"Where Does the Circle End?": Representation as a Critical Aspect of Reflection in Teaching Social and Behavioral Sciences in Medicine.

OBJECTIVE: This paper describes a reflective learning program within a larger curriculum on behavioral and social science that makes use of close reading, written representation of experience, discussion, and textual response. This response may in turn lead to further reflection, representation, and response in a circular pattern. A unique feature of this program is that it pays attention to the representation itself as the pivotal activity within reflective learning. Using the narrative methods that are the hallmark of this program, faculty writings were analyzed to characterize the essential benefits that derive from these practices. METHODS: In the context of a faculty development seminar on the teaching of behavioral and social sciences in medical curricula, a group of 15 faculty members wrote brief narratives of reflective learning experiences in which they had made use of the methods described above. Their responses were submitted to iterative close reading and discussion, and potential themes were identified. RESULTS: Four themes emerged: writing as attention to self, writing as attention to other, writing as reader/writer contract, and writing as discovery. In each instance, writing provides a new or deepened perspective, and in each case, the dividends for the writer are amplified by the narrative skills of those who read, listen, and respond. CONCLUSIONS: The narrative pedagogy described and modeled herein provides a potentially promising approach to teaching the social, cultural, behavioral, and interpersonal aspects of medical education and practice. Future research will deepen our understanding of the benefits and limitations of this pedagogy and expand our appreciation of its applications.

Statement of Partnership and Humility: A Structural Intervention to Improve Equity and Justice in Medical Education.

PROBLEM: Due to generational exposure to the Black Lives Matter movement, other anti-bias social movements, and diverse peer advocacy groups, health professions students are often more knowledgeable than their teachers about ways in which systemic racism and bias have led to scientific inaccuracies that contribute to health inequities. However, traditional hierarchies and concerns about retaliation may limit educational communities from benefiting maximally from students' contributions. APPROACH: In spring 2021, faculty and students at the Vagelos College of Physicians and Surgeons, Columbia University, designed a structural innovation to engage faculty and students in partnership toward decreasing bias in medical education. This article discusses development and implementation of a Statement of Partnership and Humility (SPH) disclosure slide on which faculty acknowledge consideration of potential teaching biases and invite student feedback. OUTCOMES: The initial primary goal of the SPH slide was to increase faculty awareness and engagement in anti-bias topics; however, the unexpected dividends of decreasing faculty anxiety about receiving student feedback and promoting student engagement have proven equally powerful in promoting a healthy, inclusive learning environment. NEXT STEPS: Next steps include gathering qualitative and quantitative data to elicit both faculty and student perspectives on the use of the SPH slide, particularly with regard to psychological safety and openness to feedback.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial.

BACKGROUND: Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures. OBJECTIVE: This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities. METHODS: The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses. RESULTS: This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027. CONCLUSIONS: SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54486.

Preparing Medical Students for Anti-racism at the Bedside: Teaching Skills to Mitigate Racism and Bias in Clinical Encounters.

Introduction: Systemic racism perpetuates health disparities and negatively impacts health care delivery and patient outcomes. Racism and bias can affect every aspect of clinical care, including history-taking, physical examination, laboratory interpretation, note-writing, oral presentation, and decision-making. Medical students must learn racism- and bias-mitigation skills early in their professional development to provide high-quality, equitable care. Methods: In November 2021, senior medical students and faculty with expertise in promoting health equity and justice in medicine designed and cotaught a Zoom-based, 75-minute, interactive session for second-year medical students. Participants prepared by reading assigned articles. Breakout rooms were used to facilitate small-group discussions. Session topics included use of a structural vulnerability assessment tool, examples of how bias can impact the physical exam, demonstration of how language can transmit bias, and skill practice using neutral instead of stigmatizing language. Results: Forty second-year medical students participated in the session. Thirty-one students (78%) completed Likert-type surveys evaluating reaction and learning. Results showed improvements in students' perceptions of their abilities to assess for structural factors that influence health, recognize ways bias can impact clinical encounters, and apply skills to minimize bias in clinical care and decision-making. Discussion: Providing opportunities for health care learners to think critically about how bias impacts patients and communities and equipping them with tools to begin dismantling exclusionary, racist practices in medicine are achievable and crucial to actualizing a just and equitable health system. This educational session can be adapted for training across health care professions and the educational continuum.

Reading the Self: Medical Students' Experience of Reflecting on Their Writing Over Time.

PURPOSE: To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors. METHOD: In 2018, the authors conducted 5 focus groups with 18 third-year students from the Columbia University Vagelos College of Physicians and Surgeons class of 2019 to examine students' experience with Signature Reflections. Using an iterative, thematic approach, they developed codes to reflect common patterns in the transcripts, distilled conceptually similar codes, and assembled the code categories into themes. RESULTS: Three core themes (safe space, narrative experience, mirror of self) and 1 overarching theme (moving through time) were identified. Students frequently experienced relief at having a safe reflective space that promoted grappling with their fears or vulnerabilities and highlighted contextual factors (e.g., trusted faculty-mentors, protected time) that fostered a safe space for reflection and exploration. They often emphasized the value of tangible documentation of their medical school journey (narrative experience) and reported using Signature Reflections to examine their emerging identity (mirror of self). Overlapping with the core themes was a deep appreciation for the temporal perspective facilitated by the Signature Reflections (moving through time). CONCLUSIONS: A longitudinal narrative medicine-based portfolio curriculum with pauses for meta-reflection allowed students, with faculty support, to observe their trajectory through medical school, explore fears and vulnerabilities, and narrate their own growth. Findings suggest that narrative medicine curricula should be required and sufficiently longitudinal to facilitate opportunities to practice the skill of writing for insight, foster relationships with faculty, and strengthen students' temporal perspectives of their development.

Satisfaction with telephonic interpreters in pediatric care.

OBJECTIVES: To compare satisfaction among Spanish-speaking mothers who did and did not use telephonic interpreters during pediatric visits, and to examine resident physician attitudes about telephonic interpreter use. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: Anonymous surveys were administered to 98 mothers limited in English proficiency and presenting for well-baby visits in an urban university hospital-affiliated practice. Pediatric visits were performed by 24 non-Spanish-proficient pediatric residents. The first 46 women (baseline cohort) received routine services, including ad-hoc interpretation or no interpretation; the second 52 women (intervention cohort) used a dual-headset telephonic interpreter service. OUTCOME MEASURES: Mothers completed postvisit interviews assessing overall satisfaction, comfort and ease of communication. Pediatric residents completed self-administered questionnaires assessing attitudes about and experience with telephonic interpretation. RESULTS: The intervention cohort overwhelmingly rated telephonic interpretation as "very helpful" (94%), indicating the visit would have been "harder" without the service (98%). Significantly more intervention cohort mothers reported it was "very easy" to communicate with the physician (83% vs. 22%, P < 0.01), they understood "all" that the physician told them (97% vs. 80%, P < 0.05) and they were "very satisfied" with the clinic overall (85% vs. 57%, P < 0.05). Almost all intervention cohort mothers (96%) reported a preference to use telephonic interpretation at their subsequent visit; however, only one-third of residents believed their patients would prefer to use the telephonic interpreter in the future. CONCLUSIONS: Mothers who used telephonic interpretation reported significantly greater communication and overall satisfaction compared to mothers in routine care. Pediatric residents substantially underestimated their patients' desire to use telephonic interpreters.

Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings.

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.