P1 Portfolio: Sample Reflective Essay C 1/10 Feedback on portfolio C This essay is from a portfolio that, after considering the evidence and the essay, was graded a P+ overall. The comments below relate to the essay AND to the evidence from assignments, projects, teamwork comments and evidence of achievement records held in eMed. Using Basic and Clinical Sciences You have elaborated well on your learning in this capability, Feedback showing that you have altered your opinion and your approach, not just learnt more of it. Some comment on your only individual assignment in this section was expected. A good Pass. Social and Cultural Aspects of Health and Disease Feedback

An admirable effort at demonstrating how you have learnt about the direct and indirect links between socio-cultural factors and health. I would note only that maybe “identity and belonging is the essence of existence” for most cultures not just the “many” that you assert. Plus the overwhelming effect of poverty on health status could have been elaborated on here.

Patient Assessment and Management Feedback

This is another good section as you reveal how you have learnt new skills and developed different approaches to improve your newly learnt clinical methods. N.B. I think that you mean mnemonics rather than pneumonic (meaning ‘of the lungs’)

Effective Communication Feedback

You have adequately shown a reflective response to markers’ comments on your assignments and your interaction with patients. This is an important area as you state and deserves the attention you have given it. N.B. A couple of spelling errors crept into this report –attention to detail is important here.

Team Work Feedback

A great deal of sensible and developing insight is demonstrated here and in the eMed Teamwork comments. I think that you might be a bit more cautious in taking all the kudos for the improved grades in project work that resulted from your taking on the leadership but you obviously understand and have developed in this capability.

Self-Directed Learning and Critical Evaluation Feedback

This section is not particularly well written as it does not flow well, but the substance is very comprehensive (especially regarding the self-directed learning) and charts a very good understanding and development of this capability. This is supported by your evidence.

Ethics and Legal Responsibilities Feedback

You touch here on some vital issues and although sometimes you show that you are still not clear about these, you are able to reflect on your own misgivings and confusion in the face of ethical dilemmas. Although this is rather generically written at times, overall a high degree of maturity is obvious here.

Reflective Practitioner Feedback

My only concern up to this point had been a lack of emotional element or involvement in your reflection, but this segment of your essay demonstrates some distinct learning points that reveal your involvement and connection with patients. Overall you have shown some key insights into your learning, your behaviour and your role as a medical student and how this will affect you as you continue in your training.

Overall Feedback

Overall this is an excellent portfolio and essay as you have been able to show with appropriate evidence and insight how, what and why you have learnt and altered your opinions through Phase 1. Continuing to develop these skills is your next challenge. Well done.

P1 Portfolio: Sample Reflective Essay C SAMPLE REFLECTIVE ESSAY C

2/10

2.1 Using Basic and Clinical Sciences Understanding the scientific foundation of health is essential in research and clinical practice. At the beginning of the course, I was more skeptical, particularly in relation to embryology and biochemistry. I believed a doctor is exclusively concerned with physical symptoms, while intensive scientific knowledge is too theoretical for clinical application. I realised this was short-sighted when I interviewed the mother of a girl with VATER syndrome. Understanding the process responsible for a congenital malformation, and its disparity from normal, is essential, as a solid foundation of health is necessary before considering abnormality and treatment.

While most of my assessments have been through group projects, I have found this beneficial, allowing concentrated study in one specialty, collaboration and reflection. In, ‘Mechanisms and Consequences of Itch and Pain’, feedback suggested the information was ‘in general terms’. Discussing this with staff and peers, I realised that medicine, being an integrated and multifaceted field, requires in-depth analysis, spanning several domains of science, to attain comprehensive knowledge. Reading one textbook does not suffice, and viewing issues from various viewpoints is necessary. Consequently, In ‘Fussy eating in young children’, we researched alternate theories, including possible evolutionary traits which went “beyond the requirements” and was “well written”.

Researching in detail, particularly from differing perspectives and ideas became apparent in ‘Quality of Medical Practice: alternative therapies for arthritis’, where we found a plethora of contradicting information. Understanding the clinical validity of certain treatments is imperative to effectively inform patients, as was the case when my father considered using such treatments. Through this assignment I facilitated him in making a more informed decision.

