2014; 36: 121–129
Medical students’ reflective writing about a task-based learning experience on public health communication YANG HUANG KOH, MEE LIAN WONG & JEANETTE JEN-MAI LEE National University of Singapore, Singapore
Abstract Background: Medical educators constantly face the challenge of preparing students for public health practice. Aims: This study aimed to analyze students’ reflections to gain insight into their task-based experiences in the public health communication selective. We have also examined their self-reported learning outcomes and benefits with regard to application of public health communication. Method: Each student wrote a semi-structured reflective journal about his or her experiences leading to the delivery of a public health talk by the group. Records from 41 students were content-analyzed for recurring themes and sub-themes. Results: Students reported a wide range of personal and professional issues. Their writings were characterized by a deep sense of self-awareness and social relatedness such as increased self-worth, communications skills, and collaborative learning. The learning encounter challenged assumptions, and enhanced awareness of the complexity of behaviour change Students also wrote about learning being more enjoyable and how the selective had forced them to adopt a more thoughtful stance towards knowledge acquisition and assimilation. Conclusions: Task-based learning combined with a process for reflection holds promise as an educational strategy for teaching public health communication, and cultivating the habits of reflective practice.
Introduction
Practice points
Preparing medical students for professional practice has always been challenging. It is not enough for educators to simply develop the knowledge base of their students. Educators must ensure their students also develop the affective and intellectual processes so essential to ‘defensible and ethical decision-making that is grounded in the best available evidence’ (Baird 2008). To meet this challenge, increasing numbers of medical educational programmes have applied pedagogical strategies to improve learning outcomes. One such strategy is that of a task-based learning (TBL) approach which designs learning around an actual task addressed by healthcare professionals (Parry 1989). TBL has been shown to be an ‘educationally sound, effective and efficient strategy for delivering relevant education’ (Harden et al. 1996). In undergraduate education for health professionals, TBL supports integration of medical knowledge with patient care by providing the context for learning (Patel et al. 1988; Lockyer 1992; Lofaro & Abernathy 1994) and developing transferable skills (Halloran 2006). However, one cannot assume that task performance alone can produce learning. Indeed, learning requires ‘an ongoing dialectal process of action and reflection’ (Marsick & Watkins 1990, p.8). Without reflection, a task experience will merely become another event (Saltmarsh 1996). Although many
. TBL combined with a process for reflection holds promise as an educational strategy for teaching public health communication. . Self-reported learning outcomes include enhanced selfawareness and social relatedness, and an appreciation of the need to consider the audience’s needs and expectations. . TBL provides the context for self-directed and collaborative learning.
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students fail to appreciate the utility of reflective exercises, research has shown that reflection enriches learning and constitutes a clinically relevant skill for future practice (Mann et al. 2009). Increasingly, reflection is also seen to promote collaborative learning among peers and colleagues (Biesta 2007). To that end, effective learning must combine action and reflection to help students develop new understanding and appreciation of task experiences, and a motivation to cope differently with future challenges (Dewey 1933; Boud et al. 1985; Schon 1983, 1987; Mezirow 1991; Kolb 1994). Educators often use artefacts to facilitate reflection. One commonly used artefact is the reflective journal (Henderson et al. 2003; Sandars 2009). Writing a journal helps the student
Correspondence: Yang Huang Koh, Health Promotion Board, Health Promotion Academy, No. 3, Second Hospital Avenue, Singapore 168937, Singapore. Tel: (65)-64353820; fax: (65)-64383609; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/020121–9 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.849329
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become aware of his or her actions, thoughts and emotions (Epstein 1999). It is an expression of commitment to learning and ownership of experience, and offers opportunities for collaborative learning (Aronson 2010). It is important that proper guidance and education about reflection accompany the use of an artifact, otherwise it may lead to reflection that is devoid of learning (Wong et al. 1995). Structured prompts, such as asking questions, are often used to facilitate critical reflection. In the medical professions, reflective journals have been used to help medical students and residents learn from and make sense of their experiences so as to improve learning outcomes and clinical performance (Sobral 2000; Blatt et al. 2007; Mamede et al. 2008; Toy et al. 2009; Haywood et al. 2010). To date, there is little research describing students’ reflections documented as verbatim regarding the teaching of public health communication (PHC). This study attempts to fill the void. We analyzed students’ writings to gain insight into their learning experiences and examine what learning outcomes and benefits students reported with regard to application of concepts of PHC. Information gained from this study can help us appreciate task-based learning, reflective learning, and the use of these two pedagogical approaches to engage students more effectively in the application of public health knowledge.
Background The study was conducted among third-year medical students posted to the Saw Swee Hock School of Public Health (SPH) at the National University of Singapore (NUS) for the selective on PHC. Prior to 2012, PHC teaching was conducted as a ‘stand alone’ series of 2-hour tutorials where students applied the course content they had previously learnt through role playing doctor-patient communication skills in small groups. With effect from 2012, however, the selective has become embedded within the family medicine posting, the rationale
Methods Sample The participants in this study were drawn from the academic cohort of 2012/13. They were divided into five batches of 20 to 22 students each and staggered to take the selective over five time periods from July 2012 to April 2013. Students were not allocated into sequential batches in any pre-determined manner that might have biased the results.
Selective The posting comprised six hours spread over two weeks, during which students had to perform several tasks (Figure 1) that included delivering a one-hour lunchtime talk to an audience of SPH. As the group was large, only some students got to present. The rest researched content and prepared teaching materials. At the end of the posting, students completed a feedback survey. Throughout the selective, students reflected on their experiences and recorded entries on an individual basis soon right after: (1) tutorial briefing, (2) proposal presentation to the class and (3) delivery of talk. Students received a one-page reflection guideline and a list of question prompts to help them write their journal (Appendix).
Session 1
Session 2
Tutorial Briefing (2 hours)
Proposal presentaon (2 hours)
Conduct of talk (1 hour)
Tasks:
Tasks:
Tasks:
Tasks:
Students brainstorm ideas, discuss and come to a consensus on the title/theme and activities for the talk; design a publicity poster; arrange for interview with SPH staff; write journal
Students present their ideas and proposal and receive feedback from team mates and tutor; review presentation; assign roles and duties among themselves; make plans for rehearsals; write journal
Students conduct final preparations and rehearsals; deliver talk to SPH staff; conduct evaluation; write journal
Students receive feedback about the talk; share thoughts and reflections on what they have learnt; give feedback on the learning encounter; submit journal to course administrator
Figure 1. 122
being that one-to-one communication skills are better framed within a clinical practice context. Following these changes, it was learnt that the ‘new’ PHC should introduce a broader community perspective to promoting health and focus on health communication to larger groups instead. The new focus gives us an opportunity to try out new instructional strategies and examine how the new pedagogical approach might contribute to the teaching/learning of PHC more effectively.
Session 3
Post-talk debrief (2 hours)
Conceptual framework showing learning tasks in the PHC selective.
Medical students’ reflective writing
Table 1. Socio-demographic characteristics of 2012/13 academic cohort (N ¼ 106).
Data collection To protect confidentiality, journals were submitted to the course administrator who replaced each student’s name with a numerical code before passing the records to the researchers for analysis.
Data analysis For this study, data saturation was reached after analysing 36 reflection records. An additional five records were analysed to confirm data saturation and ensure sample sufficiently reflected the diversity of the student cohort. The final sample (N ¼ 41) represented approximately 38% of the 2012/13 academic cohort posted to SPH. As many journals were handwritten, a manual analysis was undertaken. The three members of the research team independently read through each record to identify broad themes/patterns in the meanings embedded in the students’ writings. Criteria for thematic analysis were based on certain phrases or statements that either (a) kept recurring, (b) addressed the research questions, (c) were particularly revealing of the phenomenon, or (d) stood out from the rest as being minority opinions. The principal investigator (KYH) prepared a preliminary summary of the commonly repeated themes and verbatim excerpts from the essays to support the themes. The principal investigator then analyzed the records again, including line by line analysis of content, to uncover common sub-themes/ meanings as well as ‘deviant’ meanings that stood out from the rest. The investigator then met with the research team to discuss and refine a list of emerging themes and their meanings. Sub-themes were then categorised according to how they relate to the research questions. As a result, three major themes were identified: personal and professional growth, enhanced learning, and commitment to patient care. The research team consulted and agreed on the final list of themes and sub-themes, and chose quotes that best represented/expressed the thematic meanings, and the minority opinions.
Validity The trustworthiness of the data and interpretations was further validated through the authors’ observations and cross-checking with tutors’ observations and students’ feedback during the group debrief. This study was approved by the Institutional Review Board of the National University of Singapore.
Male n ¼ 61
Female n ¼ 45
Total n ¼ 106
49 1 9 2 61
39 4 2 0 45
88 5 11 2 106
Chinese Malay Indian Others Total
Table 2. List of topics.
Batch
Theme
A
Insomnia
B C D
Health for the family Health and well-being Living with loss and grief Physical activity
E
Topic Sex: not the only thing that keeps you up at night Your family is healthy? Truth or Myth Living the good life Aging gracefully: don’t let the small things in life get you down Exercise for life
Table 3. Themes and sub-themes from reflection records (N ¼ 41).
