Small-group Teaching Emphasizing Reflection Can Positively Influence Medical Studentsʼ Values

We read with great interest the article “Vanquishing Virtue: The Impact of Medical Education,”1 whole-heartedly agree with Drs. Coulehan's and Williams' conclusions, and share their concerns regarding the “tacit” conditioning medical students undergo during their education. One approach we have found helpful at East Carolina University is the incorporation of a longitudinal reflection group experience2 to complement a second-year ambulatory continuity clinical program. We found that participation in a biweekly facilitated discussion/reflection group provided many of the students a needed humanizing effect on their experiences. Reflection groups lessened the sense of individual isolation and allowed the acceptance and deepening of emotional and cognitive responses to suffering, diversity, poverty, fear, etc. We further found that reflection groups provided an integrated learning experience that nurtured the students' self-awareness and lessened the propensity of medical education to encourage detachment. A growing body of evidence suggests that physicians who can utilize their own self-awareness are more effective, satisfied, and efficient in providing care3; that physicians' humanism correlates with patient satisfaction and adherence to medical advice; and that medical students tend to lose their humanistic and altruistic attitudes and values during medical school training. Increased self-awareness allows physicians to use themselves as instruments in the process of caring for patients. The ability to be compassionate is linked to physicians' own emotional responses to patients. Emotion without benefit of self-awareness may actually inhibit compassion and become a source of stress. In our analysis of the first year of experience with reflection groups we were struck by a pattern of collaborative and empathic communication that developed over time. During the initial reflection group sessions students would serially raise topics of individual concern without regard for the previous topic on the floor. Very little discussion and deepening took place in these sessions, and many students left feeling unsatisfied by their experience. Over time, and when it became clear that there would be opportunities for everyone to speak and participate in a safe, supported way, the dialogue assumed a cooperative, generative format in which exploration and empathy were paramount. The results were much more satisfying and meaningful for the group members. Based on our experience, we would hypothesize that Dr. Friccione would have had a very different experience had she had a group of her peers to talk and reflect with during her medical school experience. And while some of her values and attitudes might have changed and become more realistic and mature, the core of her desire to serve and tend to the suffering of others using heart, head, and hands would have been cultivated and reinforced rather than shattered. We would suggest that rather than just “immunize” against tacit values of detachment, self-interest, and objectivity, medical schools need to adopt and integrate approaches that are proactive in fostering self-awareness, social responsibility, and compassion during the process of education. Providing a humanizing experience for medical students will lay the foundation for subsequent humanistic practice.