiritually explicit questions on their beliefs and practices. Third, their inner life can become a "place" where they look for answers and try to find ways to deal with their human and professional challenges. [p. 1197]
Chaplains might consider parallels between these dynamics in residents' reflections and what may be at play in CPE and in chaplaincy exercises of reflection beyond CPE. Though the article is aimed at physicians, it may allow chaplains to see profession-based reflection from a new angle and, in the process, encourage better understanding of the inner lives of medical residents (and perhaps all physicians) that are often shielded to outsiders. If chaplains work where there are medical education programs, the article could serve as a ground for exploring the potential of journaling exercises with chaplains' involvement.


Suggestions for Use of the Article for Student Discussion: 

This month's article would seem best suited to CPE groups that have interaction with medical residents. Discussion could open with a question about how insights from reflections compare or contrast with the students' experience of physicians, especially residents. The group could then go into the enumeration of reflection themes on pp. 1195-1196, with a view toward how students might or might not relate to these themes. At a deep level, are these themes common with chaplains, or are there some themes that indicate particular challenges of the process of medical training and practice? Perhaps at this point, the group could go back in the article to review how this data was collected. Could this particular methodology be useful to chaplains' for self-understanding? Have students ever heard the term metacognition [--see pp. 1193 and 1194] before? What do students make of the authors' description of the dynamics of engagement with one's "inner life" at the top of p. 119? Does that resonate with them? Also, what do students think of the very conceptualization of "inner life" [--see esp. pp. 1191-1192]? Finally, students could discuss the six recommendations that the authors make at the bottom on p. 1198 to the top of p. 119. Are there any of these that chaplains might seek to promote for the sake of physicians' well-being, and might any of them be applicable for chaplains' own professional lives?


Related Items of Interest:

I.  For more on the broad and inclusive sense of spirituality prevalent in the healthcare literature, see the following exemplary definition, from p. 646 of Puchalski, C. M., Vitillo, R., Hull, S. K. and Reller, N., "Improving the spiritual dimension of whole person care: reaching national and international consensus," Journal of Palliative Medicine 17, no. 6 (June 2014): 642-656.

Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sa- cred. Spirituality is expressed through beliefs, values, traditions, and practices.
The Puchalski, et al. article was featured as our June 2014 Article-of-the-Month.


II.  Two predecessor articles relating to this research project:

Duggan, A. P., Vicini, A., Allen, L. and Shaughnessy, A. F. "Learning to see beneath the surface: a qualitative analysis of family medicine residents' reflections about communication." Journal of Health Communication 20, no. 12 (2015): 1441-1448. [(Abstract:) Patients share straightforward statements with physicians such as describing their fears about their diagnosis. Physicians need to also understanding implicit, indirect, subtle communication cues that give broader context to patients' illness experiences. This project examines physicians' written reflections that offer insight into their interpretation of both the stated and the tacit aspects of their observations about communication, their resulting responses, and their intended actions. Tufts University Family Medicine residents (N = 33) of the Tufts Family Medicine Cambridge Health Alliance completed three reflective exercises each week over the course of 1 year (756 reflective entries). An interdisciplinary research team identified communication-related concepts within the reflections. Identified themes include (a) physicians recognizing and discovering mutual interplay of their communication with and patient disclosure, (b) physicians paying attention to subtleties of patient behavior as indicative of a fuller picture of patients' lives and their coping with illness, and (c) physician images of growth and awareness about communication indicative of their potential for growth and improvement. The project extends the literature in communication and medical education by examining explicit and tacit points of reflection about communication. The project (a) allows for unpacking the multifaceted aspects of reflection and (b) bridges reflective theory and medical education with communication foundations.]