Themes and sub-themes Theme 1: Personal and professional growth Apprehension Self-awareness Challenged assumptions Collaboration Achievement Theme 2: Enhanced learning Communication to target audience and patient Complexity of behaviour change Theory-practice integration Self-directed learning Theme 3: Commitment to patient care Respect for patients and holistic care
Number of records (%) 17 16 13 30 21
(41%) (39%) (32%) (73%) (51%)
29 10 20 17
(71%) (24%) (49%) (41%)
19 (46%)
batches of students. For this section, we included only those sub-themes that appeared in 20% or more of the records. A typical essay described a variety of personal and professional issues. While the majority of students described and analysed their experiences in depth, some produced scanty and superficial reports. A handful went beyond description and analysis to construct new learning paradigm and challenge existing assumptions. These writings were characterized by a deep sense of self-awareness, emotional expressions and feelings.
Results One-hundred-and-six third-year medical students aged between 20 and 21 years chose the PHC selective. Table 1 describes the cohort’s socio-demographic characteristics by gender and ethnicity. Table 2 shows the topics chosen by the students. forty-one reflection records were analysed. Of these, 29 contributed to the thoughts and feelings of the quotes. Table 3 highlights major themes and sub-themes that emerged from the student reflections. These were consistent across different
Theme 1: Personal and professional growth Apprehension. Close to half the students were apprehensive when told they had to deliver a public talk. Many ‘did not know what to expect’ (S2.5), complaining that the tutorial briefing was too brief and not ‘structured’ enough (S3.14). They cited four reasons for their apprehension. Many ‘did not feel that members of the public will be convinced or assured of what medical students present because students are still not professionals’ (S2.13). Second, given the unfamiliarity of the
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task, heavy workload, and tight deadline, many were doubtful they could ‘pull through with it’ (S2.6).Third, many anticipated difficulty working with a wide range of personalities and temperaments. Finally, they were not used to the new method of teaching, preferring ‘structured learning with tutorials and a presentation’ (S3.14). They felt that there were too many unknown factors such as: ‘we were not provided much information regarding our audience’ and ‘lack of information (about) the topic’ (S3.17). Following the initial surprise, ‘things just fell into place’ (S3.14). Students described how they coped with the challenge by drawing on past experiences, brainstorming ideas, prioritising and sharing work. Inspite of the tension, one student wrote, ‘I was . . . grateful in a sense to be put under that sort of pressure because it’s only then can we bring our best efforts’ (S3.2). Another student described the preparation for the talk as ‘a rather enjoyable time’ (S3.14). Self-awareness. Students felt that reflecting on the task helped them to know themselves better, both personally and professionally. They gained insight into various personal characteristics including work ethics, limitations and strengths. Having taken the initiative to lead the group and develop the self-administered quiz before and after the talk, one student wrote, ‘I am actually more responsible than I thought of myself’ (S3.16). Some also wrote about living up to the expectations of their team-mates and the audience. Some students commented that the task experience uncovered areas of limitations. One wrote about feeling reticent about sharing ideas in class, wishing she could be more assertive. Reflecting on lessons learned from a difficult group encounter, this student observed, ‘My group members were all more questioning and outgoing than I am, so I should learn from them. However, I think being quiet pays off because listening is an important part of communication’ (S2.6). Others discussed how taking on new challenges resulted in discovering their unique strengths. Having successfully worked with people he had ‘never spoken to before’, one student observed, ‘I’m more adaptable than I expected . . . and this was a real confidence boost that I could likewise adapt in the workforce’ (S3.2). Another unearthed a ‘spontaneous side’ to her personality which she ‘always thought to be non-existent’ (S3.12). Yet, others realised they were good at leading, organising, public speaking, and designing posters and slides. Challenged assumptions. Some students observed that they had entered the PHC selective harbouring certain inaccurate assumptions and stereotypes regarding their team-mates. Reflecting on his experiences, one student wrote, ‘Initially I expected members to shun taking on tasks for their own selfinterest, but I was proven wrong’ (S3.9). This student was impressed that in-spite of looming tests, his team-mates gladly undertook tasks to complete the project successfully. Another ‘dreaded working with people who had rather poor EQ [Emotional Quotient]’ He later relented, ‘I found that he had actually done a pretty good presentation . . . as a worker, he was a rather decent person’ (S3.14). Others were 124
surprised that ‘by-the-book’ medical students (S3.11) could generate creative ideas and concluded that group effort was not such a bad thing after all. Collaboration. The concept of collaboration was a recurring theme in the journals. Two-third of the students expressed wariness about collaborating with ‘people of different personalities and opinions’ (S3.1). One student concluded, ‘It’s true that not everyone knew each other, but we decide to give it a try anyway, because in real life, we would not be grouped with people we knew as well’ (S3.1). There were reflections on the nuances and benefits associated with collaboration. Students came to realize it was possible for people with ‘different personalities’ (S3.1) to work well together, and that effective collaboration involved building rapport, listening, showing respect, caring and appreciating diversity. Some students discussed realizing that everyone has a unique role to play. One student commented that teamwork does not have to be about ‘equitable contribution from everyone’. She elaborated, ‘Good teamwork is by establishing a common mentality and goals amongst a group of people with different mindsets . . . I have learnt that my team members . . . are willing to give their best. Some of them are leaders, some are creative idea generators, some are IT experts and some are fabulous public speakers, and all of us work together to make our project as successful as possible’ (S3.13). Another student wrote about being ‘pleasantly surprised’ with her team-mates. She shared, ‘I was touched that my group mate was looking out for my well-being, and that this was a group that wasn’t selfish, or all about self-preservation, which was quite rare nowadays’ (S3.4). When faced with opposing views, students commented on the need ‘to adapt and avoid conflicts’ (S3.11), ‘work together towards the common goal of the project’ (S3.5), and come to a ‘peaceful compromise’ (S2.6). There were several experiences where students wrote about having to ‘express disapproval’ (S3.12) or communicate negative feedback. In one case, a student had to disagree with a colleague regarding his slides. She wrote, ‘One cannot simply agree with everything that others say!. . . What I have found to be a good substitute to criticism is proposal . . . If I disagreed with someone, I would avoid criticizing his ideas, but I allowed myself to propose something else. In this way, I was able to express my own ideas without having to find fault with other people’s ideas’ (S3.12). Achievement. Overall, students evidenced a positive attitude towards the end of the selective, seeing it as giving them the opportunity to collaborate with their peers to accomplish something that is meaningful and relevant to their future practice as a doctor: Students discussed how coping with difficult situations resulted in their becoming more confident. For one student, the experience had left a ‘lasting impact’ on her; she ‘felt accomplished at having made a presentation to complete strangers over the course of a few days’ and were ‘heartened’ that her group ‘worked seamlessly together to deliver an effective presentation’ (S3.17). Others wrote about discovering positive things and feeling proud about themselves and their team-mates. As one student
Medical students’ reflective writing
boasted, ‘The experience . . . has reinforced the power of teamwork to me, as we are able to face unprecedented challenges with confidence and courage when we know that we are not alone’. He further added, ‘I now realize that with enough thought and effort put in, even students giving a presentation can have something to give away to our audience’ (S3.13).
Theme 2: Enhanced learning Communication to target audience and the patient. Twothird of the students discussed the struggles they went through while developing ideas for the talk. Students found that they did not know their target audience. Reflecting on the gap, one student concluded, ‘I realised . . . it is important to look at the patient, in this case, audience’s ideas, concerns and expectations . . . this was what we were lacking in, as we had not done a proper survey/focus group discussion in order to find out what in particular the audience would like to hear and discuss’ (S3.14). They also struggled to find ways to engage the audience. Students shared about: ‘personalising the message’ (S2.13), ‘keeping the message short and simple’ (S2.1), ‘avoid the use of medical jargon’, ‘attract the attention’ (S2.15), ‘giving the audience a sense of self-control’ (S2.4), ‘stimulating their visual, hearing and physical senses’ (S3.8), ‘give them instant feedback’, ‘use emotional/positive appeal’ (S2.13), ‘increase participation’ (S2.10) and so on. Students discussed how they might apply lessons learned to their future practice. A student’s comment on this issue speaks for the majority, ‘In patient education, I could definitely apply the same principles. When conveying any message, to be simple, genuine, personal, clear, and honest, to know my target audience and what they value. When prompting behaviour (change), I would set realistic goals for them, giving them a sense of self-control, and using positive appeal’ (S3.4). Another student had the opportunity to ponder on the importance of patient-centred care. She mused, ‘Every patient is different . . . Knowing when to use the appropriate methods . . . may be more effective in convincing a patient to make the necessary lifestyle modification’ (S3.10).
