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Personal reflection in medical educationAukes, Lense Cornelis

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PERSONAL REFLECTION IN MEDICAL EDUCATION

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Personal Reflection in Medical Education Dissertation for the University of Groningen, the Netherlands, with references and summary in Dutch. The study presented in this thesis was carried out at the Graduate School for Health Research SHARE of the University of Groningen, within the program of Research in Medical Education (RME). Address for correspondence L.C. Aukes Center for Research and Innovation of Medical Education University Medical Center Groningen Ant. Deusinglaan 1, 9713 AV Groningen The Netherlands [email protected] Design Augment Consult, Groningen, Cover: Douwe J. Buiter UMCG Press Gildeprint Drukkerijen B.V. Enschede © Aukes, L.C., 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the author. ISBN 978-90-77113-66-0

RIJKSUNIVERSITEIT GRONINGEN

Personal Reflection in Medical Education

Proefschrift

ter verkrijging van het doctoraat in de Medische Wetenschappen

aan de Rijksuniversiteit Groningen op gezag van de

Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op

woensdag 29 oktober 2008 om 16.15 uur

door

Lense Cornelis Aukes

geboren op 24 januari 1946

te Steenwijk

Promotores: Prof. dr. J.P.J. Slaets

Prof. dr. R.P. Zwierstra

Copromotor: Dr. J. Cohen-Schotanus Beoordelingscommissie: Prof. dr. R.O.B. Gans

Prof. dr. M. Grypdonck Prof. dr. H.G. Schmidt

Voor mijn moeder, Trijn Aukes-Boer De gedachten zijn vrij, wie kan ze beletten? Ze ijlen voorbij naar eigene wetten. Geen mens kan ze raden of grijpen of schaden. Hoe sterk hij ook zij, de gedachten zijn vrij! Die Gedanken sind frei, wer kann sie erraten? Sie fliehen vorbei wie nächtliche Schatten. Kein Mensch kann sie wissen, kein Jäger erschießen mit Pulver und Blei: Die Gedanken sind frei! Thoughts are free, who can ever guess them? They just flee by like nocturnal shadows No man can know them, no hunter can shoot them with powder and lead: Thoughts are free! – Schoolliedje

Voorbeeld van persoonlijk reflecteren in het medisch onderwijs In de lijn Beroepsvoorbereiding van curriculum G2010 van de Faculteit der Medische Wetenschappen in Groningen moeten studenten regelmatig reflectie-verslagen schrijven over hun praktijkervaringen en de feedback die ze daarbij krijgen. De studenten van deze coachgroep mochten daarnaast ook een reactie schrijven op het boek van Pascal Mercier. Nachttrein naar Lissabon – Pascal Mercier ‘Ben je blij dat het voorbij is?’, vroeg Maria João en kwam naast me zitten. Ze nam me op. ‘Of ben je er uiteindelijk verdrietig om?’ Nu schijn ik dan eindelijk te weten wat me er steeds opnieuw toe dwingt de verre tocht naar de school te ondernemen: ik wil terug naar die paar minuten op het schoolplein waarin het verleden van ons af was gevallen zonder dat de toekomst al was begonnen. De tijd stond stil en hield de adem in op een manier zoals ze dat later nooit meer heeft gedaan. Zijn het de bruine knieën van Maria João en de geur van zeep in haar lichtgetinte jurk waar ik naar terug wil? Of gaat het om het verlangen - het pathetische verlangen, als in een droom - nog één keer op dat punt in mijn leven te staan en een heel andere richting om te kunnen slaan dan de richting die van mij de man heeft gemaakt die ik nu ben? Blz. 60. ‘Deze passage heb ik gekozen om iets over te schrijven, omdat deze me deed stilstaan bij mijn eigen keuzes. Ik ben niet één van die studenten die al vanaf jongs af aan dokter wilde worden. Ik wilde paardrijdinstructrice of ballerina worden, archeoloog of stewardess. Pas toen ik eindexamen had gedaan was mijn besluit genomen: na lang wikken en wegen toch geneeskunde. Als ik hier eerder mee was geweest, had ik een pakket kunnen kiezen dat aansloot op de studie. In plaats daarvan moest ik nog een jaar lang natuurkunde en scheikunde volgen om vervolgens examen te doen in deze vakken en mee te mogen loten. Waarom besloot ik toch tot geneeskunde? Omdat ik graag met mensen werk en de gedachte mensen ‘beter’ te kunnen maken stond me aan. Op het moment dat ik in Londen gebeld werd door mijn moeder dat ik ingeloot was, wist ik dat ik de goede keuze had gemaakt: ik was ontzettend blij en was er zeker van dat dit was wat ik met mijn leven wilde doen. Mijn vader is arts. Toch heb ik daar in mijn jeugd weinig van gemerkt: hij vertelde bijna nooit over zijn werk en heeft mij nooit in die richting gepusht. Ik had zelfs het idee dat hij er liever niet over praatte als hij thuiskwam: zijn manier om zijn werk niet mee naar huis te

emen. Zo is het nog steeds als ik thuiskom: hij vindt het heel leuk om mijn verhalen te n

horen en vertelt me dingen uit de tijd van zijn eigen co-schappen, maar ik hoor hem nooit over zijn huidige baan als patholoog. Ik denk dat hij bang is om mij die kant op te duwen tegen mijn wil zoals zijn vader bij hem had geprobeerd, waarmee mijn vader recht tegenover het karakter van Prado’s vader staat. Alleen als ik er naar vraag, hoor ik meer over wat hij dagelijks doet. Ik ben hier blij mee, ik weet zeker dat de keuze om geneeskunde te gaan studeren mijn eigen keuze was. Het feit dat Prado zijn keuze om zijn vaders wil te volgen nu in twijfel trekt, is iets wat ik heel herkenbaar vind. Wat zou er gebeurd zijn als ik uitgeloot was of toch iets anders had uitgekozen? Was ik dan toch culturele antropologie gaan studeren en had de slechte banenmarkt me niet tegengehouden, zoals nu het geval was? Zou dat beter bij me gepast hebben? Zou het echt een passie geworden zijn, zoals geneeskunde dat nooit is geworden? Want geneeskunde is voor mij niet de passie die het voor sommige anderen is. Ik vind het een leuke studie en ook het werk lijkt me leuk en vind ik interessant om te doen, maar dat lijken zoveel andere studies en banen me ook. Is dit een goede keuze geweest? Er zijn momenten geweest waarop ik had willen stoppen. Mijn eerste toetscijfer. De celbiologie waar ik niet doorkwam. Het auto-ongeluk dat mij de andere kant van het bed liet zien. Het moment dat ik na 2 maanden de vrijheid van het reizen te hebben geproefd, weer terug de schoolbanken in moest. Toch ben ik doorgegaan, want gelukkig waren er ook een heleboel momenten waarop ik wel zeker wist dat ik arts wilde worden. Mijn ervaringen tijdens de zorgstage. De dankbaarheid op het gezicht van een man bij wiens OK ik geassisteerd had tijdens mijn stage in Malawi. Het Algemeen Vormend Vak ‘Geneeskunde in de Tropen’ dat ik aan het organiseren ben. De poligesprekken tijdens mijn co-schap neurologie. Waarom twijfel ik dan nog steeds? Als ik nu weer voor die keuze had gestaan, had ik dan hetzelfde gedaan? Ik weet het niet. Sinds ik ben gaan studeren ben ik best wel veranderd: ik ben veel zelfstandiger geworden, ik trek mijn eigen pad, ik heb passies voor muziek, dans en reizen ontwikkeld. Ik heb gemerkt dat ik niet onsterfelijk ben en moet genieten van het leven en van mijn mogelijkheden. Er zijn zoveel dingen die ik wil leren, boeken die ik wil lezen, landen die ik wil zien. Teveel voor één leven. Ik denk dat dat de grootste reden van mijn twijfel is: ik wil te veel en als arts ga ik niet genoeg tijd hebben om alles te doen en leren wat ik wil. Ik moet kiezen tussen mijn werk en al die dingen. Echter als ik realistisch ben weet ik dat ik toch niet alles kan doen wat ik wil, ook al zou ik de rest van mijn leven tijd hebben. Ondanks mijn twijfels heb ik wel plezier in mijn studie: ik houd ervan nieuwe dingen te leren en de omgang met patiënten vind ik inspirerend. Ik houd van het puzzelen met symptomen en diagnostiek om tot een DD te komen en ik vind het een uitdaging het beste voor de patiënt te verkrijgen. Of geneeskunde een goede keus is geweest? Ik denk het wel. Maar dat was culturele antropologie ook geweest.’ Rinske Grond, vierdejaars student geneeskunde

Forget your perfect offering. There is a crack in everything. That’s how the light gets in – Leonard Cohen

Table of Contents 1. Introduction 11 2. Visualizing reflection: the Float Model 15

Aukes, Leo C., Cohen-Schotanus, Janke, Zwierstra, Rein P., Slaets, Joris P.J. (2008) Visualizing reflective practice in medicine: the Float Model as an educational tool, Submitted.

3. Measuring personal reflection: The Groningen Reflection Ability Scale (GRAS) 27

Aukes, Leo C., Geertsma, Jelle, Cohen-Schotanus, Janke, Zwierstra, Rein P., Slaets, Joris P.J. (2007) The development of a scale to measure personal reflection in medical practice and education, Medical Teacher, 29:2, 177-182.

4. Validation of the GRAS (the Groningen Reflection Ability Scale) 39

Aukes, Leo C., Geertsma, Jelle, Cohen-Schotanus, Janke, Zwierstra, Rein P., Slaets, Joris P.J. (2008) A validity study of an instrument measuring personal reflection in medical education. Submitted.

5. The effect of enhanced experiential learning on personal reflection 53

Aukes, Leo C., Geertsma, Jelle, Dekker, Hanke, Cohen-Schotanus, Janke, Zwierstra, Rein P., Slaets, Joris P.J. (2008) The effect of enhanced experiential learning on personal reflection of undergraduate medical students. Medical Education Online. In press.

6. A conceptual framework for personal reflection in healthcare practice 67 and education

Aukes, Leo C., Cohen-Schotanus, Janke, Zwierstra, Rein P., Slaets, Joris P.J. (2008) Personal reflection in healthcare practice and health science education; a conceptual framework. Submitted.

7. Discussion, Conclusions, Perspectives 87

Summary 101 Samenvatting 109 Dankwoord 117 Curriculum Vitae 123 Appendixes

1. The GRAS, English and Dutch version 124 2. Oefenstof tot doordenken / Food for reflection 127 3. Graduate School for Health Research SHARE 137

‘Does acknowledging uncertainty undermine a patient’s sense of hope and confidence in his physician and the proposed therapy? Paradoxically, taking uncertainty into account can enhance a physician’s therapeutic effectiveness, because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than resorting to evasion, half-truth, and even lies. And it makes it easier for the doctor to change course if the first strategy fails, to keep trying. Uncertainty sometimes is essential for success.’ Jerome Groopman. How doctors think, Boston, New York: Houghton Mifflin Company 2007; 155. Derjenige, der sich mit Einsicht für beschränkt erklärt, ist de Vollkommenheit am nächsten. – Johann Wolfgang von Goethe

1. Introduction Becoming an excellent doctor Encouragement of medical students to use reflection to become an excellent doctor is one of the most appealing challenges in medical education in the past decade.1-3 Reflection is at the heart of educational transformation – from mainly theory and discipline-based learning, focussed on separate constructs of knowledge and skills, to competence-based learning, focussed on the acquisition of core competences, i.e. meaningfully integrated units of knowledge, skills, attitudes and behaviour.3-5 Medical educators have a distinct responsibility to provide effective pre- and postgraduate education of the reflective competences of medical students and doctors.1-3,6-8 In this thesis we will focus on personal reflection in particular, as a critical factor of balanced conduct in medicine. Changes in society and profession The educational transformation reflects changes in society and the medical profession. Patients, patient organizations, healthcare institutions, insurance companies and governments have a growing awareness of and demands about the quality of care, each from their own perspective.1,2 In the medical profession ‘reflective practice’ is seen as best practice and an excellent doctor as a ‘reflective professional’.4,5 The aim of reflective professionalism is balanced conduct, which is focussed primarily on improvement of patient care but also on inter-professional relationships, expertise development and the doctor’s own well-being.8-10 Paradigmatic change The transformation along the medical educational continuum – from undergraduate curriculum to postgraduate training and lifelong learning – also reflects a paradigmatic shift in the perspective on and conceptualisation of the medical profession and medical education. Teaching and learning is no longer just seen as an application of separate medical discipline-based knowledge and technical skills. Today, a doctor’s expertise is conceptualised as a solid clinical competence that is

embedded in a broad spectrum of professional and personal competences.3-6, 11,12

A definition of reflective practice A comprehensible definition of the intellectual, reflective, affective and behavioural competences of doctors is given by Epstein and Hundert.5 They define reflective practice in medicine as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individuals and communities being served’. This definition is attractive because it offers a sense of direction for educational encouragement of reflection and a sense of urgency for the need of reflection as a coordinative competence of doctors to integrate all their other diverse competences. Personal reflection We distinguish two modes of reflection in medical education and practice: personal reflection and scientific reflection. Personal reflection is mainly oriented towards experience, in particular the process of making sense out of experience. Scientific reflection is mainly oriented towards clinical reasoning and literature in order to optimize the degree of evidence-based clinical judgments.13 Our research focuses on personal reflection, which we define as ‘the careful exploration and appraisal of experience, thus clarifying and creating meaning for the benefit of balanced functioning, learning and development’. ‘Experience’ primarily concerns one’s own experience, through self-reflective self-understanding, but also experience of patients, students and significant others through empathetic reflective communication.14

We would like to emphasize that we do not regard personal reflection as an alternative, but as a supplement to scientific reflection. Seeing personal reflection as an alternative may be an appealing but dreadful pitfall, a pre-scientific regression. Our basic belief underlying the research questions in this thesis is that personal reflection is a prerequisite for the acquaintance and maintenance of balanced professional conduct in health care. This balance is primarily for the benefit of patient care, but also for the improvement and maintenance of expertise and for the doctor’s self-care and own well-being. This thesis is intended to contribute to augmented recognition, use and encouragement of personal reflection in medical education. The thesis The subsequent chapters will address the following issues of personal reflection in medical education: visualization, measurement, validation,

the effect of experiential learning, a conceptual framework, conclusions, discussion and perspectives. Chapter 2. The challenge in this study was to make the rather abstract construct of reflection more concrete for medical educators who play a pivotal role in enhancing the use of reflection by students. They need a picture of personal reflection in medicine, its relevance and use in practice. Therefore, an educational model, the Float Model, has been developed. Chapter 3. There are no instruments that appropriately measure personal reflection concerning the ambiguity of multifaceted aspects and problems of experience. The research question in this study was: Is it possible to measure the personal reflection ability of medical students in a practical way? This is why the Groningen Reflection Ability Scale (GRAS) was developed. Chapter 4. An associated important question was: What is the validity of an instrument to measure the construct of personal reflection? In this validation study the GRAS scores were compared with scores of other reflective measurement tools. Chapter 5. The claim of experience-based learning programmes is that they are effective for the acquisition of reflection by the participating students. Is experiential learning indeed an effective educational method to foster personal reflection? In order to answer that question the growth in reflection by the students who participated in this program was analysed using the GRAS. Chapter 6. The concept of reflection remains poorly defined, which can result in unrealistic expectations about reflection and the use of inappropriate educational methods. This chapter provides a conceptual framework of personal reflection in health care practice, resulting in a definition of reflection as a competence. Chapter 7. In the last chapter the conclusions, discussion and new perspectives are formulated. References 1. General Medical Council. The Doctor as Teacher. London: General Medical Council

1999. 2. ABIM (American Board of Internal Medicine), ACP-ASIM (American College of

Physicians-American Society of Internal Medicine), EFIM (the European Federation of

Internal Medicine). Medical professionalism in the new millennium: a physician’s charter. Ann Intern Med 2002;136 (3):243−6.

3. CanMEDS 2000 Project. Skills for the New Millennium: Report of the Societal Needs Working Group [improved version]. Ottawa: Royal College of Physicians and Surgeons of Canada 2005.

4. Epstein RM. Mindful practice. JAMA 1999;282 (9):833−9. 5. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA

2002;287 (2):226−35. 6. Stern DT. Measuring Medical Professionalism. New York: Oxford University Press

2005. 7. Van Luyck SJ (Ed). Professional Behaviour: Teaching, Assessing and Coaching

Students. Final Report. Project Team Consilium Abeundi, appointed by the NL Council of Medical Deans of the Dutch Federation of University Medical Centers. Maastricht: Maastricht University Press 2005.

8. Hilton SR, Slotnick HB. Proto-professionalism: how professionalisation occurs across the continuum of medical education. Med Educ 2005;39 (1):58−65.

9. Guest CB, Regehr G, Tiberius RG. The life long challenge of expertise. Med Educ 2001;35 (1):78–81.

10. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol 2003;84 (4):822−48.

11. Verkerk, M., Lindemann H., Maeckelberghe E., Feenstra E., Hartoungh R. & De Bree M. Enhancing Reflection: An Interpersonal Exercise in Ethics Education. The Hastings Center Report 2004 (34).

12. Benammar, K. Conscious action through conscious thinking, reflection tools in experientiel learning (Bewust handelen door bewust denken – Reflectietools in het leerproces). Public lecture, Hogeschool van Amsterdam 2004.

13. Sackett DL, Haynes RB, Guatt GH, Tugwell P. Clinical Epidemiology: a Basic Science for Clinical Medicine. 2nd Edition. Boston: Little, Brown and Company 1991.

14. Ciaramicoli AP, Ketcham K. The Power of Empathy: a Practical Guide to Creating Intimacy, Self-Understanding and Lasting Love in Your Life. New York: Penguin Group 2000.

Chapter 2. The Float Model

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Chapter 2. Visualizing reflection: the Float Model To welcome uncertainty, as clinicians, we need an internal ‘ballast’ – the ability to stay calm in the face of not knowing. – Ronald M. Epstein 2008 TDiep in mezelf ben ik erg oppervlakkig. T– TAva Gardner TAbstract Health care educators need a greater understanding of reflection, how it works in practice and how to facilitate its development and use. We have distilled two basic modes of Treflection, ‘scientific reflection’ and ‘personal reflection’. Together with the modes of ‘behaviour’ and ‘clinical reasoning’, we created practice-based descriptions Tand combined T the parts in an educational model using the angler’s float as a metaphor. The Float Model was developed during courses for medical educators. It has a variety of applications. The entire float sTymbolizes the physician as a professional reflective practitioner at work. It Tcan prevent misinterpretations, such as mixing up scientific reflection and personal reflection, taking reflection as a goal in itself instead of a means to an end, denying unconscious aspects and the basic mindful attitude. T The water is the clinical context and culture. TExamples are given to reveal blends of balanced and unbalanced reflection underneath the water, shaping profiles of the physician’s reflective conduct at the surface. TIntroduction Health care professionals play a key role as educators and role models in encouraging reflection in education programmes. They are faced with various practical questions (see Box 1). The concept of reflection is multifaceted and often not well understood, the definitions are ambiguous, and educators need to convey this concept to their students. The lack or even abundance of information may result in unrealistic expectations, ignorance and even cynicism, instead of bridging reflective theory and reflective practice (Inui, 2003). Teacher instructions should focus on increasing understanding of the use of different modes of reflection, Tthe need for each in creating balanced conduct, and how to Tencourage them. This Tarticle does not offer new ideas on reflection but describes an educational tool designed to encourage reflection: the angler’s float. Examples are provided to


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illustrate its practical use. Like any metaphor, the Float Model has its strengths and limitations, which will be discussed. TReflection as a competence to be fostered and practiced TEncouragement of reflection in medical education is acknowledged as a key factor in becoming a ‘good doctor’ (ABIM, ACP-ASIM & EFIM, 2002). I Tn particular, self-reflection on and learning from experience is regarded as a key factor in developing balanced professional conduct and learning (Maudsley & Strivens, 2000), and in the Tintegration of technical-logical and subjective-personal competences (Epstein, 1999). This balance primarily benefits the patients (Hilton & Slotnick, 2005) and encourages lifelong improvement of expertise (Guest et al., 2001), but can also enhance the well-being of the professionals themselves (Brown & Ryan, 2003). As such, the challenge is to find a way to structure information so that educators and students recognize the concept and value of reflection and develop competences to use reflection purposely. Box 1. Practice questions TAs attending physician you are expected to assess a student you have observed for a week. You wonder how to give her effective feedback about her negative self-esteem, while in your opinion her performance was adequate. TAs a faculty member you are expected to promote a new curriculum. You wonder how to explain the relevance of reflection in medicine in plain words to a group of physicians who you want to convince to participate in the curriculum as clinical coaches/facilitators of residents. TAs a head of the department of gynaecology you have the bright idea to start an annual award for the most professional resident. You know the faculty culture is an important hidden incentive for fostering professionalism, but you wonder which trophy to choose that symbolizes your educational mission. TIn the literature, the logical-cognitive and affective-attitudinal dimensions of reflection within and outside the domain of health care and health care education, have been distinguished and promoted by many authors, using many terms, such as ‘reflection’, ‘reflectivity’, ‘reflection-in-action’, ‘reflection-on-action’ and mindfulness (Dewey, 1933; Balint, 1964; Schön, 1987; Kolb, 1984; Pitkala et al., 2000; Milos & Hitchcock, 2005; Habermas, 1987; Argyris & Schön, 1974; TSalovey & Mayer, 1990; Goleman, 1995; TMezirow, 1992; Ericsson, 2004; King &


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Kitchener, 1994; Epstein, 1999; TKabat-Zinn, 1990 and 2005; Procee, 2006 T). For the sake of simplicity we Twill distinguish the mode of ‘scientific reflection’ Twhich corresponds to the logical-cognitive orientation of critical reflection, and ‘personal reflection’ Twhich corresponds to T the affective-attitudinal dimensions. TThese two modes of reflection have empirical support. T In one of the rare empirical studies on the nature of reflective practice in medicine, Mamede and Schmidt (2004) revealed a five-factor model (deliberate induction, deliberate deduction, testing and synthesizing, openness for reflection, and meta-reasoning). The first three components mainly resemble the physician’s daily ‘clinical reasoning’ and ‘scientific reflection’ processes. They consider the last two components as the affective, attitudinal and meta-level dimensions of reflection (Mamede & Schmidt, 2004), which resemble the mode of ‘personal reflection’. T

The Float Model The float as a whole symbolizes the physician as a professional reflective practitioner. The complete picture enables a first ‘whole’ impression and global appraisal of reflective conduct as balanced or unbalanced. Above the water, ‘behaviour’ becomes visible. Just beneath the surface lies ‘clinical reasoning’ as expert-thinking-in-operation, followed by ‘scientific reflection’ and ‘personal reflection’. Special attention will be paid to the mindful attitude and to unconscious aspects. The water symbolizes the clinical context and culture (see Figure 1). For practical educational purposes, these modes of thinking and reflection are described separately, though in actual practice they are obviously intermingled. Cognitive-emotional blends have relative weights beneath the surface. The levelled structure of the Float Model enables a more in-depth description, inspection and understanding of types of reflective behaviour of students, residents and physicians. Behaviour The physician’s conduct is primarily visible as ‘behaviour’ above the water’s surface – the ultimate proof of professionalism in health care. Its key function is to provide good health care, to maintain adequate professional relationships and to sustain appropriate self-care. Health care professionals experience their own behaviour or performance as a ‘whole’. Others, such as patients, colleagues and clinical supervisors, also experience the performance of a physician or student as a ‘whole’, revealing both the expert and the person of the professional.


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For educational purposes behaviour can be differentiated into ‘expert behaviour’ and ‘professional behaviour’ (Van Luyk, 2005). Expert behaviour is the expression of diagnostic, therapeutic and communicative abilities, such as applying medical knowledge and ‘clinical reasoning’ profiled by the physician’s medical specialty. Professional behaviour can be defined as the enduring expression and maintenance of professional and social codes common to physicians as a group and the physician as a person (Van Luyk, 2005).

Figure 1. The Float Model of reflective practice

BEHAVIOUR Visible Behaviour Function: providing medical care, maintaining professional relationships, self-care CLINICAL REASONING / JUDGMENT Problem and patient-oriented understanding, judgment, decision embedded in personal thoughts and feelings Function: problem-solving SCIENTIFIC REFLECTION Critical appraisal of literature and own practice embedded in clinical epidemiology Function: optimizing evidence (EBM) PERSONAL REFLECTION Mindful awareness, attendance and exploration of experience Function: optimizing balance Unconscious thinking: rational and irrational thoughts and feelings, intuition

Clinical reasoning The core competence of expert-thinking-in-operation, just under the surface, is clinical reasoning and judgment. It is the physician’s ongoing process of problem- and patient-oriented understanding, judgment and decision. Its key function is medical problem solving. Clinical reasoning becomes apparent primarily in expert behaviour, during history taking, physical examination, decision-making and communication with patients, and in care-oriented inter-professional cooperation (Snoek, 1989).


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Clinical reasoning is embedded in personal thoughts and feelings which bubble up continuously. This embedding is not only inextricable but also significant as the basis of the capability of physicians to elicit, make sense and synthesize the perspectives of patients and their families. The function of the embedding of clinical reasoning in personal thinking is to preserve the problem and patient and relationship-orientation in daily medical care (Epstein, 1999). Scientific reflection Closely connected to clinical reasoning is ‘scientific reflection’: the physician’s critical appraisal of both literature and own practice (Sackett et al., 1991). In fact, scientific reflection is the critical meta-cognitive twin of clinical reasoning-in-action, together forming the solid whole of medical expertise. This strong relationship has been accepted as ‘deliberate practise’ and as the evidence base of medicine (EBM). The key function of scientific reflection is to accomplish and optimize the degree of scientifically based clinical judgments. It is preferentially based on clinical epidemiology and on the physician’s involvement in relating research findings to his or her practice. Scientific reflection and engagement become apparent behaviourally in the critical appraisal of literature, the maintenance of a critical attitude and distance to one’s reasoning and judgments, and linking one’s conduct to clinical epidemiological theory. However, this does not happen automatically or easily because it requires at least the knowledge and application of basic clinical epidemiology principles (Clark & Croft, 1998). Personal reflection Personal reflection is the exploration and appraisal of experience, thus clarifying and creating meaning for the benefit of balanced functioning, learning and development (Aukes et al., 2007). Personal reflection involves attending sensations, images, feelings and thoughts rather than intellectualizing (Epstein, 1999; Coulehan, 2005). Its key function is coordination, optimizing balance in conduct and learning, and the preservation of the physician’s self-care. We prefer the term ‘personal reflection’ to ‘self-reflection’ to emphasize its complementary function with respect to ‘objective’ scientific reflection, and its inter-subjective character. Personal reflection can be oriented towards one’s own experience as well as the experiences of others, such as patients, students or colleagues. Three frequently used stages in the purposeful use of reflection are: awareness of experience, the inquiry into selected experiences, and the new perspectives and actions which may result from these (Atkins & Murphy, 1993; Korthagen et al.,


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2001). Raising awareness of experience is connected with ‘mindfulness’. This entails an open-minded, non-judgmental attitude towards experience (Kabat-Zinn, 1990; Epstein, 1999). The personal reflection ability combines a mindful attitude towards experience together with the careful exploration and articulation of selected parts of experience. These selected elements might include a certain event, a sequence of actions and reactions, bodily sensations, rational and irrational thoughts, feelings, or beliefs. Personal reflection becomes apparent above the water level in an open-minded attitude, empathy, flexible use of communication and meta-communication, and appropriate handling of feedback and dialogue. Unconscious thinking We treat unconscious thinking separately because it is an influential but often neglected aspect of rational conduct and health care practice. A clinical example is the so-called ‘encapsulated’ clinical reasoning expertise, which can be made explicit when called for (Schmidt et al., 1990). A personal example is the fact that judgments by individual physicians are subject to an unconscious and unintentional self-serving bias, even when efforts are made to avoid this (Dana & Loewenstein, 2003). An interaction example is the phenomenon of ‘transference’ and ‘counter transference’ that occurs in any relationship that is characterized by affection, hierarchy and/or dependency (Patterson, 1959). Unconscious thinking contains both rational and irrational cognitive-emotional and bodily routines and intuitions. It is positioned at the bottom, but blends with every mode of reasoning, reflection and action within the whole float model. From a simple ‘evidence-based’ perspective these subjective and unconscious aspects may be regarded as irrational abnormalities or threats of rational conduct, to be neglected or primarily to be seen as a part of the physician’s private domain. However, in modern integrative medicine and reflective and mindful practice these aspects are recognized as the important ‘internal data’ of clinical expertise and professional conduct, which therefore need regular attention in education (Khushf, 1999; Kabat-Zinn, 1990; Epstein, 1999; Haramati & Lumpkin, 2004). The water The water symbolizes the professional and cultural context within which the physician’s functioning is embedded. A network of interdependent relationships between the physician, the patients and their families, colleagues and other health care workers, constitutes the clinical setting. Obviously, there are influences from wider circles around the health care professional, such as hospital managers, the health care system and society. The functioning of other health care professionals


7

or patients can also be seen as Float Models, with their own characteristic configurations of behaviour, thoughts, feelings and reflection. Examples of reflective behaviour Using the Float Model, three basic configurations of reflective behaviour can be distinguished: (1) balanced reflection (the standing float), (2) inappropriate reflection (the submerging float) and (3) superficial reflection (the tilted float) (See Figure 2). 1. Balanced reflection – the standing float There are without doubt present and future medical doctors who project a global image of balanced professional excellence and presence in daily functioning. In Epstein’s (1999) words: people ‘acting with compassion, technical competence, presence, and insight’. However, it is harder to imagine and describe the habits of the mind lying behind their behavioural habits. In addition to their sophisticated technical-logical expertise, they categorically demonstrate a kind of ‘presence’ and an open and responsive attitude. They demonstrate this open mind in various ways: with respect to their own processes of clinical judgment (scientific reflection), towards their patients (empathetic communication), but also with respect to their own personal thoughts, feelings and bodily sensations (personal reflection). In particular it is their personal reflection ability that enables them to maintain the subtle balance in the sea of practice reality. Observable characteristics of balanced reflection are: - Accepting the existence of thoughts, feelings and bodily sensations as relevant

internal data rather than making disparaging remarks or neglecting them. - Taking the time to explore and analyse these aspects and their influence on

one’s own conduct and interaction with others, rather than not participating or jumping to judgments and conclusions.

