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Twelve tips for teaching reflection at all levels of medical education

Authors:

Abstract

Review of studies published in medical education journals over the last decade reveals a diversity of pedagogical approaches and educational goals related to teaching reflection. The following tips outline an approach to the design, implementation, and evaluation of reflection in medical education. The method is based on the available literature and the author's experience. They are organized in the sequence that an educator might use in developing a reflective activity. The 12 tips provide guidance from conceptualization and structure of the reflective exercise to implementation and feedback and assessment. The final tip relates to the development of the faculty member's own reflective ability. With a better understanding of the conceptual frameworks underlying critical reflection and greater advance planning, medical educators will be able to create exercises and longitudinal curricula that not only enable greater learning from the experience being reflected upon but also develop reflective skills for life-long learning.
2010, 1–6, Early Online
TWELVE TIPS
Twelve tips for teaching reflection at all levels
of medical education
LOUISE ARONSON
University of California, USA
Abstract
Background: Review of studies published in medical education journals over the last decade reveals a diversity of pedagogical
approaches and educational goals related to teaching reflection.
Aim: The following tips outline an approach to the design, implementation, and evaluation of reflection in medical education.
Method: The method is based on the available literature and the author’s experience. They are organized in the sequence that
an educator might use in developing a reflective activity.
Results: The 12 tips provide guidance from conceptualization and structure of the reflective exercise to implementation and
feedback and assessment. The final tip relates to the development of the faculty member’s own reflective ability.
Conclusion: With a better understanding of the conceptual frameworks underlying critical reflection and greater advance
planning, medical educators will be able to create exercises and longitudinal curricula that not only enable greater learning
from the experience being reflected upon but also develop reflective skills for life-long learning.
Introduction
In recent years, professional organizations and accrediting
bodies have called for the inclusion of reflection at all levels
of medical education (ACGME 1999; ABIM Foundation,
ACP-ASIM Foundation, European Federation of Internal
Medicine 2002; Frank 2009; GMC 2009). These calls come in
response to a growing literature in medical education sug-
gesting that reflection improves learning and performance in
essential competencies. Specifically, reflective learning can
improve professionalism and clinical reasoning, and reflective
practice can contribute to continuous practice improvement
and better management of complex health systems and
patients (Mann et al. 2007; Sandars 2009). This work builds
on an extensive and decades-old literature on the benefits
of reflection in higher education and life-long learning,
but offers only partial guidance for medical educators in
deciding how best to teach and develop reflective skill in
their learners.
Review of studies published in medical education journals
over the last decade reveals a diversity of pedagogical
approaches and educational goals. The following tips outline
an approach to the design, implementation, and evaluation
of reflection in medical education based on the available
literature and author experience. The tips are ordered in a
sequence an educator might use in planning a reflective
activity and are applicable to learners in undergraduate,
graduate, and continuing education settings.
Tip 1
Define reflection
Because reflection is a familiar concept in everyday life,
medical educators must distinguish the common usage of the
term from the particular skill set associated with important
educational outcomes. Colloquially, to reflect means to look
back and consider something. While such thoughtfulness
can result in insight and learning, it does not automatically
lead to the high level analysis, questioning, and reframing
required for transformative learning. Critical reflection,by
contrast, has been described by Mezirow as follows:
...the process of becoming critically aware of how
and why our presuppositions have come to constrain
the way we perceive, understand, and feel about our
world; of reformulating these assumptions to permit
a more inclusive, discriminating, permeable and
integrative perspective; and of making decisions or
otherwise acting on these new understandings. More
inclusive, discriminating, permeable and integrative
perspectives are superior perspectives that adults
choose if they can because they are motivated to
better understand the meaning of their experience
(Mezirow 1990).
Simply put, critical reflection is the process of analyzing,
questioning, and reframing an experience in order to make
Correspondence: L. Aronson, Department of Medicine, Division of Geriatrics, University of California, 3333 California St, Suite 380, San Francisco,
CA 94118, USA. Tel: 1 415 514 3154; fax: 1 415 514 0702; email: aronsonl@medicine.ucsf.edu
ISSN 0142–159X print/ISSN 1466–187X online/10/000001–6 ß2010 Informa UK, Ltd. 1
DOI: 10.3109/0142159X.2010.507714
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an assessment of it for the purposes of learning (reflective
learning) and/or to improve practice (reflective practice). If we
take the example of a medical mistake, a superficial, educa-
tionally ineffective reflection will consist of a description of the
events or a description accompanied by reasons such as
the team/clinic was busy and other people failed in their
responsibilities. A more useful and deeper reflection would
include consideration of how and why decisions were made,
underlying beliefs and values of both individuals and institu-
tions, assumptions about roles, abilities and responsibilities,
personal behavioral triggers, and similar past experiences
(‘‘when pressed for time, I ...’’), contributing hospital/clinic
circumstances and policies, other perspectives on the events
(frank discussion with team members, consultation of the
literature or other people who might provide alternative
insights and interpretations), explicit notation of lessons
learned and creation of a specific, timely, and measurable
plan for personal and/or system change to avoid future
similar errors. Effective reflection, then, requires time, effort
and a willingness to question actions, underlying beliefs
and values and to solicit different viewpoints. This ‘‘triple
loop’’ approach moves beyond merely seeking an alternate
plan for future similar experiences (single loop) or identifying
reasons for the outcome (double loop) to also questioning
underlying conceptual frameworks and systems of power
(Argyris & Scho
¨n 1974; Carr & Kemmis 1986).
