Clinical Debrief: learning and well-being together.

BACKGROUND: Clinical environments can be so stressful to medical students as to be detrimental to their learning and well-being. Our intervention, Clinical Debrief, integrates learning through clinical experience with the development of positive coping strategies. Students shared cases and experiences during weekly small group classroom discussions, facilitated by general practitioners (from outside their current hospital placement), throughout two consecutive 12-week blocks of their first clinical year. Alongside enquiry-based and clinical reasoning learning, we gave students a safe space to reflect on their affect. Our aim was to critically examine students' views in Clinical Debrief.
METHOD: Anonymised quantitative and qualitative evaluation data were collected over 3 years using online questionnaires on completion of each 12-week block. The data relating to psychological supervision were analysed independently and in parallel, using thematic analysis for qualitative data. We aim to help students develop positive coping mechanisms, promoting empathy,self-awarenessand wellbeing
RESULTS: A total of 1857 evaluations were extracted (response rate 67%). The median (interquartile range) overall rating for Clinical Debrief sessions was 9 (8-10), where 10 indicates 'excellent' and 1 indicates 'significant improvement needed'. The rating for the supervisory aspects of the sessions and free-text comments were positive. Students appreciated safe environments, the session structure, facilitator role modelling, transitional support and processing of emotional experiences. DISCUSSION: Mandatory integrated longitudinal supervision, using trained clinician facilitators, was positively received by students in transition to clinical placements. Normalising the emotional impact of medical work destigmatises distress. Linking clinical reasoning with affective state awareness to contextualise case management, following Mezirow's transformative learning theory, brings added benefit to learning and well-being. Student demand for the expansion of Clinical Debrief is evidence of success.

Introduction

Medical students in the clinical environment witness suffering, conflict and loss. Making sense of emotionally testing experiences is important for their health, retention in the profession and patient outcomes,1 but under time pressure, learning knowledge often takes priority over psychological supervision. The hidden curriculum models detached concern and the objectification of patients as an aid to coping, leading to a well‐documented reduction in empathy or setting up cognitive dissonance that creates disillusionment with medicine.2

There are increasing calls to teach coping strategies, in order to help students develop resilience and to prevent burnout.1, 3 How this can best be achieved is still a matter of debate, with some doubt about a one size fits all solution.4 Ishak reports stress reduction with peer support around difficult cases.5 Gishen describes Shwartz Centre Rounds (SCRs) as fostering undergraduate compassion.6 We have developed a model of psychological supervision for our students integrated with case‐based learning of clinical reasoning: Clinical Debrief.

… integrating longitudinal psychologicalsupervision with learning clinical reasoning and preparation for practice

Context

Clinical Debrief is a weekly small group case‐based classroom discussion (running for 2 hours and 15 minutes) facilitated throughout two 12‐week blocks in Year 3 of our 5‐year undergraduate medical programme. The running time includes a 15‐minute coffee break, which is an important informal social component.4

We aim to help students to develop positive coping mechanisms, promoting empathy, self‐awareness and well‐being. This is achieved through the exploration of students’ clinical experiences (including the hidden curriculum), integrating longitudinal psychological supervision with learning clinical reasoning and preparation for practice (Box 1).

General practitioner (GP) medical educators, who are not otherwise part of the student placement, facilitate Clinical Debrief. Psychological supervision is not labelled explicitly as such to students. It is approached in more nuanced ways, with prompts such as, ‘How was your week?’, followed by probing, e.g. ‘Was there anything surprising?’. All students present real cases and issues from their week. Facilitators help students to unpick the impact of patient contact, explore difficult emotional reactions and encourage the retention of empathy.

Students are empowered with the responsibility and tools to resolve their own issues. With the development of critical thinking skills, we apply Mezirow's transformative learning theory, encouraging students to challenge personal and cultural ‘frames of reference’.7 Students facing professional dilemmas are encouraged to consider the different ways in which they might respond and practise role‐play with peers for difficult conversations, using the approach that ‘Problem focused, rather than emotion focused, coping often provides a better solution’.8

Students can use discussions as a basis for their reflections in written portfolios, but this is not compulsory. A socially relaxed atmosphere with little hierarchy is created to allow students the safety to explore emotionally testing situations.

The aim of this study was to critically analyse students’ views of Clinical Debrief.

