Article Review: Reflection in medical education

Reflection in medical education

A hot topic in medical education is the incorporation of "reflection" into learning and clinical practice. This Medical Teacher article defines reflection broadly as:

"a metacognitive process 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."

Huh? Quite a wordy definition. I think of reflection as:
  • Thinking about how we think
  • Making sense of a situation so that future actions can be more informed
Reflection requires self-awareness to recognize a situation which may challenge one's beliefs or understanding. There are three types of reflection:

1. Reflection for learning
This type of reflection revolves around a specific experience, such as feeling uncomfortable with a complex medical resuscitation code or learning that you missed a diagnosis. Learners should ask themselves such introspective questions as:
  • Did anything surprise me about the situation?
  • Did I have the information/skills to deal with this situation?
  • Do I need additional information/skills to deal with this same situation in the future?
2. Reflection to develop a therapeutic relationship
This reflective practice is to help finetune your emotional intelligence. Patient-physician and interprofessional relationships are evaluated. Why was a particular patient able to push all your buttons and really frustrate you? Whenever a situation evokes a strong emotion in you, ask yourself:
  • What emotions am I feeling?
  • Why do I feel like this?
  • Are there other situations in my life or my encounters with others when I feel the same?
  • What are the consequences of these emotions for me and for others?
3. Reflection to develop professional practice
Managing Emergency Department cases requires the rapid and complex integration of knowledge, skills, and prior experiences. More experienced clinicians seem to make correct decisions quicker in challenging cases. Why is that? They can draw on their collection of past experiences in similar situations. This is one type of reflection.

Challenges in incorporating reflection in medical education
  • Low motivation for learners: Medical schools are noticing that students having little motivation to document and/or discuss their reflective learning experiences. These exercises are often viewed as additional required assignments, without an in-depth discussion about why they are important. Reflection journals may be viewed as another "hoop to jump through".
  • Exposing deficiencies to evaluators: Your reflection portfolio involves exposing and describing thoughts about your deficits or vulnerabilities. In a private journal, this is a constructive exercise. However, portfolios are increasingly being used in evaluating your performance. This creates an ethical dilemma of how honest you want to be in a non-private document.
My thoughts
Reflection is important in enhancing life-long learning at all levels, but I am not a fan of using it as a summative assessment tool by administrators. If reflection pieces are ever shared, they should be done in a non-judgmental, small-group setting such that everyone has to share something from their portfolios.

You can download the PDF appendix on building a reflection journal from the Medical Teacher website.

Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Med Teach. 2009 Aug;31(8):685-95.
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