Complexity of behaviour change. The writings indicate an emerging awareness of the complexity of behaviour change. Students realized that a one-off talk is not enough to change people’s behaviour. They recognised that people are at ‘different points in their behavioural states of change’ (S3.6), with different beliefs and misconceptions. One student reflected, ‘ . . . especially in our Asian society, where misconceptions like these are passed down for years in our families. I foresee having to tackle such a barrier in the future – where patients have age-old beliefs ingrained in them’ (S2.3). Another student noted that ‘there needs to be more than just (giving) information’ in a talk (S2.5). Yet, another wrote about sustaining ‘impact even after the talk has ended’ and suggested that a talk should stimulate discussion and encourage people to share health messages with their friends.
Theory-practice integration. Although close to half of the students gave examples of how particular theories or concepts applied to the task, some did not automatically relate theoretical knowledge on behaviour change to the task until prompted by the tutor during the post-talk debrief. One student confessed, ‘When (the tutor) had mentioned about the health belief model (HBM), I realized that none of us had actually given it serious thought when crafting this presentation’ (S3.14). One student enthused about the HBM, ‘This selective has reinforced this HBM, a concept that was taught a couple of years ago. I really appreciate this . . . recap because I feel that this is a really important aspect of medicine. With this model as a guide it really helps us as future doctors to think from the patient’s perspective – the push and pull factors that trigger someone to perform a certain course of action’ (S3.2). Not all students agreed with her. One found theories more ‘enlightening’ than ‘practical’ when it came to solving real life problems: ‘Enlightenment about theories and application . . . how practical is it to use theories all the time instead of responding to what audience needs – a ‘human touch?’ (S2.6). Another felt that there was no need for a ‘strict structure to follow’ when counselling patients (S3.14). However, further analysis of the records showed that the perceived lack of utility of theoretical knowledge among some students was not because they did not find theoretical knowledge useful, rather, they had applied it subconsciously as observed by this student: ‘It is interesting to note that we subconsciously used the HBM even though we didn’t think about it’ (S2.17). Self-directed learning. Student reflections generally evidenced a highly positive attitude towards the learning encounter. When describing what they liked most about the selective, one student commented on its authenticity: ‘ . . . the public health talk has provided us with a platform to learn the skill that is definitely not present in textbooks’ (S2.5). Another wrote about being engaged: ‘When I realized that we were indeed doing a topic that interested the SPH staff, it made us even more motivated to put up a good talk’ (S2.1). Other comments included having the opportunity to research on topics not normally taught in the medical curriculum. Interestingly in the feedback survey, 60% of the PHC student cohort (n ¼ 106) rated the reflective exercises ‘useful’ or ‘very useful’ (Table 4). One student explained, ‘Without reflection, I would have let this experience fade into a distant memory without identifying the principles of public health education. . .. Now I have more knowledge. . . to tap into if tasked to conduct a public health talk in the future’ (S3.6). Another concluded, ‘Reflection is of paramount importance to the growth of every individual . . . If reflection is done habitually, growth and development can result . . . Although a single reflective exercise by no means will cause a radical change in the mindset of every medical student, I firmly believe that the introduction of such exercises is a giant leap in the right direction’ (S3.7). A few also commented on the discrepancy in curricular significance for different learning activities, pointing out that reflective exercises deserved a ‘more significant grading’ (S2.5) in the public health curriculum.
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Table 4. Students’ feedback regarding the PHC selective (N ¼ 106 students).
Batch 1 (Pilot) (n ¼ 23 students) Question Tutorial: PH Communication Objectives and content were clear Content relevant to Phase III Learnt something useful and relevant to future role as a doctor Found writing reflections useful [question inserted only for Batch 4 & 5]
Batches 2–5 (n ¼ 83 students)
Score 4–5 (%)
Score 1–2 (%)
Score 4–5 (%)
Score 1–2 (%)
61 50 76 Not applicable
6 11 6 Not applicable
83.5 79.3 82.9 60
0 2.1 0 4.0
The scoring is based on a Likert Scale of Strongly Agree (5), Agree (4), Neutral (3), Disagree (2) and Strongly Disagree (1). Scores did not add up to 100% as ‘3’ was excluded.
Still others wrote about the benefits of collaborative learning. Two types of team collaboration emerged from the writings: cognitive (e.g. researching and sharing information, giving and receiving feedback, learning by observation), and emotional (encouraging, affirming, giving support). The following sentiment was frequently repeated: ‘All of us were eager to learn from each other and were really positive towards the constructive advice given by fellow teammates’ (S2.2). Writings were also filled with colourful descriptions of how the brainstorming process had generated creative ideas. Having been exposed to didactic lectures in the first two years, another student stated, ‘(The selective has) helped me to think differently as compared to when I started medical school’ (S2.16). Perhaps, the most impressive comment must come from this student: ‘I derived a lot of satisfaction from putting effort into this presentation for the fact that it was not graded’ (S3.7).
Theme 3: Commitment to patient care Respect for patients and holistic care. Having gained insight into PHC, several students realized that diversity is an integral part of a doctor’s work, requiring one to be respectful of people with differing backgrounds and beliefs. One student narrated, ‘For example, the delightful Malay lady that I interviewed . . . her reasons were all based on religion not the science that we studied. Does that mean I should correct her? I learnt of course not!! Respect for our patients takes precedence as it’s only if they think you respect them would they trust you’ (S2.5). A number of such desires were expressed, including: (1) avoiding a ‘paternalistic traditional role’ (S3.13); (2) engaging the patients ‘to appreciate how they can have a different take on decisions’ (S3.16); (3) integrating their views into clinical decision making (S3.16); (4) working ‘around these beliefs to best help the patient’; (5) giving ‘the patient hope’ (S2.9); and (5) being ‘passionate and sincere’ (S2.1). Students also became aware that a doctor’s work must necessarily ‘contribute to behaviour change to improve the health of communities’ (S2.13). To achieve this, one student highlighted the importance of ‘working together . . . in a multidisciplinary team’ (S3.7). The following excerpt summarized students’ thoughts on this issue: ‘I learnt that public health is very relevant to our roles as clinicians. Patient education and helping our patients share greater responsibility 126
for their health is one of the ways towards a happier and healthier population. This is relevant regardless of the field of medicine we decide to pursue. As such, we as future doctors have to be skilled in planning and executing an effective health talk that will. . . challenge them to take action for their health’ (S3.6).
Deviant findings Not all students described positive learning outcomes and benefits associated with the selective. A small number (n ¼ 3) made judgemental comments about their colleagues, complaining that ‘nobody stepped up, nor did anyone take the initiative’ (S3.4), not being punctual, and not contributing enough to the project. One student rejected the notion of shared decision making between doctor and patient, insisting that the ‘final decision’ should reside with the doctor who is the expert. Two students disliked the way the selective was taught. One was ‘deeply skeptical about behavior change models’ (S4.1). She wrote, ‘I think there are aspects of each model that work but that could equally be learnt from experience and exposure, but using an entire model in a rote fashion just doesn’t work for me.’ Another complained that ‘there is nothing more soul numbing than the idea of a cliche´ topic being presented in a controlled environment’ (S4.11).
Discussion Medical educators constantly face the challenge of preparing students to be effective public health practitioners. While there has been a growing trend in medical education to implement a variety of educational strategies to better prepare students for a changing profession, information with which to assess student learning outcomes has been lacking. Our findings suggest that TBL that incorporates a process for reflection, which in this study was facilitated by reflective journal writing, has potential as a curricular strategy to enhance the quality of medical education. Students in the study reported a broad range of learning outcomes and benefits. The results are consistent with previous studies on TBL and reflective learning (Mann et al. 2009). Students expressed that they had become more appreciative of their team-mates and it was possible for people of different temperaments to work well together.
Medical students’ reflective writing
In the process, they discovered their own sense of identity including strengths and limitations, and how they related to others within the context of task performance. Some students reported experiencing a sense of empathy and respect for patients, and a realization that each person has his or her own narrative. Their writings indicated a growing awareness of the socio-cultural determinants of behaviour change. For these students, the learning experiences enabled them to appreciate the role patient education can play in impacting lives at both individual and community level. The task also provided a context within which students developed their reflective skills with the aid of journal writing. Through reflection, students gained confidence in becoming a public health communicator. For example, students became aware of past attitudes and behaviours that affect patient communication, and the need to ‘know your audience’. Fostering reflective skills should be a key component in medical education and life-long professional growth (Westberg & Jason 1994; GMC 2005; CFPC 2007). The ‘new’ learning approach had also forced students to assume a more questioning and thoughtful stance towards knowledge acquisition and assimilation. Instead of being passive recipients of knowledge, students adopted a deeper and more collaborative approach to learning. Essays were filled with positive emotions such as ‘heartening’, ‘satisfied’, ‘pride’, ‘achievement’ and ‘touched’. Such emotional expressions can help students appreciate the importance of building trust, collective decision making, achieving consensus, and providing emotional support. For many, this ‘real world’ experience facilitated the process of theorypractice integration and brought conceptual knowledge to life. It was apparent from the writings that many students regarded the learning encounter as providing valuable learning experiences that prepared them for future practice as a doctor. We also found a small number of students making judgemental comments about their colleagues. Although these were atypical findings, they may represent the ‘tip of the ice-berg’ suggesting that there may be a need to address this issue early in the medical curriculum. A few felt that the talk should be conducted with a bigger audience and held at a community venue to enhance authenticity. Clearly, TBL is not a simple panacea for our educational challenges. As our study shows, however, it can play a role in enhancing the educational and professional development of a medical student (Harden et al. 1996). For TBL to be meaningful: (1) learning must be situated in an authentic context that is able to stimulate experiential learning (Kolb 1984; Marsick & Watkins 1990; Boud et al. 1993); and (2) students must be given a ‘safe space’ to examine their experiences and draw insights for future applications (Eyler et al. 1996; Henderson et al. 2003). Writing, drawing or talking about one’s experiences helped to uncover hidden prejudices and generate insights (Eyler et al. 1996). Overall, our findings are consistent with most researchers’ conclusion that reflection is a useful learning strategy (Mann et al. 2009). To that end, the SSH-SPH may consider integrating reflection into the public health curricular structure instead of having just a once-off activity.
