Ospital ng Maynila Medical
Center, Philippines
Abstract
Up to this
time, medical anecdotal reporting is used solely in research methodology
discussion and is usually frowned upon when invoked in patient management. This
paper reports on the use of medical anecdotal reporting (MAR) as a
teaching-learning activity in the Department of Surgery of Ospital ng Maynila
Medical Center. MAR is operationally defined as a brief written report on an
actual medical event that involves an actual patient seen by a trainee. The
medical observation must have an impact on the trainee in terms of insight
gained and which the reporter thinks is worth sharing with colleagues. The
insight may come in three forms, namely: a discovery; a stimulus for
investigation and research; and a reinforcement or validation of previously held
philosophy and principles. Each clinical trainee was required to submit at least
one brief MAR a month, posted in the Department’s group email and trainee’s
online journal and presented in the Department’s conference. Formative
evaluation of the MAR showed that it could be used as an evaluation tool by the
faculty as well as a meaningful learning activity by the trainees. Through the
MAR, the trainees gained insights or learning through reflection and analysis of
the event. They experienced all aspects of physician-patient biopsychosocial
interaction. They were given opportunities to be expressive and to polish their
written communication skills. Through the MAR, the faculty was able to observe
and evaluate the cognitive and affective levels of competency of the trainees.
Introduction
Up to this
time, in the practice of medicine, the phrase “ medical anecdotal reporting” or
“medical anecdote” or simply “anecdote” is only encountered when there is a
discussion of the basis of a physician’s decision-making in patient management.
As a rule, it is frowned upon when invoked in patient management. Its usage for
other purposes has not been reported.
This paper
reports on the use of medical anecdotal reporting (MAR) as a teaching-learning
activity in the Department of Surgery of Ospital ng Maynila Medical Center (OMMC
Surgery).
The
specific objectives of the paper were to: 1) trace the origin and rationale of
the MAR; 2) describe the procedures on MAR; 3) present the formative evaluation
done in August, 2004; and 4) identify areas of improvement and refinement.
Methods
The
records of the OMMC Surgery that pertained to the development and utilization of
MAR were reviewed to answer the four specific objectives of the paper.
Part of
the formative evaluation was a questionnaire used primarily to assess whether
the MAR was achieving its intended objectives or not. It was also done to get
a formal feedback from the 15 surgical residents and 4 core consultants of the
Department. A 26-item structured questionnaire was utilized. Topic areas
included concept of MAR, utility, and attitude toward it. Attitudinal questions
were formatted as 5-point Likert scales. The questionnaire also included space
for free-form comments. Through the formative evaluation, areas of improvement
and refinement were identified and planned.
The MAR
was initiated in 2004 by the chairperson of OMMC Surgery who had realized the
importance of reflective learning after managing patients. He decided to design
MAR as a teaching-learning activity for surgical residents of OMMC Surgery in
April, 2004.
The 2001
vision-mission for a model in surgical education and the core values of
excellence, quality, professionalism and innovativeness also served as the
driving forces for the development and utilization of the MAR by OMMC Surgery.
Description of the Procedures of MAR
MAR is
operationally defined as a brief written report on an actual medical event that
involves an actual patient seen by a trainee. The medical observation must have
an impact on the trainee in terms of insight gained and which the reporter
thinks is worth sharing with colleagues. The insight may come in three forms,
namely: a discovery; a stimulus for investigation and research; and a
reinforcement or validation of previously held philosophy and principles. Each
clinical trainee was required to submit at least one brief MAR one month, posted
in the Department’s group email and trainee’s online journal and presented in
the Department’s Tuesday and Thursday conferences. See Appendices for samples
of MAR.
From April
to August 2004, a total of 64 MAR done by 15 surgical residents and the
chairperson had been written, presented, and posted in the Department’s egroup.
Table 1
shows the classification of the MAR in terms of discovery, stimulus for
investigation and research, and reinforcement or validation of previously held
philosophy and principles. Most of the MAR were classified as reinforcement.
Table 1.
Classification of MAR in terms of discovery, stimulus for investigation and
research, and reinforcement or validation of previously held philosophy and
principles.
|
Reporter |
Reporter |
Discovery |
Stimulus |
Reinforcement |
Combination |
|
1 |
Dr. Joson |
0 |
1 |
3 |
1 |
|
2 |
Padua |
0 |
0 |
3 |
2 |
|
3 |
Roque |
0 |
1 |
1 |
2 |
|
4 |
Turingan |
0 |
0 |
5 |
0 |
|
5 |
Chan |
1 |
0 |
2 |
2 |
|
6 |
Chua |
1 |
0 |
1 |
3 |
|
7 |
De Guzman |
0 |
2 |
3 |
0 |
|
8 |
C Leyson |
0 |
0 |
4 |
1 |
|
9 |
O Leyson |
3 |
0 |
1 |
1 |
|
10 |
Pingul |
1 |
1 |
1 |
1 |
|
11 |
Aludino |
0 |
1 |
3 |
1 |
|
12 |
Cabahug |
0 |
0 |
3 |
0 |
|
13 |
De Leon |
1 |
0 |
4 |
0 |
|
14 |
Mujer |
0 |
0 |
2 |
3 |
|
15 |
Guerra |
0 |
0 |
2 |
3 |
|
16 |
Medina |
1 |
0 |
3 |
0 |
|
Total |
TOTAL |
8 |
6 |
41 |
19 |
Table 2
shows the distribution of the insights as to physical, psychosocial, and ethical
aspect of patient management.