Tip 2
Decide on learning goals for the reflective exercise
Reflection should not feel like busy work or an add-on activity.
By providing rigorous learning objectives synergistic with
those in other parts of the course, clerkship, or continuing
education program, the educator signals an expectation that
the goal of the reflective exercise is meaningful learning
and practice improvement. The benefits of this approach are
twofold since in addition to improved immediate outcomes,
a more positive learning experience from reflection is associ-
ated with greater effort in future reflection (Sobral 2005).
This is crucial since reflection is part of an experiential learning
cycle in which experience leads to reflection which leads to
reconceptualization which informs subsequent experience
which is followed by further reflection, and so forth (Kolb
1984).
In selecting learning goals, educators should answer the
following questions: Are there key competencies, attitudes,
content areas, or skills in need of greater attention or
assessment? How can the exercise be used to help learners
integrate (1) new learning with existing knowledge; (2) affec-
tive with cognitive experience; and/or (3) past with present
or present with future practice? Will reflective learning or
reflective skill building be an explicit focus of the exercise?
Is one of the goals to identify learning or practice needs
and strategies to address them? The literature suggests that
reflection may be most effective as a learning strategy and
that it is more useful in resolving complex rather than
simple clinical challenges (Mamede & Schmidt 2005;
Mann et al. 2007). Prompts can take any number of forms
but are most useful if they ask the learner to choose a
‘‘disorienting dilemma,’’ i.e. a situation that cannot be resolved
using previous problem solving strategies (Mezirow 2000).
Such dilemmas generally arise from experiences which
triggered questions or concerns, such as: (1) a situation
where they did not have the necessary knowledge or skills;
(2) a situation that went well but they are not entirely sure
why; (3) a complex, surprising, or clinically uncertain situation;
or (4) a situation in which they felt personally or professionally
challenged (Scho
¨n 1983).
Tip 3
Choose an appropriate instructional method for
the reflection
In designing a reflective exercise, educators must consider
whether the assignment will take place ‘‘in class’’ or at home
and whether the exercise will be oral, written, or completed
using new media such as audio recording, blogs, or digital
storytelling (Sandars 2009). Most of the medical literature on
reflection discusses written exercises with a range of applica-
tions from critical incident reports to storytelling (Branch
et al. 1993; DasGupta & Charon 2004; Wald 2009). With
the exception of a single study of oral versus written
reflections, there are no data for the superiority or inferiority
of any approach (Baernstein & Fryer-Edwards 2003). Certainly,
oral reflection is most suitable to what Scho
¨n called reflection-
in-action and what Eva and Regehr call self-monitoring,
reflection that occurs during a surprising or troubling experi-
ence (Scho
¨n 1983; Eva & Regehr 2008). In medical education,
most reflection is reflection-on-action which occurs after
the event. For this type of reflection, written exercises and
perhaps some of the new digitally recorded media offer
multiple advantages. Creation of an artifact shows commit-
ment to learning and ownership of experience. It promotes
critical thinking and offers more opportunities for feedback,
including feedback from different sources. A trainee critically
reflecting through development of an artifact on a patient
care experience might receive feedback on medical knowl-
edge and learning goals from a preceptor and feedback on
professionalism and reflective skill from a mentor. Finally,
artifacts allow for the longitudinal integration of learning,
creation of a record for use in ongoing self-assessment,
mentored reflection, evaluation of progress within and across
multiple domains, and inclusion in a portfolio or maintenance
of certification program. Reflection artifacts can be produced
in class or as homework. In class reflection will be shorter
but assures timely compliance and can sometimes be explic-
itly linked to other educational activities. Assignments com-
pleted outside of formal sessions offer the advantages of
allowing learners more time to choose an appropriate expe-
rience upon which to reflect and opportunities to look things
up and seek the feedback necessary to help them reframe their
experience. Educators should consider their learning objec-
tives when deciding which instructional methods to use for a
given reflection exercise.
