By Brian Simko

(Cover image: Woman Medical Professional Briefing Her Colleagues by Jacob Lund Photography from NounProject.com)

Brian Simko has over a decade of experience in the field of Medical Education. He is currently pursuing his Master's degree in Organizational Performance and Workplace Learning at Boise State University. He is dedicated to improving the student experience through his work as part of the Academic Applications team in Health Information Technology & Services supporting the University of Michigan Medical School.

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Background

What do you think of when you hear the word “reflection”? Introspection? A useful passive activity? Done in the moment or retroactively? Something done by yourself or with others? 

These questions hopefully caused you to pause and reflect on reflection, reaffirming your knowledge or questioning it. Reflection, as a pedagogical strategy, is utilized widely in education. It is a critical component of many educational theories, especially Transformational Learning. 

Transformational Learning, developed by Jack Mezirow, is a holistic, human-centered approach to internalizing a change in mindset. [1] It includes an epiphany, where one is confronted with a new and sometimes uncomfortable revelation. Sharan Merriam & Laura L. Bierema describe it as a cognitive process that requires thinking, reflection, recognizing others have similar experiences, and examining one’s beliefs and assumptions when confronted with new information. [2]

Reflection is a critical component of this theory and it’s important for educators to be aware of some potential misconceptions around the process. In medicine, reflection is needed in order to continuously improve patient outcomes in a rapidly changing landscape. Without critical reflection, assumptions may creep into practice, negatively impacting patient care.

Also, reflection isn't a one-and-done event. Finding time to dedicate toward reflection in a physician’s busy schedule takes intentional planning and effort in order to become a habit. [3] For medical educators, it's vital to cultivate students’ abilities to develop the skills and how to find time to successfully complete reflection in the clinical environment.

Reflection: Three Keys to Keep in Mind

Medical students may have various comfort levels around reflection. There could be three areas where some misunderstanding exists:

What is reflection? 

When asked to reflect as part of a learning experience, students’ misunderstanding of the concept can lead to varied results. Some learners may:

1. Not value reflection

2. Conflate “reflection” with “a lesson learned”

3. See reflection as an individual process

4. Believe reflection is only for discussing how they feel about something

A systematic review of the literature surrounding reflection demonstrates what it means to reflect ahead of time and how setting expectations could benefit learners. [4] The term “reflection” is used in a variety of ways. [5] Letting students know ahead of time what you expect their reflections to include could align the class. Without a shared understanding, students completing the activity could have varying degrees of success. 

Levels of reflection

Reflection can be described within two dimensions: 

• Iterative: Experiences occur sequentially. Reflection is seen as looking at past events, and considering what went well, what didn’t, and what can be improved next time. In addition, reflection can occur in the moment, allowing quick pivots based on new information as it occurs. 

• Vertical: Reflection can be considered on multiple levels, from superficial to deeper analysis, based on the type of questions a learner is asking themself. 

It’s important for educators to set up expectations and guide learners to ensure they get the most out of reflective practice. For learners who may not have experience with reflective practice, it is prudent to scaffold the expectations appropriately by identifying what level of reflection you want them to engage in.  

How to reflect 

When asked to reflect on an experience, what questions do you ask yourself? 

In the book, Make it Stick [6], neurosurgeon Mike Ebersold comments:

I’d go home that night thinking about what happened and what could I do, for example, to improve the way a suturing went. How can I take a bigger bite with my needle, or a smaller bite, or should the stitches be closer together? What if I modified it this way or that way? 

The above quote demonstrates how reflection can be used in a physician’s career, but how does one accurately self-reflect and have it become a habit? Reflection is not always intuitive; like any skill it takes practice. [7] Rubrics can be an excellent way to facilitate what questions you want students to ask themselves. Defining reflection and providing tools to guide students on how to achieve the desired reflection levels can help your learners attain them. With practice, learners will adapt to perform reflection-in-practice [8] (developed by Donald Schon as part of his reflective model [9]), demonstrating deep reflection characteristics using tacit knowledge to adjust to changing circumstances. 

Now, how can educators integrate strategies to minimize confusion in these three areas?

Explain the Why

Actively monitoring your learning experience to include reflection as a deliberate and guided process can provide multiple benefits to learners. Self-awareness leads to self-monitoring, which improves individual performance. In addition, reflection leads to self-assessment, which can lead to individuals incorporating self-directed learning to their work (Merriam & Bierema, 2014). Encouraging the mindfulness that is needed to notice [10] the "disorienting dilemma" (Mezirow, 1978) or experience the “surprise” (Schon, 1984) begins the cycle of being a lifelong learner. Processing new information, reflecting on it, and adjusting future behavior is an increasingly important skill to possess to keep up with the constant changes in medical knowledge. 