Table 2.
Distribution of insights of residents as to physical, psychosocial and ethical
aspect of patient management. Most of the MAR were on the physical and
psychosocial aspects.
|
Reporter |
Reporter |
Physical |
Psychosocial |
Ethical |
|
1 |
Dr.
Joson |
4 |
0 |
1 |
|
2 |
Padua |
3 |
2 |
0 |
|
3 |
Roque |
3 |
1 |
0 |
|
4 |
Turingan |
3 |
2 |
0 |
|
5 |
Chan |
2 |
3 |
0 |
|
6 |
Chua |
4 |
1 |
0 |
|
7 |
De
Guzman |
3 |
2 |
0 |
|
8 |
C
Leyson |
0 |
5 |
0 |
|
9 |
O
Leyson |
3 |
2 |
0 |
|
10 |
Pingul |
2 |
2 |
0 |
|
11 |
Aludino |
2 |
2 |
1 |
|
12 |
Cabahug |
1 |
2 |
0 |
|
13 |
De
Leon |
3 |
2 |
0 |
|
14 |
Mujer |
1 |
3 |
1 |
|
15 |
Guerra |
3 |
2 |
0 |
|
16 |
Medina |
0 |
4 |
0 |
|
Total |
TOTAL |
36 |
36 |
2 |
Results
of the questionnaire showed all residents and consultanfs understood the concept
of MAR as designed by the Department. Through the MAR, the trainees gained
insights or learning through reflection and analysis of the event. They
experienced all aspects of physician-patient biopsychosocial interaction. They
were given opportunities to be expressive and to polish their written
communication skills. Through the MAR, the faculty was able to observe and
evaluate the cognitive and affective levels of competency of the trainees. All
residents and consultants were satisfied with the MAR. They believed it had
achieved its intended objectives. They would like it continued with
refinements.
Areas of Refinements and
Improvement
Discussion
Search
of the Medline and HERDIN (1) in August, 2004 did not yield any paper on the use
of “medical anecdotal reporting” as a teaching-learning activity for medical
students and clinical trainees. The types of teaching-learning activity that
are closest to the objectives of the medical anedoctal reporting are the
learning portfolio (2-3), medical case reporting and discussion, and reflection
papers.
Both
learning portfolio and medical anecdotal reporting promote reflective learning.
A collection of medical anecdotal reports may constitute a learning portfolio.
However, a learning portfolio per se may not necessarily be medical anecdoctal
reporting as the former is simply a purposeful and selective collection of
learning activities of a student which may not include the latter.
Both
medical case reporting and discussion and medical anecdotal reporting deal with
one-patient experience. The main difference between the two is that the former
traditionally focuses on the processes of conventional medical management of a
patient while the latter focuses on the insights gained during the management.
The insights are derived from a reflection of what transpired in the
physician-patient interaction and this reflection is not limited to the physical
aspect of health care but can stretch to the psychosocial and ethical aspects of
health management.
Reflection
papers (4-5) in medicine are closest and similar to the medical anecdotal
reporting of OMMC Surgery. The only difference that may differentiate the two
will be the objectives formulated by the facilitators for such a reflective
learning activity. In OMMC Surgery, the primary objectives are to record the
insights of the trainees and share them and in the process learn from them, both
an individual and group bases. Secondary objectives are to improve English
composition and to complement the evaluation tools of the faculty.
In the
formative evaluation, majority if not all of the residents agreed that the MAR
facilitated improvement in the management of even the physical aspect of their
patients’ problem, not just the psychosocial and ethical aspects. This was
despite the residents being taught in their respective medical schools not to
rely on anecdotes in patient management. Even with evidence-based medicine
being in vogue nowadays, it seems that the use of anecdotes and lived
experiences cannot totally be delegated to the background (6-7).
Another
significant observation during the formative evaluation was that majority of the
insights of the residents dwell on the psychosocial and ethical aspects of
medical practice. This finding was heartwarming to the Department’s
administration considering that for the past 20 years, there has been difficulty
in developing and integrating social health sciences and bioethics in medical
education (8-13). Most of the time, the advocacy focuses on the undergraduate
years. There are infrequent reports advocating their use in the clinical
residency, most of them in family medicine (14-15), and practically none in
surgery. The way it has been designed and based on the nature of its outputs,
MAR can very well be a practical innovative strategy and model towards
integrating social health sciences and bioethics in clinical medicine.
Thus, with
all its benefits in terms of reflective learning, improving competency in
biopsychosocial management of the trainees and a valuable evaluation tool for
the faculty, the authors recommend its adoption in the clinical training
departments.