Shaughnessy, A. F. and Duggan, A. P. "Family medicine residents' reactions to introducing a reflective exercise into training." Education for Health 26, no. 3 (September-December 2013): 141-146. [(Abstract:) INTRODUCTION: Teaching residents how to reflect and providing ongoing experience in reflection may aid their development into adaptable, life-long learning professionals. We introduced an ongoing reflective exercise into the curriculum of a family medicine residency program. Residents were provided 15 minutes, three times a week, to complete these reflective exercises. We termed these reflective exercises "clinical blogs" since they were entered into a web-based computer portfolio, though they were not publicly available. The aim of this study is to explore family medicine residents' responses to the introduction of an ongoing reflective exercise and examine strengths and challenges of the reflective process. METHODS: We invited a cohort of family medicine residents (8 residents) who had all participated in the reflective exercises as part of their residency to participate in one of two offered focus groups to share their experience with the reflective exercise. An investigator not connected to the training program led each focus group using minimal structure in order to allow for the breadth of residents' experiences to be revealed. The focus groups were audio recorded, and the recordings were transcribed verbatim without identifying participants. We used a grounded theory approach, using open coding to analyze the focus group transcripts and to identify themes. RESULTS: Four residents participated in each focus group. We identified four main themes regarding family medicine residents' responses of the reflective practice exercises: (1) Residents viewed blogging (reflecting) as a method of enhanced personal and professional self-development; (2) Despite the reflective exercises being valued as self-development, residents see an inherent conflict between self-development and professional duties; (3) Residents recognize their emotional responses, but writing about emotional issues is difficult for some residents; and (4) Clinical blogging in our residency has not reached its potential due to the way it was introduced. DISCUSSION: The themes indicate that future efforts at integrating reflective practice should further test the methods through which regular reflective practices are introduced. Identified themes provide evidence for reflection as enhancing capacity for self-development and suggest the potential for clinical blogging as a method to build a cornerstone for the capacity for reflective practice in medicine.]


III.  This month's article may raise for chaplains a question of how physicians' might relate to the educational modalities of CPE. The following articles should be of interest.

Allbrook, D. B. "A metamorphosis: doctor to chaplain." Medical Journal of Australia 172, no. 8 (April 17, 2000): 390-391. [This is a personal reflection by an Australian retired palliative care physician and academic after a year in a hospital pastoral care (chaplaincy training) program. The author addresses implications for his understanding of the practice of medicine and offers a description of the role of the chaplain.]

Faris, I. B. "Perspectives from a surgeon turned hospital chaplain." Medical Journal of Australia 172, no. 8 (April 17, 2000): 389-90. [An Australian retired surgeon reflects upon his experience in a hospital chaplaincy program and the perspective he has gained, in the process, on the practice of medicine.]

Tarumi, Y., Taube, A. and Watanabe, S. "Clinical Pastoral Education: a physician's experience and reflection on the meaning of spiritual care in palliative care." Journal of Pastoral Care & Counselingg 57, no. 1 (Spring 2003): 27-31. [A Canadian physician "reflects on her experience as a chaplain intern and how this Clinical Pastoral Education experience led to a deeper understanding of spiritual care in the palliative setting" (--from the abstract).]

Todres, I. D., Catlin, E. A. and Thiel, M. M. "The intensivist in a spiritual care training program adapted for clinicians." Critical Care Medicine 33, no. 12 (December 2005): 2733-2736. [This is a report of how a special Clinical Pastoral Education program for physicians at Massachusetts General Hospital affected those physicians. Integration papers revealed that "clinical practice became infused with new awareness, sensitivity, and language; graduates learned to relate more meaningfully to patients/families of patients and discover a richer relationship with them; spiritual distress was (newly) recognizable in patients, caregivers, and self" (--from the abstract, but see also, p. 2735).]


IV.  Readers may find the following older articles thought-provoking along the lines of this month's selection:

Kreitzer, M. J., Zhang, L. and Trotter, M. J. "Transformative professional development: outcomes of the Inner Life Renewal Program." Complementary Health Practice Review 11, no. 1 (January 2006): 57-62. [(Abstract:) Health professionals have jobs that are inherently stressful and most have had little opportunity or encouragement to focus on self-care. Over the past 10 years, professional development programs such as the "Courage to Teach" have been developed for teachers in primary and secondary schools. Reported outcomes include personal and professional growth, increased satisfaction and well-being, and renewed passion and commitment for teaching. Based on this model of transformational professional development, a program was developed for health professionals, the Inner Life Renewal Program. Four cohorts of health professionals have completed the program. This brief report provides descriptive information regarding the structure, format, and process of the program and evaluative data based on program evaluations and participant interviews. Outcomes reported by participants include an increase in self-awareness, improved listening skills and relationships with colleagues, and an increased ability to manage or cope with stress.]