L. Aronson
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Tip 4
Decide whether you will use a structured or
unstructured approach and create a prompt
Absent guidance and education about reflection, a majority
of learners produce reflections which are largely anecdotes
devoid of learning (Wong et al. 1995; Niemi 1997). This may in
part be why learners – and some educators – object to
reflection. In response to these findings, educators have used
structured approaches to help learners reflect in deeper and
more educationally meaningful ways (Johns 1994; Wald et al.
2009). Although structure and guidance leading to deeper
learning can be offered by an educator as part of feedback on
an unstructured reflection (‘‘what reasoning did you use
to come to that conclusion?’’ ‘‘It seems you’ve made some
significant assumptions here’’), given the low placement of
most novice reflectors on the continuum of non-reflection to
critical reflection, the more efficient approach is to provide
both upfront guidance and feedback. This can be done by
using a structured prompt which makes explicit the compo-
nents of critical reflection: discussion of processes and
assumptions as well as actions and thoughts; consideration
of the role of associated emotions and relevant past experi-
ences; solicitation of feedback and review of relevant literature
where appropriate; explicit notation of lessons learned; and
creation of a plan to improve future behavior and outcomes.
Arguments against structured reflections include concerns
that structure limits and distorts the very response the exercise
is designed to elicit and that it risks encouraging mindless
‘‘recipe following’’ rather than insightful analysis (Boud &
Walker 1998; Branch & Paranjape 2002). One potential
strategy to mitigate these concerns is to start with a free
write approach and follow that with a structured analysis.
Tip 5
Make a plan for dealing with ethical and emotional
concerns
Reflection is not therapy. Educators should make this clear
at the outset of the exercise so as to avoid inappropriate
disclosures. Even with this caveat, however, readers of
reflections sometimes will come across concerning revelations.
These typically consist of psychological distress on the part of
the writer or depictions of unprofessional, illegal, or trouble-
some statements or actions by the writer or others. Educators
must plan in advance for how they will handle such material.
In deciding on an approach, it is crucial to remember that a
reflection presents just one view of a situation and as such may
be misleading or inaccurate. Equally, it would be irresponsible
to disregard comments which suggest the possibility of
illegality or danger to the learner, patients, or others.
If the reflections will be shared without the learners’
presence, a good initial approach is to contact the author of the
disturbing content to gather more information. If the sharing
will take place in a group, the educator should decide
in advance how she/he will deal with worrisome revelations
to ensure not only that appropriate action is taken but also
the safety and privacy of the writer and those mentioned in the
reflection and role modeling of a professional response,
even if that response is acknowledgment of concern and
referral to qualified help. The best way of dealing with such
situations is to develop programmatic or institutional guide-
lines so individual educators do not have to decide on next
steps under trying circumstances and manage the situation
without organizational support. Some key considerations in
designing guidelines include:
In cases of reflector distress: Is the reflector of danger to
self or others or merely in need of support? If in need of
support, is the educator for the reflection exercise qualified
to provide that support and if not, who is?
In cases of inappropriate behavior: Is this a legal issue or a
professional one? If the latter, is this a learning opportunity
or an occasion for referral to a disciplinary body (or both)?
If accusations have been made, implicitly or explicitly,
who will determine the facts of the situation and how?
Tip 6
Create a mechanism to follow up on learners’ plan
Reflection is iterative. The goal is to learn from experience,
but in order to ascertain whether what was learned was useful,
it needs to be applied (Kolb 1984). Either in the reflection
itself, perhaps with the help of a structured prompt, or in the
feedback, the learner should be encouraged to make a plan
to address learning gaps or test out behavioral hypotheses
generated by their analysis. Ideally, the reflector will state
explicitly the relevance of the topic to their practice beyond
the individual described experience. If not, educators and/or
peers can help them see the larger issue in the feedback
session. For example, if a clinician writes about an encounter
with a patient who has left her practice as a result of the
experience described in the reflection, she should be encour-
aged to identify the issues relevant to her own behavior or the
care of other patients which can be extrapolated from that
experience. For trainees, if the reflection – or the initial
reflective session – is structured early enough in a course
or clerkship, learners can reflect on how the plan worked
at follow up sessions or discuss the outcome of the plan in
small group. This increases the utility of the reflection and the
learners’ accountability. Similarly, continuing education and
recertification programs could encourage deeper reflection
by offering additional credits for evidence of application of
reflective learning to clinical practice.