Initially, I had difficulty with biology, having not studied it in high school. However, a number of strategies, including reading before and after lectures, and a study group have helped solidify my knowledge. Gaining a sound understanding of basic ideas and principles was necessary to comprehend more complex mechanisms in subsequent courses. Another subject I initially disliked learning was histology. I had difficulty visualising three-dimensional structures from slides and remembering intricate details. This changed as I realised understanding the role of a structure facilitates understanding why and where it has certain features. Disease and health are integrated in many facets of the homeostatic system of the human body. I was surprised to learn that elevated blood glucose in diabetes mellitus can have profound effects in almost all systems. Thus, by learning through scenarios, I have better been able to understand that disease, and consequently health, cannot be isolated to one region, but rather a complex interplay of systems.

P1 Portfolio: Sample Reflective Essay C 2.2 Social and Cultural Aspects of Health and Disease

3/10

Becoming proficient at understanding and appreciating the impact of various backgrounds on health, will be mandatory as I set out in clinical practice in our multicultural society.

In the assignment ‘Global Impact of Alcohol’ I researched the role of social expectations and cultural influences on the consumption of alcohol. Interestingly, those of higher socio-economic status in developed nations were less likely to be alcohol dependent, while the opposite was true in developing nations, with increased buying power. These differences in social and economic influences reflect varying intervention strategies, with developed nations implementing primary harm-minimisation, whilst developing nations concentrate limited resources into tertiary strategies.

In ‘Sex, Gender and Health’ I found delineations of the terms gender and sex, which I believed to be interchangeable, particularly surprising. Identity and the sense of belonging is the essence of existence for many cultures. In many regions, expectations of women and conformity to social traditions prevent protection from and treatment for HIV. Consequently, being culturally aware of customs and traditions is imperative in formulating efficacious treatment strategies.

During research on a negotiated assignment, I observed a number of pre-natal consultations. I was told by obstetricians that women from the Pacific-Islands and Middle-East are most predisposed to gestational diabetes, yet often fail to present to appropriate ante-natal clinics. Understanding the cultural reasons which may preclude earlier detection is necessary, so as to implement changes and alleviate unnecessary morbidity.

The importance of being culturally specific to patients in clinical practice became evident when we discussed Aboriginal and Indigenous cultures. I was surprised to learn that not meeting ones eyes is considered respectful, while shaking of the head implies understanding. Throughout clinical visits, dealing with patients from non-English speaking backgrounds has been difficult. However I have found that staying patient, speaking in simple terminology and use of non-verbal communication has been beneficial. Eliciting a social history is particularly important in clinical examinations, as often physical presentations are used by patients to initiate discussion of emotional or social problems.

The myriad of cultural and experiential backgrounds studying medicine has resulted in passionate discussions. During one scenario group when discussing appropriate strategies against a possible H5N1 pandemic, those from Asian nations where existing precautions are high, had differing perspectives to those having never experienced such situations. Remaining accepting and inclusive of all perspectives is imperative to learn from others and facilitate formulation of ones own beliefs. I am confident this experience will continue throughout the course.

P1 Portfolio: Sample Reflective Essay C 2.3 Patient Assessment and Management

4/10

Due to its practical and clinical components, I have found this capability interesting and enjoyable. In ‘Maria: medical, ethical and legal issues in the case of a pregnant minor’ I was surprised to learn that depression in adolescence and pregnancy can be mistaken for mood swings or hormonal imbalance. It is thus imperative that doctors are aware of this condition, its diagnosis and those particularly at-risk. Its differing presenting symptoms and rather subjective diagnostic criteria make depression difficult to diagnose, while management of psychological and physical manifestations is often complex and interrelated. This assignment initiated my interest in psychiatry, and how neural imbalances can clinically manifest.

‘ERCP or MRCP? Diagnostic imaging in diseases of the liver and pancreas’ was worthwhile in understanding the different approaches to diagnosis. Particularly interesting was what criteria are used to distinguish between diagnostic imaging techniques, with each process having its advantages and disadvantages. Understanding patients’ complaints through a thorough history and formulating correct differential diagnosis is imperative in knowing which tests to conduct to efficaciously ascertain the cause of disease.

