Reflective writing is used extensively as a learning and assessment tool in medical curricula. The goal, as described by Epstein,1 is to “develop not only one's knowledge and skills, but also habits of mind that allow for informed flexibility, ongoing learning, and humility.”
We present the results of an educational project using reflective writing to integrate delirium education in a geriatric rotation curriculum for internal medicine residents. This topic is high yield, as delirium in hospitalized elderly patients is a medical emergency and an indicator of poor outcomes.2 There is evidence of poor recognition, documentation, and management of delirium in hospitals.3,4 Additionally, geriatric medicine competencies for internal and family medicine residency programs emphasize residents' ability to diagnose and effectively manage delirium.5
This small group didactic activity employs case-based discussions followed by reflective writing to evaluate learners' conceptual understanding of an evidence-based screening, with an interdisciplinary management approach to delirium. Essays written by residents in Research Electronic Data Capture (REDCap) during January and July 2014 were analyzed independently by 2 researchers. Qualitative analysis was used to extract themes related to problems identified during management of delirious patients, current practices, concepts learned during the activity, and interventions the residents thought they would be able to employ in future patient encounters. Quotations that the researchers deemed to be most representative of the responses were selected for inclusion. Minor edits were made to the quotations for clarity and grammar. The study was approved by the Institutional Review Board at Cleveland Clinic.
A total of 16 essays were reviewed (results summarized in the table). Learners identified presence of potentially inappropriate medicines, sleep problems, and hyperactive delirium (agitated patient) as the leading problems when encountering delirious patients. Residents reported that they would use the following 3 leading interventions more often in future encounters with delirious patients: (1) review of medication list and dose reduction/discontinuation of potentially inappropriate medications; (2) employing nonpharmacologic interventions, especially targeting sleep hygiene; and (3) pain control.
We successfully implemented this curriculum for internal medicine residents during their geriatric rotation. The reflective essay writing exercise has been helpful in activating learning and grounding the topic in personal experience for residents, who are able to reflect on current practices, errors, and changes they can implement in future management of delirious patients.
There are limitations in our curriculum. Internal medicine residents in our program receive this structured didactic exercise during their geriatric rotation, which usually falls during the third year of their training. To improve its educational impact, this activity can be added to the curriculum for inpatient medicine rotations with incorporation of cases from the rotation. Additionally, use of reflective writing may not be a representation of bedside interactions and actual change in residents' behavior. Therefore, bedside observations in the clinical settings using a clinical evaluation exercise tool or review of patient charts could be added to provide residents with real-time feedback.