Construct clinical reasoning skills to prioritise differential diagnoses, investigations and management options, with attention given to cognitive biases

Develop and apply authentic communication skills to use with peers, colleagues and patients

Recognise the impact of diversity on clinical interactions and shared decision making

Develop skills to learn through discussion and analysis of individuals’ and peers’ real clinical experiences. Consider the emotional impact of these experiences and identify strategies for building resilience

Make a clear presentation to peers and senior colleagues of a clinical situation or condition in medical language appropriate to the context of the communication

Demonstrate the ability to evaluate a patient's history in order to determine the health care and social needs of that individual patient

Describe ways in which ‘the patient journey’, longitudinal care and attention to patient safety affects health

Critically appraise ethical issues portrayed in lay and medical media and apply a recognised ethical framework to reflect on how they might change practice

Understand and make early preparations for undergraduate assessment, including the national Situational Judgement Test and Prescribing Safety Assessment

Appraise and appreciate how the integration of primary and secondary care can improve patient care in preparation for Year‐4 GP placements

Method

We analysed students’ responses to psychological supervision using 3 years of evaluation data. Both free‐text and quantitative data were examined, independently and in parallel.

All students were routinely invited to participate in an online survey on completion of each 12‐week block. Students gave a global rating for Clinical Debrief, ranging from 1 (significant improvement needed) to 10 (excellent), and rated 10 fixed‐response statements on seven‐point Likert scales, with 1 indicating ‘strongly disagree’, 4 indicating ‘neutral’ and 7 indicating ‘strongly agree’. Here we present the responses to the four statements relating to clinical supervision.

Overall global ratings for the Clinical Debrief sessions were summarised numerically as the median and interquartile range (IQR). Likert‐scale responses to the four questions relating to supervisory aspects of Clinical Debrief were summarised graphically as a diverging stacked bar chart.

Two questions invited open‐ended free‐text comments:

Please give examples of the most useful aspects of the Clinical Debrief (this may include aspects relating to the tutor, the structure and the content of the sessions).

Please suggest ways in which the Clinical Debrief could be improved (this may include aspects relating to the tutor, the structure and the content of the sessions).

Systematic qualitative analysis was conducted by RF and LC using thematic analysis, initially familiarising themselves with the data, followed by the generation of codes, and then collaborating to construct and revise themes.9 Both are GPs involved in the facilitation and development of Clinical Debrief, and have responsibility for programme quality assurance.

Illustrative quotes are unidentifiable and quantitative data are aggregated. Publication was not considered to require approval by the University Ethics Committee as these anonymised evaluation data were routinely collected using a survey approved by the programme. Permission for use was granted by the head of the programme, independent from the authorship team, following correspondence with the editors for advice.

Results

Clinical Debrief occurs in two 12‐week blocks in Year 3. Students have the opportunity to give feedback for each block. We have feedback data from three cohorts, for 2016/17, 2017/18 and 2018/19. There were 2770 possible responses from 1385 students. A total of 1857 distinct evaluations were extracted, giving an overall response rate of 67%. The median (IQR) overall rating for the Clinical Debrief sessions was 9 (8–10). Likert‐scale responses are presented in Figure 1; themes and illustrative quotes are presented in Table 1.

Figure 1

Likert‐scale responses to statements about the Clinical Debrief.

Table 1

Most useful aspects of Clinical Debrief

Responses to the question about the most useful aspects of Clinical Debrief
Theme	Subthemes	Illustrative free‐text comments
Safe environment	Continuity	Student 1: Great to have a constant person that sees us through each semester Student 2: [Useful] having a consistent figure over a long period of time to talk to
	Group size	Student 3: Good size group and tutor created a very comfortable environment
	Non‐judgemental	Student 1: …we were able to let our guard down and be ourselves with no fear of judgment from peers or tutor, which meant that we could discuss personal topics openly Student 3: …everyone felt comfortable bringing up sensitive subjects Student 4: Always able to say if anything bothered us, marked us … in the ward
Session structure	Student‐led	Student 5: The degree of autonomy in determining, as a group, what to focus on in the sessions encourages and develops self‐directed learning Student 6: Clinical Debrief has been one of my favourite parts of the course this semester, this is down to the tutor's ability to teach us whilst still giving us the opportunity to lead the session ourselves
	Flexibility	Student 7: The tutor was very flexible … he would work the session around what we had seen during the week rather than coming with a set lesson plan. This was very effective in making the learning relatable for us
Facilitator role modelling	Professional	Student 8: Tutor helped in learning to think like a doctor Student 9: The tutor had a wide range of knowledge, very interactive
	Personal	Student 5: Felt very safe and comfortable to bring up topics from during the week which we might not have shared as the tutor was very approachable Student 9: [Tutor was] very friendly and willing to share his life experience with us
Transitional support		Student 10: I've learnt a lot during our sessions without feeling like I'm doing a lot of work. The atmosphere has just been really relaxed and it's made the transition into clinical years a lot less stressful than it could've been Student 11: Nice to be able to discuss personal issues arising, e.g. how we are finding medicine, approaches of clinicians to patients, delicate/complex patient cases and morals
Processing emotional experience	Talking as emotional regulation	Student 12: Speaking about things we have encountered in the week is really, really comforting Student 13: The tutor was really good at allowing us to discuss topics that we needed to talk about from our weeks – it always felt cathartic to have the discussions Student 14: It was good to have someone I can comfortably speak to about the things that happened in the hospital that either bothered me or confused me Student 15: I found it very therapeutic going through my highlights and lowlights of the week. Having a safe space to really reflect on my life each week and see where I could make it better
	Reflection	Student 16: By discussion of events, personal experiences on the ward and by listening to the group's interpretation of these events, I have been able to reflect in my portfolio with a deeper level of understanding