Clinical sessions have been most enjoyable and rewarding. I have particularly found visualisation and application of theoretical learning fascinating. Through examination and history taking of a patient with chronic cardiac failure, I was able to relate signs and symptoms to changes to anatomical structures and pathological processes; understanding her shortness of breath stemmed from pulmonary oedema due to left sided heart failure.

I have however, had some difficulty in certain components of clinical practice. In first year I had difficulty in percussion. Subsequently, following my tutor’s advice, I have practiced on friends, family and even tables, greatly improving my technique. Similarly I have had trouble in history taking, with a tendency to jump around without a directed approach. Speaking to peers in older years, I developed pneumonics, leading to cohesive and structured methods to elicit a history. I plan to continue practicing through hospital visits and ‘mock osce’ role playing with friends, particularly before the end of phase clinical exam.

Through my job as a pathology specimen collector, I have improved my patient communication, medical and drug history taking and understanding which diagnostic tests are common for suspected conditions. Furthermore, conducting venepuncture, wound swabs, skin scrapings and ECGs has been fulfilling and worthwhile, albeit difficult to master, increasing my appreciation for the range of diagnostic testing which is conducted throughout general and specialist practice.

P1 Portfolio: Sample Reflective Essay C

5/10

2.4 Effective Communication Surprisingly, I found this capability difficult, as I felt communication to be one of my strengths. My initial experiences in hospital made me nervous, feeling I was intruding on patients while exposed and vulnerable. In our first clinical session an intoxicated man began abusing us. This shocked and made me uncomfortable talking to patients. However as time has progressed I have realised that patient interaction is essential to learn, and hence, be able to treat future patients. By increasing patient contact, I have improved immensely, to a level where I feel confident and proficient.

In the communication assignment, while I was able to identify and “acknowledging feelings” with effective “summarising skills”, I had a tendency to rush questions. This stems from my urgency not to forget key components. As the course progresses, I hope to be better able to reflect on a patient’s comments through active reflection. Pausing to consider what has been identified before embarking on subsequent questioning, is a skill I hope to develop, as it results in more appropriate and specific questions. I intend to increase patient contact hours, along with a colleague, to receive immediate peer feedback to improve upon.

While I find talking in medical terms relatively easy, translating medical jargon into lay terms has been difficult. This was the case in ‘Fussy eating in young children’. In this project we made an educational resource in the form of a website which was “too technical for the general public”. I improved upon this in ‘Atherosclerosis - An Educational Resource’, taking care to compose a context appropriate resource. I incorporated diagrams, user-friendly icons and split up pages, to increase aesthetic appeal, summarise information and draw attention, utilising feedback from my parents and non-medical friends.

Another problem I encountered in the course was being concise in reports. I was given an F in a generic effective communication comment, as I was unspecific and excessive in length. As the average physician-patient consultation is 10 minutes (Deveugele et al. 2002), it is imperative to be succinct in providing information. While I did achieve this subsequently, it is an issue I have struggled with and hope to improve in future courses.

On one occasion working as a pathology collector, a patient began crying, overburdened by the stress of her illness. While initially I was shocked and unsure of what to do, I commented that the tests ordered would give her some answers and indicate a way forward, and to remain positive. Working as a doctor I will be dealing with people in high emotional stress in a majority of cases. Dealing sensitively and appropriately to an individual’s concerns is essential.

P1 Portfolio: Sample Reflective Essay C

6/10

2.5 Teamwork This capability has been challenging yet ultimately satisfying. In first-year I found group projects relatively easy, as the second-years undertook leadership roles. While I completed my work on time and attended meetings, I felt unsure of my place within the group. Throughout high school I had thrived in leadership roles, while for the past 2 years I have been team manager for a football team, organising players and administrative details. As the team consists of friends from a similar background, I found working within it easier and comfortable. In group projects, composed of differing personalities and characteristics, I gave the impression of indifference toward the team, being “polite… but detached.” I realised that wanting to be an important team member can manifest itself through motivation, leading by example, and providing an enjoyable environment. I implemented these strategies in subsequent projects, which improved the team’s marks and overall ambience.

