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Using students' writings to teach and learn from the informal curriculum

Thanks to T. Robert Vu, MD, of the Indiana University School of Medicine, for the following article.

An AMA grant in 2004 led to development of a narrative medicine program for students in the Indiana University School of Medicine (IUSM) Medicine Clerkship. Through the program, students have heightened their awareness of professionalism by recording descriptions of events that embody professionalism (or lack thereof) via a password-protected IUSM website. Students are asked to indicate what they've learned from these events by selecting applicable terms from an NBME checklist of professionalism domains.

But reflection is only part of this program. The clerkship director then edits these narratives and distributes them to students for monthly small group reflection and discussion sessions. There, aided by expert faculty, students choose stories that resonate with them for reading aloud to their classmates. The student-reader is asked why s/he chose a narrative, and a facilitated dialogue ensues. A sample:

"Our team and the ICU team were rounding and we all entered a patient's room. There were at least 15 of us in the room. Our teams spoke about the patient, examined him, adjusted the ventilator settings, and then left—all oblivious to the family member who was in the room the entire time. After we had all left, I noticed that the intern—who had just started the service that morning—kneeled down beside the patient's wife and began explaining what the team had just done. No one else noticed what she had done, but I was very impressed by her behavior."

Because student narratives often express powerful themes of professionalism, humanism, and the human condition, as well as descriptions of role modeling (positive and negative), this reflective journaling activity has become a formal part of the Medicine Clerkship's curriculum. As "lived" experiences and sentinel events, these stories stimulate discussions that are of greater perceived relevance and interest to students than "paper"/hypothetical cases.

The narratives create many "teachable moments" and opportunities to invite students into deeper group dialogue on issues they uncover. IUSM's success has stimulated the Surgery Clerkship to adopt a similar journaling activity, and the student narratives—open to wider use after the student-authors graduate—have been used as "substrate" for faculty development, grand rounds, student publications, residency retreats, school publications, and behavioral and social science curricula.