Reflection in Medical Education

I love those who can smile in trouble, who can gather strength from distress, and grow brave by reflection.–Leonardo da Vinci

I thought I’d write to you about reflection in this blog entry.  I can hear the meds students groaning already:)  You see, we ask the meds students to do a fair bit of reflection in undergraduate medical education, starting with term 1 when we ask them to reflect on being a physician, and on through to their last portfolio assignment in pre-clerkship when we ask them to reflect on how well they have progressed in their learning about the roles of a physician.

Reflect is a rather over-used and under-thought term and so as I progress through this, you may want to substitute another term.  I happen to like “critical analysis” because a lot of reflection should include that, and a lot of what we’re asking the meds students to do includes critical thinking.

When we talk to the medical students we talk to them about the stages of reflection and we use one model of reflection for learning or “reflection in and on action” (Schon, 1983), that of experiential learning by David A. Kolb.  Kolb (with Roger Fry) is well-known for his conceptualization of reflection as a critical part of learning (Kolb, 1984).  He postulates a cycle of reflection where a learner experiences something concrete (Concrete Experience), observes and reflects upon it (Observation and Reflection), generalizes the learning in Abstract Conceptualization and then applies the learning to new experiences in Active Experimentation.  This starts the cycle again, with a spiral approach so that one is not repeating the same learning over and over.    Kolb also notes that one can enter the cycle at any stage in the 4 steps.

When we present to the meds students we use this graphic:

Screen Shot 2013-04-09 at 7.28.32 AM

To me this theory is important as it allows for some very practical outcomes for reflection.  As Peter Drucker says, “Follow effective action with quiet reflection. From the quiet reflection will come even more effective action.”  Two leaders in the field agree: Dr. John Sandars defines reflection as  “A metacognitive practice that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.” (Sandars, 2009) Jack Mezirow when writing about “transformative learning” describes reflection as critical awareness of how we are constrained, and how to reformulate so as to act. (Mezirow, 1997)

So how can we assist learners to reflect in order to change their actions? How can we promote “rigourous reflection?”

Dr. Ted Ashbury and I start by asking them to jot down some thinking:  “Think of a situation where you have said, “I’m not going to fall into that trap again. I’ve thought about this, and I know I’m prone to…”!  We show them the cartoon of Charlie Brown and Lucy and the infamous football… This is helpful because one goal of reflection can be to change action, to break a cycle or pattern.


Next, we ask the students to think about a situation that has engaged their attention in the past few weeks and fill in a chart based on the 4 steps in Kolb’s theoretical framework:

 

Identify

  • Prompt
  • Observation
  • Idea
  • Catalyst
Analyze:Make connections Prior experience

Links to knowledge of yourself

Broaden:Reinforcement, Generalizations,Perspectives,

New Knowledge

Apply/Plan (Now What?)Changes or shiftsCommitment to future action/plans

And we ask them to set some goals:  SMART Goals

Specific (straightforward, not ambiguous)

Measurable (It is clear under which conditions the goals are achieved)

Acceptable (The goals should be acceptable to all stakeholders)

Realistic (The learner should be able to achieve the goals)

Time-bound (It should be clear when the goal is to be achieved)

Free Writing:  We give students time to write—free writing for at least 5 minutes (an engaging and difficult task—I recommend it!) about the prompt from the beginning of the session or “Write about your First Patient Experience, your Clinical Skills experience, your learning elsewhere in term 1, a key challenge you have chosen to work on recently, Mid-terms…???”  We also offer them a reflection written by a student in another meds school and a rubric that Eleni Katsoulas and I  designed to help us and them assess reflective writing.  They get to analyze their colleague’s writing based on the rubric:

Prompt or Catalyst Ideas (What?) Connections (So what?) Extensions (Now what?)
Observed behaviours of other Describes the behavior and the context in which it occurred -Interprets the behavior, its cause, or provides a rationale  (impact)-Seeks out primary resources/information/circumstances, to connect to and make sense of the observation  – Provides an alternative to problematic behavior based on consideration of all primary observations-Discusses implications and considers how or whether to implement change in their own behaviour-Problem may be reframed, and there is an explanation of how this represents a change from previously held beliefs

-Considers impact of framework on behavior (culture, system, etc.)

-Commits to future  action, reflection, or advocacy

 

This seems like a lot of work to accomplish reflection, doesn’t it?  However, it’s like learning skills for anything…we provide opportunities to break down the skill into discrete parts, and learners time to practice.  The idea is that the more they practice this, the more intuitive and natural it becomes.  This doesn’t negate the possibility and importance of a 30 second reflection on an interesting, provocative, or disturbing matter, but it does lead, we hope to rigourous reflection.

I thought I’d finish this section with a quotation from a medical student who was reflecting:

“If I had to choose what I felt to be the most important thing that I have taken from these experiences, it would be to remind myself, no matter how I feel, to think about how the patient is feeling. To never forget that off-hand comments made when tired or stressed have the potential to upset people to such an extent that they remember them for years.” (Macauley & Winyard, 2012).

If this is the result of rigourous reflecting, I’m all for it!

What are your thoughts on reflection in medical education?  What use do you see for it? (or do you see a use?) What strategies do you recommend?  In the next blog, I’ll send some tips for reflection, along with your suggestions.

 

Sources

Kolb, D. A. (1984) Experiential Learning, Englewood Cliffs, NJ.: Prentice Hall.

Kolb. D. A. and Fry, R. (1975) ‘Toward an applied theory of experiential learning;, in C. Cooper (ed.) Theories of Group Process, London: John Wiley.

Schön, D. (1983) The Reflective Practitioner, New York: Basic Books

Saunders, John. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-95.

Mezirow, Jack. (1997). Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education, 74, 5–12.

Macauley, CP & Winyard, PJ. (2012). Reflection: tick box exercise or learning for all? BMJ Careers.  http://careers.bmj.com/careers/advice/view-article.html?id=20009702