Tip 7
Create a conducive learning environment
To succeed, reflective exercises require the establishment
of positive learning climate through the use of an authentic
context and creation of a safe and supportive environment for
reflection. The authenticity of the exercise depends on how
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well it is tied into the larger educational program and the
individual learners’ needs at the time of the exercise. Good
learning objectives are necessary but not sufficient to link
reflection to the learners’ current activities. For example,
reflecting on surgical skills would be appropriate partway
through a surgical rotation but less useful at the conclusion
of the rotation on the eve of pen-and-paper test of surgical
knowledge. In addition to establishing relevance, educators
can increase authenticity by modeling reflection and encour-
aging other faculty to incorporate reflection into their practice
and teaching. This latter will help create a supportive
environment for reflective learning. Other critical environmen-
tal elements include providing enough time for the reflective
activity, insistence upon respectful and supportive treatment
of others in group discussions of reflection, explicitly acknowl-
edging hindsight bias and the inclination to present an
expected rather than an authentic persona, and making clear
at the outset who will have access to the reflection and for
what purposes, who will provide feedback, and whether
assessment will be formative or summative.
Tip 8
Teach learners about reflection before asking
them to do it
The conflation of reflection and critical reflection has led to
the misperception that educators can ask learners to reflect
without teaching them how to do so first. Before initiating
a reflective exercise, educators need to define reflection
(or preferably, critical reflection, as discussed above) for
their learners, provide them with evidence of the educational
and practice-related benefits of reflection, and outline the
components of good critical reflections, such as (1) linking
past, present, and future experience; (2) integrating cognitive
and emotional experience; (3) considering the experience
from multiple perspectives; (4) reframing; (5) stating the
lessons learned; and (6) planning for future learning or
behavior. It is also useful to have learners analyze one or
more reflections so they better understand what each compo-
nent means in practice. These components should be the same
as those that will be used to assess the reflections.
Tip 9
Provide feedback and follow-up
Evaluation of reflection is essential since it motivates learning
and shows that the educators and organization/institution
value the exercise. Feedback can be individual, group, faculty,
or peer and any feedback is better than none. The literature
shows that shared reflection is better than individual and self-
assessment is often inaccurate (Branch & Paranjape 2002; Eva
& Regehr 2008). In reflection, others often see things the
reflector cannot see. When done well, feedback provides
multiple perspectives on the experience, supports integration
of affective and cognitive experience, discourages uncritical
acceptance of experience and guides what Eva and Regehr
have called ‘‘self-directed assessment seeking.’’ This can be
accomplished by identifying the reflector’s key concerns,
pointing out where assumptions were made, offering alternate
interpretations or data, and by asking for clarification of
reasoning, omissions, and conclusions.
The nature of the feedback merits note as well since
reflective exercises often serve two purposes: addressing the
relevant learning objectives and developing reflective skill.
Educators should provide feedback not just on the content of
a reflection but on the learner’s reflective skill as well. Often,
it will be possible to comment on many different aspects of the
reflection. The goal should not be comprehensive feedback
but feedback which is challenging rather than overwhelming,
aligned with the learning objectives, and educationally useful.
Aim for 2–3 key teaching points, one of which addresses
the learner’s reflective skill. In the process feedback, note the
elements of reflection the learner has incorporated effectively
and offer one more they might include or improve on their
next reflection.
Tip 10
Assess the reflection
Assessment can be linked to or distinct from feedback.
The goal of the feedback is deeper learning. The goal of
assessment may include learning but also involves evaluation
of the learners’ abilities in the topic areas of the reflection
and/or in reflection itself. Assessment can be done in narrative
by stating judgments about the learners’ abilities or engage-
ment with the exercise or by using validated and reliable
scoring rubrics (Learman et al. 2008; Wald et al. 2009). These
methods can be combined to provide learners with a score
indicating their level of reflective skill and also narrative noting
the adequacy of the reflection in addressing the assigned topic,
what was done well, and suggested next steps.
Educators must decide whether assessment will be forma-
tive, with the exclusive goal of developing learners’ abilities, or
summative and used for grading purposes in courses or
clerkships, advancement in a training program or certification
process, or award of continuing medical education (CME)
credit. Some have argued that the goal of reflection is to
nurture a skill the trainee or practitioner can apply throughout
their career so its assessment should always be low stakes and
formative. Others believe an exclusively formative approach
encourages focus on complex topics and professional
vulnerabilities without fear of negative evaluations. But such
arguments confuse evaluation of reflective skill with evaluation
of the reflector. Extensive data demonstrate that evaluation
drives learning. Monitoring and enforcing compliance with
codes of professionalism and other complex, value-laden skills
and behaviors vital to medical competence are part of the
core missions of professional schools, training programs, and
certifying organizations. Assessment signals that the topic or
skill being assessed matters and should be part of a clinician’s
continuous professional development. This is not to say that
every reflective exercise requires summative assessment but
rather that periodic summative assessment should be consid-
ered as part of any program aimed at cultivating reflective skill.