- Using various communication modes such as active empathetic listening, meta-communication, or engaging in a dialogue rather than just debate or joking.

- Proper timing. Timing is a subtle aspect of the art of professional performance which is employed by physicians in relation to their patients, medical educators in relation to their students and, for example, artists in interactions with their public. Proper timing means asking the right question at the right level at the right moment, and to the right person. In other words, asking oneself (self-reflection, inner consultation), a patient (empathetic communication), a colleague (consultation) or a resident (supervision, coaching).


8

Figure 2. Profiles of reflective conduct

Balanced reflection: asking the right question at the right level at the right moment

Inappropriate reflection: inability to cope with clinical, scientific or personal uncertainty or complexity

Superficial or non-reflection – a defensive attitude towards feedback and learning from experience and errors

2. Inappropriate reflection – the submerging float Medical practice is full of residents and professionals drowning in a sea of conflicting demands. What is going on in their minds and hearts? They may be overwhelmed and burdened, unable to cope with different types of clinical or personal thoughts and feelings, uncertainty or stress. For example: the endlessly questioning physician applying too much clinical reasoning without appropriate action; the cynical physician frustrated at the discrepancy between his/her own values and the demanding behaviour of patients, colleagues or supervisors; and the overly empathetic physician with too much personal feeling and too little professional distance. 3. Superficial or non-reflection – the tilted float Manifestations of the non-reflective practitioner are overactive residents or colleagues with a tendency towards over-treatment, hectic communicative behaviour towards patients and colleagues, or ‘tilted’ emotional reactions to criticism or feedback. To have a proper reflective conversation with, or to give effective feedback to, non-reflective students or colleagues can be quite a paradoxical exercise. Most likely the main problem is not an insufficiency of deliberate clinical reasoning or scientific reflection, but an insufficient balance caused by insufficient personal reflection. An example is the student with a defensive attitude towards feedback or one who blames others for personal dysfunction. In such difficult cases the Float Model can be used by the supervisor to illustrate at least the level of his/her feedback. Another example of superficial scientific reflection and inappropriate personal reflection is the protocol-driven resident or physician demonstrating misplaced certainty or presumed evidence beyond patients and their wishes. Protocols, as


9

guidelines to therapeutic procedures concerning standard medical problems, are intended to keep medical care and clinical reasoning problem and patient-oriented, which is a real challenge in a technical, market or commerce-driven context (Rotter & Hall, 1992). However, the use of protocols can also serve as a survival strategy or buttress which is embraced whenever physicians find themselves overwhelmed by the maelstrom of litigation or professional and personal burnout. Applications The Float Model has been applied at different levels of medical education and curriculum development in order to distinguish and understand the basic modes of reflection and the need for each in creating a balanced practitioner. The Float Model has also given supervisors and clinical facilitators in clerkships a simplified but nevertheless thought-provoking metaphor about reflection. It stimulated them to (a) articulate their own opinions on reflection and professionalism more explicitly and (b) structure nuances in their observation of and feedback to students and residents. Box 2. Application of the Float Model Student: ‘I felt so upset because Mrs. X (a cancer patient) asked me precisely how the radiotherapy she had to undergo would proceed. I do not know anything about that procedure yet. I felt stupid, because I should have known!’ Clinician: ‘How did you react to the patient?’ Student: ‘I promised to notify the appropriate personal so that she would be well-informed in time.’ Clinician: ‘How did the patient react?’ Student: ‘She was satisfied, despite the fact that I did not give her a straight answer’. The clinician stimulates the student to observe and describe empirically the behavioural fact (above the water) that, although she felt upset, she communicated well with the patient; the fact of her lack of medical knowledge; the fact of her personal feelings, thoughts and judgments about it. He invites the student to explore her personal and professional habits, values and opinions that colour her reaction. The clinician could use the Float Model to visualize the interconnection between these aspects. The Float Model was used to help students clarify the profile of their self-assessment. It can be used to locate skills or lack of them at each level, as factors of success and failure in achieving balance in professional functioning and learning.


10

The metaphor of the angler’s float has been effective in ‘getting the message across’ in diverse lectures by medical specialists. Discussion The Float Model was designed as an educational tool for medical educators in order to encourage better understanding and use of reflection. The descriptions were developed from our experiences as educators and developers in medical education. We have not yet formally evaluated the effect of its application. However, our practice-based results show that the Float Model often worked well as a thought-provoking metaphor. It stimulated the participants to articulate their own thoughts on reflection and professionalism during the course and it also guided inter-collegial consultation. The use of metaphors has advantages. Metaphorical thinking is a strong mechanism through which we comprehend abstract concepts, perform abstract reasoning, understand our experiences and shape the way we act on that understanding (Lakoff, 1993). Medical students use memory aids such as acronyms which are also examples of metaphorical tools for memorizing medical knowledge. Physicians are familiar with the use of metaphors as effective tools in patient education. Metaphorical language can bridge the gap between the professional language of the physician and the layman’s language of patients, between the expert clinical instructor and the novice medical resident, or between highly specialized health care workers who struggle to speak each other’s language. Obviously, an educational model as the Float has its limitations. The separate levels can be described more completely if their interdependence and interaction within a specific context are explicitly revealed. Its vertical structure may obstruct the use of circular models. The essence of the float is to visualize balanced conduct and the need for a reflective equilibrium. Each health care professional or educator can recognize its detailed components and add own priorities. Further research should explore the effectiveness of the Float Model in different educational settings and the applicability of various theory-based approaches. These may include a cognitive-psychological clarification of expert thinking and scientific and personal reflection; a psychodynamic view of defensive behaviour and unconscious thinking; and the interaction between the professional’s float and the patient’s float. We conclude with a final remark about the inbuilt conflict between aspects of the cognitive-logical and the personal-subjective modes of reflection, which is the result of differences in their nature, focus, aim and criteria for success (Grabov,


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1997; Taylor, 2007). In a mainly evidence-based professional culture it is important to realize that, despite the fact that the value of reflective and mindful practice is supported by empirical observation and research, it is fundamentally personal and subjective (Epstein; 1999). Encouraging awareness, acceptance and understanding of this inherent tension is an educational challenge. The Float Model can be used to compartmentalize, identify and manage the different modes of thinking and reflection. How each of them can be encouraged and assessed should be part of further educational research. References ABIM (American Board of Internal Medicine), ACP-ASIM (American College of Physicians-American

Society of Internal Medicine) & EFIM (the European Federation of Internal Medicine) (2002). Medical professionalism in the new millennium: A physician’s charter. Annals of Internal Medicine, 136, 243−246.

Argyris, C. & Schön, D.A. (1974) Theory in Practice: Increasing Professional Effectiveness (San Francisco, California, Jossey-Bass Publishers).

Altkins, S. & Murphy, K. (1993) Reflection: a review of the literature. Journal of Advanced Nursing, 18 (8), pp. 1188−1192.

Aukes, L.C., Geertsma, J., Cohen-Schotanus, J., Zwierstra, R.P. & Slaets, J.P.J. (2007). The development of a scale to measure personal reflection in medical practice and education. Medical Teacher, 29, 177−182.

Balint, M (1964) The Doctor, his Patient and the Illness, 2 P

ndP edn (London, Pitman Medical).

Brown, K.W. & Ryan, R.M. (2003) The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology 84: 822−848.

Clark, R. & Croft, P. (1998) Critical Reading for the Reflective Practitioner: a Guide for Primary Care (Oxford, Butterworth-Heinemann).

Coulehan, J (2005) Today’s professionalism: engaging the mind but not the heart, Academic Medicine, 80 (10), 892−898.

Dana, J & Loewenstein, G. (2003) A social science perspective on gifts to physicians from industry, Journal of the American Medical Association, 290 (2), 252−255.

Dewey, J. (1933) How We Think: a Restatement of the Relation of Reflective Thinking to the Educative Process (Boston, Heath).

Epstein, R.M. (1999). Mindful practice. Journal of the American Medical Association, 282, 833−839. Ericson, K.A. (2004) Deliberate practice and the acquisition and maintenance of expert performance in

medicine and related domains, Academic Medicine, 79 (10 Suppl.), 70−81. Goleman, D. (1995) Emotional Intelligence (New York, Bantam Books). Grabov, V. (1997) The many facets of transformative learning theory and practice. In: Transformative

Learning in Action: Insights from Practice. New Directions for Adult and Continuing Education no. 74, P. Cranton (Ed.), 89-96 (San Francisco, CA: Jossey-Bass).

Guest, C.B., Regehr, G. & Tiberius, R.G. (2001) The life long challenge of expertise, Medical Education, 35 (1), 78–81.

Habermas, J. (1987) The Theory of Communicative Action (Cambridge, Polity Press). Haramati, A., & Lumpkin M.D. (2004) Complementary and alternative medicine: Opportunities for

education and research. Exper. Biol. and Med. 229:695-697. Hilton, S.R. & Slotnick, H.B. (2005) Proto-professionalism: how professionalisation occurs across the

continuum of medical education, Medical Education, 39 (1), 58−65.


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Inui, T.S. (2003) A Flag in the Wind: Educating for Professionalism in Medicine (Washington DC, Association of American Medical Colleges).

Kabat-Zinn, J. (1990) Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Dell Publishing).

Kabat-Zinn, J. (2005) Full Catastrophe Living, Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. 15 P

thP Anniversary Edition. (New York: Delta).

Khushf, G. (1999) The aesthetics of clinical judgment: Exploring the link between diagnostic elegance and effective resource utilization. Medicine, Health Care and Philosophy, 2, 141−159.

King PM, Kitchener KS. (1994). Developing Reflective Judgment: Understanding and Promoting Intellectual Growth and Critical Thinking in Adolescents and Adults (San Francisco, Jossey-Bass).

Kolb, D.A. (1984) Experiential Learning: Experience as the Source of Learning and Development (Englewood Cliffs, New Jersey, Prentice-Hall).

Korthagen, F.A.J. in coop. with J. Kessels et al. (2001). Linking practice and theory: the pedagogy of realistic teacher education (Mahwah, NJ [etc.]: Lawrence Erlbaum Associates).

Lakoff, G. (1993) The contemporary theory of metaphor, in: A. Ortony (Ed) Metaphor and Thought, 2P

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edn, 202−251 (Cambridge, Cambridge University Press). Mamede, S. & Schmidt. H.G. (2004) The structure of reflective practice in medicine, Medical Education,

38, 1302−1308. Maudsley, G. & Strivens, J. (2000). Promoting professional knowledge, experiential learning and critical

thinking for medical students. Medical Education, 34, 535−544. Merirow, J. (1992) Transformation theory. Adult Education Quarterly, 42 (4), 250−252. Milos, J. & Hitchcock, D.L. (2005) Logic and Critical Thinking in Medicine: Evidence-based Practice

(Chicago, IL, AMA Press). Patterson, C.H. (1959) Transference and countertransference. In: Counseling and psychotherapy: theory

and practice. 1 P

stP edition (New York: Harper & Row).

Pitkala, K, Mantyranta, T., Strandberg, T.E., Makela, M, Vanhanen, H. & Varonen, H. (2000) Evidence-based medicine: how to teach critical scientific thinking to medical undergraduates, Medical Teacher, 22 (1), 22−27.

Procee, H. (2006) Reflection in education: a Kantian epistemology. Educ Theory, 56 (3), pp. 237−253. Rotter, D.L. & Hall, J.A. (1992) Doctors Talking with Patients, Patients Talking with Doctors (Westport,

CT, Auburn House). Sackett. D.L., Haynes, R.B. & Tugwell, P. (1991) Clinical Epidemiology: a Basic Science for Clinical

Medicine (Boston/Toronto, Little, Brown and Company). Salovey, P. & Mayer, J. (1990) Emotional intelligence, Imagination, Cognition, and Personality, 9 (3),

185−211. Schmidt H.G., Norman, G.R. & Boshuizen, H.P. (1990) A cognitive perspective on medical expertise:

theory and implication, Academic Medicine, 65 (10) 611-621. Schön, D.A. (1987) Educating the Reflective Practitioner: Towards a New Design for Teaching and

Learning in the Profession (San Francisco, Jossey-Bass). Snoek, J.W. Het denken van de neuroloog (How neurologists think). Thesis, University of Groningen

1989. Taylor, E.W. (2007) An update of transformative learning theory: a critical review of the empirical

research (1999-2005). International Journal of Lifelong Education, vol. 26, nr. 2: 173-192. Van Luijk, S.J. (Ed) (2005) Professional Behaviour: Teaching, Assessing and Coaching Students. Final

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Chapter 3. The GRAS

Chapter 3. Measuring personal reflection: The Groningen Reflection Ability Scale (GRAS) De zekerheid van de natuur is de som van vele onzekerheden, die allemaal te meten zijn. Hoe meer onzekerheid je meet, des te zekerder ben je van de uitkomst. – Gerrit Krol Abstract Aim: Personal reflection is important for acquiring, maintaining and enhancing balanced medical professionalism. A new scale, the Groningen Reflection Ability Scale (GRAS), was developed to measure the personal reflection ability of medical students. Method: Explorative literature study was conducted to gather an initial pool of items. Item selection took place using qualitative and quantitative methods. Medical teachers screened the initial item-pool on relevance, expert-analysis was used for screening the fidelity to the criterion and large samples of medical students and medical teachers were used to investigate the psychometric characteristics of the items. Finally, explorative factor analysis was used to investigate the structure of the scale. Results: The psychometric quality and content validity of the GRAS are satisfactory. The items cover three aspects of personal reflection: self-reflection, empathetic reflection and reflective communication. The 23-item scale proved to be easy to complete and to administer. Conclusion: The GRAS is a practical measurement instrument that yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at individual and group level. Introduction Doctors have to solve complex problems and they are expected to do that in cooperation with patients and their families, in multi-professional collaboration, in a professional and personal way, and while learning from their experiences. This complexity, inherent to clinical practice, demands not only skillful behaviour and sophisticated types of clinical reasoning and scientific reflection, but also personal

Chapter 3. The GRAS

reflection. The aim of this study was to construct a practical scale for measuring the ability of personal reflection. This article describes the development of the Groningen Reflection Ability Scale (GRAS), the psychometric and substantial characteristics of the items, and the structure of the scale. Box 1. Practice points - Personal reflection is an important construct in medicine that can be measured. - Whereas available instruments are mainly focused on critical thinking regarding well-

defined clinical problems, the GRAS is measuring personal reflection regarding important multi-facetted problems in medicine.

- The GRAS is a one-dimensional scale, covering three relevant aspects of personal reflection: Self-reflection, empathetic reflection and reflective communication.

- The GRAS yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at individual and group level.

Reflection is required for adapting professional functioning to the patients’ needs or to new circumstances when there are no obvious solutions, for transformation of new knowledge and into practice, or for life-long personal and professional learning. In literature large numbers of forms and functions of reflection are distinguished and promoted. For example, mindful practice (Epstein 1999), coping with ill-structured problems (King & Kitchener 1994), awareness of emotions (Boud & Walker 1993), assumptions (Van Manen 1990), or morality (Kohlberg 1984), learning from experience (Schön 1987), deep learning (Marton et al. 1984) or critical learning (Mezirow 1992), and the assessment of integral learning outcomes (Shumway & Harden 2003). Reflection, especially personal reflection on experience, is seen as a key factor for acquiring and maintaining balanced professionalism along the continuum of medical education (General Medical Council 1999; Irvine 1999; Simpson et al. 2002; BIM, ACP-ASIM & EFIM 2002; CanMEDS 2000/2005; Crues & Crues 2006). However, in contrast to the richness of opinions and efforts for implementing reflection in medical education, the attention given to instruments to measure reflection is relatively poor (Kember & Leung 2000; Arnold 2002). The available instruments are mainly focused on clinical reasoning and critical thinking regarding well-defined problems (King & Kitchener 1994), or on specific aspects of reflection in medical and nursing education, such as identity formation (Niemi 1997), moral reasoning (Kohlberg 1984), or reflective writing (Wong et al. 1995).

Chapter 3. The GRAS

In order to structure this confusing amount of types of reflection and to clarify the focus of this study, we distinguish three cognitive-emotional levels of the doctor as a reflective practitioner. First of all there is clinical reasoning, the problem- and patient-oriented understanding, judgment and decision, with the key function of problem solving. Then comes scientific reflection as the predominant type of critical thinking in medicine: The critical appraisal of literature and own practice, preferentially grounded in evidence and clinical epidemiology (Sackett et al., 1991), with the key function of optimizing scientifically-based clinical decisions or evidence based medicine (EBM). Finally there is personal reflection on experience, with the key function of optimizing balanced professionalism in medicine. According to Donald Schön’s theory (1987) of the reflective practitioner, clinical reasoning can be conceptualized as ‘reflection-in-action’, and scientific thinking as the prototype of ‘reflection-on-action’ in medicine. We have a preference to describe personal reflection as ‘reflection-on-experience’ to emphasize the direction of reflective attention to the process of sense-making in medical practice, and to the dynamics of rational and irrational thoughts and emotions, assumptions and beliefs in that process. Personal reflection in medicine can be described as the exploration and appraisal of one’s own and other’s experiences, thus clarifying and creating meaning, for the benefit of balanced functioning, learning and development. This definition of personal reflection integrates some key aspects complementary to scientific reflection: Mindfulness rather than intellectualism; attention for experience rather than action; appropriate communication, such as handling a dialogue and feedback rather than debate and discussion; clarifying the process of sense-making rather than problem solving; resulting in transforming or confirming one’s own perspective on professional practice and identity. Such a perspective fits in a multi-levelled model of balanced reflective practice, with the mentioned cognitive-emotional levels of clinical reasoning (doctor as expert), scientific reflection (doctor as scholar) and personal reflection (doctor as person). It cannot be denied, however, that in the pragmatic problem-solving culture of medical practice and education personal reflection often was, and is, seen as a hard to conceive subjective and abstract issue. Personal reflection is usually seen more as a private attitude or personality trait of doctors, and thus by definition positioned outside the medical toolkit, and the professional and educational domain (Coulehan 2005). One explication for this separation is the fact that scientific reflection, obviously of vital importance for the medical profession and strongly established in medical education (Freidson 1994), is also so predominant that it often seems to be prototypical for reflection in medicine. This would be a mistake and a threat for

Chapter 3. The GRAS

balanced medical professionalism by constituting an overall one-dimensional technical view, regarding relatively well-structured clinical problems. And thus disregarding important less structured problems in patient care, inter-collegial cooperation and own functioning. For balanced medical professionalism it is of vital importance that the doctor keeps an awareness of the tacit constitutive processes of attention, selection and socialization (Epstein, 1999). We agree with Hilton and Slotnick (2005), who state that ‘skills, knowledge and experience are necessary for professionalism, but sophisticated reflection on the doctor’s part is also required to produce insights enabling the individual to better address the needs of patients specifically, and society generally’. We use the term personal reflection for this mode of reflection. Taking personal reflection seriously, as a real mental hygienic component of balanced medical functioning, that can be practiced and developed within certain personal and cultural boundaries, implies the need for instruments by which it can be measured. Methods Participants and methods of the item selection procedure First an initial item pool was constructed with descriptions of reflection gathered from literature, personality theory and educational practice. Then, item selection took place using qualitative and quantitative methods: Medical teachers screened the initial item pool on fidelity to the criterion, expert-analysis was used for screening the relevance, large samples of medical students and medical teachers were used to investigate the psychometric characteristics of the items, and explorative factor analysis was used to investigate the structure of the scale. This item selection procedure will be described now step by step (see Table 1). Start. The principal researcher started with the screening of descriptions of reflection from different sources. Descriptions of reflective ability, behaviour and personal characteristics as mentioned in the literature on reflection, in lists used in the Five Factor personality theory (De Raad & Doddema 1999; Hendriks 1997), and from own educational practice were accumulated and screened with the criterion: ‘Which descriptions are associated with personal reflection in a medical context?’ This resulted in a pool with items that could be scored on a 5-point Likert scale, with the question: To which extent does this description applies to you? (1 meaning ‘totally disagree’ until 5 ‘totally agree’). Step 1. The resulting list of items was discussed and screened at face value by 11 colleagues participating in curriculum development and medical teaching. Some items were reformulated based on experiences in medical education and in a joint

Chapter 3. The GRAS

multi-centre project on reflective professional behaviour. Then the list was judged by 20 faculty members (both medical doctors and social scientists) who were participating in a curriculum project aiming at developing competent reflective doctors. Ten respondents were asked to judge the items as ‘characteristic for the good doctor’, and 10 respondents as ‘characteristic for the bad doctor’. Non-discriminating items were removed. Step 2. The resulting list of items was completed by a sample of 350 first-year medical students of Groningen University and 38 medical teachers (general practitioners, participating as facilitator). The facilitators asked the students to complete the scales during one of their coach-group sessions. This measurement was followed by psychometric analysis. For item-variance a criterion standard deviation of 0.75 was taken, whereas a SD of 1.0 on a 5-point Likert scale is usually seen as sufficient (Nunnaly 1967). Items with a SD< 0.75 were removed. The item intercorrelation was controlled by checking items that systematically scored low or negative. The item discrimination was calculated with using item-rest correlations. Table 1: The item collection and selection procedure of the GRAS

Steps and Goal

Scale N items

Participants

Action

Start Item collection

3456 1

Principal researcher

Using literature

Step 1. Face validity analysis

81

1120

Researchers and colleagues Faculty members

Using experience

Step 2. Psychometric item analysis

61

35038

1st year students Medical teachers

Measurement

Step 3. Face validity analysis

50

3821

Medical teachers (same group) Experts

Measurement Expert-analysis

Step 4. Psychometric structure analysis (construct validation)

23

5833814

1029

1st ~ 6th years students Medical teachers (same group) Medical skills teachers 1st ~ 6th years students (next study year)

Measurement Measurement

Step 3. The resulting item list was completed again by the same 38 medical teachers. The results were used for both psychometric and expert analysis. After psychometric analysis, the items were analysed twice by experts. Firstly 19

Chapter 3. The GRAS

experienced medical staff members independently judged the items, with the criterion: ‘How relevant is this item for the measurement of reflection?’, on a 5-point Likert scale (1 meaning ‘not relevant at all’ until 5 ‘very relevant’). Items with a mean score >4 and a SD < 1 on these ratings were interpreted as highly relevant and were kept in the list. Three well-known experts from outside the faculty then analysed the reduced list. They scored each item for relevance on paper, followed by a semi-structured focus-group meeting, in which each item was discussed critically for relevance, conceptual clarity and social desirability. In some cases of doubt psychometrically less satisfactory items with a high score at relevance were reformulated and kept in the list, because relevance was considered to be of prime importance. Step 4. For psychometric item and structure analysis two measurements were completed. The first measurement, with a sample of 583 first-years to sixth-year medical students and 38 medical teachers, the same as in step 1; and 14 experienced teachers in medical skills, was used for psychometric item analysis. This was needed because of reformulations of some items after the expert-consultation in step 3. The second measurement, with a sample of 1029 first-year to sixth-year medical students in the next study year, was used for psychometric structure analysis. The scale was constructed as a one-dimensional scale, but we were interested in exploring possible subsets of items, that are distinct from other item groups and homogeneous within a group, as pointers of the content validity of personal reflection. Therefore explorative factor analysis (with varimax rotation) was used. Results Results of the item selection procedure The principal researcher started the item collection procedure by screening about 100 descriptions from literature on reflection and 3456 personal characteristics from lists used in the Five Factor personality theory, resulting in a pool of 81 items. After screening fidelity to the criterion by researchers and faculty members (step 1) 20 items were removed. The measurement with the resulting 61-item list (step 2) resulted in the following psychometric qualifications. Item difficulty: The average of the items was between 3 and 4. Item-variance: With a criterion standard deviation of 0.75 33 items were removed. The item-discrimination: 1 item with an item-rest correlation of ri-r < 0.20 was discarded. This psychometric analysis resulted in 27 psychometrically satisfying and 34 less satisfying items. However, 23 of the 34 psychometrically less satisfying items were judged as relevant by the

Chapter 3. The GRAS

researchers from a substantial and educational point of view. Consequently these 23 items were reformulated and kept in the list, resulting in a 50-item list. The psychometric analysis (step 3) resulted in 27 psychometrical satisfying items. During the fidelity to the criterion analysis by faculty experts 4 of these 27 psychometrical satisfying items were judged as weak on relevance and removed, as a consequence of the prime importance of relevance. 6 of the psychometrically unsatisfying items were kept because they were judged as relevant, resulting in a 29-item list. The fidelity to the criterion analyses by three extern experts of this list resulted in a 23-item list. This 23-item list was used for two final measurements (step 4) for psychometric item and structure analysis. This blended procedure of psychometric and expert analyses, reductions and reformulations, resulted in the definitive Groningen Reflection Ability Scale (GRAS), containing 23 items – of which 14 items remained from the initial list of 61 items (step 1), and 19 items were new or re-formulated. Characteristics of the definitive scale The GRAS has a satisfactory internal consistency: A Cronbach’s alpha of 0.83 for the 1st measurement (step 4) and 0.74 for the 2nd measurement (step 4), an item-difficulty (between 4.23 and 3.50) and item variance (between 1.04 and 0.67) (all related to the Dutch items). The scale proved to be easy to administer and to complete, within 10 minutes. The scores can be calculated without time-consuming coding procedures. The initial content validation, by means of structure analysis using explorative factor analysis, was based on three criteria: Eigenvalues, Scree test and substantial criterion. (a) Using an eigenvalue criterion of >1 resulted in 7 factors that were difficult to interpret. (b) However, with the Scree test, the first factor could be isolated with a jump of 10.5% explained variance between factor 1 and 2. In addition, the first three factors could be isolated with a smaller jump of 0.8% explained variance between factor 3 and 4. (c) Using the substantial criterion, the first three factors could be interpreted as three relevant groups of items (Table 2): Self-reflection (10 items): Introspection, exploration, understanding and appraisal of experiences; empathetic reflection (6 items): Replacement in and taking into consideration the situation of others, openness to different ways of thinking, contextual understanding and appraisal; and reflective communication (7 items): Reflective behaviour, openness for feedback and discussion, taking responsibility for own statements and actions, ethical accountability. Table 2. Summary of principal components (with eigenvalues) contributing to each subgroup of items as a result of explorative factor analysis of the GRAS structure.