While Transformative Learning is typically about individual change, it can serve as the basis for cultivating organizational change. Individuals who transform can assist others as mentors and help influence others to experience that “aha” moment that is paramount in Transformational Learning. [11]

Transformational Learning frames an experience leading to changing perceptions about a topic. Critical reflection is paramount to effectively question prior beliefs to restructure our thought processes when engaging with new information. 

For physicians, this means adjusting to new data that comes out about treatment options and adjusting a patient’s plan for care. This type of self-reflection needs to be cultivated from the beginning of a physician’s education. It will also help students consolidate their knowledge throughout medical school for long-term processing, serving as a form of retrieval practice. Lastly, it will also give them the skills to continuously receive new information, internalize it, and act on it to improve patient care. 

Putting it into action

In designing learning activities to foster a Transformational Learning experience and guide toward deep reflective practice, consider the following: 

Sample questions

Utilizing questions to guide your reflective practice provides guidance for students:

• Prior to the learning experience, ask yourself what:

  • Do I know entering this situation?

  • Is my attitude towards it? 

  • Do I want to learn? 

  • Are some areas I might be struggling with?

• After the learning experience, what or how:

  • Do I know now that I didn’t before?

  • Went differently than I thought it would? 

  • Would you explain three ideas to a classmate about your experience? 

  • Does the experience affect my previous conceptions?

  • Can I take this new information to make an impact on a larger scale? 

Socialize their learning 

Mentors provide a sounding board for a learner to reflect. Conversations between mentors and learners facilitate reflective practices, allowing the learner to raise questions or seek clarifications in a trusting environment. Developed mentor–mentee relationships ensure reflection becomes a process, not just a one-time event. In addition, a coach may help identify blind spots where there is growth in behavior needed. [12] External feedback is a key ingredient to improving self-assessment. Individually, learners may not be able to assess themselves as accurately as one would think. 

Provide support structures

Detailed rubrics can help learners scaffold their learning effectively. In addition, providing opportunities for learners to engage with their peers after a learning activity promotes the stage of Transformational Learning where one recognizes others have shared an experience. 

Having learners utilize different means to submit and share reflections (for example, digital storytelling) can encourage authentic reflection among learners. Seeing physicians put reflection into practice themselves also models the desired behavior for when they are in the clinical space.

Incorporating these elements into your curriculum holistically creates a consistent experience for your medical students. These strategies can encourage the development of their reflection skills early in their health care career. In summary: Intentional reflection takes practice and guidance, and we need to support our learners in their growth. 

References

1. Mezirow, J., & Marsick, V. J. (1978). Education for perspective transformation : women’s re-entry programs in community colleges. U.S. Dept. Of Health, Education & Welfare, National Institute Of Education, Educational Resources Information Center.

2. Merriam, S. B., & Bierema, L. L. (2014). Adult learning: Linking theory and practice. Jossey-Bass.

3. Cutrer, W. B., Miller, B., Pusic, M. V., Mejicano, G., Mangrulkar, R. S., Gruppen, L. D., Hawkins, R. E., Skochelak, S. E., & Moore, D. E. (2017). Fostering the Development of Master Adaptive Learners. Academic Medicine, 92(1), 70–75. https://doi.org/10.1097/acm.0000000000001323

4. Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education, 14(4), 595–621. https://doi.org/10.1007/s10459-007-9090-2

5. Uygur, J., Stuart, E., De Paor, M., Wallace, E., Duffy, S., O’Shea, M., Smith, S., & Pawlikowska, T. (2019). A Best Evidence in Medical Education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51. Medical Teacher, 41(1), 3–16. https://doi.org/10.1080/0142159x.2018.1505037

6. Brown, P. C., Roediger III, H. L., & McDaniel, M. A. (2014). Make it stick : the science of successful learning. The Belknap Press Of Harvard University Press.

7. Wald, H. S., Borkan, J. M., Taylor, J. S., Anthony, D., & Reis, S. P. (2012). Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for Assessing Reflective Writing. Academic Medicine, 87(1), 41–50. https://doi.org/10.1097/ACM.0b013e31823b55fa

8. Thompson, N., & Pascal, J. (2012). Developing critically reflective practice. Reflective Practice, 13(2), 311–325. https://doi.org/10.1080/14623943.2012.657795 

9. Schön, D. A. (1991). The Reflective Practitioner: How Professionals Think in action. Temple Smith.

10. Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685–695. https://doi.org/10.1080/01421590903050374

11. Watkins, Karen & Marsick, Victoria & Faller, Pierre. (2012). Transformative learning in the workplace leading learning for self and organizational change. In Edward Woodbury Taylor, & Cranton, P (Eds.). The handbook of transformative learning: theory, research, and practice (pp.373-387). Jossey-Bass.

12. Hargreaves, K. (2016). Reflection in Medical Education. Journal of University Teaching and Learning Practice, 13(2), 79–98. https://doi.org/10.53761/1.13.2.6