L. Aronson
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Tip 11
Make this exercise part of a larger curriculum
to encourage reflection
Reflection is a skill which requires development and can be
applied broadly in medical education. For trainees, the best
approach to developing reflective skills may be a longitudinal
integrated curriculum with different mileposts in terms of both
reflective skills and application contexts as the learner moves
through their professional program. At the student level,
for example, one potential trajectory might begin with
understanding the components of critical reflection, move to
demonstrating the ability to apply those components to
learning strategies and/or clinically relevant skills which
can be practiced in the preclinical years such as leadership
or teamwork, then apply critical reflection to clinical practice
and clinical reasoning, and finally critically reflect on their
development over the course of the training period.
At alternative approach which also would work at the
residency level, would be competency-based, aligning reflec-
tive skill building with competency assessment, and increasing
reflection expectations while moving through competency
mileposts, using the reflections to identify knowledge and
skill gaps, integrate learning across rotations, and plan for
future practice. In continuing education, exposure to reflective
exercises may be single or episodic making integration
into a larger curriculum difficult except via recertification
processes or longitudinal CME activities. Moreover, since
reflection is a relatively new phenomenon in medicine,
educators need to consider how a single exercise might
serve a diverse learner group with a broad array of reflective
skills.
Tip 12
Reflect on the process of teaching reflection
Practice the skills you are teaching. This is faculty development
and continuous educational practice improvement and should
take place prior to, during, and after teaching reflection. If you
select a structured approach, use the structure yourself.
Identify someone from whom to seek feedback. If you will
take a structured approach to feedback, have that person use
your format to comment on your reflection. If you will assess
your learners’ reflections, have your own reflection assessed
in the same manner. Your reflection should produce insights
about yourself as a reflector, learner, and educator as well as
about the challenges of the exercise you have designed. You
can then re-examine your reflective exercise and modify it
to more effectively avoid the potential pitfalls described
by Boud and Walker, including: recipe following, reflection
without learning, mismatch between the exercise and its
learning context, intellectualizing, inappropriate disclosure,
uncritical acceptance of experience, and raising issues
beyond the educator’s expertise (Boud & Walker 1998).
Apply what you have learned to your next reflective teaching
session.
Conclusion
In trying to incorporate reflection in their teaching, many
educators have implemented exercises which elicit anecdotes
rather than the sort of analysis, questioning, and reframing
of experience likely to produce meaningful educational
outcomes. With a better understanding of the conceptual
frameworks underlying critical reflection and greater advance
planning, medical educators will be able to create exercises
and longitudinal curricula that not only enable greater learning
from the experience being reflected upon but also develop
reflective skills for life-long learning.
Declaration of interest: The author reports no conflicts
of interest. The author alone is responsible for the content and
writing of the article.
Notes on contributor
LOUISE ARONSON, MD MFA is an associate professor of medicine at the
University of California, San Francisco where she directs the reflective
learning curriculum, the Pathways to Discovery Program, and the Northern
California Geriatric Education Center.
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... The study was conducted in the Postgraduate Centre of Family Medicine at Riyadh, Saudi Arabia, where the SDFM program is conducted. It was carried out in a natural setting to provide a holistic understanding of the experience [14]. The SDFM is a postgraduate training program under the umbrella of the Ministry Of Health (MOH) in Saudi Arabia. ...
... The type of assessment in the SDFM program, either summative or formative, was vague for some participants until late in the program. This again might indicate the importance of clear purposes, guidelines, and instructions regarding portfolio assessment before implementation [14]. In fact, effective assessment in medical education is usually supported by a comprehensive grading and reporting system, which helps by clarifying expectations, maintaining a reasonable workload, and self-assessment promotion [24]. ...
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Background The use of the portfolio methodology in medical education can serve as a tool for learning, assessment, and reflection on practice. This study concentrates on perceptions of the portfolio assessment methodology among participants in the Saudi Diploma of Family Medicine program. Methods In this qualitative interview study, data were collected and analysed using a grounded theory approach. Results Nine codes emerged: (1) Importance of understanding the definition, objectives, and process of portfolio assessment, (2) Impact of different understandings on the part of various trainers, (3) Role of the type of assessment, (4) Workload and stress of portfolio assessment, (5) Effectiveness of the portfolio contents, (6) Role of the mentor’s feedback, (7) Role in the learning process, (8) Role in practice, (9) Suggestions for portfolio improvement. Open codes were then regrouped into three axial codes: context, strategy, and outcome of portfolio assessment. Conclusion This study explored a general explanation of portfolio assessment shaped by the postgraduate students. It identifies the importance of portfolio understanding in student acceptability of the portfolio assessment methodology. Thus, proper implementation is vital for the success of assessing the student by the portfolio methodology. The students perceived reflection as the most valuable part of the process, which facilitated their learning, confidence, and self-assessment. Mentor feedback is a good strategy for coping with portfolio challenges. Our findings provide some evidence of positive outcomes of portfolio assessment in practice and professional development.