“People with Disabilities and the Health Care System” received a P-, for a number of reasons. Firstly, interviewing intellectually disabled patients was challenging and we were unable to ascertain patients’ major issues arising from the provider’s ability to improve quality of life, and provide structured multidisciplinary therapy. However, it was our own inadequate group teamwork which reflected the poor mark. It was the first instance where I was a second year in the project. We did not set meeting times, delegate tasks nor set goals. We had poor team dynamics, and were dismissive of other’s views. While components of the project were well written, as a whole the piece did not have a unified message about disability and team management.

I did subsequently take a leadership role in group projects, delegating tasks and actively motivating and encouraging others, without seeming domineering. I found giving feedback to others, maintaining a cordial environment, and willing to listen, helped immensely in our performance. These ideas were validated in the project, ‘Assessing cardiovascular health and risk factors’, where we analysed theoretical models of team dynamics. Within multi-dimensional teams, members take on specific roles dependent on their prospective outcomes. A successful team must acknowledge these roles and adapt them to meet specific goals. I enjoyed this assignment as it let us conceptualise and ascertain whether theoretical models can be practically implemented.

In the negotiated assignment on ‘Multidisciplinary team care in the management of diabetes in pregnancy’, it was fascinating to see how individuals from different specialties implement their own expertise to produce suitable outcomes. Patients found such team oriented clinics convenient, as many facets of their conditions are identified and managed simultaneously. The health professionals involved demonstrated that teamwork is essential for quality patient management.

P1 Portfolio: Sample Reflective Essay C

7/10

2.6 Ethics and Legal Responsibilities Ambiguity and non-definitive answers have made this capability challenging. In, “Genetics of Thalassaemia”, I identified potential abuse of gene therapy for eugenics. I was interested to read perspectives which claim genes and the environment equally affect personality and lifestyle, so why should we control only one of these aspects? This changed my view from definitively no, to a more lenient and liberal approach, although adamant that regulations must be implemented.

In ‘Maria: medical, ethical and legal issues in the case of a pregnant minor’, I conducted extensive research particularly in ethics journals, and utilised the ‘ethics wheel’ to draw a more theoretical framework from which to base my practical beliefs. I enjoyed learning about ethical and legal expectations in regards to patient autonomy, confidentiality and right to care. Essentially, the doctor’s obligation is to maintain these rights, ensuring satisfaction.

Another issue the assignment raised was that legal and ethical frameworks are not necessarily complimentary, and may contradict one another. The issue of abortion, while legal in Australia conflicts with my own moral and ethical criteria. I found this bewildering, as I assumed laws to inherently uphold what is ethically right. What has become clear throughout the course is that there is no universal ethical position on any issue. Differing perspectives dictate varying actions and legislations.

Conflicting perspectives were apparent in an ethics tutorial considering organ recipients. An interesting dilemma that arose was whether the patient in better health should be given the organ or the patient who otherwise would die sooner. While I felt doctors should not have the right to determine who deserves to live or die, at the end of the day, there is only one liver, only finite resource; hard decisions, inevitably must be made. I have had trouble coming to grips with this fact, and remain hesitant to accept such a concession.

Through my work, I am required to conduct venepuncture. Being faced with patients with HIV and hepatitis, I found myself judging their lifestyles and character. As I reflected on this attitude, I was disappointed and surprised. I realised the feelings stemmed from my own anxiety at contracting their disease. A similar ‘blame’ mentality exists in clinical practice. In the obesity scenario we learnt that stigma and indifference held by health professionals against obese patients prevent them from seeking treatment. It is not a doctor’s position to judge and make assumptions on patients. It is our responsibility to address and manage patients no matter their affliction. 2.7 Self-Directed Learning and Critical Evaluation Throughout phase 1, I have learned to evaluate the strength of findings and the validity of applications to particular cases. ‘Quality of Medical Practice: alternative therapies for arthritis’, illustrated the

P1 Portfolio: Sample Reflective Essay C 8/10 importance of reading and appraising a range of resources, where a wide variety of studies found conflicting data. Utilistaion of meta-analyses and investigation of resources through critical appraisal checklists was a useful way of objectively identifying reliable findings, and isolating shortcomings. Consideration and critical evaluation of resources is essential in determining treatment approaches. Formulating negotiated assignments has been challenging yet rewarding. I have obtained new skills relating to formulating clinical questions, liaising with health professionals, identifying limitations and becoming flexible. This was the case in ‘Multidisciplinary team care in the management of diabetes in pregnancy’. Originally I outlined the analysis of teamwork in one hospital. However, to identify whether such an approach was overtly beneficial, comparing two different teamwork-oriented management styles would provide a more sound evidence base from which to formulate conclusions. Hence, I was able to adapt my assignment to compare differing teamwork strategies, as well as comparing traditional segmental approaches. This process of negotiating assignments will be beneficial, particularly when I become involved in research opportunities.

