2014, 36: 415–421
Medical student storytelling on an institutional blog: A case study analysis KATHERINE A. BECKER1 & KAREN FREBERG2 1
University of Wisconsin-Milwaukee, USA, 2University of Louisville, USA
Abstract Background: Despite the proclivity and proliferation of blogs on the Internet, the use of blogs at medical institutions is not well documented. Aims: In examining the structured stories that medical students share with the digital community, we may better understand how students use institutional blogs to discuss their medical school experiences while maintaining their role as a medical student ambassador for the program. Methods: We conducted a case study to analyze the stories within 309 medical student blogs from one medical institution in the United States. Results: In an attempt to communicate their experiences to different benefactors, student bloggers engaged in structured and personal storytelling. Structured stories offered medical school advice to prospective students, while personal stories embodied features of a personal diary where students recounted significant milestones, talked about personal relationships and engaged in emotional reflection and disclosure. Conclusion: Institutional blogs may provide social marketing for medical institutions, as students strategically framed their experiences to reflect a positive attitude about the medical institution and focused on providing advice to prospective students. Although these structured stories limit complete disclosure, students may still achieve benefits by engaging in emotional disclosure and personal reflection.
Introduction
Practice points
Blogs have rapidly evolved and transformed all aspects of society—from the way we share, create and curate information with individuals and communities to organizations. Blogs can range from ‘‘personal, diary-like pages to in-depth public affairs analysis . . . Some provide description of . . . selected links, others tell about details of a writer’s day, and some offer personal opinions and commentaries on the news of a day’’ (Kent 2008, p. 33). The increase in medical students from the ‘‘Net Generation’’, also known as Generation Y (Gibson & Manuel 2003) or Millenials (Howe & Strauss 2000), has lead to an increase in blog use. Blogs allow students to connect with peers (Jones & Madden 2002) and create a portfolio to store personal thoughts and information sources (Williams & Jacobs 2004). These blogs are not static sites but can be easily shared with other people to produce virtual communities of active learners that are enhanced through the sharing of stories and resources (Kennedy 2004). One of the many applications and uses of blogs is to share experiences and events through storytelling. Storytelling is not only focused on the psychological dimensions of the persuasive nature of shared experiences and characters but also the actual social structure itself (Meadows 2003). The social structure can be a physical environment and place or it can be a digital environment where stories are created. Creators of
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New technology like blogs presents medical students with an avenue for self-expression to discuss the multiemotional experience that students face during medical school. Institutional blogs may provide students with an opportunity to communicate about the challenges and joys of medical education and offer advice to prospective and current medical students. Strategic and structured storytelling within institutionally affiliated blogs has benefits for students as well as the medical institution. Having students serve as brand ambassadors by sharing their stories in a structured and strategic manner will help maintain a perception of trust and credibility towards the institution they represent and foster a supportive environment where students can engage in emotional disclosure.
these digital stories have the opportunity to contribute and share their experiences with others virtually and edit the content in real-time to transform the story (Meadows 2003). Storytelling can also be viewed from a strategic and applied
Correspondence: Katherine A. Becker, University of Wisconsin-Milwaukee, Garland Hall 219 P.O. Box 413, Milwaukee, WI 53201-0413, USA. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/50415–421 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.891007
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perspective. Strategic storytelling, as Tyler (2007) discusses, occurs when audiences in a community have a meeting and a superior (e.g. someone in higher management or even an organizational leader) shares organizational stories with them. Strategic storytelling leads into instructional storytelling, which is presented as a structured and formalized storytelling session aimed at advancing the organization’s goals. Instructional storytelling expresses details to a receiver about how certain activities, professions and experiences are being practiced. Similar to storytelling, there is a certain structure or progression to the story that includes a description of actions, characters and experiences from an individual’s perspective. Structured storytelling focuses on stories that highlight particular experiences, events and lessons learned in a natural progression of events and time in order to align with the principles of an institution or organization. Storytelling can emerge in a variety of blogging communication, including medical institutions. The presence of blogs is increasing at some medical institutions worldwide because of the ease of use and ability to obtain an online presence (McGee & Begg 2008). Despite the pervasiveness of blogging among medical students at these institutions (Pinnilla et al. 2013), the use of blogs in medical school is not well documented by health professional educators (Bains et al. 2007; McGee & Begg 2008). The limited research on the content within medical student blogs has focused on the benefits of blogging for medical students (Bains et al. 2007; McGee & Begg 2008). Blogging provides a platform for critical reflection and peer interaction (Boulos et al. 2006) and is associated with improved psychological well being, as well as future academic and professional success (Cross et al. 2001). In a recent study, Pinnilla et al. (2013) conducted a thematic analysis of English and German medical student blogs and concluded that blogs provide a medium for students to discuss various experiences related to medical school and social life. Although researchers have initially started examining the content of medical student blogs, there is no research about the use or benefits of institutional blogs in medical programs, and the benefits that these blogs may provide for the institution or student bloggers. The growing prevalence of institutional blogs warrants the need to understand the unique personal and institutional features of these blogs and the stories that students construct about their experiences in medical school. One institutional medical school blog in the United States is Tour the Life at Indiana University School of Medicine. This institutional blog was created in 2006 to have a select number of medical students write about their academic, clinical and personal experiences to provide an insider’s account of medical school for prospective students (i.e. blogs.medicine.iu.edu). Interested students are selected to blog by contacting University administrators who then choose 10 medical student representatives. The designated bloggers are responsible for posting a blog twice a week for a semester or longer, although it appears that the program does not strictly enforce the posting requirement given the sporadic postings by some of the bloggers (i.e. once a month or once every couple of months). According to the website, bloggers are 416
encouraged to ‘‘not whine’’ on the blogs since potential students may learn from a bad experience, and the school hopes that the blogs will attract prospective students to the program (i.e. blogs.medicine.iu.edu). The Indiana University School of Medicine Office of Admissions oversees the blogs; however, the office serves more as technical support (e.g. archiving old blogs when the student is done blogging) than a communication mediary. Students post directly to their unique webpage on the institutional blogging platform. Because the blogs are affiliated with the medical institution and linked to the Admissions website, stories within the blogs are strategically constructed in order to align with the principles of the institution (e.g. recruit prospective medical students). However, it is possible that students may discuss other personal and professional experiences without directly referencing prospective students or focusing on recruitment to the medical program. Given the limited research on the content within medical student blogs and the potential benefits of structured and purposefully implemented blogs (Pinnilla et al. 2013), we explore two research questions: (a) what do medical student bloggers disclose to the virtual community as they begin to construct an online medical professional identity and (b) how do students structure stories to align with the principles of the institution while also sharing personal stories about medical school.