... In general, self-reflection and critical reflection is important as it supports learning progress throughout one's studies and is a mandatory ability for the whole working life as a dentist [20,21]. However, it is a challenge for both students and teachers because reflection is a complex issue, including the processes of analyzing, questioning and reframing of an experience [22]. An appropriate method and a continuity of reflection during a longitudinal curriculum are needed for successful teaching of reflection [22]. ...
... However, it is a challenge for both students and teachers because reflection is a complex issue, including the processes of analyzing, questioning and reframing of an experience [22]. An appropriate method and a continuity of reflection during a longitudinal curriculum are needed for successful teaching of reflection [22]. As a visual metaphor, PRISM clearly differs from other approaches to foster self-reflection in the dental education setting; several recent examples include e-portfolios, briefing and debriefing sessions before and after clinical practice, reflective writing as well as video-based peer-feedback [23][24][25][26]. ...
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Objectives To compare Pictorial Representation of Illness and Self-Measure (PRISM) and a numeric scale for self-reflection in dental students. Methods Fourth year dental students were randomly assigned to each receive one interview based on PRISM or a numeric scale to self-assess their competencies at the beginning (t1), the middle (t2) and the end (t3) of integrated clinical course. Questionnaires were used to assess self-perceived benefit of the interviews at each time points. Results Students in PRISM group perceived a higher benefit regarding the self-assessment of their practical skills at all time points ( P < 0.05), for theoretical knowledge at t2 and t3 ( P < 0.05) and reaching the course objectives at t3 ( P = 0.04). At all time points, PRISM group rated their interview ( P = 0.04), the applied instrument (PRISM, P = 0.01) and the benefit of the combination of both higher than numeric scale group ( P < 0.05). Conclusion In this preliminary study, PRISM was superior against a numeric scale and can be recommended for dental education to facilitate self-assessment.
... [5][6][7][8][9] In particular, reflection can occur after meaningful or significant experiences and stimulates medical students to understand 'why things are the way they are.' [10][11][12][13] Authentic reflection can be difficult to both capture and implement in a curriculum. [14][15][16][17][18][19] Despite this, medical curricula are creating initiatives to guide reflection. For example, reflective portfolios are being widely applied as an educational structure for encouraging formalized reflection on experiences. ...
... Reflection is more effective when multiple sources and perspectives are included. 7, 19 We concur with de la Croix and Veen that diversity in reflection needs to be appreciated, 14 and that personal ways of reflecting, both inside and outside of the curriculum, should be accepted in medical school. Moreover, formal curricular opportunities with a diverse group of classmates may be essential for some students to gain exposure to differing experience, perspectives, and beliefs. ...
Article
Background: Medical curricula are increasingly providing opportunities to guide reflection for medical students. However, educational approaches are often limited to formalized classroom initiatives where reflection is prescriptive and measurable. There is paucity of literature that explores the personal ways students may experience authentic reflection outside of curricular time. The purpose of this study was to understand how social networks might shape dimensions of reflection. Methods: This study employed a qualitative social network analysis approach with a core sample of seven first year undergraduate medical students who described their relationships with 61 individuals in their networks. Data consisted of participant generated sociograms and individual semi-structured interviews. Results: Many learners struggled to find significant ways to involve their social networks outside of medicine in their new educational experiences. It appeared that some medical students began in-grouping, becoming more socially exclusive. Interestingly, participants emphasized how curricular opportunities such as reflective portfolio sessions were useful for capturing a diversity of perspectives. Conclusions: Our study is one of the first to characterize the social networks inside and outside of medical school that students utilize to discuss and reflect on early significant clinical experiences. Recent commentary in the literature has suggested reflection is diverse and personal in nature and our study offers empirical evidence to demonstrate this. Our insights emphasize the importance of moving from an instrumental approach to an authentic socially situated approach if we wish to cultivate reflective lifelong learning.
... In order to contemplate and integrate the lessons learned from the students' community experiences, reflection should take place after such a service-based experience [48]. Aronson [53] defined critical reflection as "the process of analyzing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice)." Moreover, the help and support of another person (e.g., a peer, supervisor, or mentor) seems important in realizing the potential of such reflection [30]. ...