There are some limitations to this study. First, interpretation of qualitative data is an inherently subjective process. To reduce researcher bias, multiple researchers analysed the data. Conclusions were also cross-checked with tutors’ observations and students’ feedback (Table 4) thus establishing research triangulation. Second, students may have provided politically correct responses. However this is minimal as reports were confidential and not graded. Third, the findings were confined to students’ reflections. It would have been preferable to have included the written perspectives of the tutors and the modular co-ordinator regarding learning outcomes. Including oneto-one interviews could have allowed a more in-depth exploration of students’ thoughts, but was excluded due to insufficient time. Finally, the context for this research was a NUS third year medical undergraduate programme on PHC. However, the findings are likely to be relevant to other subject areas.
Conclusion Medical schools are constantly challenged to improve the way medicine is taught and learnt. Journal records allowed us to gain insights into how students thought and felt about taskbased learning experiences. Our findings highlighted the learning outcomes and benefits students reported. TBL, combined with reflection, helps to: (1) engage students more effectively in the application of public health knowledge to ‘solve’ real-world issues; (2) develop their skills in critical thinking and self-directed learning; and (3) inculcate in them a sense of social responsibility to their patients and the community they serve. Further research is needed to examine the nature of learning structure, and how task activities and tutor-student interaction might be harnessed to help our students move from superficially engaging with experiences to creating a practice of reflection that is part of their daily life.
Acknowledgements The authors would like to thank the 2012/13 cohort of thirdyear medical students of the NUS for their support and participation in this research, as well as the tutors who supervised the selective. Declaration of interest: The authors report no declarations of interest.
Notes on Contributors YANG HUANG KOH, MPH, MBBS, is the Principal Consultant of the Health Promotion Board Singapore, and an Adjunct Asst-Professor at the Saw Swee Hock School of Public Health. MEE LIAN WONG, MPH, MD, is Program Director and Associate Professor in the Saw Swee Hock School of Public Health of the National University of Singapore JEANETTE JEN-MAI LEE, MBBS, is the Vice Dean (Education) of the Saw Swee Hock School of Public Health of the National University of Singapore.
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References Aronson L. 2010. Do writing and storytelling skill influence assessment of reflective ability in medical students written reflections? Acad Med 85:S29–S32. Baird MA. 2008. Towards the development of a reflective radiographer: Challenges and constraints. Biomed Imag Intervention J 4(1):1–8. Biesta G. 2007. Foundations of democratic education: Kant, Dewey, and Arendt in democratic practices as learning opportunities. Rotterdam: Sense Publishers. Blatt B, Plack M, Maring J, Simmens SJ. 2007. Acting on reflection: The effect of reflection on students clinical performance on a standardized patient examination. J Gen Int Med 22:49–54. Boud D, Keogh R, Walker D. 1985. Reflections: Turning experience into learning. London: Kogan Page. Boud D, Cohen R, Walker D. (Eds.) 1993. Using experience for learning. Milton Keynes: Society for Research into Higher Education and Open University Press. College of Family Physicians of Canada (CFPC). 2007. Eligibility requirements and general information. [Accessed 3 March 2013] Available from http://www.cfpc.ca/eligibility/. Dewey J. 1933. How we think. Revised edition. Boston: D.C, Heath. Epstein RM. 1999. Mindful practice. J Am Med Assoc 282:833–839. Eyler J, Giles DE, Schmiede A. 1996. A practitioners guide to reflection in service-learning: students voices and reflections. Nashville: Vanderbilt University. General Medical Council (GMC) 2005. Licensing and revalidation factsheet. [Accessed 13 March 2013] Available from http://www.gmc-uk.org/ doctors/licensing.asp Halloran DO. 2006. Task-based learning: A way of promoting transferable skills in the curriculum. J Vocational Educ Train 531:101–116. Harden RM, Laidlaw JM, Ker JS, Mitchell HE. 1996. AMEE Medical Education Guide No. 7. Task-based learning; an educational strategy for undergraduate, postgraduate and continuing medical education, part 1. Med Teach 181:7–13. Haywood C, Lanzkron S, Hughes M, Massa M, Ratanawongsa N, Beach MC. 2010. A video-intervention to improve clinician attitudes toward patients with sickle cell disease: The results of a randomized experiment. J Gen Internal Med 265:518–523. Henderson E, Hogan H, Grant A, Berlin A. 2003. Conflict and coping strategies: A qualitative study of student attitudes to significant event analysis. Medical Education 37:438–446. Kolb DA. 1984. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall.
Appendix: Reflection guideline on how to write a reflection journal This tutorial requires you to complete a community service activity, in this case, to design and deliver a public ‘talk’ to about 30–40 staff from the SPH. Purpose: The purpose of writing reflective journal is to help you critically examine your own knowledge and what you have been taught about public health communications and theories of behaviour change in the light of your experience. For you to learn from the service experience, you will need to ‘reflect’ on your experiences. This means stepping back from the experience and actually thinking about what happened and why it happened. You may find this difficult to do in the beginning, but the experience is extremely valuable in the end. Think of your journal as a combination of an activity log, a diary, and a critical thinking essay. This means you take note of what you actually did, as well as your perceptions, 128
Kolb DA. 1994. Learning styles and disciplinary differences. In: Feldman KA, Paulsen MB, editors. Teaching and learning in the college classroom. Needham Heights, MA: Ginn Press. pp. 151–164. Lockyer JM. 1992. Physician performance: The roles of knowledge, skill, and environment. Teach Learn Med 4(2):86–96. Lofaro MJ, Abernathy CM. 1994. An innovative course in surgical critical care for second-year medical students. Acad Med 69:241–243. Mamede S, Schmidt HG, Penaforte JC. 2008. Effects of reflective practice on the accuracy of medical diagnosis. Med Educ 42(5): 468–475. Mann K, Gordon J, MacLeod A. 2009. Reflection and reflective practice in health professions education: A systematic review. Advance Health Sci Educ 14:595–621. Marsick VJ, Watkins KE. 1990. Informal and incidental learning in the workplace. London: Routledge. Mezirow J. 1991. Transforming dimensions of adult learning. San Francisco, CA: Jossey-Bass. Parry KM. 1989. The curriculum for the year 2000. Report of a Conference of the Association for the Study of Medical Education. Med Educ 23:301–304. Patel VL, Groen GJ, Scott HM. 1988. Biomedical knowledge in explanation of clinical problems by medical students. Med Educ 22:398–406. Saltmarsh J. 1996. Education for critical citizenship: John Doweys contribution to the pedagogy of community service learning. Michigan J Community Service Learn 3:13–24. Sandars J. 2009. The use of reflection in medical education: AMEE Guide No. 44. Med Teach 31:685–695. Schon D. 1983. The reflective practitioner. San Francisco: Jossey-Bass. Schon D. 1987. Educating the reflective practitioner. San Francisco: Jossey-Bass. Sobral D. 2000. An appraisal of medical students reflection-in-learning. Med Educ 34:182–187. Toy EC, Harms KP, Morris Jr RK, Simmons JR, Kaplan AL, Ownby AR. 2009. The effect of monthly resident reflection on achieving rotation goals. Teach Learn Med J 21:15–19. Westberg J, Jason H. 1994. Fostering learners reflection and selfassessment. Fam Med 26:278–282. Wong KY, Kember D, Chung YF, Yan L. 1995. Assessing the level of student reflection from reflective journals. J Advanced Nurs 22(1):48–57.
emotions, expectations, challenges, and successes. MOST IMPORTANTLY, you take a step back and look at the entire situation (including yourself and your role) from the outside. Thus, you note how the experiences fit or connect with what you have heard, read, or studied about public health communications. In a journal entry, you write what you like, not what you think the tutor/lecturer wants to hear. You just write freely, and not worry about grammar or making a good impression. And it doesn’t have to be long. Write as soon as possible after each experience. Use the template to record your entries. Submit it via e-mail by the due date to your tutor. . Information collected will help us review and improve the way we conduct our teaching. We just want your thoughts and impressions. . When you are discussing people (including your colleagues), do not use their real names. Instead, invent a name for that person.