Chapter 3. The GRAS

Factors I II III (3.98) (1.56) (1.47) Factor loading+ Communalities I take a closer look at my own habits of thinking

.63

.40 I want to know why I do what I do .59 .39 I find it important to know what certain rules and guidelines are based on .56 .37

I want to understand myself .55 .32

I am aware of the emotions that influence my thinking .51 .35 .31

I am aware of the emotions that influence my behaviour .44 .33 .38

I am able to view my own behaviour from a distance .40 .25

I test my own judgments against those of others .39 .18

I can see an experience from different standpoints .36 .28

I am aware of the cultural influences on my opinions .36 .19 I am aware of the possible emotional impact of information on others .56 .42

I can empathize with someone else’s situation .56 .22

I am aware of my own limitations .46 .22

I reject different ways of thinking .45 .30

Sometimes others say that I do overestimate myself .45 .37 I am able to understand people with a different cultural / religious background .42 .25

I do not like to have my standpoints discussed .57 .33 I sometimes find myself having difficulty in illustrating an ethical standpoint .51 .30

I am accountable for what I say .50 .34

I take responsibility for what I say .49 .35

I am open to discussion about my opinions .33 .46 .33 I sometimes find myself having difficulty in thinking of alternative solutions .46 .21

I do not welcome remarks about my personal functioning .31 .44 .32

All factor loadings > 0.30 are reported. + after Varimax rotation. Factor 1. Self-reflection. Factor 2: Empathetic Reflection. Factor 3: Reflective Communication.

Table 2 shows the item loadings for all the three factors and the communalities (h2). The eigenvalues of each factor are: Factor 1, Self-reflection: 3.98; factor 2,

Chapter 3. The GRAS

Empathetic Reflection: 1.56; and factor 3, Reflective Communication: 1.47. The correlations between the three factors are: 0.62 for factor 1 ~ factor 2; 0.57 for factor 1 ~ factor 3; and 0.42 for factor 2 ~ factor 3. The Kaiser–Meyer–Olkin (KMO) statistic as ‘goodness of fit’ is 0.78 (p < 0.001). Measured by the KMO statistics, sampling adequacy predicts if data are likely to factor well. KMO overall should be 0.60 or higher to proceed with factor analysis. The total variance explained (30%), the eigenvalues and the factor loadings are an indication that the three factor model is not working well. As a consequence the communalities, measuring the percent of variance in a given variable explained by all the factors jointly, are low. The correlations with attenuation correction between each of the item groups are high enough to support the interpretation of one-dimensionality. These psychometric results indicate that the GRAS is a one-dimensional scale with three relevant aspects of that dimension. Discussion The aim of this study was to develop a scale to measure one mode of reflection in medicine, personal reflection. The study resulted in a 23-item scale of the GRAS (on a 5-point Likert scale) which proved to be easy to administer and to complete (within 10 minutes). Scores can be calculated without time consuming coding procedures. According to the standards for educational and psychological testing (American Educational Research Association et al. 1999), the GRAS (with Cronbach’s alpha’s of 0.83 and 0.74) can be regarded as ‘good’ for less important decisions at an individual level (0.70 ~ 0.80) and a group level (0.60 ~ 0.70), and ‘not quite sufficient reliable’ for important decisions at an individual level (0.80 ~ 0.90). Whereas other scales only focus at one specific aspect (Niemi 1997; Wong et al. 1995) or at critical reflection on well-defined clinical problems (King & Kitchener 1994), the GRAS focuses at personal reflection on experience and less structured problems. The GRAS is a one-dimensional scale. The conceptual argument is the fact that the GRAS was developed as a one dimensional scale and item selection took place in one domain of theory and literature about reflection. The three factors, being a result of explorative factor analysis, must therefore be interpreted primarily as facets of one dimension. The psychometric argument is that the proportion of variance represented by the first principal component is a good approximation of the proportion of variance represented by the first common factor (Falissard, 1999), which is supported by the correlations of each of the three factors. The factors are

Chapter 3. The GRAS

not independent enough to use as separate scales and thus as separate scores of individuals with practical consequences. This means that in practice a one-GRAS-score is leading. On the other hand, the three GRAS factors are probably distinctive facets of the concept of reflection in medicine. The content validity of the scale is satisfactory, because the items are grounded in reflection literature, and covering three substantive aspects of personal reflection in the context of medical practice and education: Self-reflection, Empathetic Reflection; and Reflective Communication. We see self reflection as the introspective aspect of personal reflection: The careful exploration and appraisal of experience, as a prerequisite for framing or reframing one’s thoughts, feelings, beliefs, norms or methods; empathetic reflection as the social, inter-subjective extension of self-reflection: Contextual understanding and appraisal, i.e. empathetic placement in and thinking about the position of others, such as patients and colleagues; and reflective communication as the behavioural expression of both self-reflection and empathetic reflection, for example the handling of feedback or a dialogue, or dealing with interpersonal differences. The GRAS can be used in medical education for programme evaluation: Effect measurements on the reflection ability of medical students and doctors. The GRAS measures not only the effect of one course, but moreover to which extent the curriculum influences the growth-curve of medical students as reflective practitioners over a prolonged time, both at individual and group level. The GRAS can also be used for cross-sectional comparison between groups of medical students from different curricula, cultures and language, or between doctors from different medical expert disciplines. A possible limited and paradoxical aspect of the GRAS is its self-rated character. Applicants are asked to judge their own reflection ability, which presupposes already a certain degree of self-reflection and self-observation. Although there is research demonstrating that it is a hard task to self-assess ones performance adequately (Norman, 1999; Kruger & Dunning 1999;), self judgments on personal characteristics do not automatically appear less accurate than peer judgments (Hofstee et al. 1998). Although the content validity of the GRAS is satisfactory, further research can explore the external validity by comparing the GRAS with familiar reflection scales and with reflective criterion behaviour. Further research about the varied forms and functions of reflection in medicine is needed. In the development of the GRAS we had a restricted focus on personal

Chapter 3. The GRAS

reflection, conceptualized as one dimension. The GRAS can be used in combination with other measures, in a multi-method application, in order to capture the richness of reflection in medicine, both for practical and theoretical purposes. In further research the possible extension of the scale in a three factor model can be explored. We agree with Falissard (1999) that a priori unidimensionality is not true because, in our case, the reality of reflection in medicine does not correspond to any rigorous mathematical model. Reflection in medicine is a multidimensional construct that reflects the complexity of cognitive-emotional and meta-cognitive processes in medicine. Conclusion The GRAS is a practical measurement instrument that yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at individual and group level. The GRAS is a one-dimensional scale with three relevant aspects of that dimension: Self-reflection, empathetic reflection and reflective communication. The 23 items on a 5-point Likert scale are easy to complete, resulting in a one-GRAS score. Scores can be calculated without time-consuming coding procedures. References

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American Educational Research Association, American Psychological Association, National Council on Measurement in Education. (1999) The Standards for Educational and Psychological Testing [Rev. ed.] (Washington, DC, American Educational Research Association).

Arnold L. 2002. Assessing professional behaviour: Yesterday, today and tomorrow. Acad Med 77:502–515.

Boud D, Walker D. 1993. Barriers to reflection on experience, in: D Boud, R Cohen & D Walker (Eds), Using Experience for Learning, (Bristol, Open University Press).

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the 9th Conference of the European Association for Personality Psychology, Guilford, 7-11 July. Irvine D. 1999. The performance of doctors: The new professionalism. Lancet 353:1174–1177. Kember D, Leung DYP. 2000. Development of a questionnaire to measure the level of reflective thinking.

Assessment and Evaluation of Higher Education 25:381–389. King PM, Kitchener KS. 1994. Developing Reflective Judgment:Understanding and Promoting

Intellectual Growth and Critical Thinking in Adolescents and Adults (San Francisco, Jossey-Bass). Kohlberg L. 1984. The Psychology of Moral Development: The Nature and Validation of Moral Stages

(San Francisco, Harper & Row). Kruger J, Dunning D. 1999. Unskilled and unaware of it: How difficulties in recognizing one’s own

incompetence lead to inflated self-assessments. J Pers Soc Psychol 77:1121–1134. Marton F, Hounsell D, Entwistle N (Eds). 1984. The Experience of Learning (Edinburgh, Scottish

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Chapter 3. The GRAS

Chapter 4. Validation of the Groningen Reflection Ability Scale (GRAS) The quest for certainty blocks the search for meaning. Uncertainty is the very condition to impel man to unfold his powers. – Erich Fromm Abstract Purpose: Encouraging personal reflection by medical students is important. This study examines the validity of a recently developed instrument for measuring personal reflection in medical education, the Groningen Reflection Ability Scale (GRAS). Method: In two studies, medical students completed the GRAS and related validated scales: 4 Korthagen reflection scales, the Need For Cognition (NFC) scale, the Open-Mindedness scale, and the Personal Need For Structure (PNFS) scale. The correlations between the scales were analysed. Results: Study 1 showed significant decreasing correlations with the Korthagen scales, ranging from .67 with the most reflective scale to .32 with the least reflective scale; the GRAS Self-Reflection items explained most of the variance. Study 2 showed significant positive correlations with the NFC scale (.56) and the Open-Mindedness scale(.56), and a low negative correlation with the PNFS scale (-.14) (both studies p < .01, 2-tailed, all correlations with attenuation correction). Conclusions: The study supports the claim that the GRAS is a measure that contributes to valid inferences about the personal reflection ability of medical students. Introduction Today, best medical practice is seen as ‘reflective practice’ and a good doctor as a ‘reflective practitioner’ (Epstein 1999; CanMEDS 2005; Coulehan 2005). Therefore, reflection is considered as a key issue in medical education (ABIM, ACP-ASIM & EFIM 2002). An empirical study by Mamede and Schmidt on the nature of reflective practice in medicine revealed five factors of reflection. The first three factors (deliberate induction, deliberate deduction, and testing and synthesizing) resemble the more cognitive, logical dimension of medical expertise,

such as clinical reasoning and scientific reflection. The last two factors are openness for reflection and meta-reasoning, which they describe as the more affective, attitudinal and meta-level dimension of reflection (Mamede and Schmidt 2004). This article focuses on this last dimension of reflection, which we call personal reflection. The Groningen Reflection Ability Scale (GRAS) was developed to measure the personal reflection ability of medical students and doctors (Aukes et al. 2007). The aim of this validity study is to investigate to what extent the GRAS covers the construct of personal reflection in medicine. This was done by matching the GRAS with several related previously validated scales, taken at the same time. The ultimate purpose, obviously, is to ensure that the inferences based on GRAS scores are correct, suitable, interpretable and practically useful. Among the problems in fostering and assessing reflection in medical education (Coulehan 2005; Arnold 2002), there are two co-dependent obstacles in particular that are relevant when examining the validity of the GRAS. These are a lack of conceptual clarity (Atkins & Murphy 1993; Procee 2006) and a lack of instruments to measure reflection (Kember & Leung 2000; Arnold 2002). These are serious problems because what is not conceptualized well cannot be measured adequately (Shumway & Harden 2003). A third obstacle is the fact that the systematic development of measurement scales is difficult and time-consuming. The available instruments for measuring reflection are mainly focused on critical thinking regarding well-defined problems (King & Kitchener 1994). However, critical thinking is not identical to reflection (Polanyi 1974; Mezirow 1998; Mamede & Schmidt 2004). Quite a lot of problems arising in patient care, inter-collegial cooperation and lifelong personal and professional learning are multifaceted and complex. For example, if a doctor, despite feedback from colleagues, does not recognize the influence of the multicultural background of the patient on his/her process of diagnosing, therapy and communication. These problems require not just cognitive modes of critical reflection, but also supplementary affective personal modes of reflection in order to improve the quality of medical care and the medical profession (Epstein 1999; Coulehan 2005). In the literature, there is informal consensus that one of the main functions of reflection is the acquisition of knowledge and understanding by using one’s own experience as a supplementary source to theory and handbooks, and that therefore reflection is interconnected with the

subjective and affective dimension of the person of the professional (Schön 1983; Atkins & Murphy 1993; Mamede & Schmidt 2004; Procee 2006). In line with these findings, we define personal reflection as ‘the careful exploration and appraisal of experience, thus clarifying and creating meaning, for the benefit of balanced functioning, learning and development’ (Aukes et al. 2007). Hypotheses The test construction of the GRAS was grounded firmly in the theoretical domain, based on literature research, systematic construction of theoretical items, appraisal of items by experts and explorative study of the structure (Aukes et al. 2007). Therefore, on theoretical grounds, the construct validity was satisfactory (Cronbach & Meehl 1955; Cronbach 1971). Nonetheless, the question to what extent the GRAS covers the different aspects of this important construct of personal reflection in medicine remained. Thus, the validity of the GRAS was tested by examining the correlations of the GRAS with previously validated scales expected to measure related aspects of the same construct (Cronbach & Meehl 1955; APA et al. 1954; AERA, APA & NCMI 1999). Two studies were performed, with hypotheses about the empirical relationships between the GRAS and the related scales, built on the following expectations. Study 1 In the first study, the correlations between the GRAS and the 4 Korthagen reflection scales (1993) were analysed. Korthagen’s vision of reflection resembles Donald Schön’s (1987) idea of ‘reflection-on-action’. His vision approaches our definition of personal reflection-on-experience. We prefer ‘experience’ because this term emphasizes the more affective focus on the personal thoughts, feelings and values related to ‘action’ rather than the cognitive focus on testing the degree of evidence of one’s clinical reasoning (Epstein 1999). In his scale construction, Korthagen (1993) distinguishes two learning orientations on which students differ in the degree to which their learning relies on reflection: an Internal Orientation and an External Orientation. Students with an Internal Orientation predominantly use personal thoughts and experience as a source. An External Orientation is based on support and guidance from outside and predominantly using the knowledge, experience or authority of others as a source. Korthagen (1993) applies each of these orientations to the domains of ‘learning’ and ‘communication & cooperation’, resulting in 4 reflection scales:

- the Self-Internal orientation on learning (SI) (‘I reflect on myself’)

- the Self-External orientation on learning (SE) (‘I like it when others comment on my conduct’)

- the Fellow-students Internal orientation on communication and cooperation (FI) (‘I am interested in my fellow students’)

- the Fellow-students External orientation on communication and cooperation (FE) (‘I consider it important to receive information from a supervisor about my way of dealing with my fellow students’).

Because medical students, as young professionals, are expected to learn how to act and think autonomously, personal reflection is primarily associated with SI rather than with SE, and primarily with a commitment to personal thinking and learning rather than with communication and cooperation with fellows. In our opinion, however, most of the items in the Korthagen scales, even the reflective FI items, are more focused on communication than on reflection – except the SI items on learning. Hence, we expected the SI scale to represent the GRAS concept of personal reflection most, followed in decreasing order by the SE, FI and the FE scales. This expectation was articulated in hypothesis 1: The correlation levels of the GRAS with Korthagen will decrease from SI on learning to FE on communication and cooperation. Study 2 In the second study, the correlations of the GRAS with three related cognitive-emotional scales were analysed: the Need For Cognition (NFC) scale (Petty & Jarvis 1996) (‘I prefer to be responsible for situations which need much thinking’), the Personal Need For Structure (PNFS) scale (Neuberg et al. 1997) (‘I don’t like situations that are uncertain’), and the Open-Mindedness scale (Webster & Kruglanski 1994) (‘I always see so many possible solutions to problems I face’). Personal reflection on experience has an encompassing focus on subjective thoughts, feelings and values. It is associated with attention for and active structuring of experience, which are characteristics of a deep approach to functioning and learning (Vermunt 1992; Mezirow 1998; Entwistle & McCune 2004). Personal reflection requires an open attitude towards reflection on experience and a tolerance of uncertainty and ambiguity (Mamede & Schmidt 2004). Therefore, the NFC and Open-Mindedness scales are expected to measure valid attitudinal aspects of personal reflection, leading to hypothesis 2: The GRAS is positively correlated with the NFC and Open-Mindedness scales. The expected relationship between the GRAS and the Personal Need For Structure (PNFS) scale is more complex. Professional functioning of

doctors is generally speaking based on two sources: explicit and implicit (tacit) knowledge and structuring of experience (Polanyi 1974). On the one hand, when doctors are testing the degree of evidence of their clinical judgements, through critical scientific reflection, they are mainly focused on the appraisal of their own explicit expert information processing and literature. This requires a logical meta-cognitive ability, in combination with pragmatic clinical structuring and decisiveness. This combination possibly correlates positively with their personal need for structure, order and decisiveness. On the other hand, when doctors use personal reflection in order to learn from their experience, they are mainly focused on tacit knowledge and sense-making, mostly concerning ill-defined problems. Thus, the mode of personal reflection requires an open mind for structuring tacit knowledge and experience. However, an overall strong need for structure and preference for order and decisiveness (Webster & Kruglanski 1994) may be seen as a potential block to reflection because it obstructs the necessary tolerance towards uncertainty, openness towards reflection and meta-reasoning (Mamede & Schmidt 2004). Consequently, hypothesis 3 was formulated as: The GRAS is neutral or negatively correlated with the PNFS scale. Method Participants and procedure In study 1, 285 first-year medical students completed the GRAS and the 4 Korthagen scales. The whole cohort of 350 students was invited, in a letter from the programme coordinator, to complete the scales as part of the programme evaluation of a new curriculum. In study 2 a sample of 583 medical students (first through to sixth year) completed the GRAS and the three social-psychological scales discussed in the introduction. The first to fourth-year students were invited to complete the scales at the end of their mandatory progress knowledge test; the fifth and sixth-year students were invited by email during their clerkships. Instruments The GRAS uses a 5-point Likert scale containing 23 items, with a satisfactory Cronbach’s alpha, which reliably and feasibly measures the personal reflection ability of medical students (Aukes et al. 2007). The GRAS was developed as a one-dimensional scale, resulting in one GRAS personal reflection score. Principle component analysis showed three groups of items or factors, indicating three aspects of that one dimension. These factors cannot be interpreted as three subscales, but should be seen as preliminary gradations of the construct of personal reflection. Consequently, they cannot be used as separate scores for assessing and

ranking individuals, but they can be used for scientific validity studies. The three factors are ‘Self-Reflection’ (10 items), which assesses the exploration of own experience, thoughts and feelings, ‘Empathetic Reflection’ (6 items), aimed at understanding the experiences of others, and ‘Reflective Communication’ (7 items), measuring openness and responsiveness to feedback. See Table 1 for some representative items. In study 1 the students completed the GRAS and the 4 Korthagen reflection scales (5-point Likert scales, short version), namely (1) the Self-Internal (SI) scale (11 items), representing the internal orientation on learning, (2) the Self-External (SE) scale (10 items), representing the external orientation on learning, (3) the Fellow-students Internal (FI) scale (10 items), representing the Table 1. Three representative items from each of the GRAS factors (translated from Dutch) Self-Reflection (10 items) I take a close look at my own habits of thinking I am aware of the emotions that influence my thinking

I want to know why I do what I do Empathetic Reflection (6 items) I am aware of the possible emotional impact of information on others I can empathize with someone else’s situation

I reject different ways of thinking (reversed item) Reflective Communication (7 items) I take responsibility for what I say I am open to discussion about my opinions I sometimes find myself having difficulty in illustrating an ethical standpoint (reversed item) internal orientation on communication and cooperation, and (4) the Fellow-students External (FE) scale (10 items), representing the external orientation on communication and cooperation (Korthagen 1993). In study 2 the students completed the GRAS and three social-psychological scales. The first of these, the Need For Cognition scale (NFC) (Petty & Jarvis 1996), measures the personal need for deeper thinking and interest in exploring multifaceted problems. Its short version (15 items) was used. Second, the Close-Mindedness scale (CM), a

subscale of the Need for Closure scale (Webster & Kruglanski 1994), measures intolerance of experience, uncertainty and diversity. Its short version (8 items) was used and scores were computed using its reversed version, measuring Open-Mindedness. Third is the Personal Need For Structure (PNFS) scale (Neuberg et al. 1997). The PNFS measures the need for structured tasks, instructions and situations; its short version (11 items) was used. The Dutch translations of all these scales were used (Pieters et al. 1987). Analyses In study 1 the Pearson’s correlations with attenuation correction were computed between the GRAS and the Korthagen scales. The differences between the correlation levels were tested with a t-test for the differences between dependent correlations. The contribution of the GRAS item groups to the variance with the Korthagen scales was explored using correlation analysis. In study 2 the correlations (Pearson’s r) were computed between the GRAS item groups and the three social-psychological scales (NFC, CM, PNFS). Results Study 1: the relationship GRAS ~ Korthagen The first study obtained responses from 285 first-year students (62%). Table 2 shows the correlations between the GRAS and the successive Korthagen scales. All the correlations are significant at p < .01, 2-tailed, except the two correlations between FE and Empathetic Reflection ( .19, p < .05 2-tailed) and Reflective Communication ( .15 n.s.). The highest correlation of GRAS with Korthagen is with the most reflective SI scale (.67), and the lowest correlation of GRAS is with the least reflective FE scale (.32). T-tests of the differences between the GRAS correlations show that most of the differences are significant, except those between SI (.67) and SE (.62), and between SE (.62) and FI (.56). Additional explorative study of the contribution of the GRAS item groups shows the following correlations. The maximum correlations are between GRAS Self-Reflection and the most reflective Korthagen SI scale (.75), and between GRAS Reflective Communication and the next reflective SE scale (.65). This suggests that GRAS Self-Reflection is associated mostly with an internal orientation on learning and functioning. GRAS Reflective Communication is associated mostly with an external orientation on learning and functioning. The exploration of the contributions of the GRAS item groups to the variance with the Korthagen scales resulted in the following contributions: Self-Reflection

56%, Reflective Communication 42% and Empathetic Reflection 27%. This means that the GRAS Self-Reflection items explain most of the variance in the Korthagen scales. In short, the results in Table 2 imply that the first hypothesis is supported. Table 2. Correlations between the GRAS and Korthagen reflection scales, with attenuation correction

KORTHAGEN scales

GRAS 23 items

Self-Reflection 10 items

Empathetic Reflection 6 items

Reflective Communication 7 items

1. Self-Internal (SI) 11 items

.67**

.75**

.47**

.32**

2. Self-External (SE) 10 items

.62**

.53**

.34**

.65**

3. Fellow-students Internal (FI) 10 items

.56**

.56**

.52**

.32**

4. Fellow-students External (FE) 10 items

.32**

.38**

.19*

.15

** p < .01 (2-tailed) * p < .05 (2-tailed) All the differences between the correlation levels of the GRAS (23 items) are significant, except between .67 and .62, and between .62 and .56. The negative items of the GRAS are reversed. Study 2: the relationship GRAS ~ NFC, Close-Mindedness and PNFS scales The second study obtained responses from 583 first to sixth-year medical students (31%). As Table 3 shows, this study resulted in positive correlations between the GRAS and the NFC scale (.56) and the Open-Mindedness scale (.56), and a low negative correlation with the PNFS scale (-.14) (all p < .01, 2-tailed with attenuation correction). Explorative study of the relationships with the item groups shows the highest correlations between GRAS Self-Reflection and the NFC scale(.54) and the Open-Mindedness scale(.50), and a low negative correlation between GRAS Reflective Communication and the PNFS scale (-.25) (all p <. 01, 2-tailed with attenuation correction). This means that GRAS Self-Reflection is associated predominantly with the NFC and Open-Mindedness scales, and that GRAS Reflective Communication is negatively related to the PNFS scale to a small degree. In short, the

results in Table 3 imply that the second and third hypotheses are confirmed. Discussion The aim of this study was to test to what extent the GRAS covers the construct of personal reflection in medicine, by analysing the correlations of the GRAS with several related and validated scales concerning reflection. All the hypotheses could be confirmed.

Table 3. Correlations between the GRAS and the three familiar reflection scales

GRAS 23 items

Self-Reflection 10 items

Empathetic Reflection 6 items

Reflective Communication 7 items

Need For Cognition (NFC) 15 items

.56**

.54**

.38**

.49**

Open-Mindedness (reversed Close-Mindedness) 8 items

.56**

.50**

.38**

.47**

Personal Need For Structure (PNFS) 11 items

-.14**

-.03

-.09*

-.25**

** p < .01 (2-tailed) * p < .05 (2-tailed) The first hypothesis – a decreasing relationship between the GRAS and 4 Korthagen reflection scales – has been confirmed. This relationship was expected because personal reflection was associated primarily with self-reflection concerning own thoughts, feelings, and experience. GRAS Self-Reflection turns out to be associated mostly with SI (.75) and explains most of the variance (56%). GRAS Reflective Communication is associated to a lesser extent with SE (.65) and explains 42% of the variance. These results indicate that the GRAS and the Korthagen scales to a certain extent measure related aspects of reflection. However, the correlations are not high enough to conclude that an identical construct is measured. In our opinion this difference is a result of a differentiation in conceptual focus. This difference can be interpreted as the GRAS covering more the concept of self-reflection, and the Korthagen scales more the concept of communication. In exploring this difference, the results show that the highest correlation between the GRAS and Korthagen is found between Empathetic Reflection and FI (.52). This correlation is, however, lower than the highest correlations of the GRAS with Korthagen, namely GRAS Self-Reflection .75 and GRAS Reflective

Communication .65. This indicates that the difference between the GRAS and Korthagen is based mainly on the GRAS items of Empathetic Reflection. We may therefore conclude that the GRAS covers the empathetic aspect of personal reflection more than Korthagen. The second hypothesis – a positive correlation between GRAS and the Need For Cognition (NFC) and Open-Mindedness scales – has been confirmed (.56 and .56). This relationship is based primarily on the GRAS Self-Reflection items. This indicates that personal reflection, as measured by the GRAS, is associated positively with a need for complex thinking and an open-minded attitude. The third hypothesis – neutral or a negative correlation between the GRAS and the Personal Need For Structure (PNFS) scale – has been confirmed (-.14). To a small degree GRAS Reflective Communication is related negatively (-.25) to a need for personal structure. This indicates that personal reflection is to a small extent associated positively with a tolerance for lack of structure and uncertainty. Both studies contribute to the validity of the GRAS as an instrument for measuring personal reflection. The GRAS score is associated with an internal orientation on personal learning and functioning, open-mindedness, a need for complex thinking, and to a small degree with a tolerance for lack of structure and certainty. A possible limitation of this study may be the non-response rate of 38% in the first study and 69% in the second. An explanation of the latter is the fact that the students’ participation in the second study was probably experienced as more voluntary than the first. In the second study, filling in the scales was the last voluntary task of a compulsory and important progress test, and the fifth and sixth-year students busy with their clerkships were more difficult to stimulate by email. It is difficult to interpret what this means with regard to a possible bias in this study. The size of both studies in these quite homogeneous groups was large enough to evaluate the concurrent validity. Conflicting interpretations are possible – the extra task to complete the scales (about 15 minutes) could have been done by only the most intrinsically motivated and thus reflective students (Sobral 2001), or by the students with the highest need for authority, thus externally less reflective, orientated students (Korthagen 1993), or by the high achievers and probably more reflective students (Sobral 2001) who finished their progress test more quickly.