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Students’ volunteering is an effective way to manage health crises, including pandemics. Due to the limited capacity of the healthcare system at the time of the COVID-19 outbreak, the engagement of students in volunteering services seemed invaluable. Based on different teaching–learning theories, in this survey study, we aimed to evaluate the potential of the volunteering service project launched by the Poznan University of Medical Sciences during the COVID-19 pandemic as a learning opportunity for undergraduate healthcare students. The results indicate the potential of involving students in volunteering activities for educational purposes, as well as other values, including attitudes and professional identity development, which could be difficult to realize using traditional teaching methods. However, stimulating students’ reflectiveness seems necessary to reach its full educational effectiveness. Medical teachers should provide students with more opportunities for volunteering and service learning and consider making these a constant element of the curriculum beyond the COVID-19 pandemic.
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Dentists often experience uncertainty when deciding on the most effective treatment for a particular patient. There are various sources of uncertainty and different strategies for coping with it, such as reducing or accepting it and learning how to make decisions despite feeling uncertain. The overall objectives of the thesis are to contribute with information that reduces uncertainty regarding the treatment of cariously exposed pulps in young permanent teeth and to improve dental education to ensure that future dental students manage well despite uncertainty. By means of a systematic review and a model analysis, the thesis evaluates the available evidence and cost-effectiveness of a pulp capping procedure compared to a root canal treatment to reduce the uncertainty regarding the cost-effectiveness of treatments for young permanent teeth with vital pulps exposed by caries. The thesis also addresses the acceptance of uncertainty. A reflection exercise was developed and tested in a group of dental students. Prompts from an established model were used to stimulate the students to write reflections during the risk assessment of a root-filled tooth. The effect of the reflections on the student’s awareness of and comfort with uncertainty was explored with a repeated questionnaire. The written reflections were analyzed with a qualitative method to explore how dental students reflected on clinical experience in relation to uncertainty. In the systematic review, the success rate for pulp capping in children and adolescents varied between 64 and 100 percent in the included studies. The model indicated that pulp capping procedures are cost-effective compared to root canal treatment in teeth with pulp exposure due to caries. Fewer teeth were extracted after a pulp capping during the 9 years the patients were followed in the model and the cost for the initial treatment and follow-up treatments during this time period was lower compared to a root canal treatment. The reflection exercise had an effect on the students’ responses to the questions regarding how certain they believed an experienced colleague would feel, and how certain they felt of their capacity to handle the case. Most students did not state that they felt certain about assessing the risk for exacerbation of apical periodontitis in root-filled teeth but felt certain of their own capacity to handle the case, as well as comfortable with their ability to handle the situation and do their best for the patient. Three themes about experience and lack of experience were identified in the reflections: “the meaning of clinical experience”, “assumed differences regarding assessment” and “relating to the same risk factors”. The following conclusions were drawn from the four studies: For children and adolescents with pulp exposure due to caries, pulp capping procedures are cost-effective compared to root canal treatment, but there is a lack of prospective studies concerning root canal treatment. Moreover, the existing studies on pulp capping procedures are of low quality. Most final-year dental students participating in a reflection exercise did not feel certain of their risk assessment of root-filled teeth but still felt certain of their capacity to handle the situation, as well as comfortable with their ability to do the best for the patient. The students believed that clinical experience leads to certainty even when the scientific evidence is lacking and experts who meet students have a great responsibility to be transparent with their own uncertainty.
Article
Introduction: Reflective practice (RP) forms a core component of medical professionalism but, despite its benefits, it remains largely undervalued among medical students. The aim of this study was to explore medical students’ attitudes and barriers to engagement with RP in the undergraduate programme at a UK based medical school. Methods: This was a qualitative study based on the methodology of phenomenology. All penultimate year medical students at University College London Medical School (n=361) were approached for this study and altogether thirteen participants were recruited, with data collected through two focus group discussions. Thematic analysis was used to generate the coding framework. Results: Five key themes emerged around student attitudes to RP, which were grouped into three domains: ‘value of RP’, ‘barriers to engagement’, and ‘strategies for enabling RP’. ‘Value of RP’ centred on the themes of humanising medicine and developing empathy, developing professionalism and RP as a tool for sense-making. ‘Barriers to engagement’ centred on the purpose and tokenism of RP and in the third domain, ‘strategies for enabling RP’, the theme of student agency in RP emerged strongly. Conclusion: Overall, the value of RP was not fully appreciated until students began their clinical placements. Potential strategies identified by participants for optimising engagement included student co-design and positioning RP within a broader pastoral role early in the undergraduate curriculum.
