Reflection in medical education

M. Hassani

In the name of God

Provide an overview of the concept & its role in learning and self-direction

Provide practical advice for the effective implementation

Assessment of reflection in undergraduate, postgraduate and continuing medical education

Latin origins: ‘to bend’ or ‘to turn back’

From physics to education

Reflection is a metacognitive process

that occursbefore, during and after situations

with the purpose of developing greater understanding of

both the self and the situation so that

future actions can be informed by this understanding.

The use of reflection in medical education: AMEE Guide No. 44. Sandars J et al. Med Teach. (2009)

A metacognitive process that occursbefore, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future actions can be informed by this understanding.

A metacognitive process

Thinking about thinking’

A self-regulatory process that selects, monitors and evaluates a cognitive process

A process that can be controlled


Before, during and after situations

Before an experience (anticipatory reflection)

During an experience (reflection-in- action)

Following experience (reflection-on- action)

(Westberg and Jason, 2001)


Understanding of both the self and the situation

Paying deliberate, analytical attention to:1.One’s own actions in relation to intentions2.From an external observer’s perspective


Future actions can be informed by this understanding

Making sense of a situation will not improve practice unless these insights can

change future responses to situations.

I’m always late for work

That was a awful holiday

I’ve had a very productive weekend

I keep running out of money before the end of the month

I failed my exam

Personal experiences Personal beliefs and values Interactions with patients Interactions with colleagues Learning gains and needs Observations What went well What they were thinking Any new goals that emerged Any assumptions or biases What others were feeling


A patient death

Some students wrote about problems with preceptors, the limits of medicine, and other difficult topics.

Noticing the contrast in a preceptor's negative attitude in treating a suicide survivor ("voluntarily" ill) with attitude in caring for an older, dying patient

Sometimes, students’ experience evoked unexpected thoughts and questions about medical practice.

Students questioned themselves when suddenly faced with difficult ethical situations

Feeling ethically challenged in the face of a dying patient who refuses care


1. Reflection for learning

2. Reflection to develop a therapeutic relationship

3. Reflection to develop professional practice




Reflection for learning

Kolb's experiential learning cycle (1984)

What happened

Analysis

Make generalizations

Planning future

actions




Reflection for learning

Simplified Kolb’s learning cycle




Reflection to develop a therapeutic relationship

A ‘good’ clinician:1. Appropriate knowledge and

skills2. Establish and maintain a

therapeutic relationship with patients and their carers

Effective reasoning is a mainly subconscious process with modulation of logical information processing by emotions (personal belief and value systems)




Reflection to develop professional practice

Reflective Practice

“Critical thinking in Action on Action”

(Neil Thompson 2009)

Masters of your own lifelong learning

Reflective Practice Capacity - Blood Supply of Professionalism

The Effective reflective practitioner is able to recognise and explore confusing or unique (positive or negative) events that occur during practice

The Ineffective practitioner is confined to repetitive and routine practice, neglecting opportunities to think about what he/she is doing

1. Motivation for reflection

2. Metacognitive skills for reflection Noticing Processing Future action

3. Reflective storytelling and writing

4. Personal development plans and portfolios

1.Motivation for reflection

2.Metacognitive skills for reflection Noticing Processing Future action

3.Reflective storytelling and writing

4.Personal development plans and portfolios

Motivation for reflection

Recognizing importance of Reflection

Clear goals:1. Internal factors:

• Self-efficacy• Perceived ease of the task

2. External factors:• Assessment (assessed

portfolio for personal and professional reflective learning)


2.Metacognitive skills for reflection Noticing Processing Altered future action



Metacognitive skills for reflection

Developing metacognitive skills to monitor and evaluate the key aspects of reflection:

1. Noticing2. Processing3. Altered Future action





Noticing

The recognition of when our existing mental

models and personal theories are being challenged by the

experience of a particular event or situation.





Noticing

Techniques for noticing:

1. Self monitoring:• Participating in mindful

practice• ‘Thought catching’ approach

(hindsight bias)

2. Feedback from others:• Sarcastic comment• Non-verbal behavior

3. Critical incidents and significant event analysis• ‘Moments of surprise’





Processing

To develop an understanding of

both the self and the situation with several techniques depending on the intention of

reflection.1. Reflection for learning2. Reflection to develop a

therapeutic relationship






Future action

The aim of reflection isto inform future actions

which respect the context to which they are

being applied; so that they can be more

purposiveand deliberate.

Gibbs (1988) reflective cycle

Guided reflection (John’s model of reflection)

The What? model of structured reflection by Driscoll

1. Descriptio

n

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 1: Description of the event

Where was I? Who else was there? Why was I there? What was I doing? What other people were

doing? What the context of the

event was? What happened? What my part was? What parts the other people

played? What the result was?

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 2: Feelings

How was I feeling at the beginning?

What was I thinking about at the time?

How it made me feel? What did other people’s

actions make me think / feel? How did I feel about the

outcome of the event? What do I think about it now?

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 3: Evaluation

What was good about the experience for me, the patient, others?

What was bad about the experience for me, the patient, for others?

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 4: Analysis

Breaking it down What went well? What did I do well / not so

well? What did others do well? Did it go as expected? Why / why not? What theory / research helps

me understand the experience?

What went wrong or did not turn out how it should have done?

Which way I, or others, contributed to this?

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 5: Conclusion

Could I have done anything differently?

What are the key things I have learned from this incident - about me, my performance, others and their performance?

Can this be evidence of achievement of placement outcomes / competencies?

1. Description

2. Feelings

3. Evaluation

4. Analysis

5. Conclusion

6. Action Plan

Stage 6: Action Plan

What would I do in a similar situation in the future?

What aspects of my knowledge / skills could I develop?

How will I do this? What goals can I set myself

for the future? What outcomes /

competencies do I need to focus on now?

Experiences resulting in challenge and change are usually associated with the presence of strong emotions

Consequences of these experiences

Role of facilitator

A description of events (What?)

An analysis of events (So What?)

Proposed actions following events (Now What?)





Reflective storytelling and writing

Add a different perspective or clarity to your initial thoughts

Allows the learner to release emotion

Evidence to include in your portfolio to help you achieve your placement outcomes





Starting reflective writing

Have a pen and paper available at all times (’Putting your thoughts on paper)

Oral, written, using new media (audio recording, blogs, or digital storytelling)

Write down ideas as they come to you

Don’t worry about structure, order, spelling, grammar

Make sense later with the help of a more formalised structure





Personal development plans and portfolios

To encourage and assess reflective learning:

1. Identification of learning needs:“not having knowledge about the latest treatment for diabetes”

2. Developing a plan to meet the identified learning needs:“attending a training course or reading an article”

3. Measurable learning outcomes which provide the evidence that the learning needs have been fulfilled

A safe overall environment

Inability to shut off thoughts and anxious attention to self

Confidentiality: when the assessor is also the facilitator

Improve critical thinking ability

Help ourselves to make more sense of difficult and complex practice

Enhance personal development by leading to self-awareness

“Remind us that there is no end point to learning about their everyday practice”

Experiment with different approaches until you find one that ‘fits’

See it as an essential aspect to your practice rather than an ‘add on’.

Start small and work up to the big issues

Be willing to challenge your assumptions and practices

Be spontaneous – it is from the frank and honest self that important insights arise

Express yourself freely – you don’t need to observe the normal academic practices involved in writing

Remain open to ideas – early conclusions can inhibit further insights and solutions

When you reflect on a situation you do not simply see more, you see differently

Remember the purpose of reflection is to learn from an experience

One small step…

Reflection in medical education

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