Medical students’ reflective writing
. All information collected is confidential and known only to the tutor. For example, I will not disclose who actually wrote this journal. I hope this will encourage you to share freely. A sample of question prompts Use this structure to write your journal.
At students’ own time (You can choose to record your experiences after each meeting OR you can collapse them into one entry.) Date: _____________
Venue: _________________
Time: _____________________
Activity log
What happened before, during, and after the event? List the people, things, content in sequence. Has anything surprised you? What made an impact on you? Do you have the information or skills to deal with the situation? If there is a lack of information or skills, why do you think you have this lack? What is the underlying reason for unresolved issues, if any?
Diary
What made you feel happy/satisfied or uncomfortable/unhappy/frustrated? In either case, why do you think you felt that way? Who or what was involved with you when the feelings occurred? What were some things you wanted to say or ask, but did not? Why not? What have you contributed? What have you learnt about yourself and your group members? Are there any striking thoughts, ideas, or insights?
Critical thinking
Integrate any of the theoretical issues related to behaviour change and health communications you have learnt from lectures/readings with your observations/experiences. How might you apply/relate theoretical content and experience to your role as a doctor in patient education and patient care?
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Medical students’ reflective writing about a task-based learning experience on public health communication YANG HUANG KOH, MEE LIAN WONG & JEANETTE JEN-MAI LEE National University of Singapore, Singapore
Abstract Background: Medical educators constantly face the challenge of preparing students for public health practice. Aims: This study aimed to analyze students’ reflections to gain insight into their task-based experiences in the public health communication selective. We have also examined their self-reported learning outcomes and benefits with regard to application of public health communication. Method: Each student wrote a semi-structured reflective journal about his or her experiences leading to the delivery of a public health talk by the group. Records from 41 students were content-analyzed for recurring themes and sub-themes. Results: Students reported a wide range of personal and professional issues. Their writings were characterized by a deep sense of self-awareness and social relatedness such as increased self-worth, communications skills, and collaborative learning. The learning encounter challenged assumptions, and enhanced awareness of the complexity of behaviour change Students also wrote about learning being more enjoyable and how the selective had forced them to adopt a more thoughtful stance towards knowledge acquisition and assimilation. Conclusions: Task-based learning combined with a process for reflection holds promise as an educational strategy for teaching public health communication, and cultivating the habits of reflective practice.
Introduction
Practice points
Preparing medical students for professional practice has always been challenging. It is not enough for educators to simply develop the knowledge base of their students. Educators must ensure their students also develop the affective and intellectual processes so essential to ‘defensible and ethical decision-making that is grounded in the best available evidence’ (Baird 2008). To meet this challenge, increasing numbers of medical educational programmes have applied pedagogical strategies to improve learning outcomes. One such strategy is that of a task-based learning (TBL) approach which designs learning around an actual task addressed by healthcare professionals (Parry 1989). TBL has been shown to be an ‘educationally sound, effective and efficient strategy for delivering relevant education’ (Harden et al. 1996). In undergraduate education for health professionals, TBL supports integration of medical knowledge with patient care by providing the context for learning (Patel et al. 1988; Lockyer 1992; Lofaro & Abernathy 1994) and developing transferable skills (Halloran 2006). However, one cannot assume that task performance alone can produce learning. Indeed, learning requires ‘an ongoing dialectal process of action and reflection’ (Marsick & Watkins 1990, p.8). Without reflection, a task experience will merely become another event (Saltmarsh 1996). Although many
. TBL combined with a process for reflection holds promise as an educational strategy for teaching public health communication. . Self-reported learning outcomes include enhanced selfawareness and social relatedness, and an appreciation of the need to consider the audience’s needs and expectations. . TBL provides the context for self-directed and collaborative learning.
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students fail to appreciate the utility of reflective exercises, research has shown that reflection enriches learning and constitutes a clinically relevant skill for future practice (Mann et al. 2009). Increasingly, reflection is also seen to promote collaborative learning among peers and colleagues (Biesta 2007). To that end, effective learning must combine action and reflection to help students develop new understanding and appreciation of task experiences, and a motivation to cope differently with future challenges (Dewey 1933; Boud et al. 1985; Schon 1983, 1987; Mezirow 1991; Kolb 1994). Educators often use artefacts to facilitate reflection. One commonly used artefact is the reflective journal (Henderson et al. 2003; Sandars 2009). Writing a journal helps the student
Correspondence: Yang Huang Koh, Health Promotion Board, Health Promotion Academy, No. 3, Second Hospital Avenue, Singapore 168937, Singapore. Tel: (65)-64353820; fax: (65)-64383609; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/14/020121–9 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2013.849329
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become aware of his or her actions, thoughts and emotions (Epstein 1999). It is an expression of commitment to learning and ownership of experience, and offers opportunities for collaborative learning (Aronson 2010). It is important that proper guidance and education about reflection accompany the use of an artifact, otherwise it may lead to reflection that is devoid of learning (Wong et al. 1995). Structured prompts, such as asking questions, are often used to facilitate critical reflection. In the medical professions, reflective journals have been used to help medical students and residents learn from and make sense of their experiences so as to improve learning outcomes and clinical performance (Sobral 2000; Blatt et al. 2007; Mamede et al. 2008; Toy et al. 2009; Haywood et al. 2010). To date, there is little research describing students’ reflections documented as verbatim regarding the teaching of public health communication (PHC). This study attempts to fill the void. We analyzed students’ writings to gain insight into their learning experiences and examine what learning outcomes and benefits students reported with regard to application of concepts of PHC. Information gained from this study can help us appreciate task-based learning, reflective learning, and the use of these two pedagogical approaches to engage students more effectively in the application of public health knowledge.
Background The study was conducted among third-year medical students posted to the Saw Swee Hock School of Public Health (SPH) at the National University of Singapore (NUS) for the selective on PHC. Prior to 2012, PHC teaching was conducted as a ‘stand alone’ series of 2-hour tutorials where students applied the course content they had previously learnt through role playing doctor-patient communication skills in small groups. With effect from 2012, however, the selective has become embedded within the family medicine posting, the rationale
Methods Sample The participants in this study were drawn from the academic cohort of 2012/13. They were divided into five batches of 20 to 22 students each and staggered to take the selective over five time periods from July 2012 to April 2013. Students were not allocated into sequential batches in any pre-determined manner that might have biased the results.
Selective The posting comprised six hours spread over two weeks, during which students had to perform several tasks (Figure 1) that included delivering a one-hour lunchtime talk to an audience of SPH. As the group was large, only some students got to present. The rest researched content and prepared teaching materials. At the end of the posting, students completed a feedback survey. Throughout the selective, students reflected on their experiences and recorded entries on an individual basis soon right after: (1) tutorial briefing, (2) proposal presentation to the class and (3) delivery of talk. Students received a one-page reflection guideline and a list of question prompts to help them write their journal (Appendix).
Session 1
Session 2
Tutorial Briefing (2 hours)
Proposal presentaon (2 hours)
Conduct of talk (1 hour)
Tasks:
Tasks:
Tasks:
Tasks:
Students brainstorm ideas, discuss and come to a consensus on the title/theme and activities for the talk; design a publicity poster; arrange for interview with SPH staff; write journal
Students present their ideas and proposal and receive feedback from team mates and tutor; review presentation; assign roles and duties among themselves; make plans for rehearsals; write journal
Students conduct final preparations and rehearsals; deliver talk to SPH staff; conduct evaluation; write journal
Students receive feedback about the talk; share thoughts and reflections on what they have learnt; give feedback on the learning encounter; submit journal to course administrator
Figure 1. 122
being that one-to-one communication skills are better framed within a clinical practice context. Following these changes, it was learnt that the ‘new’ PHC should introduce a broader community perspective to promoting health and focus on health communication to larger groups instead. The new focus gives us an opportunity to try out new instructional strategies and examine how the new pedagogical approach might contribute to the teaching/learning of PHC more effectively.
Session 3
Post-talk debrief (2 hours)
Conceptual framework showing learning tasks in the PHC selective.
Medical students’ reflective writing
Table 1. Socio-demographic characteristics of 2012/13 academic cohort (N ¼ 106).
Data collection To protect confidentiality, journals were submitted to the course administrator who replaced each student’s name with a numerical code before passing the records to the researchers for analysis.
Data analysis For this study, data saturation was reached after analysing 36 reflection records. An additional five records were analysed to confirm data saturation and ensure sample sufficiently reflected the diversity of the student cohort. The final sample (N ¼ 41) represented approximately 38% of the 2012/13 academic cohort posted to SPH. As many journals were handwritten, a manual analysis was undertaken. The three members of the research team independently read through each record to identify broad themes/patterns in the meanings embedded in the students’ writings. Criteria for thematic analysis were based on certain phrases or statements that either (a) kept recurring, (b) addressed the research questions, (c) were particularly revealing of the phenomenon, or (d) stood out from the rest as being minority opinions. The principal investigator (KYH) prepared a preliminary summary of the commonly repeated themes and verbatim excerpts from the essays to support the themes. The principal investigator then analyzed the records again, including line by line analysis of content, to uncover common sub-themes/ meanings as well as ‘deviant’ meanings that stood out from the rest. The investigator then met with the research team to discuss and refine a list of emerging themes and their meanings. Sub-themes were then categorised according to how they relate to the research questions. As a result, three major themes were identified: personal and professional growth, enhanced learning, and commitment to patient care. The research team consulted and agreed on the final list of themes and sub-themes, and chose quotes that best represented/expressed the thematic meanings, and the minority opinions.