Methods We conducted a case study that analyzed all of the blogging content for 10 medical students at Indiana University School of Medicine. For our study, we used the content from the 10 bloggers who were listed as ‘‘active bloggers’’ (i.e. as of 31 December 2012). According to the website, ‘‘active’’ bloggers are students who are currently blogging on the Tour the Life website, although the frequency of blogs is often limited to one blog a month. Of the 10 student bloggers, half were female. Three of the students were out-of-state residents (i.e. Ohio, California and Michigan) and seven were in-state residents. Four of the bloggers were located at the dominant medical center in Indianapolis; three of the bloggers were at the Terre Haute campus; two bloggers were at the Northwest campus; and one blogger was at the Evansville campus. Across the 10 bloggers, all four years of medical school were represented. The demographic information from these bloggers was also representative of the student population at Indiana University School of Medicine. The length of blogging varied across students: some of the students had blogged for several years, while other student’s only blogged for a semester. Across the 10 bloggers, there was a total of 309 blog posts, with the first blog post on 10 July 2010 and the last blog post on 28 December 2012. All of the content was able to be accessed in the online public domain, so we did not obtain IRB approval or anonymize the content from the student bloggers. Similar studies involving content analysis and qualitative methods have also not obtained IRB (e.g. Fullwood et al. 2009). However, out of respect for the bloggers, we only use the first name of the student blogger when reporting the data in the study.
Medical students’ structured stories
Procedure and analysis We inductively coded the blogs using a conventional approach to content analysis (Hsieh & Shannon 2005). Each researcher independently organized blogging content into a preliminary categorical scheme where tentative labels were applied. Preliminary codes were then shared and discussed between the two researchers. The researchers then returned to the data using constant comparison as highlighted by Lincoln & Guba (1985) in order to further develop preliminary codes. Through constant comparison, each incident of data was compared to other incidents to identify similarities and differences (Corbin & Strauss 2008). Incidents found to be conceptually similar were grouped together under higher-level descriptive codes. Findings were evaluated based on the fit and the thoroughness of the categories. After reaching consensus on the reliability of the coding scheme, quotations that were deemed particularly representative of the themes were selected from the blogs and agreed upon by the researchers. The data analysis was then written and tied to relevant literature to explain the findings.
Results
not be too personal or inappropriate for the digital environment: I don’t want to share too much personal information. All I can say is that your physical health can make a huge difference in your memory and focus . . . (Allison). In addition to being conscious of the information that they disclosed on the blogs, students were also cognizant about their tone and language when disclosing personal information. When students would complain about certain aspects of medical school, they would provide clarification to the reader, so the reader did not draw inaccurate conclusions from an ambiguous blog post: I am here to be a physician, so some of the problems I have with being in Indiana can be ignored (I don’t have any problems with the people or the school, just the weather and the food) . . . I exercise to get those endorphins going, and most importantly I try to spend my little leisure time doing the things that I used to do in San Diego (definitely inappropriate to share) (Paul).
Structured storytelling Emphasis on advice for prospective students The institutional affiliation led some of the students to use features of structured and strategic storytelling when blogging about their personal and professional experiences. Many stories were structured to provide advice to prospective and current medical students about lessons learned and best practices: The lesson, for those contemplating school, or for those in school, if you care to listen to someone who has failed a class, is that you must be prepared to pursue all means available to you when you begin this journey. Your pride and ego mean nothing, they must be sacrificed as hostages in the short term . . . (Patrick). Structured stories most often discussed time spent studying for exams, interactions with patients and other medical providers during rotations, challenges with balancing one’s personal and professional life and newly acquired medical knowledge. When advice was offered, student bloggers would deliberately mention the phrases ‘‘prospective students’’ or ‘‘future medical students’’ to articulate the intended audience for the advice.
Toeing the institutional line Student’s awareness of their institutional affiliation and online identity led to strategic storytelling where students would cautiously avoid certain personal disclosures within their structured stories. In some stories, students deliberately mentioned that they were withholding certain personal information or story details in order to
In this story, the student provides further clarification to the reader about his problems with school, so the reader does not make inaccurate inferences. In addition, the student states that some information is ‘‘definitely inappropriate to share’’ on the blogs. This excerpt highlights that students are aware of their role as a representative of the medical school and strategically structure stories about their medical school thoughts and experiences. Many students were also strategic with how they discussed negative experiences or hardships. These types of stories often included a ‘‘silver lining’’ or ‘‘lessons learned’’ from the difficult experience: Don’t get me wrong – third year can be really difficult. It is more lonely and isolating than the first two years, as most of my friends are on different rotations. I’m so exhausted most nights that it’s hard to go out and see them. And the first few weeks, when I was lost and confused and the new residents were starting as well, it was absolute madness and it tested my anxiety to a great degree . . . (Molly) In this case, the student acknowledges the unique hardships during the third year of medical school, but includes a silver lining sentence about why the hardships are warranted: ‘‘But any sacrifice I’m making is bringing me closer to the person I was born to be. And because of that, I am filled with peace’’. Many students strategically framed stories in a way to share advice and informational support to prospective and current medical students who might encounter similar experiences: You may be asking yourself, why is she sharing so many details? Well the answer is pretty simple . . . There have been many people who have
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encouraged me and renewed my passion to become a physician simply by sharing their experiences (Jennifer). This advice and informational support was often written after the challenge or obstacle ended. Students would recount the difficult experience and share their personal lessons learned: I spent 12 hours painstakingly re-creating Histo slides and making flashcards for myself, and IT WORKED (Allison). In examining the elements of strategic storytelling used by the students, it is also important to consider what students did not discuss on the blogs. Students adhered to the institution’s principle of not whining on the blogs. There was an absence of negative and critical language in the blogging content, especially when talking about the program or patient interactions. In addition, many stories used anonymity when talking about patients or other people within their professional academic network.