Further empirical research is needed in this domain of reflection in medicine. Reflection is undoubtedly a multidimensional construct that reflects the complexity of cognitive-emotional and meta-cognitive processes. The GRAS, focusing on personal reflection on experience, is a one-dimensional scale with three aspects – self-reflection, empathetic reflection and reflective communication. The relationship with other modes of reflection in medicine must be explored, such as the related dimension of mindful attention awareness (Brown & Ryan 2003). The question to which degree personal reflection is a stable trait or a changeable state, and its implications for fostering and measuring reflection, is part of a theoretical debate and further research (Rees 2005). In the vision of Hilton and Slotnick (2005), reflection and reflective professionalism is more a state than a trait. The cognitive logical dimension of reflection (Mamede & Schmidt 2004) is usually taken as trainable dimension, although intelligence is also seen as an aspect of personality (Furnham & Heaven 1999). The more affective, attitudinal and personal dimension of reflection (Mamede & Schmidt 2004) is more internally oriented, and probably more closely linked to the doctor’s personality (Atkins & Murphy 1993; Epstein 1999). The personal traits of the doctor and the environment play an influential role in shaping the reflection ability and reflective behaviour. Furthermore, the question is how stable traits in fact are – as well as the question whether stability is rather an artefact of the chosen personality model or practice model. Modern variants of the Five Factor personality theory take the interaction between person and environment more into account, and the way in which this interaction is shaped by the actor as characteristic for personality (De Raad & Doddema-Winsemius 2006). Taking reflective professionalism as a state, our hypothesis in further research is that the personal reflection ability, which can be practised and developed over time, is a significant cognitive-emotional moderator variable between reflection as a personal trait and reflective behaviour. The GRAS is a self-rating test of reflection ability, more than an external assessment of reflective performance such as assessment by medical teachers or peers. Further research is needed to test a possible self-rating effect, for example by using the GRAS in a 360-degree assessment setting. Further research is also needed to test the predictive validity of the GRAS on the criterion of reflective behaviour in actual practice. Conclusion

This validation study contributes to the required conceptual clarification of the construct of personal reflection in medicine. The study supports the claim that the GRAS is a measure that yields reliable data that contribute to valid inferences about the personal reflection ability of medical students. References ABIM (American Board of Internal Medicine), ACP-ASIM (American College of Physicians-

American Society of Internal Medicine) & EFIM (the European Federation of Internal Medicine) (2002). Medical professionalism in the new millennium: A physician’s charter. Annals of Internal Medicine, 136, 243−246.

American Educational Research Association, American Psychological Association, National Council on Measurement in Education. 1999. The Standards for Educational and Psychological Testing, [Rev. ed.] (Washington, DC, American Educational Research Association).

American Psychological Association, American Educational Research Association, National Council on Measurements Used in Education, Joint Committee on Test Standards.1954. Technical recommendations for psychological tests and diagnostic techniques. Psychol Bull (Suppl.) 51:1−38.

Arnold L. 2002. Assessing professional behaviour: yesterday, today and tomorrow. Acad Med 77: 502−515.

Atkins S, Murphy K. 1993. Reflection: a review of the literature. J Adv Nurs 18: 1188−1192. Aukes LC, Geertsma J, Cohen-Schotanus J, Zwierstra RP, Slaets JPJ. 2007. The development

of a scale to measure personal reflection in medical practice and education. Med Teach 29:177−182.

Brown KW, Ryan RM. 2003. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol 84:822−848.

CanMEDS 2000 Project. 2005. Skills for the New Millennium: Report of the Societal Needs Working Group, [improved version] (Ottawa, Royal College of Physicians and Surgeons of Canada).

Coulehan J. 2005. Viewpoint: today’s professionalism: engaging the mind but not the heart. Acad Med 80:892−898.

Cronbach LJ, Meehl PE. 1955. Construct validity in psychological tests. Psychol Bull 52:281−302.

Cronbach LJ. 1971. Test validation, in: RL Thorndike (Ed.), Educational Measurement, 2nd edn (Washington, DC, American Council on Education).

De Raad B, Doddema-Winsemius M. 2006. De Big 5 Persoonlijkheidsfactoren: een Methode voor het Beschrijven van Persoonlijkheidseigenschappen, [in Dutch] (Amsterdam, Uitgeverij Nieuwezijds).

Entwistle N, McCune V. 2004. The conceptual bases of study strategy inventories. Educ Psychol Rev 16:325−345.

Epstein RM. (1999) Mindful practice. JAMA 282:833−839. Furnham A, Heaven P. 1999. Personality and Social Behaviour (London, Arnold). Hilton SR, Slotnick HB. 2005. Proto-professionalism: how professionalisation occurs across

the continuum of medical education. Med Educ 39:58-65. Kember D, Leung DYP, Jones A, Loke AY, McKay J., Sinclair K, Tse H, et al. 2000.

Development of a questionnaire to measure the level of reflective thinking. Assess Eval Higher Educ 25:381−395.

King PM, Kitchener KS. 1994. Developing Reflective Judgment: Understanding and Promoting Intellectual Growth and Critical Thinking in Adolescents and Adults (San Francisco, Jossey-Bass).

Korthagen F. 1993. Measuring the reflective attitude of prospective mathematics teachers in the Netherlands. Eur J Teach Educ 16:225−236.

Mamede S, Schmidt HG. 2004. The structure of reflective practice in medicine. Med Educ 38:1302−1308.

Mezirow J. 1998. On critical reflection. Adult Educ Quart 48:185−198. Neuberg SL, Judice TN, West SG. 1997. What the Need for Closure scale measures and what

it does not: toward differentiating among related epistemic motives. J Pers Soc Psychol 72:1396−1412. Dutch version of the Need for Closure scale: CRATYLUS (1995) Een Nederlandse Need for Closure vragenlijst. Ned Tijdschr Psychol 50:231−232.

Petty RE, Jarvis WBG. 1996. An individual differences perspective on assessing cognitive processes, in: N Schwarz, S Sudman (Eds), Answering Questions: Methodology for Determining Cognitive and Communicative Processes in Survey Research (San Francisco, Jossey-Bass).

Pieters RGM, Verplanken B, Modde JM. 1987. Neiging tot nadenken: samenhang met beredeneerd gedrag (Need for cognition: association with deliberative action), [in Dutch]. Ned Tijdschr Psychol 42:62−70.

Polanyi M. 1974. Personal Knowledge: Towards a Post-critical Philosophy (Chicago, University of Chicago Press).

Procee H. 2006. Reflection in education: a Kantian epistemology. Educ Theory 56:237−253. Rees C. 2005. Proto-professionalism and the three questions about development. Med Educ

39:7−11. Schön DA. 1983. The Reflective Practitioner (London, Temple Smith). Schön DA. 1987. Educating the Reflective Practitioner: Towards a New Design for Teaching

and Learning in the Profession (San Francisco, Jossey-Bass). Shumway JM, Harden RM. 2003. AMEE GUIDE No 25: The assessment of learning

outcomes for the competent and reflective physician. Med Teach 25:569−584. Sobral D. 2001. Medical students’ reflection in learning in relation to approaches to study and

academic achievement. Med Teach 23:508−513. Vermunt JDHM. 1992. Leerstijlen en het Sturen van Leerprocessen in het Hoger Onderwijs:

Naar Procesgerichte Instructie in Zelfstandig Denken (Learning styles and regulation of learning processes in higher education: towards process directed instruction in independent thinking), [Dissertation in Dutch] (Amsterdam/Lisse, Swets & Zeitlinger).

Webster DM, Kruglanski AW. 1994. Individual differences in need for cognitive closure. J Pers Soc Psychol 67:1049−1062

Chapter 5. Experiential learning and personal reflection

Chapter 5. The effect of enhanced experiential learning on the personal reflection of undergraduate medical students Experience is the name everyone gives to their mistakes. – Oscar Wilde Abstract Objective: This study’s aim was to test the expectation that enhanced experiential learning is an effective educational method that encourages personal reflection in medical students. Methods: Using a pre-post-test follow-up design the level of the personal reflection ability of an exposure group of first-year medical students participating in a new enhanced experiential learning programme was compared to that of a control group of second and third-year medical students participating in a standard problem-based learning programme. Personal reflection was assessed using the Groningen Reflection Ability Scale (GRAS). The growth in reflection by the students was analysed with multilevel analysis. Results: After one year, first-year medical students in the exposure group achieved a level of personal reflection comparable to that reached by students of the control group in their third year. This difference in growth of reflection was significant (p < .001), with a small to average effect size (ES = .18). The reflection growth curve of the control group declined slightly in the third year as a function of study time. Conclusion: Enhanced experiential learning has a positive effect on the personal reflection ability of undergraduate medical students. Introduction Increasingly, the focus of medical and other health professional training is moving from technical expertise to clinical competence, where clinical competence is becoming embedded in professional and personal competences in which reflection plays a central role.1-3 This refocus on competence and reflective professionalism requires proper methods and strategies for training and assessment.4-5. Experiential learning is a well-known educational method for fostering reflection with a long tradition.6-7 Learning from experience requires reflection, but reflection on experience does not necessarily occur. Therefore, merely offering experience is insufficient.8-9 Offering authentic experience 10 and the use of portfolios are noted as being effective methods for enhancing reflection on experience and assessing


reflective competence.11,12 This study was designed to test the expectation that an enhanced experiential learning programme stimulates the development of a personal reflection ability. Personal reflection in medicine and other health professions is mainly internally oriented to experience and attendance to personal physical and cognitive-emotional processes, such as irrational thoughts and feelings and the use of tacit knowledge.13-

15 Personal reflection is expected to enable health professionals to adapt to the patients’ needs and new circumstances, and to help them cope with their own lives as health professionals.15,16 Personal reflection can be defined as the careful exploration and appraisal of experience, thus clarifying and creating meaning for the benefit of balanced functioning, learning and development.14 Unfortunately, personal reflection cannot simply be taught face to face from teacher to student, although it can be acquired through practice in a motivating setting.15,17 Various conditions are noted in the literature as being significant in the development of personal reflection as an essential of the medical competence.8,18,19 Many of these conditions go beyond the opportunities available to the health sciences curricula. Nevertheless, when undergraduate students participate in relevant clinical settings during short periods, they have an opportunity early in their studies to experience what it is to be a health professional. Experiential learning is a frequently applied educational method for stimulating the growth of students’ reflective abilities and the attitude required to become reflective practitioners.20,18 In addition, positive effects of encouragement and the assessment of reflective performance are reported in the portfolio literature.11,12,21 Nonetheless, despite high expectations and practical efforts, acquiring reflective competence in medical training and maintaining reflective performance in practice is quite complicated.22

There is little empirical evidence on the effects of experiential learning on personal reflection.12,23 One reason for this might be that reflection on experience is not self-evident. Young students can be provided with opportunities for practice (learning) and experience, but they will not reflect on and learn from them automatically.23 They are not accustomed to conscious reflection and therefore have to deliberately learn to reflect on their functioning or learning.9,23 Other barriers are conceptual ambiguity,17 the dominance of traditional learning, the hospital culture and the hidden curriculum,19 as well as a lack of instruments for the proper assessment of reflective competences.19 The discrepancy between the educator’s ambitious expectations and students’ concrete levels of reflection can be disappointing.23


Moreover, when reflection is applied, it does not automatically lead to insights and deeper learning, especially when its purpose remains unclear and reflection is unsupported.25 Internally oriented personal reflection is a particularly difficult type of reflection that cannot be achieved without support.26

Consequently, supported or enhanced experiential learning is viewed as a necessary precondition for understanding the relevance of reflection and learning to use it. In the literature, the following principles for strengthening the effectiveness of experiential learning are mentioned: authentic experience,23 supported participation in practice at a level appropriate to the student’s stage of training,18 a clear portfolio structure with a thoroughly planned portfolio introduction in the early stages of training,11 and a supportive mentor system and appropriate assessment.11, 12, 21

Our longitudinal study was designed to examine the expectation that enhanced experiential learning nurtures the students’ personal reflection abilities, resulting in the hypothesis that the growth of the personal reflection ability of students in an enhanced experiential learning programme is stronger than that of students in a standard educational programme. Method Context In 2003 a new competence-based curriculum was adopted at the medical faculty of the University of Groningen. The first-year undergraduate students of this programme were the exposure group of this study. The control group consisted of second and third-year undergraduates who participated in the existing problem-based learning (PBL) programme. Although many components of the ‘old’ PBL programme were maintained in the new curriculum, a major new competence-based module introduced an enhanced experiential learning programme that focused on professional and personal development. It was organised as a continuing educational strand throughout the curriculum. Educational programme of the exposure group The aim of the enhanced experiential learning programme was to encourage reflection on and learning from experience at an undergraduate level. This was established by means of (1) experience in authentic contexts, (2) a supportive mentor system, (3) structured portfolio use, (4) formative and summative assessment, and (5) by crediting the programme with 10 ECTS credits (European Credit Points), thus stressing its importance.


(1) Experience in authentic contexts: The compulsory authentic activities were a cycle of three interviews with one patient (pairs of students visited a chronically ill patient at home); a two-week apprenticeship in which the students were participating as ‘nurse assistant’ in different clinics and nursing homes; and a half-day observation of a general practitioner at work. (2) Supportive mentor system: Groups of ten students participated in seven coaching group meetings throughout the year. These were facilitated by coaches who were general practitioners and doctors in occupational medicine, and which were interested in medical education. They were trained beforehand in two three-hour sessions (with information about the aim and structure of the program, the method of coaching, and exercises in coaching), and during the year in three three-hour peer learning sessions. The focus of the mentoring groups was derived from the goals of the educational program: the students were supported in structured exchange, discussion and reflection concerning their practice experiences, and the use of their portfolio (see the next point). (3) Structured use of portfolio: In order to direct the students towards the aspects of their authentic experiences they should reflect on, the portfolio learning was structured around Tasks, Personal Profile and Behaviour. Tasks: The tasks were linked to patient encounters in order to give students a clear message of what was expected. Personal profile: In order to stimulate personalised reflective learning the students were obliged to write a report about their extracurricular activities and the perceived relationship of these activities and their future functioning as good doctors. Professional behaviour: This portfolio part required the students to write a self-reflective paper based on written feedback from teachers and peers received during several small group learning sessions and by on-the-job supervisors during the care clerkship. (4) Assessment forms were structured around three dimensions – task performance, aspects of communication and personal performance.27 The students wrote self-reflection reports based on their feedback forms and kept records of their study progress and professional and personal growth. (5) The workload of a full-time student during one academic year is calculated to be 60 ECT credits. The workload for this professional and personal development programme was calculated to be 280 hours or 10 ECT credits. The remaining 50 ECT credits were allocated to the rest of the PBL curriculum in the first study year.


Educational programme of the control group The control group consisted of second and third-year undergraduates who participated in the standard problem-based learning (PBL) programme of which the study load comprised 60 PBL ECT credits per study year. The PBL programme included group tutorials twice a week. During the first year the control group participated in the same two-week practical care clerkship as the exposure group, however, without the coaching group meetings and the use of portfolios. To summarise, the main difference between the exposure and the control group was the new experiential learning programme that had been added to the existing PBL programme. It consisted of three interviews with patients, coaching group meetings, and the structured use of portfolios, including formative and summative assessment of professional behaviour. Instrument The personal reflection ability of the students was measured using the Groningen Reflection Ability Scale (GRAS).14 This 5-point Likert scale (1 = totally disagree, 5 = totally agree) is easy to complete. The items are grounded in the reflection literature. The GRAS is a one-dimensional scale with relevant aspects of that dimension: self-reflection (‘I take a close look at my own habits of thinking’), empathetic reflection (‘I am aware of the possible emotional impact of information on others’), reflective communication (‘I am open to discussion about my opinions’). The internal consistency lies between Cronbach's alpha’s of 0.74 and 0.83 which is a satisfactory reliability according to the standards for testing of the American Educational Research Association. The range of the total score in this study varies between 14 (very low reflection) and 70 (very high reflection). Procedure The first-year students in the exposure group were invited by their coach to complete the questionnaires at the end of a group coaching session in the first month, the ninth month and the fourteenth month of the curriculum. The second-year and third-year students in the control group were asked to complete the questionnaires immediately after sitting written examinations – the second-year students in the 21st and 28th months, and the third-year students in the 33rd and 40th months of their respective curricula. The measurement moments, given in terms of study time (months), are shown in Figure 1. Curriculum year 1 year 2 year 3 year 4


Measurements moments (months) 1 9 14 21 28 33 40 Exposure group Control group

Figure 1. Measurement moments in study time (months) There were 394 first-year students participating in the exposure group of the study (response 98%). Not every student in the exposure group completed the questionnaires at every measurement moment: 139 students completed it once, 150 twice and 105 three times. As a consequence, 254 students participated at the first, 237 at the second, and 265 at the third measurement moment. The control group consisted of 250 second-year students (response 63%) and 243 third-year students (response 60%). Not every student in the control group completed the questionnaires at every measurement moment: 400 students completed it once and

Table 1. N measurements and percentages male / female respondents at each measurement moment.

Measurement moment: 1st 2nd 3rd

Exposure group Year 1 (N 395) 252 237 265 Male 25 26 20 Female 75 74 80 Control group Year 2 (N 198) 78 172 Male 10 18 Female 90 82 Year 3 (N 205) 59 184 Male 20 19 Female 80 81

150 twice. As a consequence, of the second-year students, 78 participated at the first and 172 at the second measurement moment, and of the third-year students, 59 participated at the first and 184 at the second measurement moment (see Table 1).


Data analysis Not every student responded at every measurement moment. Consequently, the measurements were from the same year group but not always of the same students. Although the students in the exposure and the control groups differ in their years of study experience, the assumption was that they all had comparable levels of personal reflection at the start of their studies. Full data would have comprised three measurements per student in the exposure group and two measurements per student in the control group. Due to the fact that not every student responded at every measurement moment, the data (consisting of one, two or three measurements per student) called for a multilevel analysis.28 The multilevel structure consisted of the measurements (level 1) per student (level 2). The data were analysed using the multilevel computer program MLwiN (version 2.02). The data consisted of three longitudinal measurements of the exposure group and four longitudinal measurements of the control group. The fact that respondents completed the questionnaire repeatedly means that measures were statistically not independent. The data from the second and third-year students in the control group were put together as a single data set of measurements in the standard education condition. This was appropriate because we controlled for the variables that presumably influence the GRAS score, Gender and Time. Individual measurements consisted of a single GRAS score as the dependent variable. The explanatory variable is the curriculum the student followed. In order to measure the effect of the experiential learning programme on personal reflection properly, Gender and Time (study time in months) were taken as covariates. This was done because the literature suggests that Gender and experience (study Time) can influence the level of personal reflection.29 It showed that each measurement had a different gender balance and there was a gender difference between the exposure group and the control group (Table 1). As the relationship between Time and reflection ability seemed to be non-linear due to a ceiling effect, a squared-Time variable was added to the model. The significance of the effects of the independent variables was tested by analysing the increase in the model fit when an independent variable was added to the hierarchical model. Increase in model fit, which accompanies decreasing deviance, has a chi-square distribution, whereby the number of added predictors functions as the number of degrees of freedom.30 The effect size was calculated using the formula for fit and contingency.31 For this formula an effect size of .10 is considered to be small, .30 medium and .50 large. Results


On average, students show a moderate to high level of personal reflection, as their scores are > 50 within a range of 14 −70. The scores of the exposure group indicate a steady rise, whereas the scores of the control group level off somewhat during the third year (Table 2).

Table 2. GRAS score at measurement moments

Condition Months N M GRAS score SD Exposure group

1

252

50.2

4.55

9 237 53.9 4.80 14 265 55.1 4.10 Control group 21 78 52.9 5.00 28 172 55.6 4.03 33 59 56 4.91 40 184 55.9 4.13

The multilevel analysis revealed significant effects for all variables (Table 3). The curriculum a student followed explained a significant part of the variance in the GRAS scores, with an effect size of .17. This is a small to medium effect size for multilevel analysis according to Cohen (1992).31

Figure 2 shows the observed and the predicted values of the GRAS scores against study Time, plotted as the personal reflection growth curves of the exposure group and the control group. The values show that first-year students start with a lower personal reflection score (M 50.2 after 1 month) than the second-year students (M 52.6 after 21 months), as was expected as a function of study Time. However, after one year of enhanced experiential learning the first-year students show a reflection score (M 55.1 after 14 months) which is almost as high as the second-year student score after two years (55.6 after 28 months) and of the third-year students during their third year of study (56 after 33 months and 55.9 after 40 months), as is predicted by the model. The personal reflection growth curve of the third-year students in the control group levels off somewhat (from 56 to 55.9 between months 33 and 40), that is not predicted by the model. Overall, female students had a higher average reflection score (M 54.2) than male students (M 53), however, this difference is not statistical significant (p < .10). Table 3. Comparison of fitting different kinds of models with the GRAS score as the dependent variable (n = 1247 measures). Level 1 = measures, Level 2 = students


Fixed Effects Composite model Intercept Gender Time (linear change) Time² (quadratic change) Exposure

Exposure x Gender Variance Components Between person variance Within person variance (measurement variance) Goodness-of-fit Deviance statistic χ²-change

Exposure M 44.51** 1.7* .49** -.006** 4.70** -1.15 10.54** 8.80** 7050.98 335.50**

Effect SE 0.759 0.553 0.029 0.001 0.789

* p<.01; ** p<.001 Exposure: control = 0, exposure = 1; Gender: male = 0, female = 1.

Discussion The goal of this study was to examine the expectation that enhanced experiential learning is an effective method for fostering personal reflection in medical students. The study showed that the personal reflection growth of the exposure group students, who participated in an enhanced experiential learning programme, was significantly faster than the growth of the control group students, who participated in the standard PBL programme (p < .001), with a small to average effect size (ES = .18). After one year, the first-year students showed a personal reflection ability score that students in the standard educational programme acquired after three years. This means that undergraduate students who participate in enhanced experiential learning can make use of their acquired higher level of personal reflection earlier to learn effectively from their experiences in subsequent study years. By focusing explicitly on personal reflection in this study, we have obtained better insight into the appraisal of enhanced educational strategies aimed at this important aspect of medical functioning and its measurement. The study also showed that the reflection growth curve of third-year students in the control group levelled off slightly at the end of the test period. However, as an instrument the GRAS can measure higher levels of reflection.14 A possible

57

56

55

Exposure group(observed)

Exposure group e


Figure 2. Observed and predicted GRAS scores against study time of the treatment and the control group. Dependent Variable: GRAS score explanation could be that after a few years PBL does not offer enough experience to stimulate personal reflection. By adopting Gender and Time as covariates in the model, we controlled for Gender and for the rather predominance of female respondents, compared with the percentage male - female students in the population cohort, which was 30 - 70. The effect is thus not confounded by Gender and Time. This study supports the suggestions made in the literature that reflection on experience is enhanced by features such as authentic experience,23 clear portfolio structure,21 a supportive mentor system,10 and appropriate assessment.12,21,23 Consequently, this study’s practical finding is that exposing students to authentic experience, a strong supportive mentor and a group coaching system, structured


portfolio use that includes formative and summative assessment, and appropriate study point accreditation together constitute an effective educational strategy to foster personal reflection on experience. We did not investigate the influence of each condition separately. Future research should focus on whether separate conditions or their interaction influence personal reflection. A strong point of our study is the effect size of enhanced experiential learning on personal reflection. Although the resulting ES of 0.18 is considered as small to medium in multilevel analysis,31 it acquires more significance when the relatively small difference between the exposure and the control group is taken into account. The control programme was a PBL curriculum in which the students elaborated on medical knowledge and clinical reasoning about patient problems during small tutorials, and joined the same two-week learning care clerkship as the exposure group. The exposure programme combined the existing PBL elements with a new experiential learning programme. Therefore, there were more similarities between the exposure group and the student-centred control group than would have been the case had a traditional teacher-centred educational programme served as a control condition. In addition, if the exposure group and the control group were in the same study phase, a larger difference would be expected. The design also controlled for Gender and Time. In our opinion, the above-mentioned arguments support the conclusion that the effect on personal reflection was a result of the main difference between the two conditions: the enhanced experiential learning programme. A weaker point of this study might be the paradoxical aspect of an instrument to measure reflection, in this case the GRAS, because of its self-rated character. Respondents are asked to judge their own reflection ability, which presupposes already a certain degree of self-reflection and self-observation. Although there is research demonstrating that it is a hard task to self-assess ones performance adequately,32 self-judgments on personal characteristics do not automatically appear less accurate than peer-judgments.33 Another weaker point of this study might be a possible bias in the absolute GRAS scores between the respondents and non-respondents in this quasi-experiment. However, a differential bias is not expected because a selection bias with respect to history and natural development is not plausible. Firstly, we controlled for Gender and Time/study experience. Secondly, the starting level of reflection and natural development of all students is expected to have been similar because the student cohorts are consistent and comparable groups, with the highest rankings and no major curriculum changes in the last decade.34 A second possible bias effect could be that measurements are not always of the same students. However, the use of nested data following a multilevel method is an appropriate solution to this problem, although this more demanding


technique results in an underestimation of power. A full data set would increase the power. Consequently, it is unlikely that this multilevel analysis resulted in an overestimation of the effect size. Further research is needed to examine the effect of experiential learning on personal reflection both at the ability and behaviour levels (reflective functioning in clinical practice), as part of competence-based learning and practice. In this study, the dependent variable consisted of self-rated GRAS scores of the participants. In addition, 360 degree GRAS ratings could be used to complement the self-ratings. Students’ reflective behaviour in a protected educational setting, at Miller’s ‘show how’ level (Miller, 1990), could be assessed using the Rated Case Vignettes used by Boenink et al. (2005) which are based on written patient cases. Residents’ reflective behaviour in clinical practice, at the ‘does’ level,35 could be assessed using Observed Reflective Professional Behaviour in a clinical setting. The relationship between the ability for personal reflection and reflective behaviour should be investigated, as well as the effect of personal reflection on clinical performance and professional behaviour. Conclusion To conclude, enhanced experiential learning has a positive effect on the development of personal reflection. Undergraduate medical students acquired a higher level of personal reflection which, according to the modern insights of competence-based education, is required to become a professional medical doctor. References 1. ABIM (American Board of Internal Medicine), ACP-ASIM (American College of Physicians-

American Society of Internal Medicine) & EFIM (the European Federation of Internal Medicine) (2002). Medical professionalism in the new millennium: A physician’s charter. Annals of Internal Medicine, 136, 243−246.

2. CanMEDS 2000 Project (2005). Skills for the New Millennium: Report of the Societal Needs Working Group [improved version]. Ottawa: Royal College of Physicians and Surgeons of Canada.

3. General Medical Council (1999). The Doctor as Teacher. London. 4. Epstein, R.M. & Hundert, E.M. (2002). Defining and assessing professional competence. Journal of

the American Medical Association, 287, 226−235. 5. Schuwirth, L.W.T. & van der Vleuten, C.P.M. (2007). Challenges for educationalists. British Medical

Journal, 333, 544−546. 6. Dewey, J. (1933). How We Think: A Restatement of the Relation of Reflective Thinking to the

Educative Process. Boston: Heath. 7. Kolb, D.A. (1984). Experiential Learning: Experience as the Source of Learning and Development.

Englewood Cliffs, New Jersey: Prentice Hall.