Validity The trustworthiness of the data and interpretations was further validated through the authors’ observations and cross-checking with tutors’ observations and students’ feedback during the group debrief. This study was approved by the Institutional Review Board of the National University of Singapore.
Male n ¼ 61
Female n ¼ 45
Total n ¼ 106
49 1 9 2 61
39 4 2 0 45
88 5 11 2 106
Chinese Malay Indian Others Total
Table 2. List of topics.
Batch
Theme
A
Insomnia
B C D
Health for the family Health and well-being Living with loss and grief Physical activity
E
Topic Sex: not the only thing that keeps you up at night Your family is healthy? Truth or Myth Living the good life Aging gracefully: don’t let the small things in life get you down Exercise for life
Table 3. Themes and sub-themes from reflection records (N ¼ 41).
Themes and sub-themes Theme 1: Personal and professional growth Apprehension Self-awareness Challenged assumptions Collaboration Achievement Theme 2: Enhanced learning Communication to target audience and patient Complexity of behaviour change Theory-practice integration Self-directed learning Theme 3: Commitment to patient care Respect for patients and holistic care
Number of records (%) 17 16 13 30 21
(41%) (39%) (32%) (73%) (51%)
29 10 20 17
(71%) (24%) (49%) (41%)
19 (46%)
batches of students. For this section, we included only those sub-themes that appeared in 20% or more of the records. A typical essay described a variety of personal and professional issues. While the majority of students described and analysed their experiences in depth, some produced scanty and superficial reports. A handful went beyond description and analysis to construct new learning paradigm and challenge existing assumptions. These writings were characterized by a deep sense of self-awareness, emotional expressions and feelings.
Results One-hundred-and-six third-year medical students aged between 20 and 21 years chose the PHC selective. Table 1 describes the cohort’s socio-demographic characteristics by gender and ethnicity. Table 2 shows the topics chosen by the students. forty-one reflection records were analysed. Of these, 29 contributed to the thoughts and feelings of the quotes. Table 3 highlights major themes and sub-themes that emerged from the student reflections. These were consistent across different
Theme 1: Personal and professional growth Apprehension. Close to half the students were apprehensive when told they had to deliver a public talk. Many ‘did not know what to expect’ (S2.5), complaining that the tutorial briefing was too brief and not ‘structured’ enough (S3.14). They cited four reasons for their apprehension. Many ‘did not feel that members of the public will be convinced or assured of what medical students present because students are still not professionals’ (S2.13). Second, given the unfamiliarity of the
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task, heavy workload, and tight deadline, many were doubtful they could ‘pull through with it’ (S2.6).Third, many anticipated difficulty working with a wide range of personalities and temperaments. Finally, they were not used to the new method of teaching, preferring ‘structured learning with tutorials and a presentation’ (S3.14). They felt that there were too many unknown factors such as: ‘we were not provided much information regarding our audience’ and ‘lack of information (about) the topic’ (S3.17). Following the initial surprise, ‘things just fell into place’ (S3.14). Students described how they coped with the challenge by drawing on past experiences, brainstorming ideas, prioritising and sharing work. Inspite of the tension, one student wrote, ‘I was . . . grateful in a sense to be put under that sort of pressure because it’s only then can we bring our best efforts’ (S3.2). Another student described the preparation for the talk as ‘a rather enjoyable time’ (S3.14). Self-awareness. Students felt that reflecting on the task helped them to know themselves better, both personally and professionally. They gained insight into various personal characteristics including work ethics, limitations and strengths. Having taken the initiative to lead the group and develop the self-administered quiz before and after the talk, one student wrote, ‘I am actually more responsible than I thought of myself’ (S3.16). Some also wrote about living up to the expectations of their team-mates and the audience. Some students commented that the task experience uncovered areas of limitations. One wrote about feeling reticent about sharing ideas in class, wishing she could be more assertive. Reflecting on lessons learned from a difficult group encounter, this student observed, ‘My group members were all more questioning and outgoing than I am, so I should learn from them. However, I think being quiet pays off because listening is an important part of communication’ (S2.6). Others discussed how taking on new challenges resulted in discovering their unique strengths. Having successfully worked with people he had ‘never spoken to before’, one student observed, ‘I’m more adaptable than I expected . . . and this was a real confidence boost that I could likewise adapt in the workforce’ (S3.2). Another unearthed a ‘spontaneous side’ to her personality which she ‘always thought to be non-existent’ (S3.12). Yet, others realised they were good at leading, organising, public speaking, and designing posters and slides. Challenged assumptions. Some students observed that they had entered the PHC selective harbouring certain inaccurate assumptions and stereotypes regarding their team-mates. Reflecting on his experiences, one student wrote, ‘Initially I expected members to shun taking on tasks for their own selfinterest, but I was proven wrong’ (S3.9). This student was impressed that in-spite of looming tests, his team-mates gladly undertook tasks to complete the project successfully. Another ‘dreaded working with people who had rather poor EQ [Emotional Quotient]’ He later relented, ‘I found that he had actually done a pretty good presentation . . . as a worker, he was a rather decent person’ (S3.14). Others were 124
surprised that ‘by-the-book’ medical students (S3.11) could generate creative ideas and concluded that group effort was not such a bad thing after all. Collaboration. The concept of collaboration was a recurring theme in the journals. Two-third of the students expressed wariness about collaborating with ‘people of different personalities and opinions’ (S3.1). One student concluded, ‘It’s true that not everyone knew each other, but we decide to give it a try anyway, because in real life, we would not be grouped with people we knew as well’ (S3.1). There were reflections on the nuances and benefits associated with collaboration. Students came to realize it was possible for people with ‘different personalities’ (S3.1) to work well together, and that effective collaboration involved building rapport, listening, showing respect, caring and appreciating diversity. Some students discussed realizing that everyone has a unique role to play. One student commented that teamwork does not have to be about ‘equitable contribution from everyone’. She elaborated, ‘Good teamwork is by establishing a common mentality and goals amongst a group of people with different mindsets . . . I have learnt that my team members . . . are willing to give their best. Some of them are leaders, some are creative idea generators, some are IT experts and some are fabulous public speakers, and all of us work together to make our project as successful as possible’ (S3.13). Another student wrote about being ‘pleasantly surprised’ with her team-mates. She shared, ‘I was touched that my group mate was looking out for my well-being, and that this was a group that wasn’t selfish, or all about self-preservation, which was quite rare nowadays’ (S3.4). When faced with opposing views, students commented on the need ‘to adapt and avoid conflicts’ (S3.11), ‘work together towards the common goal of the project’ (S3.5), and come to a ‘peaceful compromise’ (S2.6). There were several experiences where students wrote about having to ‘express disapproval’ (S3.12) or communicate negative feedback. In one case, a student had to disagree with a colleague regarding his slides. She wrote, ‘One cannot simply agree with everything that others say!. . . What I have found to be a good substitute to criticism is proposal . . . If I disagreed with someone, I would avoid criticizing his ideas, but I allowed myself to propose something else. In this way, I was able to express my own ideas without having to find fault with other people’s ideas’ (S3.12). Achievement. Overall, students evidenced a positive attitude towards the end of the selective, seeing it as giving them the opportunity to collaborate with their peers to accomplish something that is meaningful and relevant to their future practice as a doctor: Students discussed how coping with difficult situations resulted in their becoming more confident. For one student, the experience had left a ‘lasting impact’ on her; she ‘felt accomplished at having made a presentation to complete strangers over the course of a few days’ and were ‘heartened’ that her group ‘worked seamlessly together to deliver an effective presentation’ (S3.17). Others wrote about discovering positive things and feeling proud about themselves and their team-mates. As one student
Medical students’ reflective writing
boasted, ‘The experience . . . has reinforced the power of teamwork to me, as we are able to face unprecedented challenges with confidence and courage when we know that we are not alone’. He further added, ‘I now realize that with enough thought and effort put in, even students giving a presentation can have something to give away to our audience’ (S3.13).