Meier, D. E., Back, A. L. and Morrison, R. S. "The inner life of physicians and care of the seriously ill." JAMA 286, no. 23 (December 19, 2001): 3007-3014. [(Abstract:) Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.] [This article is available online.]


V.  For more on the idea of journaling as part of healthcare education (going beyond a focus on one's "inner life"), see:

Cayley, W. Jr., Schilling. R. and Suechting, R. "Changes in themes over time from medical student journaling." Wisconsin Medical Journal 106, no. 8 (December 2007): 486-489. [(Abstract:) CONTEXT: There has been little exploration of journaling in medical student education. OBJECTIVE: To document the themes on which medical students reflect during training. DESIGN: We evaluated journals kept by primary care medical students to identify prominent themes and determine change or constancy in themes over time. We looked at third-year medical students participating in a required primary care clerkship in a university-affiliated, community-based family medicine residency program with a rural catchment area. INTERVENTION: During 1994-1996 and 2001-2003, students were asked to keep weekly journals reflecting on their thoughts and feelings regarding "topical content, course processes and methods, and personal reflections on becoming a doctor." Faculty evaluated journals to identify change or constancy in themes over time. RESULTS: Prominent themes included gender issues, professional identity emergence, career choice, and rural practice, the experience of learning, the experience of relating to patients, and the nature of medical practice. CONCLUSIONS: We found both constancy and change in student journal themes over time. Changes in journal themes appeared to correlate with outside events and educational trends, including increased attention to reflective practice, changing demographics in medicine and the increasing acceptance of female physicians, and personal life events.] [This article is available online from the Wisconsin Medical Society.]

Mann, K., Gordon, J. and MacLeod, A. "Reflection and reflective practice in health professions education: a systematic review." Advances in Health Sciences Education: Theory and Practice 14, no. 4 (October 2009): 595-621. [(Abstract:) The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.] [This article is available online.]

van Leeuwen, R., Tiesinga, L. J., Jochemsen, H. and Post, D. "Learning effects of thematic peer-review: a qualitative analysis of reflective journals on spiritual care." Nurse Education Today 29, no. 4 (May 2009): 413-422. [(From the abstract:) This study describes the learning effects of thematic peer-review discussion groups...on developing nursing students' competence in providing spiritual care. It also discusses the factors that might influence the learning process. The method of peer-review is a form of reflective learning based on the theory of experiential learning.... It was part of an educational programme on spiritual care in nursing for third-year undergraduate nursing students from two nursing schools in the Netherlands. Reflective journals (n=203) kept by students throughout the peer-review process were analysed qualitatively The analysis shows that students reflect on spirituality in the context of personal experiences in nursing practice. In addition, they discuss the nursing process and organizational aspects of spiritual care. The results show that the first two phases in the experiential learning cycle appear prominently; these are 'inclusion of actual experience' and 'reflecting on this experience'. The phases of 'abstraction of experience' and 'experimenting with new behaviour' are less evident. We will discuss possible explanations for these findings according to factors related to education, the students and the tutors and make recommendations for follow-up research.]

Williams, R. M., Wessel, J., Gemus, M. and Foster-Seargeant, E. "Journal writing to promote reflection by physical therapy students during clinical placements." Physiotherapy Theory and Practice: An International Journal of Physical Therapy 18, no. 2 (2002): 5-15. [The purposes of this qualitative study were to describe physical therapy students' perceptions of their learning during a clinical placement and to promote their reflective thinking. Fifty-six students kept journals and reflected on at least one learning event per week in their clinical placement. They were asked to describe each learning event, their reactions to it, and its value, and to discuss the new learning, and indicate how they may respond in the future. Each journal was read by two out of four educators who independently read, coded, and categorized the events, and evaluated the level of reflection. All four then worked together to group the categories into themes. Six major themes were identified: (1) process of making clinical decisions; (2) complexity and richness of interactions with patients; (3) effects of the practice environment on learning and patient care; (4) acquisition of clinical and administrative skills; (5) value of clinical experiences in validating and integrating previous learning; and (6) acknowledgment and evaluation of different learning methods. The majority of the students (42) demonstrated a new understanding as a result of their reflections. Journal writing demonstrated that the students recognized the value of their clinical experiences and that they were reflective practitioners.]



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