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Introduction: Reflection is an important skill for dentists but there is little consensus about how reflection can most usefully be integrated into dental education. The aim of this study was to conduct focus groups to explore how students at a transitional point of dental education in one UK dental school had experienced, and conceptualised reflection. Methods: Students at the beginning of their clinical studies were recruited by email and invited to attend a single focus group. Focus groups were co-facilitated by a team of staff and student researchers and analysed using thematic analysis. Students acted as research partners in planning a topic guide, recruiting students, conducting focus groups and considering the implications of research findings for the curriculum, and contributed their perspectives to other aspects of the research. Results: Students primarily associated reflection with their clinical learning and valued the skill highly in this context. They were less familiar with the potential for reflection to support personal development and deeper learning. Themes were identified of learning, uncertainty, emotions and wellbeing, community and challenges and are discussed in detail. Conclusion: Reflection is highly valued within our dental education setting but many students may be missing out on using it to its' full potential. Changes to the undergraduate curriculum, including offering reflection from an early stage of education may be warranted.
Article
Employability is one of these concepts that polarises opinion. There are those who see it as an integral part of student education and learning, and those who see it as undermining conventional academic study. In this paper, we argue it is a key part of student learning experiences and use a case study of a particular module—'Politics in Action'—to highlight the potential benefits to students. This should be seen in conjunction with the rest of a degree programme, where employability maybe embedded but not prioritised. Student feedback reinforces the potential benefits of prioritising employability in one part of a degree programme, while acknowledging the beneficial spillover into other areas of study. There is, however, potential resource cost in adopting this type of approach to delivering such a bespoke module. It is far from being a conventional module, but the impact and benefits to student learning and understanding are clear.
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Purpose Optometry education strives to develop competencies required for reflective practice in its pupils. The forced changes in academia during COVID-19 pandemic, rapid switching to online methods imposed serious challenges on the training of reflective skills. We hypothesize that the synchronous online sessions of case-based reflections are effective in imparting training for reflective practice in optometry students. Methods A prospective study was done with planned, synchronous, online, small group workshops for case-based reflections through the second year of optometry program during ‘introduction to patient care’ course. The reflective competencies were measured with a modified Groningen Reflection Ability Scale (GRAS) at the beginning and towards conclusion. Data was analysed with Mann-Whitney one tail test and qualitative thematic methods. Results Total of 104 students participated in the study. The aggregate score showed significant improvement (p<0.05) in students’ reflective ability. A rising trend was seen in each component namely self-reflection, empathetic and communication reflections. Discussions The results demonstrate that the reflective skills can be developed using virtual patient experiences, case-based reflective practices conducted in synchronous small group workshops in online mode. Students perceived it as useful activity in developing themselves as healthcare professionals.
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Reflection and the promotion of reflective practice have become popular features of the design of educational programmes. This has often led to learning being more effectively facilitated. However, alongisde these positive initiatives have grown more disturbing developments under the general heading of reflection. They have involved both misconceptions of the nature of reflection which have led to instrumental or rule-following approaches to reflective activities, and the application of reflective strategies in ways which have sought inappropriate levels of disclosure from participants or involved otherwise unethical practices. The article examines the question: what constitutes the effective use of reflective activities? It argues that reflection needs to be flexibly deployed, that it is highly context-specific and that the social and cultural context in which reflection takes place has a powerful influence over what kinds of reflection it is possible to foster and the ways in which this might be done. The article concludes by exploring conditions in which reflective activities might appropriately be used in professional education.
Article
Purpose: To determine whether writing, one-on-one interviews with faculty, or a combination of these interventions effectively elicited reflection on professionalism for medical students. Method: The study was a randomized trial conducted in 2001 at Harborview Medical Center, Seattle, Washington, with fourth-year medical students on a four-week clinical clerkship in emergency medicine. Three interventions were evaluated: the critical incident report (CIR), the CIR followed by a one-on-one interview with a faculty member, and one-on-one interview with no CIR. Quality and quantity of professional issues raised were addressed. Results: All students (n = 68) agreed to participate; 66 completed the study components. On average, the students addressed significantly more issues of professionalism in their interviews alone than in their CIRs, 15.9 (95% confidence interval [CI] 18.2–13.6) and 7.15 (CI 8.88–5.40) issues respectively (p < .0001). Interviews preceded by CIRs were not significantly different from interviews with no CIR (13.5 versus 15.9 professionalism issues raised, respectively). In-depth explorations, including problem solving and projection to the future, occurred 2.59 times in interviews alone (CI 3.62–1.56) and 0.794 times in CIRs (CI 1.12–0.46) (p < .001). When analyzed as a proportion of total statements, the groups had similar ratios of in-depth statements (11.2% in CIRs and 15.7% in interviews alone). Conclusion: Writing did not significantly affect the quantity or quality of reflection in interviews. One-on-one interviews with a faculty mentor most effectively elicited reflection on professionalism. Future studies should examine how reflective exercises such as those evaluated can be used to promote professional development.
Article
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.