have any real beginnings or endings. You pass milestones, then because the next thing is coming up fast, you never even check to see the milestone recede in the rearview mirror (Patrick). Often, students used the word ‘‘first’’ to emphasize their excitement about a new personal or professional milestone: ‘‘My first patient encounter . . . My first moments in Italy . . . The first time I listened to someone’s heart . . . The first time I helped catch a newborn baby in my hands’’ (Molly). Throughout the medical school journey, the blogs provided a reflective diary to process emotionally difficult experiences. For example, a few stories discussed the death of a fellow classmate and students emotional reactions to this tragedy: This past Tuesday, we lost a classmate and friend, Annique, when she succumbed to her short battle with a rare form of cancer . . . she was only 37 . . . Even in her last days, Annique showed a strength and unshaken faith that we all aspire to possess. My heart aches for the family she left behind . . . She will never be forgetten (Jasmine).
Personal storytelling Transparent about the multi-emotional experience Although students appeared to strategically communicate about personal and professional stories as a way to recruit prospective students, most students went beyond the focus of providing advice to prospective students and personalized their stories in a way that was meaningful to them. Students discussed current events and shared personal stories about family, friends and holidays. Some students included YouTube videos of their favorite songs and links to more personal online information (e.g. Facebook, personal blogs and favorite nonacademic websites). Stories also included pictures of family and friends to provide further elaboration about their personal medical school story. These stories included both positive (e.g. having a baby, buying a home, matching with their first choice and doing well on an exam) and negative (e.g. failure of exams or classes, not achieving personal goals, feeling lost or hopeless and losing a patient) information regarding their personal and professional life. When describing these stories, students would often recount the different emotions resulting from these experiences: Throughout the first two years of school, I felt lost. I didn’t see how memorizing biochemical pathways was helping anyone. Now that knowledge I gained is helping people. And the even more amazing thing is that after years of feeling different (let’s just say it: weird), I feel like I am making the world better just by being me (Molly). Due the fast-paced nature of medical school, students would quickly transition from one emotional experience to the next: The funny thing about going back to medical school is that once that decision is made, you no longer 418
In addition to providing an avenue for emotional expression during distressful events, the reflective nature of the blogs allowed students to compare where they were currently at in medical school with where they were at in previous years: ‘‘I can’t believe I just finished my last spring break . . . so sad . . . Last year I was studying for a biochem test and the physiology shelf exam’’ (Sarah). These reflections provided students with a feeling of accomplishment toward becoming a future physician: ‘‘It’s incredible to me that I am 1/4th done in my quest to becoming a doctor’’ (Allison).
The transition to becoming a physician In addition to being transparent about their emotions, students were also transparent about the multiple roles they had to balance as they transitioned into the role of future physician. For example, one of the student bloggers was a wife and mother in addition to being a medical student. Several of her stories discussed the challenges of trying to balance these different roles simultaneously: At first I was 100% school school school, but then I immediately felt mediocre in the wife, mother, and personal well-being department. It’s almost impossible for me to slack on mommy duties because you can’t expect a 2 year old to understand why you can’t tuck him in, watch Dino Dan with him, or anything else he pleadingly asks (Jasmine). Throughout her blog posts, she was transparent about her personal life outside of medical school and often posted videos and pictures of her husband and son as a way to personalize her medical school story for the digital community. Even for students who appeared to be single, the fast-paced nature of medical school coupled with the intense demands
Medical students’ structured stories
from coursework and clinical rotations made it difficult to have a personal life outside of school. Often, the role of medical student would trump other roles (e.g. mother, father, friend and spouse) and cause the medical student to be absent from family and friends, as well as current events: I did not know Bin Laden was captured for a week. I did not know how bad America’s financial crisis was until somebody told me last week how scared they were about this country. I did not even think about hurricane Irene being anywhere close to Puerto Rico . . . Thank you med school (Paul). As student bloggers transitioned through medical school, they highlighted the importance of family, friends, student peers and patients as important members of their social network who helped them construct their medical professional identity. Often, students would blogs about the experiences that led them to realize the newfound responsibility entrusted to them as medical professionals: When a baby is born into my arms, I forget that I am a doctor. Everyone around me is scrambling to clip and cut the cord. My heart takes over and my mind goes blank . . . Seeing them take a first breath, come to life, brings tears to my eyes. Everytime (Molly).