Theme 2: Enhanced learning Communication to target audience and the patient. Twothird of the students discussed the struggles they went through while developing ideas for the talk. Students found that they did not know their target audience. Reflecting on the gap, one student concluded, ‘I realised . . . it is important to look at the patient, in this case, audience’s ideas, concerns and expectations . . . this was what we were lacking in, as we had not done a proper survey/focus group discussion in order to find out what in particular the audience would like to hear and discuss’ (S3.14). They also struggled to find ways to engage the audience. Students shared about: ‘personalising the message’ (S2.13), ‘keeping the message short and simple’ (S2.1), ‘avoid the use of medical jargon’, ‘attract the attention’ (S2.15), ‘giving the audience a sense of self-control’ (S2.4), ‘stimulating their visual, hearing and physical senses’ (S3.8), ‘give them instant feedback’, ‘use emotional/positive appeal’ (S2.13), ‘increase participation’ (S2.10) and so on. Students discussed how they might apply lessons learned to their future practice. A student’s comment on this issue speaks for the majority, ‘In patient education, I could definitely apply the same principles. When conveying any message, to be simple, genuine, personal, clear, and honest, to know my target audience and what they value. When prompting behaviour (change), I would set realistic goals for them, giving them a sense of self-control, and using positive appeal’ (S3.4). Another student had the opportunity to ponder on the importance of patient-centred care. She mused, ‘Every patient is different . . . Knowing when to use the appropriate methods . . . may be more effective in convincing a patient to make the necessary lifestyle modification’ (S3.10).
Complexity of behaviour change. The writings indicate an emerging awareness of the complexity of behaviour change. Students realized that a one-off talk is not enough to change people’s behaviour. They recognised that people are at ‘different points in their behavioural states of change’ (S3.6), with different beliefs and misconceptions. One student reflected, ‘ . . . especially in our Asian society, where misconceptions like these are passed down for years in our families. I foresee having to tackle such a barrier in the future – where patients have age-old beliefs ingrained in them’ (S2.3). Another student noted that ‘there needs to be more than just (giving) information’ in a talk (S2.5). Yet, another wrote about sustaining ‘impact even after the talk has ended’ and suggested that a talk should stimulate discussion and encourage people to share health messages with their friends.
Theory-practice integration. Although close to half of the students gave examples of how particular theories or concepts applied to the task, some did not automatically relate theoretical knowledge on behaviour change to the task until prompted by the tutor during the post-talk debrief. One student confessed, ‘When (the tutor) had mentioned about the health belief model (HBM), I realized that none of us had actually given it serious thought when crafting this presentation’ (S3.14). One student enthused about the HBM, ‘This selective has reinforced this HBM, a concept that was taught a couple of years ago. I really appreciate this . . . recap because I feel that this is a really important aspect of medicine. With this model as a guide it really helps us as future doctors to think from the patient’s perspective – the push and pull factors that trigger someone to perform a certain course of action’ (S3.2). Not all students agreed with her. One found theories more ‘enlightening’ than ‘practical’ when it came to solving real life problems: ‘Enlightenment about theories and application . . . how practical is it to use theories all the time instead of responding to what audience needs – a ‘human touch?’ (S2.6). Another felt that there was no need for a ‘strict structure to follow’ when counselling patients (S3.14). However, further analysis of the records showed that the perceived lack of utility of theoretical knowledge among some students was not because they did not find theoretical knowledge useful, rather, they had applied it subconsciously as observed by this student: ‘It is interesting to note that we subconsciously used the HBM even though we didn’t think about it’ (S2.17). Self-directed learning. Student reflections generally evidenced a highly positive attitude towards the learning encounter. When describing what they liked most about the selective, one student commented on its authenticity: ‘ . . . the public health talk has provided us with a platform to learn the skill that is definitely not present in textbooks’ (S2.5). Another wrote about being engaged: ‘When I realized that we were indeed doing a topic that interested the SPH staff, it made us even more motivated to put up a good talk’ (S2.1). Other comments included having the opportunity to research on topics not normally taught in the medical curriculum. Interestingly in the feedback survey, 60% of the PHC student cohort (n ¼ 106) rated the reflective exercises ‘useful’ or ‘very useful’ (Table 4). One student explained, ‘Without reflection, I would have let this experience fade into a distant memory without identifying the principles of public health education. . .. Now I have more knowledge. . . to tap into if tasked to conduct a public health talk in the future’ (S3.6). Another concluded, ‘Reflection is of paramount importance to the growth of every individual . . . If reflection is done habitually, growth and development can result . . . Although a single reflective exercise by no means will cause a radical change in the mindset of every medical student, I firmly believe that the introduction of such exercises is a giant leap in the right direction’ (S3.7). A few also commented on the discrepancy in curricular significance for different learning activities, pointing out that reflective exercises deserved a ‘more significant grading’ (S2.5) in the public health curriculum.
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Table 4. Students’ feedback regarding the PHC selective (N ¼ 106 students).
Batch 1 (Pilot) (n ¼ 23 students) Question Tutorial: PH Communication Objectives and content were clear Content relevant to Phase III Learnt something useful and relevant to future role as a doctor Found writing reflections useful [question inserted only for Batch 4 & 5]
Batches 2–5 (n ¼ 83 students)
Score 4–5 (%)
Score 1–2 (%)
Score 4–5 (%)
Score 1–2 (%)
61 50 76 Not applicable
6 11 6 Not applicable
83.5 79.3 82.9 60
0 2.1 0 4.0
The scoring is based on a Likert Scale of Strongly Agree (5), Agree (4), Neutral (3), Disagree (2) and Strongly Disagree (1). Scores did not add up to 100% as ‘3’ was excluded.
Still others wrote about the benefits of collaborative learning. Two types of team collaboration emerged from the writings: cognitive (e.g. researching and sharing information, giving and receiving feedback, learning by observation), and emotional (encouraging, affirming, giving support). The following sentiment was frequently repeated: ‘All of us were eager to learn from each other and were really positive towards the constructive advice given by fellow teammates’ (S2.2). Writings were also filled with colourful descriptions of how the brainstorming process had generated creative ideas. Having been exposed to didactic lectures in the first two years, another student stated, ‘(The selective has) helped me to think differently as compared to when I started medical school’ (S2.16). Perhaps, the most impressive comment must come from this student: ‘I derived a lot of satisfaction from putting effort into this presentation for the fact that it was not graded’ (S3.7).
Theme 3: Commitment to patient care Respect for patients and holistic care. Having gained insight into PHC, several students realized that diversity is an integral part of a doctor’s work, requiring one to be respectful of people with differing backgrounds and beliefs. One student narrated, ‘For example, the delightful Malay lady that I interviewed . . . her reasons were all based on religion not the science that we studied. Does that mean I should correct her? I learnt of course not!! Respect for our patients takes precedence as it’s only if they think you respect them would they trust you’ (S2.5). A number of such desires were expressed, including: (1) avoiding a ‘paternalistic traditional role’ (S3.13); (2) engaging the patients ‘to appreciate how they can have a different take on decisions’ (S3.16); (3) integrating their views into clinical decision making (S3.16); (4) working ‘around these beliefs to best help the patient’; (5) giving ‘the patient hope’ (S2.9); and (5) being ‘passionate and sincere’ (S2.1). Students also became aware that a doctor’s work must necessarily ‘contribute to behaviour change to improve the health of communities’ (S2.13). To achieve this, one student highlighted the importance of ‘working together . . . in a multidisciplinary team’ (S3.7). The following excerpt summarized students’ thoughts on this issue: ‘I learnt that public health is very relevant to our roles as clinicians. Patient education and helping our patients share greater responsibility 126
for their health is one of the ways towards a happier and healthier population. This is relevant regardless of the field of medicine we decide to pursue. As such, we as future doctors have to be skilled in planning and executing an effective health talk that will. . . challenge them to take action for their health’ (S3.6).
Deviant findings Not all students described positive learning outcomes and benefits associated with the selective. A small number (n ¼ 3) made judgemental comments about their colleagues, complaining that ‘nobody stepped up, nor did anyone take the initiative’ (S3.4), not being punctual, and not contributing enough to the project. One student rejected the notion of shared decision making between doctor and patient, insisting that the ‘final decision’ should reside with the doctor who is the expert. Two students disliked the way the selective was taught. One was ‘deeply skeptical about behavior change models’ (S4.1). She wrote, ‘I think there are aspects of each model that work but that could equally be learnt from experience and exposure, but using an entire model in a rote fashion just doesn’t work for me.’ Another complained that ‘there is nothing more soul numbing than the idea of a cliche´ topic being presented in a controlled environment’ (S4.11).
Discussion Medical educators constantly face the challenge of preparing students to be effective public health practitioners. While there has been a growing trend in medical education to implement a variety of educational strategies to better prepare students for a changing profession, information with which to assess student learning outcomes has been lacking. Our findings suggest that TBL that incorporates a process for reflection, which in this study was facilitated by reflective journal writing, has potential as a curricular strategy to enhance the quality of medical education. Students in the study reported a broad range of learning outcomes and benefits. The results are consistent with previous studies on TBL and reflective learning (Mann et al. 2009). Students expressed that they had become more appreciative of their team-mates and it was possible for people of different temperaments to work well together.
