Promoting reflective skills in aspiring doctors

Impartation of empathy during medical studies and thereafter

In the training of medical students, the focus is usually on the scientific and technical expertise. Skills such as moral judgement, empathy and patient centring decline in the national and international context over the course of their studies. Due to time constraints, high expectations and requirements, negative role models and the commodification of medicine, the initially very widespread humanistic ideals of the students are increasingly pushed into the background. In order to be able to actively and consciously confront the tensions that occur in everyday clinical practice between internal ideas and external reality, clinical reflection training was developed in 2007 at the University of Witten/Herdecke. The aim of this training intervention is to promote communicative and reflective skills among aspiring doctors, as well as comprehensive personality development, in order to enable an individual, humane and salutary encounter with patients and colleagues.

The Integrated Course of Additional Studies in Anthroposophic Medicine (IBAM) at the University of Witten/Herdecke has prepared training wards for the practical year at the end of the medical studies where students can independently take over patient care while receiving close guidance. This enables them to learn and train their medical skills without being exposed to external pressure and having to provide care for an entire ward. At other universities this training phase mainly includes learning by watching and taking over minor tasks. Then, when they enter the profession, reality takes over and the young doctors often find that they are unable to cope and are lacking in social skills.

The reflection training, which is held every two weeks in conjunction with the training wards of the IBAM, offers the students pre-structured learning and practice steps for perception training, perspective-taking and training to cope with uncertainties and deal with ambiguities. In discussions together with a female doctor of psychosomatic medicine, the students reflect on problems encountered in everyday working life, such as moral conflicts, dealing with "difficult" patients or colleagues, their own shortcomings and the tension they feel due to the differences between their ideals and reality. On the basis of a predetermined flowchart, the students learn and practise the identification of situations in which in-depth reflection is needed to develop appropriate and satisfactory solutions. Through the reflection process they develop new skills that enable them to provide optimal patient care and improved team development.

In the international literature the importance of reflection in the training is considered to be high. In Germany there are currently hardly any approaches to training reflective skills in medical training. A topic has therefore been scientifically investigated for the first time which on the one hand is considered to be key to the work of a doctor, but which on the other hand has so far received little attention in their training and in the evaluation of their medical studies. The discussion about good medical studies would be expanded by an important dimension as a result.


The Integrated Course of Additional Studies in Anthroposophic Medicine (IBAM)

The Integrated Course of Additional Studies in Anthroposophic Medicine (IBAM) at the University of Witten/Herdecke integrates anthroposophic aspects into the medical studies and has trained numerous doctors successfully since 2004. In addition to the specific training objectives for Anthroposophic Medicine, some of the goals which the IBAM has set itself are the strengthening of students' reflective faculties, their empathy and ability to independently further develop their personality as a doctor. These skills represent the basis for all powers of judgement required by a doctor.

During a course of studies in Anthroposophic Medicine lasting six years, the aspiring doctors acquire extended medical insights into the individual in terms of health, illness and healing. In this way the IBAM creates the preconditions for the practical realisation of Integrative Medicine which is increasingly in demand both nationally and internationally. The IBAM thereby makes a vital contribution to perspective pluralism and a reflected awareness of methods in medical training, thereby creating important preconditions for integrated patient care.

The structure of the IBAM is based on the curriculum of standard medical studies. The themes and contents of the model study programme are extended by the perspective of Anthroposophic Medicine. In didactic terms the IBAM involves training which is both student and patient-centred and which focuses on the promotion of self-activity and responsibility on the part of the students. The training objective is to enable the student to work as an anthroposophic doctor. This includes the implementation of a form of medicine that recognises the body, soul and mind and takes them into account in its treatment. Through the use of a dialogic relationship structuring process, patients should be rendered capable of achieving autonomy and assuming responsibility for their own health. For this, the doctor should learn to reflect on his or her own medical conduct as well as the targeted use of anthroposophic therapies in patient care, for example remedies based on natural ingredients, topical applications, artistic therapies, curative eurythmy, biographically oriented counselling and suggestions for the patient's inner development.

Phases and implemented objectives of the project

Since 2007 the project was initially tested in practical terms and has been evaluated since 2011/2012. The evaluation study has already been presented at several international congresses and published. It has been possible to transfer the reflection training to newly established training wards in other specialist departments and to earlier training phases during the course of study. A further addition is a course-related mentoring project, in which communicative and reflective skills are to be practised during the preclinical stage of the course – based on experienced reality and not simulated. The analysis of short questionnaires on expectations and fears with respect to the mentoring showed that the students, mentors and co-mentors consider the project to be an enrichment. In order to support the qualitative evaluation results, a quantitative pilot study is currently being conducted which is intended to compare the differences between the skills before and after a practical year with and without reflection training. Furthermore, a manual with a detailed description of the structure and implementation of the training has been compiled which is intended to serve the purpose of spreading knowledge of the concept further. In 2014 an initial workshop for lecturers from other universities was held at the annual meeting of the German Society for Medical Education in Hamburg.

What are the funds of the MAHLE FOUNDATION specifically used for? What has already been achieved with them?

The funds of the MAHLE FOUNDATION were used to help partially finance the post of a female consultant who performs reflection training and further develops, supervises and researches the project. As a result of the funding it has been possible since 2012 to evaluate the quality of and further develop the project and present it at national and international training conferences. A quantitative follow-up study is currently at the stage of data collection. The results obtained so far and the presentations at national and international scientific congresses have led to increasing awareness of the project. The creation and development of a workshop format and the first successful execution of the project at the Congress for Medical Training in Hamburg in 2014 has aroused interest in the project at other locations in Germany and Austria. First requests for support with the development of comparable reflection courses have already been received.

Funding period and outlook

The MAHLE FOUNDATION has been funding the project since 2012. After the resounding success of the first workshop in 2014 at the Annual Meeting of the German Society for Medical Education, more workshops are to be carried out at various locations in order to arouse further interest in this training format. The next step would be teacher training in which university lecturers could learn the skilful application of reflective training in a modular format for their own use.

Future developments should continue to be evaluated and the consequences of the application recorded. This should initially be carried out by the quantitative study which has already been created. In addition, a qualitative survey of the subsequent employers of the project participants is being planned. A qualitative study which has already been started examines the question of to what extent such training could help to improve the creative solving skills of students in difficult professional situations. At the same time, other clinical sites of the University of Witten/Herdecke should be acquired, as well as other national sites which would like to carry out programmes in support of professional personality development.