Discussion The benefits of engaging in strategic and structured storytelling are apparent after review of the stories written by medical student bloggers at one US institution. Student’s structured and personal stories are shared with future and current medical students, doctors in the profession, family and friends of the student blogger, as well as the institution. Stories within the student blogs provide insight about what to expect during medical school, so prospective and current medical students are aware of mistakes and challenges and have advice and informational support about certain activities and behaviors to achieve their goals. By providing these insights, student bloggers are able to establish trust and credibility not only toward the professionals involved but also the institution that hosts the blogging communities. The medical student blogs serve multiple purposes. While the initial intention of the blogs was to market the school to prospective students, the online nature of the blogs has fostered a digital environment where other audience members (e.g. peer students, family and friends) are able to understand the challenges associated with medical school. In addition, many of the students appear to use the blogs as a personal diary to recount significant milestones and discuss their emotions as they face difficult hardships and transition into the role of a physician. While some of the language and tone within the blogs highlights strategic storytelling to meet the needs of the Admissions Office and recruit prospective
students, the stories from other blog posts concentrate on student’s personal lives and emotions. In accordance with the mission of the blogs outlined by the medical institution, student bloggers used strategic storytelling by refraining from critical or negative-valenced language. Stories about challenging experiences included a ‘‘silver lining’’ approach. In addition, many of the stories were structured to include advice to prospective and current medical students based on their own experiences. The advice often focused on general tips about studying, navigating the medical school system and balancing personal and professional life during the program. While the institution’s focus for the blogs was to recruit potential students, many of the student bloggers wrote stories that were more personal in nature and did not solely focus on offering advice to prospective students nor discussing the medical school process. In these personal stories, student bloggers mentioned family, friends and peers, and discussed different personal experiences (e.g. having a baby, traveling, spending time with friends and holiday celebrations). In these instances, students also used the blogs as an outlet for emotional expression. As discussed by the student bloggers, the experiences and rigor within medical education creates an environment for students that are rife with physical, emotional and psychological challenges (Dyrbye et al. 2007, 2010). Upon entering medical school, both national and international medical students must (a) face isolation from their previous life, either moving to a new city/country or not being able to see friends and family often due to medical school obligations, and (b) will encounter some powerful experiences such as delivering a baby, cutting into flesh, staying awake for hours and having first-hand experience with end-of-life (Kiessling et al. 2004). The stress and other negative emotions associated with these experiences has led to high rates of medical student burnout (approximately 50%) and thoughts of suicidal ideation (10%) (Dyrbye et al. 2005, 2006, 2010). Burnout and stress impacts negatively on student’s physical and psychological well-being, impairs student learning, destroys personal relationships and affects patient care (Stewart et al. 1999; Lee & Graham 2001). Given the high rates of stress and burnout in medical school, it is likely that the student bloggers are using the blogs to communicate in ways that they are not communicating through other channels (e.g. face-to-face), especially since students mentioned difficulties with managing personal relationships and shared emotions such as grief resulting from the death of a classmate. During distressful events, the digital publication of one’s thoughts through blogging to a vast audience may generate an uplifting and cathartic health experience for students. Pennebaker and colleagues have found that written disclosure allows individuals to confront upsetting and challenging experiences that they face and reduces the constraints or inhibitions associated with not talking (Pennebaker 1990; Smyth & Pennebaker 2001). Therefore, the emotional writing on the blogs may allow medical students to achieve peace with the personal and professional difficulties faced during medical school and
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provide advice and informational support to current and prospective medical students.
Limitations and future research Although this study has a number of strengths, most notably being the first to explore the blogging stories at one medical institution’s blogging website, it also has some limitations. One limitation is that we did not analyze public blogs or blogs associated with other medical institutions. However, we believe that this is not a severe limitation, but rather the focus of our study. Despite the institutional affiliation of these blogs, our findings mirrored similar results to Pinnilla et al. (2013) who conducted a thematic analysis of German and English medical student blogs obtained from Google. Our findings mirrored their results: medical students shared stories about exams and clinical rotations, revealed emotional distress and other negative emotions experienced during medical school and discussed aspects of social life outside of school. Given these similarities across different blogging platforms, researchers should continue to examine how medical students construct blogs within different online settings and the benefits achieved from using these different platforms. Second, we only examined stories from ‘‘active’’ student bloggers and did not include blogs archived on the website. Additional themes might emerge by including these blogs in the analysis. Finally, we only examined the content of blogs and did not interview the individual bloggers themselves because it was beyond the scope of the current study that focused on the social media content. Future researchers should consider using interviews with student bloggers in order to triangulate the data and further understand individual student experiences. Despite these limitations, our study provides a foundation to understand the stories within institutional blogs. We offer implications for both medical student bloggers and practitioners affiliated with these institutions and how both parties can engage in transparent strategic storytelling practices with blogs to reach key audiences and provide potential benefits. An examination of the institutional blogging content allows prospective students to better understand the medical school experience, while providing the medical student blogger with an online environment to disclose personal and emotional information. In addition, institutional blogs allow medical schools to market their institution in a way that is more meaningful and personal, while also having access to stories that illuminate student experiences in the program. In examining the blogging content, we found that strategic storytelling is apparent in the language and tone selected for some of the stories; however, stories are also personal in nature. Our analysis of the stories suggests that student bloggers balance the needs of the institution, while also engaging in personal and descriptive storytelling. Medical institutions and practitioners who examine the content within institutional blogs may be better equipped to foster a supportive learning environment for students as they become physicians and begin interacting with patients. 420
Glossary Strategic storytelling: When audiences in a community have a meeting, a superior (e.g. someone in higher management or even an organizational leader) shares organizational stories with them (Tyler 2007). Incorporating storytelling into practice: How HDR practitioners foster strategic storytelling (Human Resource Development Quarterly 18(4): 559–587). Blogs: Range from ‘‘personal, diary-like pages to indepth public affairs analysis. Some provide description of . . . selected links, others tell about details of a writer’s day and some offer personal opinions and commentaries on the news of a day’’ (Kent 2008). Critical analysis of blogging in public relations (Public Relations Review 34:32–40).
Notes on Contributors KATHERINE BECKER, MA, is a doctoral student in the department of communication at the University of Wisconsin-Milwaukee. KAREN FREBERG, PhD, is an assistant professor at the University of Louisville.
Declaration of interest: We have no declarations of interest to report.
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Jones S, Madden M. 2002. The internet goes to college: How students are living in the future with today’s technology. Washington, DC: Pew Internet & American Life Project. Kennedy RS. 2004. Weblogs, social software, and the new interactivity on the web. Psychiatr Serv 55:247–249. Kent ML. 2008. Critical analysis of blogging in public relations. Public Relations Rev 34:32–40. Kiessling C, Schubert B, Scheffner D, Burger W. 2004. First year medical students’ perceptions of stress and support: A comparison between reformed and traditional track curricula. Med Educ 38(5):504–509. Lee J, Graham AV. 2001. Students’ perceptions of medical school stress and their evaluation of a wellness elective. Med Educ 35(7):652–659. Lincoln YS, Guba EG. 1985. Narrative inquiry. Newbury Park, CA: Sage. McGee JB, Begg M. 2008. What medical educators need to know about ‘‘Web 2.0’’. Med Teach 30(2):164–169. Meadows D. 2003. Digital storytelling: Research-based practices in new media. Visual Commun 2(2):189–193.
