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Medical Student Schwartz Rounds: A Powerful Medium for Medical Student Reflective Practice

Purpose Reflection is a core component of good medical practice and of growing importance given increasing rates of burnout in the field of medicine. Schwartz Rounds (SRs) are a group-based model of reflective practice. This study explored the utility of student-specific Schwartz Rounds as a medium for reflective practice amongst medical students entering their first year of clinical attachments, and how effective these are compared to standard organisation-wide Schwartz Rounds. Methods Three Medical Student Schwartz Rounds (MSSRs) were piloted over the course of a year at a major teaching hospital, focussed on the theme: “Is this what I signed up for?” Participants were asked to complete a questionnaire following the session, and this data was then analysed. Results Feedback was obtained from 93% (42/45) students who attended. Ninety per cent of students rated the sessions as “excellent or exceptional”, 93% felt the MSSRs added to their “insight and self-awareness”, and 90% plan to attend SRs again in the future. A thematic analysis of the qualitative feedback highlighted three broad themes from the pilot; group reflection is more profound than individual reflection, sharing experiences facilitated a greater sense of belonging, and group reflective practice can be intimidating. There was a statistically significant difference between students’ ratings of MSSRs, rated 8.67/10, versus written reflection, rated 4.64/10 (p<0.01). Conclusion Students were overwhelmingly positive about their experiences in this pilot, with response ratings commensurate with those from organisation-wide Schwartz Rounds. Therefore, MSSRs should be considered as a valid alternative form of reflective practice.


Introduction
Reflection forms one of the cornerstones of the GMC Good Medical Practice and, as such, is a necessary requirement in appraisal and revalidation processes. 1 Students are encouraged to engage in reflection early on in order to embed this behaviour into their personal practice. However, there is general dissatisfaction with written reflection, with some seeing it as a waste of time, and a further unnecessary requirement of training. 2 Furthermore, the recent high profile case of Dr Bawa-Garba, whose written reflections were subpoenaed, has led to further uneasiness with the reflective process. 3 Morale within the NHS is at crisis point, with a quarter of doctors reporting feeling burnt-out, and one out of eleven posts currently lying vacant. 4 The problem now extends into the medical student population, with burnout rates amongst this cohort rising, and empathy rates falling over the course of training. 5 Much focus has turned to different types of resilience training in order to boost workforce morale, and one such strategy is the implementation of Schwartz Rounds (SRs).
SRs were developed in the US over 25 years ago and were inspired by a patient, Kenneth Schwartz, who died at the age of 39 with lung cancer. SRs were initially developed to promote compassion in healthcare and to allow multi-disciplinary professionals to come together and reflect on the emotional aspects of working in healthcare. Each Round focuses on a particular theme or case, with panel members each sharing a relevant story and discussing its impact on them, before opening up to an audiencewide, confidential discussion. Crucially, these Rounds are not a problem-solving exercise, but rather a space for reflection and processing of emotions. The most thorough evaluation of Schwartz rounds was recently undertaken as a multisite, prospective NIHR study within in the UK. 6 The initial report includes evidence that the psychological wellbeing of staff who attended Rounds regularly significantly improved. The proportion of staff with significant psychological distress was reduced from 25% to 12% amongst regular attendees, compared to no change in the scores of staff who did not attend (37% to 34%). A recent GMC report on medical staff wellbeing lists Schwartz Rounds as an effective intervention to foster a compassionate and supportive culture. 7 Likewise, the recently published NHS Workforce Health and Wellbeing Framework lists Schwartz Rounds as a prime opportunity to engage in reflective practice as part of a wider mental health initiative. 8 Given the current dissatisfaction with written reflective practice, coupled with the positive benefits SRs offer to attendees, we sought to explore whether there is a role for an SR tailored specifically to medical students. A previous study looked into SRs for medical students entering their final years of medical school and explored their feelings of preparedness for practice. 9 This pilot received very positive feedback and highlighted the need for further consideration regarding the timing and format of these Rounds. We decided to explore the perspectives of students entering their first year of clinical attachments, a key transitional phase in their medical education. Students are exposed to a wealth of new experiences during this period, and we identified this as an opportunity to explore the impact reflective practice could have on the students, whilst allowing them to benefit from the support derived from the SR experience.

