The value of logbooks in learning the hidden curriculum and practicing written reflection.

Dear editor

We read with great interest the article by Alabbad et al1 that showed a lack of correlation between the volume of self-reported clinical cases medical students completed and subsequent exam scores. However, we believe that logbooks have value outside of preparation for objective structured clinical examinations and written papers: ensuring students gain experience of the hidden curriculum and providing an opportunity to practice written reflection.

Medical students often find it difficult to learn in the clinical setting as they must actively seek out opportunities through self-directed learning.2 From our experience, having the objective of recording clinical cases in a logbook gives students a purpose and helps direct their approach, particularly when on hospital wards. Instead of disappearing to work in the library, students are encouraged to remain in clinical situations and see patients. Experiencing more clinical encounters increases students’ exposure to the hidden curriculum.

The hidden curriculum represents areas of learning that fall outside the formal curriculum and are often unarticulated.3 It teaches the culture of working in the field of medicine, for example the development of a professional identity or learning to manage the emotional aspects of being a clinician.3 We believe that logbooks increase student engagement with the hidden curriculum, and, as a result, produce individuals better prepared for working as doctors.

Alabbad et al conclude that logbooks do not make good assessment tools, and we propose that they could provide an opportunity for reflective writing instead. Along with reporting a clinical case, students could be asked to record a written reflection of the experience in their logbook. By doing so, they would practice and develop a key skill found in the General Medical Council’s guidance on “Outcomes for graduates”: the doctor as a professional should continually and systematically reflect on practice.4 Reflections may include thoughts on the way a doctor handled a situation, the manner in which a patient reacted to information, or how well the student felt they performed a clinical examination.

In his guide on “The use of reflection in medical education”,5 Sandars sets out some of the common problems encountered and logbooks that include written reflections are well suited to remedying several of these. Firstly, they would be a formative aspect of the curriculum that students must complete, thus combatting low engagement in reflection. Secondly, they would promote integration of reflection within clinical teaching, as the written reflection would be considered alongside the clinical case, rather than an optional extra. Finally, if they require a signature from a clinical tutor for each case recorded, as used in the research Alabbad et al undertook, they would ensure that feedback is received through mandatory discussion of the logbook entry with the tutor. Therefore, alongside their role in ensuring student engagement with the hidden curriculum, we believe that logbooks offer an ideal opportunity for medical educators to ensure that students practice written reflection.

Dear editor

We read the letter by Joshi et al and would like to thank them for their valuable comments regarding our work.1 We agree that the concept of “the hidden curriculum” is a very important one.2 One of the main objectives from our paper is to attempt to correlate the progress done on the logbook with exam scores, and we found that higher volume of case encounters did not translate into better exam scores. It is important to note that the qualitative nature of these case encounters was not investigated and would provide more insight into the quality of these teaching opportunities. We point out that these results do not mean that the logbook should be foregone but perhaps should be redesigned to emphasize and standardize other aspects of “the hidden curriculum” of medicine such as professionalism, team building, and interpersonal interactions.