Pennebaker JW. 1990. Opening up: The healing power of expressing emotions. New York: The Guilford Press. Pinnilla S, Weckbach LT, Alig SK, Bauer H, Noerenberg D, Singer K, Tiedt S. 2013. Blogging medical students: A qualitative analysis. GMS Zeitschrift fu¨r Medizinische Ausbildung 30(1):9–20. Smyth JM, Pennebaker JW. 2001. What are the health effects of disclosure? In: Baum A, Revenson TA, Singer JE, editors. Handbook of health psychology. Mahwah, NJ: Lawrence Erlbaum Associates. pp 339–348. Stewart SM, Lam TH, Betson CL, Wong CM, Wong AMP. 1999. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ 33:243–250. Tour the Life Website (n.d.). [Accessed 15 January 2013] Available from http://blogs.medicine.iu.edu/tourthelife/. Tyler JA. 2007. Incorporating storytelling into practice: How HDR practitioners foster strategic storytelling. Hum Resource Dev Q 18(4):559–587. Williams JB, Jacobs J. 2004. Exploring the use of blogs as learning spaces in the higher education sector. Aust J Educ Technol 20:232–247.
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Medical student storytelling on an institutional blog: A case study analysis KATHERINE A. BECKER1 & KAREN FREBERG2 1
University of Wisconsin-Milwaukee, USA, 2University of Louisville, USA
Abstract Background: Despite the proclivity and proliferation of blogs on the Internet, the use of blogs at medical institutions is not well documented. Aims: In examining the structured stories that medical students share with the digital community, we may better understand how students use institutional blogs to discuss their medical school experiences while maintaining their role as a medical student ambassador for the program. Methods: We conducted a case study to analyze the stories within 309 medical student blogs from one medical institution in the United States. Results: In an attempt to communicate their experiences to different benefactors, student bloggers engaged in structured and personal storytelling. Structured stories offered medical school advice to prospective students, while personal stories embodied features of a personal diary where students recounted significant milestones, talked about personal relationships and engaged in emotional reflection and disclosure. Conclusion: Institutional blogs may provide social marketing for medical institutions, as students strategically framed their experiences to reflect a positive attitude about the medical institution and focused on providing advice to prospective students. Although these structured stories limit complete disclosure, students may still achieve benefits by engaging in emotional disclosure and personal reflection.
Introduction
Practice points
Blogs have rapidly evolved and transformed all aspects of society—from the way we share, create and curate information with individuals and communities to organizations. Blogs can range from ‘‘personal, diary-like pages to in-depth public affairs analysis . . . Some provide description of . . . selected links, others tell about details of a writer’s day, and some offer personal opinions and commentaries on the news of a day’’ (Kent 2008, p. 33). The increase in medical students from the ‘‘Net Generation’’, also known as Generation Y (Gibson & Manuel 2003) or Millenials (Howe & Strauss 2000), has lead to an increase in blog use. Blogs allow students to connect with peers (Jones & Madden 2002) and create a portfolio to store personal thoughts and information sources (Williams & Jacobs 2004). These blogs are not static sites but can be easily shared with other people to produce virtual communities of active learners that are enhanced through the sharing of stories and resources (Kennedy 2004). One of the many applications and uses of blogs is to share experiences and events through storytelling. Storytelling is not only focused on the psychological dimensions of the persuasive nature of shared experiences and characters but also the actual social structure itself (Meadows 2003). The social structure can be a physical environment and place or it can be a digital environment where stories are created. Creators of
20 14
New technology like blogs presents medical students with an avenue for self-expression to discuss the multiemotional experience that students face during medical school. Institutional blogs may provide students with an opportunity to communicate about the challenges and joys of medical education and offer advice to prospective and current medical students. Strategic and structured storytelling within institutionally affiliated blogs has benefits for students as well as the medical institution. Having students serve as brand ambassadors by sharing their stories in a structured and strategic manner will help maintain a perception of trust and credibility towards the institution they represent and foster a supportive environment where students can engage in emotional disclosure.
these digital stories have the opportunity to contribute and share their experiences with others virtually and edit the content in real-time to transform the story (Meadows 2003). Storytelling can also be viewed from a strategic and applied
Correspondence: Katherine A. Becker, University of Wisconsin-Milwaukee, Garland Hall 219 P.O. Box 413, Milwaukee, WI 53201-0413, USA. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/50415–421 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.891007
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perspective. Strategic storytelling, as Tyler (2007) discusses, occurs when audiences in a community have a meeting and a superior (e.g. someone in higher management or even an organizational leader) shares organizational stories with them. Strategic storytelling leads into instructional storytelling, which is presented as a structured and formalized storytelling session aimed at advancing the organization’s goals. Instructional storytelling expresses details to a receiver about how certain activities, professions and experiences are being practiced. Similar to storytelling, there is a certain structure or progression to the story that includes a description of actions, characters and experiences from an individual’s perspective. Structured storytelling focuses on stories that highlight particular experiences, events and lessons learned in a natural progression of events and time in order to align with the principles of an institution or organization. Storytelling can emerge in a variety of blogging communication, including medical institutions. The presence of blogs is increasing at some medical institutions worldwide because of the ease of use and ability to obtain an online presence (McGee & Begg 2008). Despite the pervasiveness of blogging among medical students at these institutions (Pinnilla et al. 2013), the use of blogs in medical school is not well documented by health professional educators (Bains et al. 2007; McGee & Begg 2008). The limited research on the content within medical student blogs has focused on the benefits of blogging for medical students (Bains et al. 2007; McGee & Begg 2008). Blogging provides a platform for critical reflection and peer interaction (Boulos et al. 2006) and is associated with improved psychological well being, as well as future academic and professional success (Cross et al. 2001). In a recent study, Pinnilla et al. (2013) conducted a thematic analysis of English and German medical student blogs and concluded that blogs provide a medium for students to discuss various experiences related to medical school and social life. Although researchers have initially started examining the content of medical student blogs, there is no research about the use or benefits of institutional blogs in medical programs, and the benefits that these blogs may provide for the institution or student bloggers. The growing prevalence of institutional blogs warrants the need to understand the unique personal and institutional features of these blogs and the stories that students construct about their experiences in medical school. One institutional medical school blog in the United States is Tour the Life at Indiana University School of Medicine. This institutional blog was created in 2006 to have a select number of medical students write about their academic, clinical and personal experiences to provide an insider’s account of medical school for prospective students (i.e. blogs.medicine.iu.edu). Interested students are selected to blog by contacting University administrators who then choose 10 medical student representatives. The designated bloggers are responsible for posting a blog twice a week for a semester or longer, although it appears that the program does not strictly enforce the posting requirement given the sporadic postings by some of the bloggers (i.e. once a month or once every couple of months). According to the website, bloggers are 416
encouraged to ‘‘not whine’’ on the blogs since potential students may learn from a bad experience, and the school hopes that the blogs will attract prospective students to the program (i.e. blogs.medicine.iu.edu). The Indiana University School of Medicine Office of Admissions oversees the blogs; however, the office serves more as technical support (e.g. archiving old blogs when the student is done blogging) than a communication mediary. Students post directly to their unique webpage on the institutional blogging platform. Because the blogs are affiliated with the medical institution and linked to the Admissions website, stories within the blogs are strategically constructed in order to align with the principles of the institution (e.g. recruit prospective medical students). However, it is possible that students may discuss other personal and professional experiences without directly referencing prospective students or focusing on recruitment to the medical program. Given the limited research on the content within medical student blogs and the potential benefits of structured and purposefully implemented blogs (Pinnilla et al. 2013), we explore two research questions: (a) what do medical student bloggers disclose to the virtual community as they begin to construct an online medical professional identity and (b) how do students structure stories to align with the principles of the institution while also sharing personal stories about medical school.