Participants and Setting
Year 3 medical students on rotation through a major UK teaching hospital were invited to attend an hour-long MSSR in the final two weeks of their clinical attachment. Attendance was encouraged but was not mandatory. This model was repeated during the following two attachments in the academic year. The theme for each of these Rounds was: "Is this what I signed up for?" Volunteer panel members, who received facilitator-led preparation in advance, spoke at the beginning of the session, and then there was an open floor-wide discussion. The content of these discussions is confidential.

Data Collection and Measures
Feedback was obtained using an adapted evaluation form from the Point of Care Foundation. A further short questionnaire was also used asking students to rate the utility of written reflection practice and the MSSR experience, and comment on their preference. All feedback was anonymous. Completion of the feedback forms was voluntary.

Analysis
Quantitative data were analysed using Microsoft Excel. The results between students' perceptions of written reflective practice and MSSRs were analysed using the paired t-test. Qualitative data from white-space comments were entered into Excel, coded, and analysed to identify the key themes, in line with the process outlined by Braun and Clarke. 10 This was carried out independently by two members of our team, with the results cross-correlated afterwards.

Attendance
Attendance at the MSSRs was voluntary. Overall, 45/84 students (53%) attended over the course of the year. One of the Rounds unfortunately clashed with a number of other teaching opportunities, and so was poorly attended, with only 10/28 students (36%). Feedback was received from 42/45 attendees (93%).

Post-Round Quantitative Evaluation
Students were asked to fill out an adapted Point of Care Foundation evaluation form after attending the Round.
Students were asked to give responses ranging from "completely disagree" through to "completely agree" to a range of statements. The percentage of students responding with "completely agree" and "agree" to each statement is listed submit your manuscript | www.dovepress.com

DovePress
Advances in Medical Education and Practice 2020:11 below (Table 1). Data from the corresponding time period of September 2018 to August 2019 of trust-wide Schwartz Rounds across Imperial College NHS Trust (ICNHT) are given as a comparison. A full breakdown of the responses for each question listed in Table 1 is shown in Figure 1. Of note, 93% of students felt the discussions were useful, and added to their self-awareness and personal insight, whilst 100% felt the Rounds added to their understanding of how their colleagues felt about their work. Crucially, 90% would recommend Schwartz Rounds to their colleagues, and "plan to attend Schwartz Rounds again", and 90% of students rated the Rounds as "excellent or exceptional".

Post-Round Qualitative Evaluation
Three broad themes emerged from the white-space comments received from the students. These are displayed in Figure 2 with representative quotes.

Comparison with Written Reflective Practice
Both quantitative and qualitative data were obtained from students regarding their perceptions of reflective practice. Students were asked to rate the utility of both written reflective practice and the MSSR experience out of 10, select their preferred type of reflection, and comment on this preference.
There was a statistically significant difference between the average ratings of the two forms of reflective practice, as shown in Figure 3. Furthermore, 38/42 students (90%) selected MSSRs as their preferred method of reflective practice, with just one student saying they preferred written reflection, and three students rating them equally (Figure 4).

Discussion Impact
From the feedback received, this early data indicates that students found the MSSRs to be impactful, improving perceptions of self-awareness and insight, whilst helping to foster closer working relationships with colleagues through shared experiences. Ninety per cent of students rated the sessions as "excellent or exceptional", with 90% planning to re-attend SRs in the future. These results closely correlated to the highly successful organisationwide Schwartz Rounds already in operation, and give strong evidence in support of the role of MSSRs moving forwards. These results also closely tally with the preliminary results from a similar student-focused study being run through the University of Surrey, indicating a growing body of evidence justifying their use. 11 Students are often invited to attend hospital-wide SRs but these can be a daunting environment for some young students given the range of seniority present. We hope that an early and graduated introduction to the format and nature of the Rounds will translate into greater attendance and participation in future multi-disciplinary Rounds.
From the students' comments, it was apparent that there was no similar structured approach to group reflection readily available. One student described attending the Round as the "best experience in [their] clinical attachment", whilst multiple students described it as a "safe space to reflect". We feel the feedback received is a clear validation of MSSRs as a tool for reflective practice amongst medical students, providing a novel and powerful medium that is currently under-utilised in the delivery of undergraduate teaching.