Medical students’ reflective writing
In the process, they discovered their own sense of identity including strengths and limitations, and how they related to others within the context of task performance. Some students reported experiencing a sense of empathy and respect for patients, and a realization that each person has his or her own narrative. Their writings indicated a growing awareness of the socio-cultural determinants of behaviour change. For these students, the learning experiences enabled them to appreciate the role patient education can play in impacting lives at both individual and community level. The task also provided a context within which students developed their reflective skills with the aid of journal writing. Through reflection, students gained confidence in becoming a public health communicator. For example, students became aware of past attitudes and behaviours that affect patient communication, and the need to ‘know your audience’. Fostering reflective skills should be a key component in medical education and life-long professional growth (Westberg & Jason 1994; GMC 2005; CFPC 2007). The ‘new’ learning approach had also forced students to assume a more questioning and thoughtful stance towards knowledge acquisition and assimilation. Instead of being passive recipients of knowledge, students adopted a deeper and more collaborative approach to learning. Essays were filled with positive emotions such as ‘heartening’, ‘satisfied’, ‘pride’, ‘achievement’ and ‘touched’. Such emotional expressions can help students appreciate the importance of building trust, collective decision making, achieving consensus, and providing emotional support. For many, this ‘real world’ experience facilitated the process of theorypractice integration and brought conceptual knowledge to life. It was apparent from the writings that many students regarded the learning encounter as providing valuable learning experiences that prepared them for future practice as a doctor. We also found a small number of students making judgemental comments about their colleagues. Although these were atypical findings, they may represent the ‘tip of the ice-berg’ suggesting that there may be a need to address this issue early in the medical curriculum. A few felt that the talk should be conducted with a bigger audience and held at a community venue to enhance authenticity. Clearly, TBL is not a simple panacea for our educational challenges. As our study shows, however, it can play a role in enhancing the educational and professional development of a medical student (Harden et al. 1996). For TBL to be meaningful: (1) learning must be situated in an authentic context that is able to stimulate experiential learning (Kolb 1984; Marsick & Watkins 1990; Boud et al. 1993); and (2) students must be given a ‘safe space’ to examine their experiences and draw insights for future applications (Eyler et al. 1996; Henderson et al. 2003). Writing, drawing or talking about one’s experiences helped to uncover hidden prejudices and generate insights (Eyler et al. 1996). Overall, our findings are consistent with most researchers’ conclusion that reflection is a useful learning strategy (Mann et al. 2009). To that end, the SSH-SPH may consider integrating reflection into the public health curricular structure instead of having just a once-off activity.
There are some limitations to this study. First, interpretation of qualitative data is an inherently subjective process. To reduce researcher bias, multiple researchers analysed the data. Conclusions were also cross-checked with tutors’ observations and students’ feedback (Table 4) thus establishing research triangulation. Second, students may have provided politically correct responses. However this is minimal as reports were confidential and not graded. Third, the findings were confined to students’ reflections. It would have been preferable to have included the written perspectives of the tutors and the modular co-ordinator regarding learning outcomes. Including oneto-one interviews could have allowed a more in-depth exploration of students’ thoughts, but was excluded due to insufficient time. Finally, the context for this research was a NUS third year medical undergraduate programme on PHC. However, the findings are likely to be relevant to other subject areas.
Conclusion Medical schools are constantly challenged to improve the way medicine is taught and learnt. Journal records allowed us to gain insights into how students thought and felt about taskbased learning experiences. Our findings highlighted the learning outcomes and benefits students reported. TBL, combined with reflection, helps to: (1) engage students more effectively in the application of public health knowledge to ‘solve’ real-world issues; (2) develop their skills in critical thinking and self-directed learning; and (3) inculcate in them a sense of social responsibility to their patients and the community they serve. Further research is needed to examine the nature of learning structure, and how task activities and tutor-student interaction might be harnessed to help our students move from superficially engaging with experiences to creating a practice of reflection that is part of their daily life.
Acknowledgements The authors would like to thank the 2012/13 cohort of thirdyear medical students of the NUS for their support and participation in this research, as well as the tutors who supervised the selective. Declaration of interest: The authors report no declarations of interest.
Notes on Contributors YANG HUANG KOH, MPH, MBBS, is the Principal Consultant of the Health Promotion Board Singapore, and an Adjunct Asst-Professor at the Saw Swee Hock School of Public Health. MEE LIAN WONG, MPH, MD, is Program Director and Associate Professor in the Saw Swee Hock School of Public Health of the National University of Singapore JEANETTE JEN-MAI LEE, MBBS, is the Vice Dean (Education) of the Saw Swee Hock School of Public Health of the National University of Singapore.
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Appendix: Reflection guideline on how to write a reflection journal This tutorial requires you to complete a community service activity, in this case, to design and deliver a public ‘talk’ to about 30–40 staff from the SPH. Purpose: The purpose of writing reflective journal is to help you critically examine your own knowledge and what you have been taught about public health communications and theories of behaviour change in the light of your experience. For you to learn from the service experience, you will need to ‘reflect’ on your experiences. This means stepping back from the experience and actually thinking about what happened and why it happened. You may find this difficult to do in the beginning, but the experience is extremely valuable in the end. Think of your journal as a combination of an activity log, a diary, and a critical thinking essay. This means you take note of what you actually did, as well as your perceptions, 128
Kolb DA. 1994. Learning styles and disciplinary differences. In: Feldman KA, Paulsen MB, editors. Teaching and learning in the college classroom. Needham Heights, MA: Ginn Press. pp. 151–164. Lockyer JM. 1992. Physician performance: The roles of knowledge, skill, and environment. Teach Learn Med 4(2):86–96. Lofaro MJ, Abernathy CM. 1994. An innovative course in surgical critical care for second-year medical students. Acad Med 69:241–243. Mamede S, Schmidt HG, Penaforte JC. 2008. Effects of reflective practice on the accuracy of medical diagnosis. Med Educ 42(5): 468–475. Mann K, Gordon J, MacLeod A. 2009. Reflection and reflective practice in health professions education: A systematic review. Advance Health Sci Educ 14:595–621. Marsick VJ, Watkins KE. 1990. Informal and incidental learning in the workplace. London: Routledge. Mezirow J. 1991. Transforming dimensions of adult learning. San Francisco, CA: Jossey-Bass. Parry KM. 1989. The curriculum for the year 2000. Report of a Conference of the Association for the Study of Medical Education. Med Educ 23:301–304. Patel VL, Groen GJ, Scott HM. 1988. Biomedical knowledge in explanation of clinical problems by medical students. Med Educ 22:398–406. Saltmarsh J. 1996. Education for critical citizenship: John Doweys contribution to the pedagogy of community service learning. Michigan J Community Service Learn 3:13–24. Sandars J. 2009. The use of reflection in medical education: AMEE Guide No. 44. Med Teach 31:685–695. Schon D. 1983. The reflective practitioner. San Francisco: Jossey-Bass. Schon D. 1987. Educating the reflective practitioner. San Francisco: Jossey-Bass. Sobral D. 2000. An appraisal of medical students reflection-in-learning. Med Educ 34:182–187. Toy EC, Harms KP, Morris Jr RK, Simmons JR, Kaplan AL, Ownby AR. 2009. The effect of monthly resident reflection on achieving rotation goals. Teach Learn Med J 21:15–19. Westberg J, Jason H. 1994. Fostering learners reflection and selfassessment. Fam Med 26:278–282. Wong KY, Kember D, Chung YF, Yan L. 1995. Assessing the level of student reflection from reflective journals. J Advanced Nurs 22(1):48–57.
emotions, expectations, challenges, and successes. MOST IMPORTANTLY, you take a step back and look at the entire situation (including yourself and your role) from the outside. Thus, you note how the experiences fit or connect with what you have heard, read, or studied about public health communications. In a journal entry, you write what you like, not what you think the tutor/lecturer wants to hear. You just write freely, and not worry about grammar or making a good impression. And it doesn’t have to be long. Write as soon as possible after each experience. Use the template to record your entries. Submit it via e-mail by the due date to your tutor. . Information collected will help us review and improve the way we conduct our teaching. We just want your thoughts and impressions. . When you are discussing people (including your colleagues), do not use their real names. Instead, invent a name for that person.
Medical students’ reflective writing
. All information collected is confidential and known only to the tutor. For example, I will not disclose who actually wrote this journal. I hope this will encourage you to share freely. A sample of question prompts Use this structure to write your journal.
At students’ own time (You can choose to record your experiences after each meeting OR you can collapse them into one entry.) Date: _____________
Venue: _________________
Time: _____________________
Activity log
What happened before, during, and after the event? List the people, things, content in sequence. Has anything surprised you? What made an impact on you? Do you have the information or skills to deal with the situation? If there is a lack of information or skills, why do you think you have this lack? What is the underlying reason for unresolved issues, if any?
Diary
What made you feel happy/satisfied or uncomfortable/unhappy/frustrated? In either case, why do you think you felt that way? Who or what was involved with you when the feelings occurred? What were some things you wanted to say or ask, but did not? Why not? What have you contributed? What have you learnt about yourself and your group members? Are there any striking thoughts, ideas, or insights?
Critical thinking
Integrate any of the theoretical issues related to behaviour change and health communications you have learnt from lectures/readings with your observations/experiences. How might you apply/relate theoretical content and experience to your role as a doctor in patient education and patient care?
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