Methods We conducted a case study that analyzed all of the blogging content for 10 medical students at Indiana University School of Medicine. For our study, we used the content from the 10 bloggers who were listed as ‘‘active bloggers’’ (i.e. as of 31 December 2012). According to the website, ‘‘active’’ bloggers are students who are currently blogging on the Tour the Life website, although the frequency of blogs is often limited to one blog a month. Of the 10 student bloggers, half were female. Three of the students were out-of-state residents (i.e. Ohio, California and Michigan) and seven were in-state residents. Four of the bloggers were located at the dominant medical center in Indianapolis; three of the bloggers were at the Terre Haute campus; two bloggers were at the Northwest campus; and one blogger was at the Evansville campus. Across the 10 bloggers, all four years of medical school were represented. The demographic information from these bloggers was also representative of the student population at Indiana University School of Medicine. The length of blogging varied across students: some of the students had blogged for several years, while other student’s only blogged for a semester. Across the 10 bloggers, there was a total of 309 blog posts, with the first blog post on 10 July 2010 and the last blog post on 28 December 2012. All of the content was able to be accessed in the online public domain, so we did not obtain IRB approval or anonymize the content from the student bloggers. Similar studies involving content analysis and qualitative methods have also not obtained IRB (e.g. Fullwood et al. 2009). However, out of respect for the bloggers, we only use the first name of the student blogger when reporting the data in the study.
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Procedure and analysis We inductively coded the blogs using a conventional approach to content analysis (Hsieh & Shannon 2005). Each researcher independently organized blogging content into a preliminary categorical scheme where tentative labels were applied. Preliminary codes were then shared and discussed between the two researchers. The researchers then returned to the data using constant comparison as highlighted by Lincoln & Guba (1985) in order to further develop preliminary codes. Through constant comparison, each incident of data was compared to other incidents to identify similarities and differences (Corbin & Strauss 2008). Incidents found to be conceptually similar were grouped together under higher-level descriptive codes. Findings were evaluated based on the fit and the thoroughness of the categories. After reaching consensus on the reliability of the coding scheme, quotations that were deemed particularly representative of the themes were selected from the blogs and agreed upon by the researchers. The data analysis was then written and tied to relevant literature to explain the findings.
Results
not be too personal or inappropriate for the digital environment: I don’t want to share too much personal information. All I can say is that your physical health can make a huge difference in your memory and focus . . . (Allison). In addition to being conscious of the information that they disclosed on the blogs, students were also cognizant about their tone and language when disclosing personal information. When students would complain about certain aspects of medical school, they would provide clarification to the reader, so the reader did not draw inaccurate conclusions from an ambiguous blog post: I am here to be a physician, so some of the problems I have with being in Indiana can be ignored (I don’t have any problems with the people or the school, just the weather and the food) . . . I exercise to get those endorphins going, and most importantly I try to spend my little leisure time doing the things that I used to do in San Diego (definitely inappropriate to share) (Paul).
Structured storytelling Emphasis on advice for prospective students The institutional affiliation led some of the students to use features of structured and strategic storytelling when blogging about their personal and professional experiences. Many stories were structured to provide advice to prospective and current medical students about lessons learned and best practices: The lesson, for those contemplating school, or for those in school, if you care to listen to someone who has failed a class, is that you must be prepared to pursue all means available to you when you begin this journey. Your pride and ego mean nothing, they must be sacrificed as hostages in the short term . . . (Patrick). Structured stories most often discussed time spent studying for exams, interactions with patients and other medical providers during rotations, challenges with balancing one’s personal and professional life and newly acquired medical knowledge. When advice was offered, student bloggers would deliberately mention the phrases ‘‘prospective students’’ or ‘‘future medical students’’ to articulate the intended audience for the advice.