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Chapter 6. A conceptual framework for personal reflection in healthcare practice and education Science arose from poetry... when times change the two can meet again on a higher level as friends. – Johann Wolfgang von Goethe Mensen worden verontrust door de opvattingen (dogmata) die zij over de dingen hebben en niet door de dingen zelf (pragmata). – Epictus, geciteerd door Laurence Sterne Abstract Personal reflection is seen as an essential and trainable professional quality in doctors and other health care practitioners and is increasingly promoted in health care education. A more precise understanding of its nature and value for optimal patient care is needed for its purposeful use in practice and for effective encouragement in education. This article offers a conceptual framework to help recognize, use and encourage personal reflection. At the meta-level of reflective practice, ‘scientific reflection’ is distinguished from ‘personal reflection’, while at the operational level, ‘information processing’ and ‘determinative judgment’ are distinguished from ‘sense making’ and ‘reflective judgment’. The main difference between both modes of reflection is their focus on operational processes. Scientific reflection is mainly oriented towards testing the evidence of expert information processing, thereby aiming for the augmentation of determinative clinical judgment, while personal reflection is mainly oriented towards clarifying the process of sense making, which aims to augment reflective judgment. The article also describes the properties of ‘sense making’ and ‘reflection on sense making’ and examines the implications of this analysis for a more profound definition of reflection as a competence necessary for effective educational encouragement. Introduction The appropriate use of personal reflection is increasingly seen as an essential and trainable professional quality of physicians and other health care professionals and is promoted in health care education (ABIM, ACP-ASIM & EFIM, 2002; CanMEDS, 2005). Supplementary to evidence-based propositional knowledge and technical-cognitive competences

unifying models for integrative patient care, balanced health care practice and competence-based learning all emphasize personal, tacit knowledge, experience and personal-affective competences (Polanyi, 1974; Schön, 1987; Epstein, 1999; Maudsley & Strivens, 2000; Epstein & Hundert, 2002; CanMEDS, 2005). A main challenge for educators in health care sciences, therefore, is to encourage the development of personal-affective competences such as ‘personal reflection’, as deliberately and effectively as technical-cognitive competences such as ‘scientific reflection’. In this article we aim to provide a conceptual framework that can be used to recognize, use and encourage personal reflection. Reframing clinical competence The positive revaluation of the personal-affective dimension of the medical profession is part of rethinking clinical competence. The initial belief was that clinical competence in medicine mainly focuses on diagnostic problem solving and that this is a general and rational competence (Barrows, Norman, Neufeld & Feightner, 1982). During the last decades this conviction has changed. Clinical competence is seen as highly dependent on the particular content and context (Elstein, Schulman & Sprafka, 1978), with knowledge being an essential factor in all competences (Van der Vleuten et al., 2000). The rise of evidence-based medicine (EBM), in 2001 welcomed in the New York Times Magazine as one of the most influential ideas of the year, was original proposed as a replacement for traditional medicine and a real paradigm shift (Haynes, 2002). A fundamental assumption of EBM is that practitioners with an understanding of the evidence from applied health care research will provide superior patient care compared to practitioners who rely on understanding basic mechanisms and on their own clinical experience. However, thus far, there is no convincing direct evidence proving this assumption, as stated by Haynes (2002), who provided one of the original definitions of the concept of EBM. He mentions that EBM has now evolved beyond the initial conception or misconception of its possibilities and is now attempting to augment rather than replace individual clinical experience and the understanding of basic disease mechanisms. Today, interpersonal skills and professional qualities are seen as essential for clinical experience, understanding and performance (Stern, 2005). The person and the professional cannot and must not be so rigorously separated because medical practice is basically a subjective ‘mindful practice’ (Epstein, 1999). While EBM initially became the symbol of one-dimensional, science-based medical expertise, CanMEDS is now the almost symbolic

expression of the enriched definition of clinical competence in medicine. CanMEDS stands for the Canadian Medical Education Directions for Specialists (CanMEDS, 2005), which formulates seven key roles of the medical specialist. Only the first role is directly related to the medical expert and decision-maker, and for strategic reasons it was placed in the centre of their model surrounded by the other six interconnected roles of communicator, collaborator, manager, health advocate, scholar and professional. Challenges to be met On the basis of this pluralistic view of medical competences, the understanding, use and encouragement of expert technical-cognitive competence can be more precisely organized (Schmidt, Norman & Boshuizen, 1990; Wimmers, 2006), while the central role of expert is not separated from but integrated with the other relevant roles of the doctor (CanMEDS, 2005). Reacting to criticism of EBM, Sackett, Haynes, Guatt & Tugwell (1991) explain that good doctors use both individual clinical expertise and the best available external evidence. Neither alone is enough, as without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient, while without current best evidence there is a risk that practice will become rapidly out of date (Sackett et al., 1991). It is likely that pluralism will also lead to a greater awareness, recognition, use and encouragement of individual experience, including personal-affective relationships and reflective competences. Probably this will not only occur in externally oriented relationships to patients, but also be internally oriented towards the person of the professional him/herself. However, this will not happen automatically, for several reasons. The knowledge that is essential for all competences is also pluralistic, such as objective evidence-based and personal experience-based knowledge about the illness, the patient, the context and professional/personal expertise. The skills needed to handle and integrate these different types of knowledge and the associated feelings are beyond scientific logic and technical reasoning. What are really needed are personal and interpersonal qualities such as personal reflection. However, authentic and critical self-reflection and observation by professionals is difficult and can be painful (Tigelaar, Dolmans, de Grave, Wolfhagen & van der Vleuten, 2006; Korthagen, 2001), as well as being difficult to acquire and maintain in combination with critical scientific reflection (Grabov, 1997; Taylor, 2007). This may explain why

EBM is easily misunderstood and misused in practice, and why doctors who methodically care for the well-being of their patients often do not take proper care of themselves and become prone to burnout or misconduct, a process that already begins while medical residents are undergoing their clerkship (Prins et al., 2007). The value of personal reflection It is here that the value of personal reflection and the need for a more precise understanding of its nature and function in health care practice becomes apparent. A better theoretical understanding of the concept of personal reflection is needed for its use in health care practice, for effective educational encouragement and for educational research. A move forward would be to formulate the ingredients needed for the development of personal reflection as a valid competence. Better understanding is also needed to prevent the development of unrealistic expectations and opinions by educators and students, for example, the unrealistic idea that reflection can be taught in the same way as a technical skill, or the fear that the encouragement of personal reflection will inevitably result in regression to a pre-scientific era of medicine. Empirical background In the domain of ‘reflective practice’ in medicine, empirical research by Mamede and Schmidt (2004) has resulted in a five-factor model. The first three factors – deliberate induction, deliberate deduction, testing and synthesizing – form the more cognitive-logical orientation. This orientation is apparent in the solid combination of clinical reasoning and scientific evidence that doctors are expected to use in every aspect of their professional conduct. This is accepted as ‘evidence-based’ practice and given the most attention in professional training (Downie, Macnaughton & Randon, 2000). The mode of ‘scientific reflection’ that we will describe further below is associated with this cognitive-logical orientation. The second orientation which Mamede and Schmidt (2004) describe as the more affective, attitudinal and meta-level dimension of reflection, consists of two factors: openness to reflection and meta-reasoning. This orientation is associated with what we call ‘personal reflection’. In the domain of patient care, there is empirical support to suggest that mindful-based intervention programmes, provided by health care professionals who are themselves educated in and demonstrate a reflective and mindful ‘presence’ are effective for somatic and psychosomatic categories of patients (Kabat-Zinn, 2005a; Segal, Williams & Teasdale, 2002). There are good reasons to suggest that

health care professionals need to pay attention to the interactions of their own mind, body and behaviour as part of their professional responsibility for personal self-care, both for their own well-being and for balanced conduct (Epstein, 1999; Brown & Ryan, 2003). Educational research has shown that focusing on separate constructs such as knowledge, skills, problem solving, attitude or unstructured practice learning is inadequate (Schmidt et al., 1990; Schuwirth & van der Vleuten, 2007). Competence-based education is an example of an integrative perspective on learning and functioning in which personal qualities are conceptualized as inbuilt elements of the definition of professional competence. In particular, reflection plays an integrating role in the accomplishment of meaningful integrated wholes, including knowledge, skills, attitudes and behaviour (CanMEDS, 2005; Epstein, 1999). These empirical findings again make it clear that ‘good practice’ in health care requires the appropriate use of personal reflection, and that the education of balanced professionals requires the effective encouragement of personal reflection. An analytical model In order to obtain a model for clarifying the characteristics of personal reflection in more detail, we will differentiate on the operational level of reflective practice between information processing and sense making, and on the meta-level between scientific reflection and personal reflection (see Figure 1).

Figure 1. Scientific reflection and personal reflection in relation to information processing and sense making

Meta-level:

Scientific reflection

Personal reflection

Operational level: Information processing Sense making

On the basis of these distinctions, the main difference between scientific reflection and personal reflection can then be explained in terms of their focus on these operational processes (information processing and sense making). We will define ‘scientific reflection’ as being mainly focused on the critical, evidence-based appraisal of clinical ‘information processing’, and ‘personal reflection’ as being mainly focused on clarifying the

process of ‘sense making’. We will argue that this difference in focus influences the aim, process and methods of both modes of reflection, the requirements and difficulties involved in integrating them into practice, as well as the educational methods and strategies for teaching and encouragement. Scientific reflection and personal reflection Scientific reflection is the critical appraisal of literature and personal practice, grounded in epidemiology and literature, with the aim of optimizing the degree of evidence-based clinical judgments (Sackett et al., 1991). The mode of scientific reflection is a component of the critical rationality orientation underpinning EBM. According to Guba & Lincoln (1994), this means: the use of applied research; the use of experimentation rather than observation only, because observations of complex phenomena can be biased; the use of probabilities to judge truth rather than expecting certainty; and the use of deductive logic to progress, rather than the inductive logic that was characteristic of the basic science underpinning traditional medicine. Personal reflection is the exploration and appraisal of experience, thus clarifying and creating meaning for the benefit of balanced functioning, learning and development (Aukes, et al., 2007). The mode of personal reflection is a component of integrative practice epistemology in which the existence and value of the professional’s experience and tacit knowledge of ‘good practice’ is acknowledged (Schön, 1983). Our definition of personal reflection is in line with the view that reflection is a meta-activity that usually consists of three phases: awareness of thoughts and feelings during professional conduct, the exploration and analysis of these experiences, and consequently the possibility of new perspectives and behaviour (Atkins & Murphy, 1993). Philosophical background There are many theories of reflection and reflective practice (Dewey, 1933; Schön, 1987; Kolb, 1984; Habermas, 1984-1987; Mezirow, 1995; King & Kitchener, 1994; Epstein, 1999), with different focuses of attention, processes and aims. This rich assortment can be structured by distinguishing two main orientations, ‘reflectivity’ and ‘reflection’ (Gur-Ze’ev, Masschelein & Blake, 2001; Procee 2006). The purposeful use of personal reflection by health care practitioners in the micro setting of their practice is mainly in line with an orientation toward ‘reflectivity’. This pragmatic orientation emphasizes the use of concrete ‘here and now’ experience, personal knowledge and feedback for functioning, learning and changing practice on a micro-level, rather than formal knowledge and

structural theories about action, learning and organization. This ‘reflectivity’ orientation is applied in a multiplicity of ways in the domain of professional functioning, learning and organization in health care, with well-known concepts such as Schön’s ‘reflection-in-action’ and ‘reflection-on-action’, Kolb’s experiential learning cycle, and Argyris’s analysis of ‘defensive patterns to change’ in organizations. These authors come from the fields of pragmatic philosophy, social psychology and phenomenology and build further on the work of theorists such as Dewey (1933), Schutz (1967), Lewin (1951) and Polanyi (1974). The second orientation, towards ‘reflection’, comes from critical social theory, characterized by its criticism of technical rationality at a more social and political level (Habermas, 1972). However, a common aim of authors of either orientation is to encourage an awareness of and ability to change ‘framing processes’ through critical reflection on experience, assumptions and beliefs. For those more oriented towards ‘reflectivity’ this is done more at a micro-level, such as in ‘transformative learning’ (Mezirow, 1995), and in the second orientation of ‘reflection’, more at the macro socio-political level such as in the theory of ‘communicative rationality’ (Habermas, 1984-1987) which offers a more profound concept of rationality. In relation to our subject of ‘personal reflection’ it is worth noting that originally even Mezirov’s theory of ‘transformative learning’ was conceptualized too much as a mere rational process. Subsequent authors who nuanced his work underlined the existence and value of the personal-affective dimension of transformative learning (Grabov, 1997; Taylor, 2007). Information processing and sense making The distinction between ‘information processing’ and ‘sense making’ comes from Weick (1995). An example of expert information processing is clinical reasoning and diagnosis, while an example of sense making is understanding experience, primarily one’s own experience as a health care professional, but also the experience of others, such as the patient’s situation and experience. Information processing and sense making are inevitably interconnected and form the heart of all professional practice. Consequently, adequate information processing is impossible without an adequate sense-making procedure. This is true in professional health care practice, but also in layperson situations, such as communication between patients and their families, and obviously between health care professionals and their patients.

As the two processes seem almost identical and because educational training is mainly focused on expert information processing, including evidence enhancement through EBM, there is a pitfall whereby initiatives for the improvement of balanced reflective practice become caught in ‘more of the same’ information processing instead of sense making. An appeal for attention to be paid to other key components of practice besides the evidence, such as the circumstances of the patient (as assessed through the expertise of the clinician), the preferences of the patients, and the individual experience of the health care professional (Hayes, 2002; Sehon & Stanley, 2003), will only be effective if there is a double reflective focus of attention on both information processing and sense making. Therefore, health care students and professionals must be encouraged to become aware of, clarify and make proper use of the underlying process of sense making. This is precisely the function of personal reflection. Differences between information processing and sense making Information processing and sense making are intertwined and may seem almost identical. For example, consider the term ‘interpretation’. While appearing to be synonymous with sense making, it is actually an aspect of information processing. An interpretation can be discussed, refuted or accepted fairly accurately using explicit rules or concepts (Weick, 1995). Rational thought, deliberate interpretation and high-level information processing are key elements of human striving, achievement and self-regulation, considered in general and in particular professional domains (Vohs & Schmeichel, 2007). Medical problem solving is mainly a sophisticated form of information processing: technical and logical information processing which weighs and interprets data, resulting in interpretations/diagnoses. In other words, it is the professional accomplishment of medical ‘facts’ and ‘diagnoses’. Sense making is a necessary condition for information processing and problem solving, but it is not a technical problem in itself. Other terms for sense making that we will use synonymously are ‘framing’, ‘ordering’ and ‘constructing’ (Mezirow, 1995). For example, medical ‘facts’ are not only accomplished, they must also be ‘made’ relevant. This is done by the doctor within his/her medical treatment perspective and by the patients within their life perspective. A communicatively competent doctor is capable of adjusting his/her expert medical information to match the patient’s (layperson) information processing competence. Proper adjustment is based on awareness that one’s medical perspective is different from the patient’s life perspective, and that within these perspectives different modes of ‘relevance’ or ‘meaning’ arise (Groffen

& Aukes, 1979). This is precisely what sense making is about, and this can be made conscious and clarified through personal reflection. Sense making influences the way we behave and react to situations, what we select and what we treat as the relevant elements or aspects of the situation or our experience. It influences how we set the boundaries of our attention, how we colour and define problems, and what we consider to be ‘normal’ behaviour by ourselves and others (Schön, 1987). The process of sense making is not just a rational process, as, for example, was initially thought in the theory of ‘transfomative learning’ (Grabov, 1997; Taylor, 2007). It contains a rich variety of components such as rational and irrational thoughts and feelings, expectations, values and intuitions, not to forget bodily sensations. Sense making is an undercurrent and a process which is often taken for granted yet colours all our interpretations, judgments, feelings and actions. Because sense making is such an influential force in information processing and behaviour, it is often taken as the systematic level and is targeted as the point of impact. This occurs for example in patient education, such as in the therapeutic training of patients using Cognitive Emotive Therapy (Beck, 1975), but it is also targeted in an attempt to influence the professional behaviour of doctors, as well as the behaviour of potential patients, such as in pharmaceutical marketing strategies (De Laat, Windmeijer & Douven, 2002; Moynihan, Heath & Henry, 2002). Each professional discipline is first and foremost identified as ‘professional’ by its characteristic mode of expert information processing which stands in the foreground, for example, lawyers are experts in legal information processing and have their own behavioural codes. However, this characteristic expert information processing is, as mentioned, inevitably connected with the underlying process of sense making which is therefore just as characteristic for the professional. In addition, it is essential to note that patients also use both information processing and sense making to establish ‘facts’, ‘diagnoses’ and ‘meaning’. This phenomenon - the customary ‘methods’ that people use to accomplish meaningful facts (so-called ‘ethnomethodology’) - was studied intensively by Garfinkel (1967). Judgments A major difference between information processing and sense making in health care is the use of different modes of judgment: ‘determinative judgments’ and ‘reflective judgments’, based on a Kantian epistemology (Procee, 2006; Khushf, 1999). Determinative judgments situate

something particular under a given universal concept or idea, they are used, for example, when ordering signs and symptoms to form a medical diagnosis. Professional expert information processing, such as in sophisticated clinical diagnosis in medicine, is mainly built on determinative judgments. Determinative judgments are to a great extent rule governed and can therefore be appraised in formal examinations or peer discussions with explicit criteria and great accuracy. In the process of sense making it is mainly reflective judgments that are in operation. Reflective judgments are operational ‘when one seeks to bring forward some kind of unity about particulars without having at one’s disposal a general concept or idea’ (Procee, 2006). This occurs, for example, when a doctor tries to understand the patient’s situation, experience, perspective or way of making sense, or when a doctor tries to understand his/her own experience, thoughts, feelings and bodily sensations. Reflective judgments are not based on explicit rules but on intuition, feeling or tacit knowledge, and can therefore not be appraised with the same criterion of accuracy that is used for determinative judgments. This does not mean that they cannot be appraised at all, as we will see. Product and process Another subtle difference between information processing and sense making is the distinction between product and process. Sense making is clearly about an activity or a process, whereas ‘interpretation’ and ‘puzzling’ (both forms of information processing) can be processes, but are mostly used to describe a product, such as a diagnosis. People make sense of something, but even so, it is the activity rather than the outcome that is in the foreground (Weick, 1995). Being result-oriented in thinking and action (thinking within an action mode) is not only a professional but also a human habit: ‘Ordinarily, when we undertake something, it is only natural to expect a desirable outcome for our efforts. We want to see results, even if this is only a pleasant feeling’ (Kabat-Zinn, 2005b). Scientific reflection is typically focused on testing the claimed results, whereas personal reflection is typically focused on exploring the tendency or the desire for results and the tendency to believe what we desire. Properties of sense making The main properties of sense making will now be described in more detail. Initially it is worth mentioning that reflection on sense making at the meta-level is not the same as sense making at the operational level, just as scientific reflection on clinical reasoning (meta-level) is not the

same as clinical reasoning (operational level). The operational and meta-levels are interwoven, theoretically and practically, and are therefore experienced as a ‘whole’ by health care professionals in daily practice. This ‘whole’ is deconstructed to provide a better understanding of its components, as well as to recognize and use them properly and integrate them to the benefit of enhanced balanced conduct. We will describe the following properties: identity, self-referential / subjectivity, requisite variety, and unconscious aspects. Identity The establishment and maintenance of identity is a core preoccupation in sense making. Identities are to a great extent constructed out of a permanent process of interaction (Strauss, 1956; Weick, 1995). This process starts initially with the interaction between mother and infant that facilitates the child’s basic trust and the transition to a true or a false self, being more or less autonomous, and offers a healthy or unhealthy sense of omnipotence which will naturally be frustrated as the child matures (Winnicott, 1989). According to Mead, identity construction is continuous, with identity undergoing continual redefinition throughout life as a consequence of the interaction between child and family, and later on between individual and school, work and society (Strauss, 1956). In education, the choice to become a doctor, to undertake the necessary study, and the choice to eventually stop this or to undertake specialist training, is part of an enduring process of sense making. Encounters with significant others, within and outside the curriculum, play an important role in this process. The self-concepts of students, the shaping of their personal and professional identities, their ability to connect with and their commitment to patients, peers and the profession, are partly formed and modified by how they experience or believe in significant others, such as their parents and teachers in the past and their supervisors, peers and patients in the present. Examples are (a) the first encounters of students with real patients, colleagues and supervisors on the ward, (b) how others react to, evaluate, give feedback or assess their performance, and (c) how students in turn respond to these reactions. ‘Interaction’ works as a three-stage process of action, reaction and reaction-on-reaction (Weick, 1969), and it is the last stage in particular that is important for exploring the effects of interaction on sense making. Self-referential/subjectivity The close connection with the development of identity reveals that sense making by health care professionals is not only goal and action-driven, enabling appropriate diagnoses (information processing) and therapeutic

action, but also occurs in the service of maintaining a consistent, positive and ‘true’ professional and personal self (Winnicott, 1989). In other words, making sense out of another’s experience, such as the doctor’s contextual understanding of the patient’s situation, is also to a great extent simultaneously self-referential. A reflective health care professional is aware of this phenomenon or has an open mind to this possibility. Emotions and feelings play an important role in colouring and shaping the process of sense making and the self. Personal reflection can be seen as a cone of light that spreads backward from a particular situation in the ‘here and now’. This cone of light will give definition to portions of lived experiences, and because it begins in the present, projects undertaken and feelings that occur in this particular context will affect any backward glance and illuminate what is seen (Schwartz, 1991). Emotions also affect sense making because recall and retrospection tend to be mood congruent (Weick, 1995). Requisite variety The self-referential quality of sense making by the health care professional indirectly influences the quality of patient care, professional development and cooperation, and self-care. The more and the richer the experience that young health care professionals foster and maintain access to (instead of completely identifying with the professional role), and the more reflective perspectives on a situation they can utilize, the more complementary meanings they should be able to read into any situation, and there will be less likelihood that they will find themselves confused, surprised or astonished (Louis, 1980). For this reason, a criterion for the quality of reflection is the number and variety of perspectives the health care professional is able to apply to a given situation (Boenink, de Jonge, Smal, Oderwald & van Tilburg, 2005). In other words, the richness of personal experience, language, thoughts and feelings is a crucial resource and starting point in sense making, personal reflection and empathetic communication with others. This principle is an example of Ashby’s law of requisite variety (Ashby, 1958) which states that ‘the larger the variety of actions available to a control system, the larger the variety of perturbations it is able to compensate’. Thus, if health care professionals have a limited range of thoughts, feelings and language, they are not sensitive enough to detect and handle the richness of the external input properly, or thus will experience the potential richness as ‘perturbation’, or will not be aware of their selective perception and enactment. ‘Enactment’ is the phenomenon that

environments are not ’given’ but to a high degree constructed by the actors (Weick ,1969). Unconscious aspects The psychological events of ‘transference’ and ‘counter transference’ are well-known examples of the unconscious aspects of sense making and reaction. Transference is the unconscious displacement of thoughts, feelings and behaviours from a previous significant relationship onto a current relationship (Patterson, 1959). This strong unconscious mechanism, which was conceptualized by Freud, occurs not only in therapeutic relationships but also takes place in any relationship characterized by affection, hierarchy and/or dependency (Patterson, 1959; Baumlin & Weaver, 2000), which is true of all health care relationships and educational relationships. ‘Counter transference’ is the complement to transference. Usually, two types of counter transference are distinguished: transference by a person higher in a hierarchy, such as a doctor or a teacher, to a dependent person such as a patient or a student; or the unconscious reaction of a person higher in a hierarchy to another person’s transference. Obviously, this last type is more interesting because it takes into account the actual three stage process of interaction – action, reaction and reaction-on-reaction – between both persons (Robertson, 1999). Transference and counter transference can differ in intensity, stability and differentiation (Körner, 1999). The effect of transference and counter transference in health care practice and education can be positive or negative. A positive effect, for example, is the stimulation of the identification of a resident with a supervisor as a positive role model. Positive transference is a central mechanism in ‘modelling’, one of the strongest characteristics of interactive practice learning (Bandura, 1986). However, transference can be negative, for example, when cynical reactions from established experts and managers towards newcomers with a so-called idealistic or unrealistic attitude towards becoming ‘a good’ doctor lead the latter to develop a similar attitude. Another case might be a disappointing discovery by a student, who finds that his/her belief in ‘a good doctor’ or ‘a good nurse’ has inevitable personal, professional and practical limitations. Depending on the intensity, stability and differentiation (Körner, 1999) and on the quality of personal reflection on that experience, cases of negative or counter transference can result in either discouragement and frustration or in encouragement and the taking of another step in the process of professional and personal growth. Properties of reflection on sense making

It is essential for personal reflection that the individual learns to focus personal reflection on the process of sense making rather than focusing automatically on expert information processing. Usually three stages of reflection are mentioned in educational models: (1) awareness of experience, (2) the inquiry into selected experiences and, out of these, (3) the possibly of establishing new perspectives and action. These are described in practical terms in educational strategies such as reflective learning, enhanced experiential learning and portfolio-based learning (Kolb, 1984; Korthagen, 2001; Schön, 1987; Snadden, 1999). However, even in these instances attention too readily passes to information processing. As the ability to focus reflective attention on the underlying process of sense making is so delicate and easily mistaken, we will describe two basic properties of ‘personal reflection on sense making’: its retrospective nature and the quality of mindfulness. The retrospective quality The act of personal reflection on sense making is retrospective (Weick, 1995). This is particularly with the inquiry into selected experiences. The idea of reflection in retrospect is derived from Schutz’s analysis of ‘meaningful lived experience’ (Schutz, 1967). People only know what the are doing after they have done it. This retrospective character has to do with the fact that time exists in two distinct forms, as pure duration and as discrete segments. Pure duration can be described as a ‘stream of experience’ with a rich wholeness of thought, feelings and sensations (Kabat-Zinn, 2005a). However, when talking about or reflecting upon experience, distinct episodes are implied. In Schutz’s words:

‘When, by my act of reflection, I turn my attention to my living experience, I am no longer taking up my position within the stream of pure duration, I am no longer living with that flow. The experiences are apprehended, distinguished, brought into relief, marked out from one another. For the act of attention, and this is of major importance for the study of meaning, presupposes an elapsed, passed-away experience, in short, one that is already in the past.’ (Schutz, 1967. p. 51)

The mindfulness quality The other quality of personal reflection is mindfulness: it is basically a non-judgmental and open-minded attitude towards experience (Kabat-Zinn, 2005a). This is particularly true with awareness of experience. Mindfulness ‘simply is a practical way to become more in touch with the fullness of your being through a systematic process of self-observation, self-inquiry, and mindful action’ (Kabat-Zinn, 2005b, p. 16). When a person only reflects automatically, superficially or in too much of a hurry,

the results do not make sense. Therefore, mindfulness is a basic aspect of personal reflection and balanced conduct. It entails being aware in the present moment, without self-judgment or other forms of conceptual overlay, of the arising and passing away of phenomena in the field of direct experience. This mindful aspect can be understood in terms of attention, intention and attitude (Shapiro & Schwartz, 1998). ‘Attention’ refers to paying attention and the extent to which this is continuous, selective and percussive. ‘Attitude’ refers to the manner in which attention is paid, examples being equanimity, curiosity, acceptance or in a non-judgmental manner. ‘Intention’ refers to the motivation leading to personal reflection and why it is undertaken (Shapiro & Schwartz, 1998). By reflecting non-judgmentally on their own or another’s experience, health care professionals are more likely to recognize situations for what they are. When they function mindfully, their attention is not entangled in the past or future, they do not act judgmentally or reject what is occurring at that moment, they are present (Germer, Siegel & Fulton, 2005, p.p. 5). ‘Presence’ is a significant quality of balanced personal and professional conduct, and ‘good practice’. When the second phase of personal reflection, the inquiry into selected experiences, is undertaken mindfully it is characterized by the willingness and ability to bring interest, enthusiasm and an attitude of detailed exploration to experience (Germer et al., 2005). Reflection as a competence After this analysis of sense making and personal reflection on sense making, we will now describe the implications for reflection as a competence of the doctor and other health care professionals. In our opinion, a definition of reflective competence is required to enable its effective encouragement in education. In this context it is remarkable that in CanMEDS 2005, which laid down the doctors’ competence framework, the ‘professional’ is one of the roles distinguished, yet reflection is not distinguished as a competence (Slaets, 2007). An explanation for this weakness is the fact that the CanMEDS uses the concept of ‘role’ which differs from the concept of ‘competence’. The CanMEDS role concept is in line with socio-psychological role theory (Merton, 1968). It is the basis of a redefinition of the position of doctors in terms of a set of seven new functions or roles to be played that are connected with internal and external expectations. The advantage of the CanMEDS framework is that ‘roles’ are usually

more concrete and recognizable than ‘competences’. The wide application of CanMEDS may result in a rising awareness and acceptance of these new roles, including their internal and external expectations, possibly resulting in more explicit norms which will conform to practice as well as educational encouragement and assessment. The disadvantage, as mentioned above, is the misconception of the ‘professional’ as a separate role. Analysing the professional aspect as a particular role may lead to the mistaken belief that the ‘professional’ can and should be trained and assessed separately from other roles. This is odd, because it seems more coherent that the ‘professional’ doctor is the one who is able to integrate all the other roles and use them professionally when necessary. The role of the ‘expert’ is at the heart of the CanMEDS’ framework, suggesting that it is the expert who is the integrator. We have explained that the overall function of personal reflection by the doctor is to coordinate and optimize balance. We therefore suggest taking reflection – scientific and personal reflection – as a valid competence that is required to preserve the doctor’s ‘reflective equilibrium’ as a prerequisite for balanced conduct, that is, the accomplishment of all roles when needed. Components of a reflective competence A profound definition of reflection as a competence should contain the two modes of scientific reflection and of personal reflection, that is, purposeful attention for and critical inquiry of clinical information processing and of sense making. Such a complete competence integrates both the critical-logical and the personal-affective dimensions of medical conduct. Personal reflection has (a) an internal oriented application: being self-reflective and attentive, taking internal data seriously, such as sensations, images, feelings, and thoughts (SIFT) that arise during interaction with patients and colleagues (Epstein et al., 2008); (b) an external oriented application: reflective / communicative / empathetic conduct in the interaction with patients, family, and colleagues; (c) and awareness of the interaction between these two applications. Personal reflection is founded on a mindfulness attitude – how attention is paid, such as with equanimity, curiosity, acceptance, and in a non-judgmental fashion. The intention of personal is important: the motivation behind reflection and why it is undertaken: for the benefit of balanced conduct, learning and development, and own well-being.