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"Opportunity to bounce ideas off one another and continue conversation in several different directions, rather than a linear written piece" "Gives you a chance to explore thoughts you may not have otherwise" "Really insightful way to think about how you feel" "It was really comforting that know that other groups have similar experiences to us." "It highlighted that I am not alone and that I have people to talk to" "Sometimes harder to share thoughts in larger groups" "Can feel intimidating to speak"

Limitations
This pilot was not without its difficulties, and the financial and logistical implications of running MSSRs may hinder other sites being able to introduce them. In the UK, SRs are licensed through the Point of Care Foundation, with a setup cost of £5000, and a £1250 membership fee thereafter. Furthermore, hour-long panellist preparation and debrief sessions must also be factored in, meaning facilitating the session can be a big undertaking. The availability of local facilitators across the country is highly variable, posing a key barrier to their introduction for some medical schools.
A key issue encountered during the first MSSR was a lack of understanding regarding the function of the Round. SRs are not a forum for raising concerns or problem-solving, and some of the initial discussion veered towards students asking the facilitators how they should have approached certain situations or dealt with certain issues. Moving forwards, the aims and function of the MSSRs were more explicitly stated to the attendees, and alternate avenues for raising concerns were highlighted to students. This meant attendees' expectations of the Round more closely allied with their experiences, and the discussion was more reflective and impactful.
It is also key to note that, whilst the vast majority of students stated a preference for MSSRs over written reflection, three students rated them equally, and one rated written reflection more highly. Furthermore, one of the key recurring themes from the qualitative analysis was that the group setting may be intimidating for some students, preventing them from participating. Reflective practice should be an integral part of a student's development, and should not be limited to single events or activities. We do not envisage MSSRs replacing all other forms of reflective practice, but rather that they are integrated to supplement and enhance the other more traditional methods already in place.

Moving Forward
This study focussed on the role of Schwartz Rounds as a form of reflective practice for students entering the key transition into clinical attachment at medical school. A clear preference was expressed for Schwartz Rounds over written reflection, and there is scope for more exploration of this finding. Is it specific to the structured, confidential format of the Schwartz Round, which enabled students to feel freer to speak openly about their experiences? Or would students prefer other types of group reflection just as much, and also display a preference for these over written reflection?
Furthermore, it would be interesting to know whether early exposure to SRs during medical school affects students' future attendance rates at SRs. The feedback received during our study indicated a strong willingness to attend future Rounds. A key finding in the NIHR study of SRs found an increase in wellbeing amongst regular attendees of SRs. Does this finding translate to the medical school population, and, if so, could MSSRs be employed to help reduce burnout amongst medical students? Would early exposure to this format of reflective practice DovePress encourage ongoing attendance beyond medical school, helping to foster a more resilient, empathetic workforce?

Conclusion
SRs are now well recognised as having a significant positive impact on the wellbeing of those who attend. A previous study looking at fifth-and sixth-year medical students indicated MSSRs might have a valid role as part of the undergraduate curriculum. 9 Our study gives more weight to this viewpoint, and in particular looks at the benefits MSSRs can give to medical students earlier on in their training. Students displayed a clear preference for group reflection as opposed to individual written reflection and felt it was more impactful. Given the financial and logistical implications of running Rounds and the potentially intimidating nature of speaking in front of a group, we do not feel that MSSRs should ever replace other forms of reflection, but that they are an extremely useful and currently under-utilised adjunct.

Ethics
This project proposal was discussed with the Medical Education Ethics Committee, Imperial College London, on the 11/3/2019, and it was agreed ethical approval was not required.