Toeing the institutional line Student’s awareness of their institutional affiliation and online identity led to strategic storytelling where students would cautiously avoid certain personal disclosures within their structured stories. In some stories, students deliberately mentioned that they were withholding certain personal information or story details in order to
In this story, the student provides further clarification to the reader about his problems with school, so the reader does not make inaccurate inferences. In addition, the student states that some information is ‘‘definitely inappropriate to share’’ on the blogs. This excerpt highlights that students are aware of their role as a representative of the medical school and strategically structure stories about their medical school thoughts and experiences. Many students were also strategic with how they discussed negative experiences or hardships. These types of stories often included a ‘‘silver lining’’ or ‘‘lessons learned’’ from the difficult experience: Don’t get me wrong – third year can be really difficult. It is more lonely and isolating than the first two years, as most of my friends are on different rotations. I’m so exhausted most nights that it’s hard to go out and see them. And the first few weeks, when I was lost and confused and the new residents were starting as well, it was absolute madness and it tested my anxiety to a great degree . . . (Molly) In this case, the student acknowledges the unique hardships during the third year of medical school, but includes a silver lining sentence about why the hardships are warranted: ‘‘But any sacrifice I’m making is bringing me closer to the person I was born to be. And because of that, I am filled with peace’’. Many students strategically framed stories in a way to share advice and informational support to prospective and current medical students who might encounter similar experiences: You may be asking yourself, why is she sharing so many details? Well the answer is pretty simple . . . There have been many people who have
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encouraged me and renewed my passion to become a physician simply by sharing their experiences (Jennifer). This advice and informational support was often written after the challenge or obstacle ended. Students would recount the difficult experience and share their personal lessons learned: I spent 12 hours painstakingly re-creating Histo slides and making flashcards for myself, and IT WORKED (Allison). In examining the elements of strategic storytelling used by the students, it is also important to consider what students did not discuss on the blogs. Students adhered to the institution’s principle of not whining on the blogs. There was an absence of negative and critical language in the blogging content, especially when talking about the program or patient interactions. In addition, many stories used anonymity when talking about patients or other people within their professional academic network.
have any real beginnings or endings. You pass milestones, then because the next thing is coming up fast, you never even check to see the milestone recede in the rearview mirror (Patrick). Often, students used the word ‘‘first’’ to emphasize their excitement about a new personal or professional milestone: ‘‘My first patient encounter . . . My first moments in Italy . . . The first time I listened to someone’s heart . . . The first time I helped catch a newborn baby in my hands’’ (Molly). Throughout the medical school journey, the blogs provided a reflective diary to process emotionally difficult experiences. For example, a few stories discussed the death of a fellow classmate and students emotional reactions to this tragedy: This past Tuesday, we lost a classmate and friend, Annique, when she succumbed to her short battle with a rare form of cancer . . . she was only 37 . . . Even in her last days, Annique showed a strength and unshaken faith that we all aspire to possess. My heart aches for the family she left behind . . . She will never be forgetten (Jasmine).
Personal storytelling Transparent about the multi-emotional experience Although students appeared to strategically communicate about personal and professional stories as a way to recruit prospective students, most students went beyond the focus of providing advice to prospective students and personalized their stories in a way that was meaningful to them. Students discussed current events and shared personal stories about family, friends and holidays. Some students included YouTube videos of their favorite songs and links to more personal online information (e.g. Facebook, personal blogs and favorite nonacademic websites). Stories also included pictures of family and friends to provide further elaboration about their personal medical school story. These stories included both positive (e.g. having a baby, buying a home, matching with their first choice and doing well on an exam) and negative (e.g. failure of exams or classes, not achieving personal goals, feeling lost or hopeless and losing a patient) information regarding their personal and professional life. When describing these stories, students would often recount the different emotions resulting from these experiences: Throughout the first two years of school, I felt lost. I didn’t see how memorizing biochemical pathways was helping anyone. Now that knowledge I gained is helping people. And the even more amazing thing is that after years of feeling different (let’s just say it: weird), I feel like I am making the world better just by being me (Molly). Due the fast-paced nature of medical school, students would quickly transition from one emotional experience to the next: The funny thing about going back to medical school is that once that decision is made, you no longer 418
In addition to providing an avenue for emotional expression during distressful events, the reflective nature of the blogs allowed students to compare where they were currently at in medical school with where they were at in previous years: ‘‘I can’t believe I just finished my last spring break . . . so sad . . . Last year I was studying for a biochem test and the physiology shelf exam’’ (Sarah). These reflections provided students with a feeling of accomplishment toward becoming a future physician: ‘‘It’s incredible to me that I am 1/4th done in my quest to becoming a doctor’’ (Allison).
The transition to becoming a physician In addition to being transparent about their emotions, students were also transparent about the multiple roles they had to balance as they transitioned into the role of future physician. For example, one of the student bloggers was a wife and mother in addition to being a medical student. Several of her stories discussed the challenges of trying to balance these different roles simultaneously: At first I was 100% school school school, but then I immediately felt mediocre in the wife, mother, and personal well-being department. It’s almost impossible for me to slack on mommy duties because you can’t expect a 2 year old to understand why you can’t tuck him in, watch Dino Dan with him, or anything else he pleadingly asks (Jasmine). Throughout her blog posts, she was transparent about her personal life outside of medical school and often posted videos and pictures of her husband and son as a way to personalize her medical school story for the digital community. Even for students who appeared to be single, the fast-paced nature of medical school coupled with the intense demands
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from coursework and clinical rotations made it difficult to have a personal life outside of school. Often, the role of medical student would trump other roles (e.g. mother, father, friend and spouse) and cause the medical student to be absent from family and friends, as well as current events: I did not know Bin Laden was captured for a week. I did not know how bad America’s financial crisis was until somebody told me last week how scared they were about this country. I did not even think about hurricane Irene being anywhere close to Puerto Rico . . . Thank you med school (Paul). As student bloggers transitioned through medical school, they highlighted the importance of family, friends, student peers and patients as important members of their social network who helped them construct their medical professional identity. Often, students would blogs about the experiences that led them to realize the newfound responsibility entrusted to them as medical professionals: When a baby is born into my arms, I forget that I am a doctor. Everyone around me is scrambling to clip and cut the cord. My heart takes over and my mind goes blank . . . Seeing them take a first breath, come to life, brings tears to my eyes. Everytime (Molly).