Recapitulation Our conceptual analysis clarifies that without a complete and profound reflective competence the several fragile aspects of integrative medicine, balanced conduct, professional and personal learning, and the self-care for the doctor’s own well-being, are too easily eroded or lost. Because scientific reflection is well described and acknowledged as the critical meta-component of ‘deliberate practise’ in medical education - and because from that perspective personal reflection is often not well understood - we have concentrated mainly on the dimension of personal reflection. The mentioned components of personal reflection as a genuine part of an excellent doctor, make clear that personal reflection is inevitably connected with the fragility of the doctor / student. These components must be considered in more detail for encouragement, assessment and further educational research.

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Chapter 7. Conclusions, Discussion, Perspectives

Chapter 7. Conclusions, Discussion and Perspectives en zo waren er nog meer dingen maar die waren niet onbegrijpelijk genoeg om hier te noemen – Rutger Kopland Conclusions The main conclusions are summarized in accordance with the sequence of the chapters. Chapter 1. Introduction/assumptions/guiding principles/research questions:

1. The core subject of this thesis is ‘personal reflection’ in medical practice and education. ‘Personal reflection’ is distinguished from ‘scientific reflection’. Personal reflection is defined as: the careful exploration and appraisal of experience, thus clarifying and creating meaning for the benefit of balanced functioning, learning and development.

2. Balanced conduct of doctors is needed for good patient care, improvement of professional expertise, self-care and preservation of personal well-being.

3. For balanced conduct a ‘reflective equilibrium’ is needed. This entails the deliberate use of ‘scientific reflection’ and ‘personal reflection’.

4. Medical educators have distinct responsibilities with respect to the encouragement of scientific and personal reflection by medical students and doctors.

5. For effective educational encouragement a more precise understanding of the nature and function of personal reflection in health care practice is needed.

This view on personal reflection resulted in the following research issues:

1. Is it possible to make the rather abstract construct of personal reflection more concrete for medical educators who play an important role in the encouragement of reflection by students?

2. Is it possible to measure the personal reflection ability of medical students in a practical way?


3. What is the validity of an instrument measuring the construct of personal

reflection? 4. Is experiential learning an effective educational method to encourage

personal reflection? 5. What is the value of a more precise conceptual understanding of personal

reflection for a definition of reflection as a competence? Chapter 2. Visualizing reflection: the Float Model:

1. The important and rather abstract construct of reflection in medicine can be made concrete for educational purposes using the Float Model.

2. The Float Model can be used to distinguish and recognize the basic modes of reflection (scientific and personal reflection) and the need for each in creating balanced conduct. It can help to reveal blends of balanced and unbalanced reflection underneath the water, shaping profiles of reflective behaviour at the surface, and to structure observations and feedback.

Chapter 3. Measuring personal reflection: The Groningen Reflection Ability Scale (GRAS) and Chapter 4. Validation of the GRAS:

1. Personal reflection is an important construct in medicine that can be measured.

2. The ability to personal reflection can be measured with the Groningen Reflection Ability Scale (GRAS).

3. The GRAS is a practical measurement instrument which yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at the individual and group levels. It is a one-dimensional scale, covering three relevant aspects of personal reflection: self-reflection, empathetic reflection and reflective communication. The 23 items on a 5-point Likert scale result in one GRAS score.

4. Whereas the instruments available are mainly focused on critical thinking concerned with well-defined clinical problems, the GRAS measures personal reflection, which focuses on important and multi-faceted problems in patient care, professional collaboration and development.

5. The GRAS can be used in combination with other measures, in order to capture the richness of reflection in medicine, both for practical and theoretical purposes.

6. Validation shows that the GRAS is positively associated with self-reflection, empathetic aspects, a need for complex thinking and an open-minded


attitude, and to a small extent with a tolerance of lack of structure and uncertainty.

Chapter 5. The effect of enhanced experiential learning on personal reflection:

1. There are indications that enhanced experiential learning (that is, offering authentic experience, supported participation in practice, a clear portfolio structure, a supportive mentor system, and appropriate assessment) has a positive effect on the development of the personal reflection ability of first-year undergraduate medical students, as measured with the GRAS.

Chapter 6. A conceptual framework for personal reflection in healthcare practice and education:

1. The multifaceted construct of reflection contains cognitive-emotional and meta-cognitive processes which have been frequently described both theoretically and empirically in the literature. We have distinguished the meta-cognitive processes occurring in ‘scientific reflection’ and ‘personal reflection’, as well as the operational cognitive-emotional processes occurring in ‘information processing’ which mainly concerns ‘determinative judgments’, and ‘sense making’ which mainly concerns ‘reflective judgments’.

2. Scientific reflection is mainly oriented towards testing the evidence of expert information processing which aims at the augmentation of determinative clinical judgment.

3. Personal reflection is mainly oriented towards clarifying the process of sense making which aims at the augmentation of reflective judgment.

4. Personal reflection is not an aim in itself and is not an alternative but a supplement to scientific reflection. The overall aim of the encouragement of personal reflection in education is to acquire and maintain the reflective equilibrium that is needed for balanced conduct in health care practice. The balanced conduct of doctors primarily benefits patient care, the development of expertise and inter-professional cooperation, but also self-care and doctors’ personal well-being.

5. Educational encouragement of reflection requires a definition of the reflection competence that must at least contain: the modes of ‘scientific reflection’ and ‘personal reflection’; purposeful attention towards ‘information processing’ and ‘sense making’; internal application (self-reflection, self inquiry) and external application (patients, family, colleagues) and the interaction between both.


Discussion The major conclusions of the studies in this thesis are that personal reflection is vital for balanced conduct in medicine, it is a measurable and trainable professional quality, it can be made more concrete for educators, and effective encouragement is possible with enhanced experiential learning. The availability of a definition of reflection competence, based on a better understanding of the nature and function of scientific and personal reflection, is important for further educational development and research. The main objections to these substantiated ideas and the interpretation of the conclusions which will be discussed, are: - Personal reflection is neither necessary nor desirable in practice and education. - Personal reflection and scientific reflection are not compatible. - Personal reflection cannot be taught/learned because it is a matter of personality

(state-trait discussion). Personal reflection is neither necessary nor desirable in practice and education Based on the literature and the studies in this thesis we have argued and illustrated that balanced conduct by doctors and other health care professionals is impossible without the purposeful use of personal reflection, mainly oriented towards sense making and reflective judgments, and used in conjunction with scientific reflection which is mainly oriented towards information processing and determinative judgments. However, critical authors such as Mulroy (1999) find that reflection is neither necessary nor desirable, and argue that education in reflection is a step in the wrong direction. According to Mulroy, the difference between determinative judgment and reflective judgment is that with the latter the choice of concept is open. Reflective judgments are ‘soft’ – they are rarely wrong because one can use whatever rules or concepts that come to mind, and the details of a situation are limited by subjective selection. With determinative judgments, a set of rules or concepts is stipulated and applied to a particular situation – they are much ‘harder’, with less degree of freedom such that if the relevant details are not noticed then the judgment will be ‘wrong’. Connecting experiences to concepts and theories requires determinative judgments in particular. Based on this distinction Mulroy criticizes the ideology of reflection in education, which leads in his opinion to the


demise of determinative judgments. Clients or patients do not consult doctors, lawyers or mechanics for ‘reflective impressions’ but for determinate diagnoses. Thus, the main purpose of professional education is to develop the capacity to make accurate determinative judgments. Mulroy states that the encouragement of reflection by students and increasing their freedom by minimizing their determinative judgments is profoundly misguided (Mulroy, 1999). Mulroy’s opinion (1999), and that of others such as the early advocates of EBM (Sackett et al., 1991), exemplifies the conviction that research-based propositional knowledge will ultimately replace traditional medicine and result in enhanced determinative judgments that make individual professional-personal experience, tacit knowledge and reflective judgment superfluous. Today this belief is nuanced, with EBM being used to augment rather than replace the individual clinical/professional/personal experience and understanding of basic disease mechanisms. It is accepted that evidence from research can be no more than one component of any clinical decision, among other key components such as the circumstances of the patient (as assessed through the expertise of the clinician) and the preferences of the patient (Haynes, 2002). We agree that scientific reflection is a vital meta-component of medical expertise, but its predominance and misconception readily leads to the false claim that it is the only relevant mode of professional reflection. We consider personal reflection to be the crucial complementary mode of reflection. Using the conceptual differentiation of information processing and determinative judgment from sense making and reflective judgment we can explicate more precisely how scientific reflection and personal reflection are interrelated. Both are needed for reflective equilibrium as a prerequisite for balanced conduct. The diagnostic process involves both determinative and reflective judgment. Expert information processing using determinative judgment entails a sequence of skillful acts through which specified signs and symptoms are brought under a disease category. Although it is often a sophisticated process it is also done in a relatively mechanical way. This expert activity, which is easily mistaken for the single sign of professional expertise, presupposes a process of sense making which also requires a sequence of skillful acts which often remain taken for granted. Through personal reflection one can raise awareness of and insight into this sense making side of the diagnostic process and professional conduct.


The encouragement of the ability of medical students to engage in personal reflection to the detriment of scientific reflection is a risk, a pitfall and a regression to pre-scientific medicine. This can easily occur when personal reflection and the personal-affective competences of doctors are advocated as morally imperative and as acceptable alternatives to scientific reflection, instrumental research-based propositional knowledge and skills. However, advocating EBM and scientific reflection as morally imperative to the detriment of personal reflection, individual professional experience and experience-based tacit knowledge is just as risky, leading to unbalanced conduct and poor patient care. Overcoming dichotomous thinking An explanation for why new insights concerning reflective professionalism are being accepted so slowly in health care practice and education despite the development of pluralistic views in these domains has to do with a persistent misconception about medical professional identity, dichotomously framed in terms of ‘hard/soft’, ‘determinative/reflective judgments’, ‘personal/professional’, ‘body/mind’. This tendency readily leads to the conviction that the personal-affective dimension is not important until it is transformed and conceptualized into the instrumental logical-technical dimension, instead of overcoming this dichotomous mode of framing the issue. This last step can be taken by using personal reflection. An assumption of the advocates of EBM-enhanced determinative judgment through the use of scientific reflection is that those whose practice is based on this type of clinical expertise will provide superior patient care when compared with practitioners who rely on understanding basic mechanisms and their own clinical experience. Thus far, there is no convincing direct evidence proving this assumption correct (Haynes, 2002). However, the simple criticism that EBM is not enough in itself is not adequate, neither is the opinion that professional/personal experience is important. What is needed is a more precise insight into why the personal-affective dimension of professional conduct is important, how it works, and how it can be encouraged effectively. In this thesis we provide good reasons to explain why understanding and the use of one’s individual clinical experience must and can be improved by using the concepts of ‘sense making’ and ‘personal reflection on sense making’. We have given examples of the effectiveness of this personal and mindful use of reflection in health care. Further research is needed to examine the assumption that a combination of the purposeful use of ‘scientific reflection’ and ‘personal reflection’ will provide improved patient care,


professional/personal development and self-care and well-being of the health care professional. Personal reflection and scientific reflection are not compatible We have provided good reasons to demonstrate that personal reflection and scientific reflection form the key components of reflective equilibrium and reflective competence in medical practice and education. It is necessary to encourage both modes of reflection equally and it is possible to encourage personal reflection in an enhanced experiential learning programme. One main objection is that the process of becoming a ‘good doctor’, as well as staying a ‘good doctor’, has two inherently conflicting aspects: the cognitive-logical and the intuitive-subjective (Grabov, 1997; Taylor, 2007). The methods and aims of scientific reflection and personal reflection are not compatible in education because this inbuilt tension between the two modes of reflection can easily become a source of constraint and disappointment (Gur-Ze’ev, Masschlein & Blake, 2001; Van Maanen, 1995). According to Van Maanen (1995) the aim of critical scientific reflection is to create doubt and engender a critique of ongoing actions, while at the same time students want to acquire practical skills and self-confidence. As such, critical reflection would disturb the functional-practice view that animates everything done by students. Neglecting this tension would indeed be a genuine professional fault. Tension is inherent to reflective professional practice in obvious ways, that is, at each level – behavioural, clinical, scientific, personal – of our Float Model and also between the levels. The challenge is how to conceptualize and deal with this tension appropriately in theory, practice and education. One of the most complete definitions of reflective and mindful practice comes from Epstein and Hundert (2000), with its encompassing intellectual, reflective, affective and behavioural competences immediately revealing this inbuilt tension. Our own definition of personal reflection also encapsulates several elements of uneasiness. For example, it combines non-judgmental exploration and the critical appraisal of experience, or the handling of different modes of certainty and uncertainty at the levels of clinical reasoning, scientific reflection and personal reflection. Translated into medicine, this clarifies one of the main paradoxes of balanced reflection and conduct in medicine and medical education: the contradiction in demands when


working with both an empathetic patient-oriented attitude and using critical scientific appraisal. It is precisely in taking this paradox as a challenge that the function of personal reflection may become clear, namely in (a) encouraging the identification and acceptance of this inherent tension of reflective professional competence in a mindful way instead of neglecting, and (b) analysing and understanding these characteristics properly with the help of the above-mentioned concepts of information processing and sense making, determinative and reflective judgments, and scientific and personal reflection. In medical education, the fostering of a critical scientific attitude and competence is a dominant part of the curriculum culture and of the internal and external expectations of students and medical educators. The undergraduate programme of enhanced experiential learning, which was shown to be effective in one of our studies concerned with the encouragement of personal reflection, was part of a competence-based programme in which critical scientific reflection was also taught, at least at an undergraduate level. The challenge is to encourage and maintain this double reflective focus at the graduate level and in further specialist training. In many ways, tension and uncertainty is inherent to a pluralistic view of reflective medical competence. A one-dimensional, technical, non-reflective view of medical expertise may suggest a tense-less competence, but this will easily create an illusion of certainty and a tension in practice by not meeting the expectations of patients and the self-care needs of professionals. Personal reflection cannot be taught / learned because it is a matter of personality (state-trait discussion) We have shown that it is possible for students to acquire the ability of personal reflection. Enhanced experiential learning seems to have an especially positive effect on the development of personal reflection in first-year undergraduate medical students. We have also shown that the encouragement of personal reflection is a delicate process that requires careful attention because it is connected with the growth of personal/professional identity. A practical critique and warning is offered by Boud and Walker (1998), who mention several examples of poor educational methods and pitfalls when encouraging reflection. These include recipe following, reflection without learning,


the intellectualizing of reflection, uncritical acceptance of experience and the excessive use of teacher power. Procee (2006) concludes that what is missing in these examples and in most approaches to reflection in education, as well as in sceptical reactions, is an appropriate theory of reflection. A more fundamental objection is that reflection cannot be taught or learned at all. One argument is that a lack of reflective judgment is a ‘stupidity’ for which there is no remedy. Procee (2006) illustrates that this is Kant’s standpoint. Although for Kant the main distinction was not between determinative and reflective judgment, but between judgment and understanding, he states that a lack of judgment is a ‘stupidity’ and not a ‘lack of understanding’. Because of the different character of judgment and reasoning, Kant suggests that examples instead of rules should be used to develop the power of judgment. Based on this vision, Procee comes to the conclusion that it is not possible to teach reflection, but only to practise it (Procee, 2006). Kabat-Zin (2005) has shown that reflective/mindful judgment can be undertaken in both formal and informal settings, but that it requires guided support and purposeful and continued practice if it is to become an effective habit. In our opinion, due to its nature (oriented towards sense making, tacit knowledge and reflective judgments) personal reflection cannot be taught theoretically or instructed in the same manner as explicit/propositional knowledge, but it can be practised and improved through enhanced experiential learning and guided support. The principles of enhanced experiential learning, which we have shown to be effective for the encouragement of personal reflection, are: offering authentic experience, supported participation in relation to practice, a clear portfolio structure, a supportive mentor system and appropriate assessment. They may be effective because they take proper account of the individual nature of personal reflection in medical practice and in the student’s learning process. Further research is needed to test and examine more specific methods of guided support. Trait or state? A related issue involves the question: To which degree is personal reflection a stable fixed personality trait or a changeable state? The interrelationship between nature and nurture factors in medical education is part of a theoretical debate, of views on ‘good practice’ in medicine and of further research (Rees, 2005). The cognitive-logical dimension of reflection (scientific reflection) is habitually seen as a trainable state, standing at the centre of professional training and education. The personal-affective dimension of reflection (personal reflection) is more internally oriented and regarded as closely linked to the doctor’s personality. We have described how, for this reason, the personal-affective component, from a one-


dimensional technical-cognitive viewpoint, is mainly placed outside the domain of the medical profession and medical education, while an integrative and pluralistic viewpoint places it inside this domain. We agree with the vision that professionalism is more a state than a trait, reached only after a prolonged period of learning, instruction and reflective experience. Experience only facilitates the development of expertise and professionalism when it is accompanied by reflection. Self-awareness and reflection on sense making is one of a doctor’s more personal attributes. Taking the personal reflection of health care professionals as a state means that it can be treated as a professional attitude and ability that can be acquired, maintained and enhanced to a great extent through practice and guided support. Having said this, we would like to add the following remarks. Cognitive-logical intelligence is theoretically regarded as an aspect of personality, together with other dimensions of intelligence such as emotional intelligence and social intelligence (Salovey & Mayer, 1990; Goleman, 1995; Furnham & Heaven, 1999). Furthermore, the question of how stable personal traits actually are, along with the issue of whether ‘stability’ is an artefact of the chosen personality or practice model, both arise. Moreover, not only the traits and states of the individual doctor but also interaction with the environment – work and cultural conditions – play an influential role in shaping a doctor’s ability to reflect and his/her reflective conduct. Modern variants of the Five Factor personality theory, for example, take the interaction between person and environment into account more than previously, along with the way in which this interaction is shaped by the actor as a characteristic of their personality. This suggests that individual, social and cultural-psychological perspectives are more integrated (De Raad & Doddema-Winsemius, 1999). Medical educators are confronted with a dilemma. Does education in personal reflection make sense for students without any talent for or attraction to reflection? Doctors will differ in their stable personal characteristics, some being naturally or culturally apt with respect to personal reflection and others not. Taking balanced professionalism as a norm, not every medical student can become a ‘good doctor’ because personal traits and/or cultural norms sets limits to their potential ability with respect to personal reflection. The same argument applies to the scientifically reflective doctor because personal traits set limits to analytical intelligence and an ability to reflect scientifically. However, a real difference in education is that


routines for the monitoring and assessment of trait restrictions concerning cognitive-analytical thinking and scientific reflection are inbuilt within the educational system to a greater degree than the personal trait restrictions concerning personal reflection. A related dilemma involves the issue of whether expressing one’s personal reflection ability makes sense in the harsh practical reality of medical practice. Medical and educational practices will differ in their reflective culture, some being positive or negative, leading to attainment or attrition. Personality and identity cannot be isolated from the environment and culture. We have seen that one’s personal and professional identity and self-awareness are shaped and maintained in interaction with the environment, while the environment is shaped through the acts of the health care professional. This mutual interaction between individual and environment plays a constitutive role in the accomplishment or the erosion of one’s reflective equilibrium and balanced conduct. Therefore, raising awareness of this mutual interaction between individual and environment, and learning how to deal with it properly, must be an aspect of the encouragement of personal reflection and the empowerment of medical students. Perspectives Based on the conclusions and discussion we wish to formulate the following perspectives for research and development in medical education. This thesis indicates that the acquaintance and maintenance of personal reflection of medical students and doctors - as an important component of their reflection competence: the combination of scientific and personal reflection - is a matter of guided support and enduring practicing, rather than instructing and teaching. Personal reflection is mainly oriented on clarifying the process of ‘sense making’ using reflective judgments - while scientific reflection is mainly oriented on evidence testing ‘information processing’ using determinative judgments. Making sense out of one’s own or other’s experience or the environment is closely linked to one’s personality and identity formation and is culturally embedded. Consequently, the personal reflection attitude/ability (state) seems to be influenced both by the personality of the student/doctor (trait) and by context factors such as the education/work organisation and culture (environment). Another consequence is that personal reflection is a fragile process that is connected to a person’s frailty. Not all medical students are predisposed to engage in personal reflection and reflective learning. However, not all educational situations are appropriate for


stimulating or using personal reflective either. It is, for example, rather unethical to ask students or doctors to reflect personally in an unsafe environment. However, the relationship between students/doctors and the situation or context is not one-sided but reciprocal. The situation/environment is a set of characteristics and positive or negative motivating context factors on the one hand. But on the other hand, their influence depends to a great deal on the personal reflective quality of the students/doctors which includes the awareness of their enactment of the situation/environment. Enactment is the selective attention, sense making and handling of diverse contextual factors. Therefore, an individually-oriented approach of students and doctors must inevitably be combined with a system-oriented approach. The latter means: (a) empowerment of individual students and doctors to become aware of and deal with the enacted situation/environment, (b) the monitoring, enhancement and maintenance of the quality of medical educators, and (c) their responsibility for a safe reflective culture in the learning and work settings. Regarding the combination of scientific and personal reflection, it was clarified that these modes of reflection are complementary and that, albeit the tension between them due to their different nature and function, they are equally needed for balanced conduct. Balanced conduct is required for good patient care, improvement of professional expertise, and self-care and preservation of one’s own well-being. Consequently, our hypothesis for further research is: the personal reflection attitude/ability (state), which can grow through guided support and enduring practicing, is a cognitive-emotional moderator variable between reflection as a personal trait and reflective conduct, with the environment (medical educators, organization, culture) as a set of possible moderator variables too. Reflective conduct is needed for a set of important outcomes (patient care, development, teamwork, self-care and well-being) (see Figure 1). The value of scientific reflection is the augmentation of determinative judgments concerning ‘evidence’, while the value of personal reflection is the augmentation of reflective judgments concerning ‘meaning and relevance’. Even though both modes of reflection are complementary and equally needed, in our view, personal reflection is of a different order than scientific reflection. Theoretically, because in order to step beside and reflect (at a meta-level) on a system/ routine of thoughts/feelings/habits, one needs less rules and a certain open-mindedness and flexibility. Personal reflection is not as much governed by logical/technical rules as scientific reflection. This characteristic offers the ‘requisite variety’ that is needed


to sense, select and handle the richness of the (patient) situation as well as the own professional/personal experience. Practically, personal reflection is of a different order because in clinical judgment and treatment concerning integral patient care ultimately ‘meaning and relevance’ is of a higher importance than ‘evidence’. This does not mean that clinical judgment and discussion are completely ‘free’ or ‘soft’, but that personal reflection is needed for balance in conduct, teamwork and discussion. Figure 1. The interrelationships between: the reflection ability (state), reflection trait, the environment, reflective behaviour, and outcomes Personal reflective ability / state

Personal reflective trait Reflective professional conduct Outcomes: - patient care - development, teamwork - self-care / well-being

Perceived Environment (medical educators, culture, organisation)

In order to examine these substantiated expectations, we suggest the following issues for the Research & Development agenda:

1. A certain level of the personal reflective attitude/ability (state) is needed for adequate reflective conduct.

2. A certain level of the reflective/professional culture of the environment is needed for acquiring the personal reflection (ability) and exposing reflective conduct.

3. A certain level of the personal reflective attitude/ability (state) is needed to recognize and handle the process of the enacted (demanding) environment in healthcare practice.

4. The reflective/professional culture of the work environment determines (a) the dominant mode of scientific reflection or personal reflection, (b) the quality of each mode of reflection, and (c) the (opportunities for) integration.

5. Compared with the scientific reflection ability, the personal reflective ability has a relative greater positive effect on balanced conduct, and thus on the quality of patient care, professional/personal development, and self care and well-being.


Trait aspects of reflection can be measured with the Five Factor Personality Inventory (FFPI) (Hendriks, 1997). The reflection ability/state can be measured with the GRAS (Aukes et al., 2007), eventually in combination with other measures in order to capture the richness of reflection, such as the Mindful Attention Awareness Scale (MAAS) (Brown & Ryan, 2003). Reflective behaviour, at least the intention to act, can be measured with the vignette-method of Boenink (2005). References Aukes, L.C., Geertsma, J., Cohen-Schotanus, J., Zwierstra, R.P. & Slaets, J.P.J. (2007) The development

of a scale to measure personal reflection in medical practice and education, Medical Teacher, 29, 177−182.

Boud, D & Walker, D (1998) Promoting Reflection in Professional Courses: The Challenge of Context, Studies in Higher Education 23, no, 2; 192.

Boenink, A.D., de Jonge, P., Smal, K., Oderwald, A. & van Tilburg, W. (2005) The effects of teaching medical professionalism by means of vignettes: an exploratory study, Medical Teacher, 27, 429−432.

Brown, K.W. & Ryan, R.M. (2003) The benefits of being present: mindfulness and its role in psychological well-being, Journal of Personality and Social Psychology, 84, 822−848.

De Raad, B. & Doddema, M (1999) Book of Traits: the Language of Stable Characteristics of People and their Behaviours (Groningen, University of Groningen, the Netherlands).

Epstein, R.M. & Hundert, E.M. (2002). Defining and assessing professional competence, Journal of the American Medical Association, 287, 226−235.

Furnham, A & Heaven, P (1999) Personality and Social Behaviour (London, Arnold). Gardner, H. (1993) Frames of Mind: The theory of multiple intelligences (New York: Basic Books). Goleman, D. (1995). Emotional intelligence (New York: Bantam Books). Grabov, V. (1997) The many facets of transformative learning theory and practice. In: P. Cranton

(Ed.)Transformative learning in action: insights from practice, 89-96. New directions for adult and continuing education no. 74 (San Francisco, CA, Jossey-Bass).

Gur-Ze’ev, I., Masschelein, J. & Blake, N. (2001) Reflectivity, reflection, and counter-education, Studies in Philosophy and Education 20, 93−106.

Haynes, R.B. (2002) What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to? BMC Health Services Research, 2:3.

Hendriks, A.A.J. (1997) The Construction of the Five-Factor Personality Inventory (FFPI) (Dissertation University of Groningen, The Netherlands).

Kabat-Zinn J. (2005) Wherever you go, there you are: mindfulness meditation in everyday life (New York, Hyperion).