Facilitators help students unpick the impact ofpatient contact, explore difficult emotional reactions and encourage retention ofempathy

Discussion

Participants gave a very positive rating to Clinical Debrief as a whole and provided evidence that the supervisory aspects were highly valued (Figure 1; Table 1). They identified Clinical Debrief as a useful cathartic space for learning, allowing reflection on personal and professional values and judgements (Figure 1), aided by structure, support and role‐modelling (Table 1).

Students commented that they may not otherwise have discussed sensitive issues

Students commented that they may not otherwise have discussed sensitive issues: ‘…comfortable to bring up topics from during the week which we might not have shared…’ (Student 5). They remarked on the sense of safety created through the small group size, continuity of tutor and peers, and the non‐judgemental environment: ‘…we were able to let our guard down and be ourselves with no fear of judgment from peers or tutor, which meant that we could discuss personal topics openly’ (Student 1). The approachability of the tutor was very highly rated and the relationship with the tutor was identified as important in allowing safe disclosure. GPs, used to dealing with distress and signposting individuals to help, used their transferable skills to benefit students, with longitudinal contact aiding the follow‐up.

Flexibility about content enabled learning that was relevant to the immediate needs of the students. Facilitator role modelling included sharing their own experiences, which students found helpful, promoting ‘thinking like a doctor’ (Student 8) and supporting their transition to clinical working: ‘it's made the transition into clinical years a lot less stressful than it could've been’ (Student 10).

Importantly, students identified a developing self‐awareness, linking affective state and cognitive abilities, and so learning to appreciate the imperative to manage well‐being proactively: ‘very therapeutic going through my highlights and lowlights of the week. Having a safe space to really reflect on my life each week and see where I could make it better’ (Student 15). We believe that incorporating learning around empathy, compassion and self‐care, in case discussions about clinical reasoning, endorses the inclusion of patient and practitioner experiences as routine and important considerations before the culture of just ‘get on with it’ takes hold.3

Considering SCRs, Gishen states ‘there is no standard model for the “what” “when” or “how” SCRs might be conducted within a training environment, nor any indication of how sustainable such initiatives would be’.6 We have demonstrated the delivery of Clinical Debrief, at scale, in a manner that we believe to be sustainable.

… the relationship with the tutor was identified asimportant in allowing safe disclosure

Gerada stresses the importance of having your ‘own repertoire of strategies to de‐stress: this includes understanding one's own perspective (or how one views work, life, and events)’.8 Clinical Debrief is mandatory for our students but we do not prescribe how they undertake self‐care, other than encouraging reflection and sharing experiences. We believe that there is value in reaching students who may not otherwise actively choose to participate in supervised groups. Only a very small minority of students struggle to relate to this method and wish to undertake more overtly assessed topics. Assessment as a driver for learning is universally recognised, and we are exploring ways to use this.

Limitations

We acknowledge that this study looks only at student reactions, which represents level 1 of Kirkpatrick's evaluation model.10 The long‐term effects on students’ behaviour and well‐being are not yet measurable. Furthermore, the multifactorial nature of Clinical Debrief, including discussions around clinical reasoning, makes it hard to discern which elements have the most impact.

Conclusions

Clinical Debrief helps our medical students make sense of what they experience and has alerted them to the value of shared reflection for their well‐being. Its situation in the programme, integrated with clinical learning rather than additional, emphasises the inseparable nature of both for sustainable careers.

Creating a culture of openness about the emotional impact of medical work destigmatises distress. During the transition to clinical environments we feel that regular early intervention is essential. In response to student demand (further evidence of success), we now plan to include Clinical Debrief for Year 5, addressing transitions to working life.

Further insights may be gained from more research on longitudinal small group reflection, looking specifically at well‐being and long‐term effects.