Communicating with patients through alternate means than physician contact has been a strong theme in phase 1. Primary and secondary prevention campaigns utilse print, electronic and mass media to educate. My interest in the internet led me to undertake a general education course on designing websites. As more individuals turn to this convenient source of information, it will be essential that the health system adapts appropriately.

During “Assessing cardiovascular health and risk factors” I found collecting data, and ensuring consent and confidentiality, was painstaking and detailed. More difficult was analysis and cleanup of data, choosing which values to discard. This experience will be worthwhile in my proposed honours project and future career.

The learning style throughout phase 1 has also been a challenge. Medicine is as much about problem solving, and application of knowledge, as remembering facts and figures. I have subsequently attempted to understand mechanisms of health and homeostasis more thoroughly. Utilisation of a study group, as well as explaining concepts to my family has moved me away from rote learning, strengthening my knowledge base.

I have become interested in whether my learning has improved with patient contact. Consequently, I have negotiated an honours research year, evaluating whether surgical training is enhanced by observation and time spent in theatre.

P1 Portfolio: Sample Reflective Essay C

9/10

2.8 Reflective Practitioner My assessments throughout the course show a development and greater understanding of what entails being a reflective practitioner. In the communications assignment, I struggled to keep the open ended interview moving in the direction I felt important. The marker commented, “I don’t believe open interview style prevents it from having a strong direction”. I had not considered this, as from my hospital experience, open ended interviews allowed patients to dictate the discussion. Upon reflection, I realised this is its very strength. This approach allows patients to identify what they need addressed. I have improved on this in subsequent clinical sessions, where I have identified issues which seem of most concern or value, and ask questions focusing on that. I hope to illustrate this improvement in another communication assignment.

The idea that patients should be in control of their health care has been an interesting realisation. I always felt that every medication and treatment should be afforded to patients. This is neither always desirable nor practical. In the cancer scenario, we learnt that in palliative care, it is the patient who decides the manner in which symptoms are managed. In a clinical session we interviewed a cancer patient who had dismissed conventional medicine for alternative homeopathy. Similarly, in a lecture we were told that treating febrile patient’s symptoms is not always recommended. This strengthened the notion that patients are in control of treatment, doctors merely provide an avenue to attain it.

In “HPV, vaccines and cervical cancer” the importance of reflecting on one’s personal background, upbringing and ethical framework in formulating opinions was identified. We had a number of discussions on whether HPV vaccines should be administered to adolescents. Those from more conservative and religious backgrounds were hesitant to approve its widespread inoculation, due to the possibility of increased unsafe, casual sex. One difficulty we had as a group was putting ourselves in the position of a parent. Empathy and understanding the emotional and experiential background of patients is fundamental. Through this appreciation, one can better understand a patients concern, and more directly address it. Experiences contribute to our overall points of view. Specifically, I noticed how my attitude towards clinical sessions changed. My first few sessions were daunting and I did not enjoy the prospect of patient contact. However as I continued with sessions, I grew in confidence and began to look forward to them. By the end of phase 1, I found clinical sessions to be the most rewarding and inspiring component of the course.

Another motivating experience was listening to a team of plastic surgeons discussing their humanitarian efforts in Pakistan, following the 2005 South Asian Earthquake. Hearing what a difference these individuals made, has been one of the main motivators for my interest in surgery, one I hope to explore further.

P1 Portfolio: Sample Reflective Essay C

10/10

In one clinical session I met a young woman about my age who had been diagnosed with Turner Syndrome, Inflammatory Bowel Disease and Lupus. In spite of her afflictions, her upbeat persona and drive to overcome adversity was awe-inspiring. I wanted to become a doctor to help people, and while I have begun to start that journey, it seems to me, that perhaps we can learn as much if not more from our patients.