Mulroy, J. (1999) The war against Grammar, Wisconsin Interest 8, no. 2;14. Procee, H. (2006). Reflection in education: a Kantian epistemology. Educational Theory, 56, 237−253. Rees, C (2005) Proto-professionalism and the three questions about development. Medical Education, 39,

pp. 9-11. Sackett, D.L., Haynes, R.B., Guatt, G.H. & Tugwell, P. (1991) Clinical epidemiology: a basic science for

clinical medicine (2nd ed.) (Boston/Toronto, Little, Brown and Company). Salovey, P. & Mayer, J.D. (1990). Emotional intelligence. Imagination, Cognition, and Personality, 9,

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Summary A problem is your chance to do your best. – Duke Ellington Doctors are expected to reflect both scientifically and personally in order to become an excellent doctor. The core subject of this thesis is personal reflection in medical practice and medical education. The aim of personal reflection is to make the individual experience of doctors meaningful for the benefit of ‘good practice’. However, what is needed is more precise knowledge about the construct of personal reflection and educational strategies for its encouragement. This resulted in the following research issues in this thesis: 1. Is it possible to make the rather abstract construct of personal

reflection more concrete for medical educators? 2. Is it possible to measure the personal reflection ability of medical

students? 3. What is the validity of an instrument to measure personal reflection? 4. Is experiential learning an effective educational method to foster

personal reflection? 5. Is it possible to describe a conceptual framework for a more precise

understanding of the nature and function of personal reflection in practice, in order to identify, use, and encourage personal reflection?

Chapter 1 Today, reflection is regarded as a key quality of the self-critical doctor and other healthcare professionals. Therefore reflection is increasingly promoted in healthcare education. The predominant mode of reflection in medicine, in the last decade, used to be ‘scientific reflection’. Its aim is the improvement of evidence-based clinical judgment, i.e. evidence-based medicine (EBM). This mode of scientific reflection fitted quite well with the professional identity of the doctor as a science-based rational practitioner. However, the misconception and ill-reflected expectation of EBM, at least in the beginning, was that it would replace the personal experience and knowledge of the doctor. This one-dimensional view is now replaced by a more multi-dimensional conceptualisation of professionalism in which ‘evidence’ is seen as one of the components of ‘good practice’ jointly with other key components, such as the personal ‘experience’ and ‘knowledge’ of the professional as well as the ‘situation’

and ‘expectations’ of the patient - as noticed and weighted by the professional. Obviously, just enunciating this more balanced view is not sufficient and can easily be illusory when it is not clarified how to recognize and use these experience-based key components of ‘good practice’ appropriately. It is here that the value of personal reflection and the need for more precise understanding of its nature and function in healthcare practice, becomes apparent. We define personal reflection as: the careful exploration and appraisal of experience, thus clarifying and creating meaning, for the benefit of balanced functioning, learning and development of doctors. Reflection is not an aim in itself. The modes of scientific and personal reflection are equally needed, i.e. a reflective equilibrium is needed, to acquire and maintain balanced conduct of medical students and doctors, which means: the augmentation of ‘evidence’ through scientific reflection and the augmentation of ‘relevance’ through personal reflection. Balanced conduct of doctors is primarily for the benefit of integral patient care, but also for the development of expertise and inter-professional cooperation, as well as the doctor’s self-care and well-being. Medical educators have therefore distinct responsibilities for the effective encouragement of the personal reflective ability of medical students and doctors. This thesis is intended to contribute to improved recognition, use and encouragement of personal reflection. Chapter 2 This chapter tries to make the rather abstract construct of reflection more concrete

for practical doctors and medical educators who play a

central role in the support of reflection by students. An obstacle is that the appeal for reflection easily remains normative and rhetorical. Consequently its impact on medical education is likely to be small and sometimes boring or even misleading. In order to prevent this, we distinguished ‘behaviour’, ‘clinical reasoning’, ‘scientific reflection’, ‘personal reflection’ and ‘unconscious thinking’ and put these parts into an educational model, using the angler’s float as a metaphor (see figure). The Float Model symbolizes the doctor as reflective professional-in-action. It can prevent some misinterpretations such as

The Float Model Behaviour Clinical Reasoning Scientific Reflection Personal Reflection Unconscious Thinking

seeing the person and the professional as entire separated parts; mixing up scientific reflection and personal reflection; taking reflection as a goal in itself instead of a means to an end, namely balanced professional behaviour; and denying the importance of unconscious and irrational thoughts, feelings and reactions. The water represents the clinical context and culture. Without water a float does not function and has no meaning, i.e. individual professional / personal habits of mind and behaviour are always cultural embedded. Examples are given to reveal blends of balanced and unbalanced reflection underneath the water, shaping professional behaviour at the surface. The limitations of the use of metaphors are discussed. Chapter 3 This chapter describes the development of a new scale: the Groningen Reflection Ability Scale (GRAS). The research question was: is it possible to measure the personal reflection ability of medical students in a practical way? Item selection took place using literature and screening of an initial item-pool (81 items) by medical teachers and experts. Large samples of medical students (N 350 and N 583) and teachers (N 38) were used to investigate the psychometric characteristics of the items. Explorative factor analysis was used to investigate the structure of the scale. The psychometric quality and content validity of the GRAS are satisfactory. The 23-item scale proved to be easy to complete and to administer. The GRAS is, on conceptual and psychometric grounds, a one-dimensional scale. The three factors (self-reflection, empathetic reflection and reflective communication), being a result of explorative factor analysis, must therefore be interpreted primarily as facets of one dimension. This means that in practice a one-GRAS-score is leading. The content validity of the scale is satisfactory because the items are grounded in reflection literature and are covering three substantial aspects of personal reflection in the context of medical practice and education. The GRAS can be used for program evaluation concerning the reflection ability of medical students and doctors. A possible limited and paradoxical aspect of the GRAS is its self-rated character. Although the content validity of the GRAS is satisfactory, further research is needed to explore the external validity. We can conclude that the GRAS is a practical measurement instrument that yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at individual and group level. The 23 items on a 5-point Likert scale are

easy to complete, resulting in a one-GRAS-score. Scores can be calculated without time-consuming coding procedures. Chapter 4 In this chapter, in two studies, the conceptual relationship (concurrent validity) between the GRAS and existing reflection scaled is explored. The aim was to test to which extent the Groningen Reflection Ability Scale (GRAS) covers the construct of personal reflection. Study 1. The correlations between the GRAS and 4 Korthagen reflection scales (1993) were analysed: (1) the Self-Internal orientation (SI) and (2) the Self-External orientation (SE) on ‘learning’, and (3) the Fellow-students Internal orientation (FI) and (4) the Fellow-students External (FE) orientation on ‘communication and cooperation’. We expected the SI scale to represent the GRAS concept of personal reflection the most, followed in decreasing order by the SE, FI and the FE scales. Hypothesis 1 therefore was: The correlation levels of the GRAS with Korthagen will decrease from SI on learning to FE on communication and cooperation. The study showed significant decreasing correlations with the Korthagen scales, ranging from .67 with the most reflective scale to .32 with the least reflective scale; the GRAS Self-Reflection items explained most of the variance. The first hypothesis has been confirmed. The results indicate that the GRAS and the Korthagen scales measure, to a certain extent, related aspects of reflection. However, the correlations are not high enough to conclude that an identical construct is measured. In our opinion this difference is a result of a differentiation in conceptual focus: the GRAS covers more the concept of self-reflection and the Korthagen scales more the concept of communication. Exploration indicates that this difference between the GRAS and Korthagen is based mainly on the GRAS items of Empathetic Reflection. We may therefore conclude that the GRAS covers the empathetic aspect of personal reflection more than Korthagen. The GRAS is a self-rating test of reflection ability, more than an external assessment of reflective performance such as assessment by medical teachers or peers. Study 2. The correlations of the GRAS with three related cognitive-emotional scales were analysed: the Need For Cognition (NFC) scale (Petty & Jarvis 1996), the Personal Need For Structure (PNFS) scale (Neuberg et al. 1997), and the Open-Mindedness scale (Webster & Kruglanski 1994). We expected the NFC and Open-Mindedness scales to measure valid attitudinal aspects of personal reflection, leading to hypothesis 2: The

GRAS is positively correlated with the NFC and Open-Mindedness scales. The expected relationship between the GRAS and the Personal Need For Structure (PNFS) scale is more complex. An overall strong need for structure and decisiveness (Webster & Kruglanski 1994), which is needed for diagnosing and treating medical problems, may be a potential block to reflection because it obstructs the necessary tolerance towards uncertainty, openness towards reflection on experience and meta-reasoning (Mamede & Schmidt 2004). This leads to hypothesis 3: The GRAS is not or negatively correlated with the PNFS scale. The study showed significant positive correlations with the NFC scale (.56) and the Open-Mindedness scale (.56), and a low negative correlation with the PNFS scale (-.14). The second hypothesis was confirmed. This relationship is primarily based on the GRAS Self-Reflection items. This indicates that personal reflection, as measured by the GRAS, is associated positively with a need for complex thinking and an open-minded attitude. The third hypothesis was confirmed too (-.14). To a small degree GRAS Reflective Communication is related negatively (-.25) to a need for personal structure. This indicates that personal reflection, as measured by the GRAS, is to a small extent associated positively with a tolerance for lack of structure and uncertainty. Further research is needed to test a possible self-rating effect, for example by using the GRAS in a 360-degree assessment setting. We can conclude that both studies support the claim that the GRAS is a measure that contributes to valid inferences about the personal reflection ability of medical students. Chapter 5 The aim of this study was to test the expectation that enhanced experiential learning is an effective educational method that encourages personal reflection in medical students. The hypothesis was: the growth of the personal reflection ability of students in an enhanced experiential learning programme is stronger than that of students in a standard educational programme. Experiential learning is widely used as an educational method for stimulating the growth of students’ reflective abilities and attitudes required to become all-round professional practitioners. Recommended principles for strengthening its effectiveness are: authentic experience, a clear portfolio structure, a supportive mentor system, and appropriate assessment. These enhancements were adopted in an experiential learning programme that was part of new competence-based curriculum program at our medical faculty.

The level of personal reflection of an exposure group of 394 first-year medical students participating in the new enhanced experiential learning programme was compared to that of a control group of 250 second and 243 third-year medical students participating in the standard problem-based learning programme. A pre-post-test follow-up design was used. Personal reflection was assessed using the Groningen Reflection Ability Scale (GRAS) (see Chapter 3). We controlled for the variables that presumably influence the GRAS score: Gender and Time. Not every student responded at every measurement moment, therefore the data called for a multilevel analysis. The study resulted in the following GRAS scores. The first-year medical students in the exposure group: at the first measurement 50.2 and at the second 55.1. In the control group, the second year students at the first measurement 52.9 and at the second 55.6; the third year students at the first measurement 56 and at the second 55,9. After one year, first-year medical students in the exposure group achieved a level of personal reflection comparable to that reached by students of the control group in their third year. The reflection growth curve of the control group declined slightly in the third year as a function of study time. The difference in growth of reflection was significant (p < .001), with a small to average effect size (ES = .18). This study supports the suggestions that the ability of personal reflection on experience is enhanced by the mentioned supportive educational principles. The exposure programme combined the existing PBL elements of the standard program with the new elements of enhanced experiential learning. A possible bias in the estimation of the effect could be that measurements are not always of the same students. We can conclude that enhanced experiential learning has a positive effect on the development of personal reflection. Undergraduate medical students acquired a higher level of personal reflection which, according to modern insights of competence-based education, is needed required to become a professional medical doctor. Chapter 6. Conceptual framework This chapter offers a conceptual framework for more precise recognition, use and encouragement of personal reflection. At a meta-level ‘personal reflection’ is distinguished from ‘scientific reflection’, and at an operational level ‘information processing’ is distinguished from ‘sense making’:

Meta-level:

Scientific reflection

Personal reflection

Operational level: Information processing Sense making

These distinctions offer an analytical model that is used to make clear that scientific reflection is mainly focused on the critical (evidence-based) appraisal of information processing, and personal reflection on clarifying sense making. The properties of sense making and reflection on sense making are described plus the implications for a definition of reflection as a competence. A profound reflective competence contains a mindful attitude; the modes of ‘scientific reflection’ and ‘personal reflection’; purposeful attention for equally ‘information processing’ and ‘sense making’; and an internal oriented self-reflective application and an external oriented reflective communicative application (patients, family, colleagues). Chapter 7 In this thesis, the urgency of personal reflection of doctors and other healthcare practitioners for the benefit of integrative patient care, professional development and cooperation, and own self-care and well-being is substantiated. For that reason the encouragement of personal reflection is increasingly promoted in healthcare education. This thesis has shown that personal reflection is a valid, comprehensible and to certain extent a measurable and trainable professional quality. The following critical reactions on this substantiated viewpoint and conclusions are discussed: (1) Personal reflection is not necessary and desirable in medical practice and education, (2) It is difficult or almost impossible to combine personal reflection with critical scientific reflection, (3) Personal reflection is not teachable and learnable, because it is a matter of personality (state-trait discussion). At the end some perspectives on further research and medical education are discussed.

Samenvatting

Samenvatting De geest heeft het vermogen dat de natuurkunde niet heeft: iets wat waar is met succes te ontkennen. – Gerrit Krol Dokters moeten wetenschappelijk en persoonlijk kunnen reflecteren om een excellente dokter te worden en te blijven. Dit proefschrift richt zich op persoonlijk reflecteren. Er is meer kennis nodig over wat persoonlijk reflecteren in de medische context precies inhoudt en wat zinvolle onderwijskundige strategieën voor het reflectieonderwijs zijn. Vragen waarop een antwoord is gezocht zijn: - Is het mogelijk het construct van persoonlijke reflectie meer concreet te maken

voor medische docenten? - Kan persoonlijke reflectie van medische studenten worden gemeten? - Wat is de validiteit van een instrument om persoonlijke reflectie te meten? - Is ervaringsleren een effectieve methode om persoonlijk reflecteren te

stimuleren? - Is het mogelijk een conceptueel raamwerk te maken waarmee de aard en functie

van persoonlijke reflectie beter begrepen kan worden om reflectie in de praktijk beter te kunnen herkennen, gebruiken en bevorderen?

Hoofdstuk 1 Reflecteren op en leren van ervaring wordt in toenemende mate beschouwd als een kwaliteitskenmerk van medische professionaliteit. Vandaar dat reflectie steeds vaker een eigen plaats inneemt in het medisch onderwijs en de medische vervolgopleidingen. Dit komt niet uit de lucht vallen. Naast wetenschappelijke evidence worden tegenwoordig ook andere kwaliteitskenmerken van good practice onderkend. De belangrijkste zijn persoonlijke kennis en ervaring van de arts evenals de situatie en verwachtingen van de patiënt - in het bijzonder het signaleren en wegen daarvan door de arts. Een centrale vraag is welke rol de ervaring speelt en vooral hoe ervaring op betekenisvolle wijze gebruikt kan worden tijdens de medische opleiding en in de medische praktijk. Juist op dit punt wordt de betekenis van persoonlijke reflectie duidelijk. Persoonlijk reflecteren is het met aandacht onderzoeken van de eigen ervaring, het bewust worden en verhelderen van de betekenis ervan voor het eigen functioneren als dokter. Het is ook verkregen inzicht inzetten voor het onderhouden en verbeteren van de kwaliteit van het eigen functioneren en van de medische praktijk.

Samenvatting

functioneren. Individuele professionele en persoonlijke denken handelinggewoontes zijn altijd cultureel ingebed en contextueel bepaald. Bijvoorbeeld door een klimaat van (on)veiligheid in het verleden of in de actuele leer- en werkomgeving. Die inbedding en de consequenties ervan voor leren en functioneren kunnen door reflectie bewust gemaakt worden. Voorbeelden worden gegeven van combinaties van evenwichtige en onevenwichtige reflectie onder water, die het professionele gedrag boven water kunnen vormen en vervormen. Ook worden de beperkingen van metafoorgebruik besproken. Hoofdstuk 3 Dit hoofdstuk beschrijft de ontwikkeling van een nieuw meetinstrument: de Groningen Reflection Ability Scale (GRAS). De onderzoeksvraag hierbij was: is het mogelijk de persoonlijke reflectievaardigheid van medische studenten op een praktische manier te meten? Itemselectie vond plaats door literatuurstudie en screening van de eerste itempool (81 items) door medische docenten en experts. Grote steekproeven onder medische studenten (N 350 en N 583) en docenten (N 38) werden vervolgens gebruikt om de structuur van de schaal te onderzoeken. De psychometrische kenmerken en de inhoudsvaliditeit van de GRAS waren bevredigend. De 23 items, op een vijfpunts Likert schaal, bleken eenvoudig in te vullen en te verwerken. De GRAS is op conceptuele en psychometrische gronden een eendimensionale schaal. De drie met behulp van exploratieve factoranalyse gevonden factoren (zelfreflectie, empathische reflectie en reflectieve communicatie) moeten daarom worden geïnterpreteerd als aspecten van één dimensie (in de praktijk wordt gewerkt met één GRAS-score). De inhoudsvaliditeit was bevredigend omdat de items op literatuur zijn gebaseerd en drie relevante aspecten van persoonlijke reflectie in de medische context representeren. De GRAS kan worden gebruikt voor het evalueren van reflectieonderwijs. Een mogelijke beperking en paradoxale kant van de GRAS is het zelfbeoordelingkarakter. Verder onderzoek is nodig naar ‘soortgenoot’ validering van de GRAS, door vergelijking met verwante reflectie instrumenten; naar externe validering door vergelijking met criterium (reflectief professioneel) gedrag in de praktijk; en naar predictieve validering door vergelijking met patiënten uitkomstmaten. Op grond van deze studie kan geconcludeerd worden dat de GRAS een praktisch meetinstrument is dat betrouwbare gegevens oplevert om tot valide uitspraken te komen over de persoonlijke reflectievaardigheid van medische studenten en artsen in opleiding. Hoofdstuk 4

Samenvatting

In dit hoofdstuk zijn twee studies beschreven naar de conceptuele relatie tussen de GRAS en bestaande reflectieschalen (concurrent validity). Het doel was om te onderzoeken in hoeverre de Groningen Reflection Ability Scale (GRAS) het construct ‘persoonlijke reflectie’ dekt. In studie 1 is de relatie tussen de GRAS en de bestaande reflectieschalen van Korthagen onderzocht. Een van de uitgangspunten bij de ontwikkeling van de GRAS was dat deze schaal, in vergelijking met de schalen van Korthagen, meer nadruk zou moeten leggen op het reflecteren zelf dan op communiceren en samenwerken. Onze opvatting was dat de Korthagen-reflectieschalen niet zozeer het reflecteren meten, maar vooral het communiceren en samenwerken. Van zijn schalen benadert onzes inziens de ‘Self-Internal’ (SI) oriëntatie op leren het meest het reflecteren zelf, in afnemende mate gevolgd door de ‘Self-External’ (SE) oriëntatie op leren, en de ‘Fellow-students-Internal’ (FI) en ‘Fellow-students-External’ (FE) oriëntatie op samenwerken. De GRAS is opgezet als een eendimensionale schaal maar heeft drie groepen van inhoudelijk samenhangende items (zelfreflectie, empathische reflectie en reflectieve communicatie) die voor valideringsonderzoek gebruikt kunnen worden. Dit resulteerde in hypothese 1: de hoogte van de correlaties van de GRAS met de Korthagen-reflectieschalen zullen afnemen van SI naar FE. Exploratief zal worden onderzocht door welke itemgroepen van de GRAS het verschil met de reflectieschalen van Korthagen wordt bepaald. Bij 285 eerstejaarsstudenten geneeskunde (response: 62 %) werden zowel de GRAS als de Korthagen-schalen afgenomen. Er bleek sprake te zijn van afnemende correlaties tussen de GRAS en de Korthagen-schalen: r = 0.67 met SI, r = 0.62 met SE, r = 0.56 met FI en r = 0.32 met FE. De hoogste correlatie was tussen zelfreflectie en Self-Internal (r = 0.75) en tussen reflectieve communicatie en Self-External (r = 0.65). De correlatie tussen empathische reflectie en de Korthagen-schalen was voor geen van de reflectie-schalen hoger dan r = 0.52 en fluctueerde weinig. De resultaten laten zien dat de GRAS en de Korthagen-schalen gedeeltelijk dezelfde aspecten van reflectie meten. De correlaties zijn echter niet hoog genoeg om te kunnen concluderen dat ze een identiek construct meten. Naar onze opvatting komt dit door een verschil in conceptuele focus: de GRAS is meer gericht op het concept van zelfreflectie terwijl de Korthagen-schalen meer op het concept van communicatie en samenwerken zijn gericht. Exploratie suggereert dat het verschil tussen de GRAS en de Korthagen-schalen voornamelijk is gebaseerd op de items van empathische reflectie. Op grond daarvan kan geconcludeerd worden dat de GRAS het empathische aspect van reflectie meer dekt dan de Korthagen-schalen.

Samenvatting

Hypothese 1 lijkt te worden bevestigd: er is een afnemend verband tussen de GRAS en de Korthagen-schalen. Exploratie van dit verband laat zien dat zelfreflectie het meest overeenkomt met een meer ‘interne oriëntatie’ op leren, en dat reflectieve communicatie voor een deel overeenkomt met een meer ‘externe oriëntatie’ op leren. De GRAS is meer dan de reflectieschalen van Korthagen gericht op het reflecteren zelf. In studie 2 is bij 285 eerstejaarsstudenten geneeskunde (response: 62 %) de correlaties tussen de GRAS en drie gerelateerde cognitief-emotionele schalen onderzocht: de Need For Cognition (NFC) schaal, de Personal Need For Structure (PNFS) schaal, en de Open-Mindedness schaal. Onze verwachting was dat de NFC and Open-Mindedness schalen valide houdingsaspecten van persoonlijke reflectie meten, wat leidde tot hypothese 2: De GRAS is positief gecorreleerd met de NFC en Open-Mindedness schalen. De verwachte relatie tussen de GRAS en de Personal Need For Structure (PNFS) schaal lag wat gecompliceerder. Enerzijds is er bij dokters een behoefte aan structuur en besluitvaardigheid die nodig is voor medische diagnostiek en behandeling. Anderzijds kan een sterke behoefte aan structuur juist een blokkade vormen voor reflectie, omdat daardoor de tolerantie voor onzekerheid die nodig is voor reflecteren, kan worden belemmerd. Dit leidde tot hypothese 3: De GRAS is neutraal of negatief gecorreleerd met de PNFS. Er was sprake van significant positieve correlaties tussen de GRAS en de NFC schaal (.56) en de Open Mindedness schaal (.56), en een lage negatieve correlatie tussen de GRAS en de PNFS schaal (-.14). Hiermee wordt hypothese 2 bevestigd. Dit verband blijkt primair gebaseerd te zijn op de GRAS zelfreflectie items. Dit suggereert dat persoonlijke reflectie - zoals gemeten door de GRAS - positief geassocieerd is met een behoefte aan complex denken en een open mind houding. Hypothese 3 wordt ook bevestigd (-.14). De GRAS items over reflectieve communicatie zijn in lichte mate negatief (-.25) gecorreleerd met een behoefte aan persoonlijke structuur. Geconcludeerd kon worden dat de persoonlijke reflectievaardigheid - zoals gemeten door de GRAS - positief gerelateerd is aan een behoefte aan complex denken en een open mind, en enigszins positief is gerelateerd aan tolerantie voor gebrek aan structuur en onzekerheid. Beide studies ondersteunen de claim, dat de GRAS betrouwbare gegevens oplevert om te komen tot valide conclusies over de persoonlijke reflectievaardigheid van medische studenten en artsen in opleiding.

Samenvatting

Hoofdstuk 5 In deze studie is onderzoek gedaan naar de verwachting dat ervaringsleren een effectieve methode is om het reflectievermogen van medische studenten te bevorderen. De hypothese was: de groei van het reflectievermogen van studenten in een op ervaringsleren gebaseerd programma is sterker dan dat van studenten in een standaard onderwijsprogramma. Ervaringsleren wordt als onderwijsmethode toegepast ter bevordering van reflectievaardigheden die nodig zijn om ‘een goede dokter’ te worden. Aanbevolen principes uit de literatuur om de effectiviteit van ervaringsleren te versterken zijn: actief gebruik maken van authentieke levensechte ervaringen, een heldere portfoliostructuur, een ondersteunend mentorsysteem en geëigende toetsvormen. Deze aanbevelingen waren opgenomen in een ervaringsleren-programma dat onderdeel was van een nieuw competentie-gestuurd curriculum, genaamd G2010, aan de medische faculteit in Groningen. Het niveau van persoonlijk reflecteren van de exposuregroep (394 eerstejaarsstudenten geneeskunde in het nieuwe ervaringslerenprogramma) werd vergeleken met dat van de controlegroep (250 tweedejaars en 243 derdejaars geneeskundestudenten die het standaard probleemgestuurde onderwijsprogramma volgden). Het reflecteren werd gemeten met de Groningen Reflection Ability Scale (GRAS). Wij controleerden voor de variabelen die waarschijnlijk de GRAS-score zouden kunnen beinvloeden: geslacht en studietijd. Voor alle groepen werden reflectie-groeicurves bepaald (GRAS-score afgezet tegen de studietijd). De verschillen in de groeicurves werden vastgesteld met behulp van een multilevelanalyse. De studie resulteerde in de volgende GRAS-scores. De eerstejaars in de exposuregroep scoorden op het eerste meetmoment 50.2 en op het tweede meetmoment 55.1. In de controlegroep scoorden de tweedejaarsstudenten op het eerste meetmoment 52.9 en op het tweede meetmoment 55.6 en de derdejaars op het eerste meetmoment 56 en op het tweede 55.9. Voor zowel de exposuregroep als de controlegroep gold dat de gemiddelde GRAS-score op het eerstvolgende meetmoment hoger lag (behalve voor de derdejaars). Er bleek een nonlineair verband te bestaan tussen studietijd (aantal maanden studie geneeskunde) en de GRAS-score. De stijging van de GRAS-score nam af naarmate de studenten verder waren met hun studie. Uiteindelijk werd een plafond bereikt. De eerstejaarsstudenten in exposuregroep bereikten dit plafond sneller dan de controlegroep studenten. Na 1 jaar bereikten de eerstejaarsstudenten in de exposure groep een niveau van persoonlijke reflectie dat vergelijkbaar is met het niveau dat studenten in de controlegroep pas in hun derde jaar bereikten. Het verschil tussen de groeicurves van het reflectievermogen was significant (p < .001), met een kleine tot gemiddelde effectsize (ES = .17).