Discussion The benefits of engaging in strategic and structured storytelling are apparent after review of the stories written by medical student bloggers at one US institution. Student’s structured and personal stories are shared with future and current medical students, doctors in the profession, family and friends of the student blogger, as well as the institution. Stories within the student blogs provide insight about what to expect during medical school, so prospective and current medical students are aware of mistakes and challenges and have advice and informational support about certain activities and behaviors to achieve their goals. By providing these insights, student bloggers are able to establish trust and credibility not only toward the professionals involved but also the institution that hosts the blogging communities. The medical student blogs serve multiple purposes. While the initial intention of the blogs was to market the school to prospective students, the online nature of the blogs has fostered a digital environment where other audience members (e.g. peer students, family and friends) are able to understand the challenges associated with medical school. In addition, many of the students appear to use the blogs as a personal diary to recount significant milestones and discuss their emotions as they face difficult hardships and transition into the role of a physician. While some of the language and tone within the blogs highlights strategic storytelling to meet the needs of the Admissions Office and recruit prospective
students, the stories from other blog posts concentrate on student’s personal lives and emotions. In accordance with the mission of the blogs outlined by the medical institution, student bloggers used strategic storytelling by refraining from critical or negative-valenced language. Stories about challenging experiences included a ‘‘silver lining’’ approach. In addition, many of the stories were structured to include advice to prospective and current medical students based on their own experiences. The advice often focused on general tips about studying, navigating the medical school system and balancing personal and professional life during the program. While the institution’s focus for the blogs was to recruit potential students, many of the student bloggers wrote stories that were more personal in nature and did not solely focus on offering advice to prospective students nor discussing the medical school process. In these personal stories, student bloggers mentioned family, friends and peers, and discussed different personal experiences (e.g. having a baby, traveling, spending time with friends and holiday celebrations). In these instances, students also used the blogs as an outlet for emotional expression. As discussed by the student bloggers, the experiences and rigor within medical education creates an environment for students that are rife with physical, emotional and psychological challenges (Dyrbye et al. 2007, 2010). Upon entering medical school, both national and international medical students must (a) face isolation from their previous life, either moving to a new city/country or not being able to see friends and family often due to medical school obligations, and (b) will encounter some powerful experiences such as delivering a baby, cutting into flesh, staying awake for hours and having first-hand experience with end-of-life (Kiessling et al. 2004). The stress and other negative emotions associated with these experiences has led to high rates of medical student burnout (approximately 50%) and thoughts of suicidal ideation (10%) (Dyrbye et al. 2005, 2006, 2010). Burnout and stress impacts negatively on student’s physical and psychological well-being, impairs student learning, destroys personal relationships and affects patient care (Stewart et al. 1999; Lee & Graham 2001). Given the high rates of stress and burnout in medical school, it is likely that the student bloggers are using the blogs to communicate in ways that they are not communicating through other channels (e.g. face-to-face), especially since students mentioned difficulties with managing personal relationships and shared emotions such as grief resulting from the death of a classmate. During distressful events, the digital publication of one’s thoughts through blogging to a vast audience may generate an uplifting and cathartic health experience for students. Pennebaker and colleagues have found that written disclosure allows individuals to confront upsetting and challenging experiences that they face and reduces the constraints or inhibitions associated with not talking (Pennebaker 1990; Smyth & Pennebaker 2001). Therefore, the emotional writing on the blogs may allow medical students to achieve peace with the personal and professional difficulties faced during medical school and
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provide advice and informational support to current and prospective medical students.
Limitations and future research Although this study has a number of strengths, most notably being the first to explore the blogging stories at one medical institution’s blogging website, it also has some limitations. One limitation is that we did not analyze public blogs or blogs associated with other medical institutions. However, we believe that this is not a severe limitation, but rather the focus of our study. Despite the institutional affiliation of these blogs, our findings mirrored similar results to Pinnilla et al. (2013) who conducted a thematic analysis of German and English medical student blogs obtained from Google. Our findings mirrored their results: medical students shared stories about exams and clinical rotations, revealed emotional distress and other negative emotions experienced during medical school and discussed aspects of social life outside of school. Given these similarities across different blogging platforms, researchers should continue to examine how medical students construct blogs within different online settings and the benefits achieved from using these different platforms. Second, we only examined stories from ‘‘active’’ student bloggers and did not include blogs archived on the website. Additional themes might emerge by including these blogs in the analysis. Finally, we only examined the content of blogs and did not interview the individual bloggers themselves because it was beyond the scope of the current study that focused on the social media content. Future researchers should consider using interviews with student bloggers in order to triangulate the data and further understand individual student experiences. Despite these limitations, our study provides a foundation to understand the stories within institutional blogs. We offer implications for both medical student bloggers and practitioners affiliated with these institutions and how both parties can engage in transparent strategic storytelling practices with blogs to reach key audiences and provide potential benefits. An examination of the institutional blogging content allows prospective students to better understand the medical school experience, while providing the medical student blogger with an online environment to disclose personal and emotional information. In addition, institutional blogs allow medical schools to market their institution in a way that is more meaningful and personal, while also having access to stories that illuminate student experiences in the program. In examining the blogging content, we found that strategic storytelling is apparent in the language and tone selected for some of the stories; however, stories are also personal in nature. Our analysis of the stories suggests that student bloggers balance the needs of the institution, while also engaging in personal and descriptive storytelling. Medical institutions and practitioners who examine the content within institutional blogs may be better equipped to foster a supportive learning environment for students as they become physicians and begin interacting with patients. 420
Glossary Strategic storytelling: When audiences in a community have a meeting, a superior (e.g. someone in higher management or even an organizational leader) shares organizational stories with them (Tyler 2007). Incorporating storytelling into practice: How HDR practitioners foster strategic storytelling (Human Resource Development Quarterly 18(4): 559–587). Blogs: Range from ‘‘personal, diary-like pages to indepth public affairs analysis. Some provide description of . . . selected links, others tell about details of a writer’s day and some offer personal opinions and commentaries on the news of a day’’ (Kent 2008). Critical analysis of blogging in public relations (Public Relations Review 34:32–40).
Notes on Contributors KATHERINE BECKER, MA, is a doctoral student in the department of communication at the University of Wisconsin-Milwaukee. KAREN FREBERG, PhD, is an assistant professor at the University of Louisville.
Declaration of interest: We have no declarations of interest to report.
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