Samenvatting

Deze studie bevestigt de hypothese dat de groei van het reflectievermogen van studenten in een gericht ervaringslerenprogramma sterker is dan van studenten in een standaard onderwijsprogramma. Daarbij komt dat het exposureprogramma een combinatie was van problem-based-learning elementen van het bestaande curriculum en nieuwe elementen van ervaringsleren. Dat betekent dat het programmatische verschil tussen de exposure- en controlegroepen relatief klein is, waardoor het verschil in reflectiegroei meer reliëf krijgt. Een mogelijke vertekening van het geschatte effect ligt in het feit dat tijdens de meetmomenten niet altijd dezelfde studenten binnen de groep de vragenlijsten invulden. Op basis van deze studie kon geconcludeerd worden dat gericht ondersteund ervaringsleren een positief effect heeft op de groei van het reflectievermogen van de deelnemende studenten. Medische studenten in de bachelorfase bereiken daardoor eerder een hoger niveau van persoonlijke reflectie. Hoofdstuk 6 In dit hoofdstuk wordt een conceptueel raamwerk beschreven om persoonlijke reflectie beter te kunnen begrijpen, herkennen, gebruiken en bevorderen. Op meta-niveau worden ‘wetenschappelijke reflectie’ en ‘persoonlijke reflectie’ onderscheiden, en op operationele niveau de processen van ‘informatieverwerking’ en ‘betekenisgeven’, zoals hieronder is samengevat:

Metaniveau:

Wetenschappelijke reflectie

Persoonlijke reflectie

Operationeel niveau: Informatieverwerking Betekenisgeven

Deze componenten vormen de bouwstenen voor een analytisch model waarmee het verschil tussen wetenschappelijke en persoonlijke reflectie kan worden verduidelijkt. Wetenschappelijke reflectie is voornamelijk gericht op de evidence-based evaluatie van klinische informatieverwerking. Persoonlijke reflectie is voornamelijk gericht op het verhelderen van het proces van betekenisgeven. De kenmerken van het proces van betekenissgeven en het reflecteren daarop (wat niet aan elkaar gelijkgesteld moet worden) worden beschreven, alsmede de consequenties daarvan voor het definiëren van reflecteren als competentie. Om in het onderwijs serieus genomen te worden is het gewenst reflecteren als competentie te benoemen. De competentie reflecteren zou ons inziens tenminste de volgende componenten moeten bevatten. Gerichte aandacht voor: de beide soorten van wetenschappelijk reflecteren en persoonlijk reflecteren; de beide processen van

Samenvatting

informatieverwerking en betekenisgeven, en de samenhang daartussen; de interne toepassing (zelfreflectie, zelfonderzoek, reageren op feedback) en de externe toepassing (reflectieve communicatie met patiënten en familie, geven van feedback); en een basishouding van onverdeelde aandacht / mindfulness in de omgang met anderen (patienten / familie) en met zichzelf. Hoofdstuk 7 In dit slothoofdstuk worden de conclusies, discussie en perspectieven beschreven. Op basis van goede redenen en evidentie uit de literatuur is aangegeven, dat persoonlijk reflecteren door dokters essentieel is voor professioneel functioneren, leren en samenwerken, en eigen welbevinden. Dat zijn de voornaamste redenen waarom in het medisch onderwijs en de medische vervolgopleidingen systematisch aandacht moet worden geschonken aan persoonlijke reflectie. Onze studies hebben laten zien dat persoonlijk reflecteren niet opgevat moet worden als een ver-van-mijn-bed-gebeuren in de privésituatie van dokters, maar als wezenlijk bestanddeel van professionele toerusting. Persoonlijk reflecteren is een professionele kwaliteit van dokters die waardevol is en die geobserveerd, benoemd, en tot op zekere hoogte gemeten kan worden, én waarvan het prakitiseren en oefenen effectief ondersteund kan worden. Vervolgens worden de volgende kritische reacties op deze conklusies besproken: (1) persoonlijk reflecteren is noodzakelijk noch wenselijk in de medische praktijk en het medisch onderwijs, (2) het is moeilijk en bijna onmogelijk om persoonlijke reflectie te combineren met kritisch wetenschappelijke reflectie, (3) persoonlijk reflecteren valt niet te onderwijzen en te leren omdat het een kwestie van persoonlijkheid is (de state-trait discussie). Tenslotte worden enkele perspectieven voor vervolgonderzoek en onderwijs geschetst.

Samenvatting

Daarnaast wordt van dokters verwacht dat zij wetenschappelijk kunnen reflecteren. Vooral in de geneeskunde is dit de meest dominerende vorm van reflectie, gericht op het versterken van de wetenschappelijke onderbouwing van klinische beslissingen: evidence based medicine (EBM). Reflectie is echter geen doel op zich, maar een onontbeerlijk ingrediënt van professioneel medisch handelen. Vandaag de dag heeft de dokter beide soorten reflectie in gelijke mate nodig om evenwichtig te kunnen functioneren te midden van de vele eisen die vanuit de maatschappij aan het medische beroep gesteld worden. Evenwichtig functioneren van dokters is in de eerste plaats van belang voor de kwaliteit van de patiëntenzorg, maar ook voor het permanent ontwikkelen van vakbekwaamheid, inter-professionele samenwerking, en niet in de laatste plaats voor hun eigen welbevinden. Vandaar dat medische opleiders een eigen verantwoordelijkheid hebben voor het bevorderen van reflectievaardigheden van medische studenten en artsen in opleiding. Dit proefschrift wil een bijdrage leveren aan het herkennen, gebruiken en bevorderen van persoonlijke reflectie in medisch onderwijs en medische vervolgopleidingen. Hoofdstuk 2 In dit hoofdstuk is geprobeerd het nogal abstracte construct van ‘persoonlijke reflectie’ te visualiseren ten behoeve van medische docenten die een belangrijke rol

spelen in het reflectieonderwijs. Pleidooien voor reflectie blijven gemakkelijk steken in een normerend en retorisch appèl, waardoor het effect in de praktijk dikwijls klein, saai en soms misleidend is. Om dat te voorkomen hebben we onderscheid gemaakt tussen ‘gedrag’, ‘klinisch redeneren’, ‘wetenschappelijke reflectie’, ‘persoonlijke reflectie’ en ‘onbewust denken’. Deze componenten zijn in een onderwijs- kundig model geplaatst, waarbij een dobber als metafoor is gebruikt (zie figuur hiernaast). Het dobbermodel symboliseert de dokter als reflectieve professional in actie. Het model kan meteen al enkele misverstanden wegnemen, zoals het los van elkaar plaatsen van persoon en professional; het verwarren van persoonlijk reflecteren en wetenschappelijk reflecteren; reflectie opvatten als doel op zich in plaats van een ingrediënt van professioneel gedrag; het

negeren van de invloed van onbewust denken (rationele en irrationele gedachten en gevoelens) en van de context op het professioneel functioneren. Het water symboliseert de klinische context en cultuur. Zonder water kan een dobber niet

De reflectieve dokter Gedrag Klinisch Redeneren Wetenschappelijk Reflecteren Persoonlijk Reflecteren Onbewust denken

Samenvatting

Dankwoord

Dankwoord ofwel het ‘dieptelood der herinnering’ –– Hella Haasse Ik voelde mij gepeild en begrepen. –– Oek de Jong Voor de samenwerking tijdens het onderzoek en de ontwikkeling van mijn eigen dobber wil ik de volgende personen bedanken. Het was me een genoegen in zee te gaan met mijn promotiecommissie. Om te beginnen met Joris Slaets, hoogleraar klinische geriatrie. Joris, zowel voor mij persoonlijk als voor de zaak ‘reflectie in de geneeskunde’ was en ben jij een ware promotor. Hoe jij patiëntzorg, onderwijs en onderzoek vakkundig en persoonlijk integreert werkte voor mij voorbeeldig. Ik heb ervan genoten – en er daardoor ook extra van geleerd – hoe jij onder wisselende omstandigheden op elegante wijze hoofdzaken weet vast te houden en er consequenties aan verbindt. Je aandacht en vertrouwen waren weldadig, waardoor je het beste in mij boven water hebt gehaald. Rein Zwierstra, hoogleraar medisch onderwijs en opleidingen. Rein, de combinatie van jouw grote ervaring in de kliniek en het onderwijs, je geestdrift, en in onze samenwerking ook je openhartigheid, werkten op mij aanstekelijk. Dat was ook al het geval vóór dit promotieproject. Bij de start hiervan vroeg jij, terwijl je je wenkbrauwen optrok: ‘Weet je zeker dat je dit (nog) wilt’? Ja, dat wist ik zeker. Janke Cohen-Schotanus, hoofd Centrum voor Innovatie en Onderzoek van Medisch Onderwijs (CIOMO). Janke, er zijn maar weinig mensen naar wie een begrip in de onderwijsliteratuur vernoemd is. Ik ben blij dat ik de strenge maar rechtvaardige ‘cesuur van Cohen’ gehaald heb. Van de commissieleden zat jij het dichtst op het dagelijkse productieproces van onderzoek, artikelen schrijven, bespreken en insturen, met daar tussendoor ook mijn persoonlijke wel en wee. Wees ervan verzekerd dat je als Friezin niet alleen in staat bent strenge boodschappen nuchter over te brengen, maar ook je genegenheid en betrokkenheid. Ook de leden van de leescommissie wil ik in mijn dankwoord betrekken. Het past bij het disciplineoverstijgende thema ‘reflectie’ dat er vertegenwoordigers uit drie verschillende vakdisciplines vertegenwoordigd waren. Zij zijn bovendien allemaal rolmodellen in hun vakgebied en dus ongevoelig voor visserslatijn.

Dankwoord

Rijk Gans, hoogleraar en hoofdopleider Interne Geneeskunde van het umcg en een warme pleitbezorger van reflectie in die opleiding. Rijk, voor mij ben jij een levend voorbeeld van de sneldenkende internist die laat zien dat interne geneeskunde een kennisintensief èn ervaringsintensief vak is dat klinisch-wetenschappelijk puzzelen en persoonlijk reflecteren vereist. Mieke Grypdonck, hoogleraar Verplegingswetenschap, jarenlang te Utrecht en nu nog te Gent. Mieke, jij bent al decennia lang dé inspiratiebron voor een integrale visie op en vormgeving van de verpleegkunde. Ik bewaar de beste herinneringen aan onze samenwerking bij de invoering van Integrerende Verpleging in Nederland, ‘om te beginnen in het AZG’; bij het van de grond tillen van Verplegingswetenschap; en tijdens vele conferenties in België en Nederland. Jij weet altijd onvermoeibaar, met wetenschappelijke en praktische kennis van zaken en groot gezag door alle modetrends heen te prikken. Het was een verrijking in jouw buurt te vertoeven. Henk Schmidt, hoogleraar psychologie aan de Erasmus Universiteit te Rotterdam. Henk, jij bent een gelauwerde onderzoeker op het terrein van de cognitie-psychologische onderbouwing van problem based learning als onderwijsmethode om medische expertise te verwerven en de rol die reflectie daarbij speelt. Ik bewaar goede herinneringen aan onze samenwerking in MUG-verband (Maastricht, Utrecht, Groningen). Ik voel me vereerd met jullie lidmaatschap van mijn leescommissie. Mocht ik tijdens de verdediging kopje onder dreigen te gaan, dan zijn mijn paranimfen, Hans van de Sande en Christophe de Jongh, uitstekend toegerust om het wetenschappelijke debat voor te zetten - inclusief na afloop op het onderdeel ‘antwoorden op niet gestelde vragen’. Zij hebben eerder op mij al flink kunnen oefenen in het reddend zwemmen. Hans, het is mij een genoegen dat ik bij jou paranimf was en dat de rollen nu omgekeerd zijn. Ik heb veel teksten en mijn reflectievermogen kunnen aanscherpen dankzij jouw altijd kritische kanttekeningen en onophoudelijke erudiete verhalen - ook tijdens ons wekelijks diner en vele andere gezamenlijke activiteiten. Stof, het allereerste artikeltje dat ik van je in handen kreeg, ging over ‘De nieuwe uitleg’ van Groningen. Die titel typeert wat ik in jou waardeer en ook van mezelf in jou herken: grenzen verleggen, wat steeds nieuwe uitleg en verantwoording vraagt. Jij houdt je nu bezig met ‘bouwen op het tweede maaiveld’ en ik met ‘denken op het tweede maaiveld’. Heeren, ik verheug mij op deze waardige variant van vriendschap: jullie als mijn secondanten te weten. De afgelopen jaren heb ik me als een vis in het water gevoeld van de kweekvijver van CIOMO. Op de eerste plaats dank ik Tineke Bouwkamp-Timmer voor haar scherpe pen en onvoorwaardelijke steun. Tineke, jij hebt veel voor me betekend bij

Dankwoord

het corrigeren en versturen van teksten, het opzoeken van literatuur en met je persoonlijke aandacht. Als er één de vinger op mijn hebbelijkheden heeft gelegd en er ook mee moest (leren) omgaan, dan ben jij het wel. Jelle Geertsma fungeerde enkele jaren als mijn assistent en steun en toeverlaat in de statistiek. Jelle, we hebben beiden in deze periode belangrijke stappen gezet – ik in het lastige proces van instrumentontwikkeling en jij in dat van je draai en dobber vinden als psycholoog/methodoloog/beeldhouwer. Ik heb veel van je geleerd en herkende mezelf denk ik in jouw volharding om die combinaties vast te willen houden. Met Hanke Dekker heb ik van meet af aan in een vanzelfsprekende afstemming samengewerkt, bij het ontwikkelen van de lijn ‘beroepsvoorbereiding’, maar ook in het kader van haar ‘Stichting ter bevordering van dingen die anders niet gebeuren’. Hanke, die schitterende naam vat jouw talenten en werkwijze perfect samen. Daar heb ik veel genoegen aan beleefd en van geleerd. De volgende collega’s dank ik voor het regelmatig kritisch meelezen, jullie collegialiteit, handige technische tips en kostbare tijd: Johanna Schönrock-Adema, Ally van Hell, Mirjam van Lohuizen, Marjolein Heijne-Penninga en Anja Karg. Elke onderzoeker hengelt naar onderzoeksgegevens. Ik dank daarom de vele respondenten die in mijn haakje wilden bijten: de studenten en coaches van het programma ‘beroepsvoorbereiding’ in het eerste jaar van G2010, en collega’s voor het invullen van vele vragenlijsten; Clara Leegsma en Henriëtte van der Meulen voor de ondersteuning bij het afnemen en verwerken van al die vragenlijsten; Karel van Spaendonck, Benno Bonke en Vera Batenburg als externe experts voor het kritisch lezen en bespreken van een eerste versie van de GRAS; de deelnemers aan onze jaarlijkse reflectieconferenties voor hun actieve bijdrage tijdens het uitwisselen van ervaringen en discussies in de verschillende fasen van het onderzoek; Erwin Houthuysen voor de prettige en inhoudelijke samenwerking tijdens zijn onderzoeksstage bij mij; Rinske Grond voor het beschikbaar stellen van haar portfoliofragment; Madelyn van Rijckevorsel voor haar scherpe tweetalige kroontjespen als Amerikaanse-Nederlandse meelezer van vele versies van artikelen en emotionele support; en Kasper Tromp voor zijn correctorschap in de laatste fase. Eigenlijk is er geen duidelijk beginpunt waar je met bedanken moet eindigen. Bij het thema ‘persoonlijk reflecteren’ is het alleszins gerechtvaardigd wat langer stil te staan bij degenen die mij tot indringende persoonlijke en professionele reflectie hebben aangezet. Op de golven van de jaren negentig dank ik Jan Pols voor de samenwerking en collegialiteit bij het ontwikkelen van Medisch Professionele Vorming (MPV). Met

Dankwoord

plezier denk ik terug aan de projecten en de uren met Harry Woldendorp met reflecties over ons organisatieadvieswerk. Ik koester de herinnering aan de jaren met Friederike Korte; al hadden we soms een zware dobber aan elkaar, het tekende de diepgang van onze verbinding. Met Els Alberstnagel en Elly Schoemaker heb ik intensief samengewerkt in het schrijfproject en de redactieraad van de serie Verpleegkunde van Wolters Noordhoff, waarvoor dank. Fokje Hellema dank ik voor de samenwerking en vriendschap die begon in de jaren’80 met Integrerende Verpleegkunde in het AZG (met veel andere collega’s) en zich voortzette als student en actievoerder Verplegingwetenschap. Mieke Walenkamp en Fokje, dank voor de inspiratie bij het schrijven van het boek over Integrerende Verpleegkunde. Met de medewerkers en studenten van Verplegingswetenschap in Groningen had ik een buitengewone tijd. De eerste lichting studenten, de ‘Death-PHO-society’, zal ik nooit vergeten; daarvan zijn intussen al velen gepromoveerd. Hans Burgerhof, bedankt voor onze samenwerking in vriendschap en je meesterschap om statistiek voor iedereen, ook voor mij, begrijpelijk te maken. Clara Venema dank ik voor de inspiratie die leidde tot liedjes en gedichten. Als ik de lijn nog verder uitwerp, kom ik terecht bij de leden van het Werkverband Organisatie Ontwikkeling in de Welzijnszorg’ (WOW). Met hen werkte ik intensief samen in de laatste twee jaren van mijn studie en in de eerste jaren als psycholoog. WOW was in 1969, in de democratiseringsperiode aan de subfaculteit psychologie in Groningen, opgezet door Wim Groffen. Wim, ik wist niet waar ik precies aan begon, maar ik voelde me aangetrokken tot jouw kijk op het vak en tot wat jij ondernam. De titel van de eerste WOW-publicatie (Wim Groffen, Met de neus op het helpen, Van Loghum Slaterus, 1975) gaf onze visie en werkwijze precies weer. (en de enige literatuurverwijzing in het gezondheidszorgbeleidsplan van staatssecretaris Hendriks uit die tijd). Ik citeer één zin uit het voorwoord: ‘Meer nog hopen we, dat deze uitgave de werkers in de hulpverlening steunt bij zelfbegeleiding of het klimaat voor begeleiding helpt scheppen, zodat met een minimum aan inmenging van buitenaf de doeltreffendheid van het helpen kan worden opgevoerd.’ Jaren ’70 jargon of nog steeds actueel? Ik denk beide. De weg die ik toen ben ingeslagen heeft uiteindelijk tot dit proefschrift geleid. Vanuit onze praktijktheoretische visie op onderzoek en ontwikkeling richtten we ons toen meer tot het ‘praktijkforum’ dan tot het ‘wetenschappelijk forum’. In dit proefschrift doe ik beide – hoop ik – al wordt dat onderscheid nu veel minder scherp ervaren dan toen. Wim, ik beschouw jou en Lolle Nauta bij wie ik bijvak wetenschapsfilosofie deed, als mijn leermeesters: aan wie je maar even hoeft te denken en je oordeelsvermogen is weer geijkt. Je hoeft als professor geen school te maken om een wetenschappelijke beroepscultuur door te geven.

Dankwoord

Het organisatieadvieswerk in combinatie met het cabaretwerk was een leerschool in kritisch opgewekte reflectie en performance. Ik wil daarom hier ook de vrienden uit de cabaretgroepen noemen waarin ik al die jaren heb mogen samenwerken: het Kweekschoolcabaret in Meppel en daarna in Groningen het NCSV-cabaret en vooral De Zuiderdiepstem. De methode van organisatieadvies en die van De Zuiderdiepstem, kwam ongeveer op hetzelfde neer: vóórgesprekken houden, stukken lezen, op werkbezoek gaan, veronderstellingen en pretenties blootleggen, kritische grenzen opzoeken (maar wel respecteren), om vervolgens in het ene geval een serieus advies te geven en in het andere een voorstelling – en het liefst allebei. De Zuiderdiepstem betekende veel voor het gezin in opbouw van Annet van Melle en mij, en onze dochters die opgroeiden in de vanzelfsprekendheid van je stem laten horen tussen de schuifdeuren. Daarom noem ik hier in dankbaarheid de namen van Nico Heemskerk, Gokky de Boer en Gré Scholtens met haar Egge Rengers: presente! Het is erg verdrietig dat Nico en Egge deze heuglijke gebeurtenis niet meer kunnen bijwonen. Ze hadden ongetwijfeld graag even willen uitleggen waar persoonlijk reflectie nu écht om gaat... Ik dank de acht heren van het koor Octafel dat de Italiaanse kunst van het vriendschappelijk / muzikaal / culinair / spiritueel samenzijn op het niveau van de ware amateur beoefent: Jan, Kees, Wouter, Christophe, Hans, Keimpe en Paul. Als dirigent aan jullie leiding te mogen geven was een van mijn meest lastige maar leerzame ervaringen. En de laatste jaren ‘Het Verdriet van Steenwijk’ - de naam zegt het al - met mijn zus Coos en haar man Henk, mijn broer Antoon en zijn vrouw Thea, en Harry de Jonge en Lucie Chrispijn. Het is bijzonder te merken dat je door samen op te treden nog meer maatjes wordt met je familie, en dat vrienden als familie worden. Coos en Antoon, onze opvoeding en onderlinge band is gebaseerd op de zekerheid dat wat normaal lijkt niet vanzelfsprekend is, en het besef dat inderdaad overal wel een barst in zit. In dat licht wordt alles duidelijk wat we met elkaar hebben en doen. Woorden schieten tekort om mijn gevoel daarvoor rechtstreeks uit te drukken – vandaar af en toe een liedje. Tot slot noem ik hier de namen van de meest dierbaren om mij heen die de grootste bijdrage hebben geleverd aan mijn reflectieve en emotionele drijfvermogen: Coos en Antoon. Annet, met wie ik een leven deelde en nu het geluk van het groot-ouderschap, jij weet als geen ander wat hierboven tussen regels geschreven staat. Onze dochters Anne, Maartje, Barbara en Hannah. En Madelyn. Door jullie voel ik mij gepeild en begrepen. Dank voor inspiratie en geduld in liefde en vriendschap.

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Curriculum Vitae

Als kinderen uit een gezin met een vader ‘in hardhout’ en een moeder met modevakschool aan huis (lerares Kostuum- en Mantelvak volgens de Danckaerts-methode), groeiden wij op met ambachtelijke noties en reflecties, zoals: ‘Hout leeft.’ ‘Het nemen van de juiste maten, daar gaat het om (armlengte, schouderbreedte, heuplengte, bovenwijdte).’ ‘Raderen is overtrekken, de kunst is zelf patroontekenen.’ ‘Kijk hoe een jurk in elkaar zit, niet alleen wie erin zit.’ ‘Om de kwaliteit te meten neem je de stof even tussen duim en wijsvinger.’ ‘Met één hand een knoopje in de draad leggen.’ ‘De stof moet goed vallen.’ ‘Mijn personages beseffen dat zij zijn overgeleverd aan hun eigen perspectief. Gaandeweg dringt tot hen door dat hun tijd, hun mogelijkheden, hun jaren beperkt zijn – dat, kortom, hun vrijheid beperkt is. Daar botsen het eerste decennium van de eenentwintigste eeuw in moreel en ideologisch opzicht frontaal op de jaren zestig van de vorige eeuw: het conflict tussen royale zelfontplooiing en morele verlichtingen, tussen individualisme en verantwoordelijkheid. (…) Het leven brengt zijn eigen morele oordelen voort: die zitten in ons, in onze lichamen, in het fysieke contact dat we met onze geliefden hebben, onze partner, onze kinderen. Los daarvan bestaat er geen moreel oordeel.’ – Jens Christian Grøndahl, De Volkskrant 29-08-2008. De persoon die zegt dat het niet kan moet de persoon die het doet niet lastigvallen. – Chinees gezegde

Curriculum Vitae

Leo Aukes werd geboren. Na de Kweekschool in Meppel ging hij psychologie studeren aan de Rijksuniversiteit Groningen. Hij werkte na zijn afstuderen in 1973 (Organisatie- en Sociale Psychologie) in het Werkverband Organisatieontwikkeling in de Welzijnszorg (WOW). Hij verrichtte daar praktijkonderzoek naar Integrale Geneeskunde in opdracht van A. Querido (Praeventiefonds), begeleidde gezondheidscentra en deed organisatieadvieswerk. Van 1981 tot 1987 was hij stafmedewerker patiëntenzorg in het Academisch Ziekenhuis Groningen (AZG). Het omvangrijkste project was de invoering van Integrerende Verpleegkunde, met meer dan 40 interne publicaties van de deelnemers zelf - als onderdeel van de invoeringsmethode. In 1987 was hij initiatiefnemer van de Posthogere Opleiding Verplegingswetenschap (PHO-V) die vanuit het AZG, de Hanze Hogeschool en de faculteit der Geneeskunde werd opgezet, en twee jaar later overging in de Universitaire Opleiding Verplegingswetenschap. Tot 1995 was hij coördinator van de Sectie Verplegingswetenschap, van de Vakgroep Gezondheidswetenschappen van de Faculteit der Medische Wetenschappen, en docent ‘Management en Beleid van Gezondheidszorg’. Van 1995 tot 2003 - vanaf 1998 vanuit het onderwijsinstituut (OWI) - was hij als Coördinator Communicatievaardigheden actief in beleid en ontwikkeling van onderwijs in communicatie, reflectie en beroepsontwikkeling, docentscholing, en toetsing. Hij was zelf ook docent en coach van studenten, en participeerde in diverse landelijke overlegorganen. Sinds 2003 is hij werkzaam vanuit het Centrum voor Innovatie en Onderzoek van Medisch Onderwijs (CIOMO) met als aandachtsgebied onderzoek en ontwikkeling van reflectie. Hij is momenteel voorzitter van de adviesgroep voor reflectie in de opleiding tot internist. Hij was actief in cabaret, treedt regelmatig op als onderdeel van organisatie-adviesprojecten, won diverse prijzen voor optredens, lezingen, en de publieks-ontwerpwedstrijd voor het stationsplein in Groningen. Van 1997 tot 2003 zat hij in de directie van Café Huis de Beurs te Groningen waar hij ondermeer debatavonden organiseerde en de actie ‘Groningen voor Korsovaren’ initieerde. Hij was bestuurlijk actief in het verband van De Open Ankh, als voorzitter van de raad van toezicht van GGZ Drenthe, en als voorzitter van het bestuur van de Schizofrenie Stichting Nederland (SSN). Momenteel is hij vice-voorzitter van de raad van commissarissen van Espria.

Curriculum Vitae

Iedere organisatieadviseur / trainer / coach / docent weet dat je er voor moet zorgen dat je deelnemers eigenaar van hun succes worden en blijven. De consequentie daarvan is dat je zelf moet leren werken ‘onder een nullijn van gratificatie’. Een beproefd hulpmiddel daarvoor is het schrijven over je projecten en ervaringen, in wat voor vorm dan ook. Hieronder enkele van mijn producten: Leo Aukes. Het herstel van de eenheid van het medisch handelen. Eindrapport ‘Berichten uit een ziekenhuisonderzoek’. Werkverband Organisatieontwikkeling in de Welzijnszorg (WOW) 1979. Wim Groffen & Leo Aukes. In overleg met de patiënt: communicatieve verrichtingen in het ziekenhuis. Deventer: Van Loghum Slaterus 1979. Aukes L.C., F.G. Hellema & M.J. Walenkamp. Verpleegkundige zorgvernieuwing, Integrerende Verpleegkunde in de praktijk. Groningen: Wolters Noordhoff 1992. Aukes L.C. (Ed.). Verplegingswetenschap in Groningen. Bundel ter gelegenheid van het eerste lustrum. Dwingeloo: Kavanah 1993. Leo Aukes & Harry Woldendorp. Sturing en zelfsturing, een punt van orde. Deventer: Kluwer 1994. Elly Schoemaker, Els Albertsnagel & Leo Aukes. De regie van het primaire proces. Groningen: Wolters Noordhoff 1999. Als je muzikant bent speel je hele leven door. Grammofoonplaat van De Zuider-diepstem, 1987. De zoon van de bruisende stad. Cassetteband van De Zuiderdiepstem, 1992.

The GRAS, English version

1. I want to know why I do what I do

2. I am aware of the emotions that influence my behaviour

3. I do not like to have my standpoints discussed

4. I do not welcome remarks about my personal functioning

5. I take a closer look at my own habits of thinking

6. I am able to view my own behaviour from a distance

7. I test my own judgments against those of others

8. Sometimes others say that I do overestimate myself

9. I find it important to know what certain rules and guidelines are based on

10. I am able to understand people with a different cultural / religious background

11. I am accountable for what I say

12. I reject different ways of thinking

13. I can see an experience from different standpoints

14. I take responsibility for what I say

15. I am open to discussion about my opinions

16. I am aware of my own limitations

17. I sometimes find myself having difficulty in illustrating an ethical standpoint

18. I am aware of the cultural influences on my opinions

19. I want to understand myself

20. I am aware of the possible emotional impact of information on others

21. I sometimes find myself having difficulty in thinking of alternative solutions

22. I can empathize with someone else’s situation

23. I am aware of the emotions that influence my thinking

The GRAS, Dutch version

1. Ik wil weten waarom ik doe wat ik doe

2. Ik heb zicht op de emoties die mijn handelen beïnvloeden

3. Ik stel mijn eigen standpunten niet graag ter discussie

4. Ik reageer afhoudend op opmerkingen over mijn persoonlijk functioneren

5. Ik neem mijn eigen denkgewoontes onder de loep

6. Ik kan mijn eigen gedrag op afstand bezien

7. Ik toets mijn oordelen aan die van anderen

8. Anderen zeggen wel eens dat ik mezelf overschat

9. Ik vind het belangrijk te weten waarop bepaalde regels en richtlijnen zijn

gebaseerd

10. Ik kan me verplaatsen in mensen met een andere culturele / religieuze

achtergrond

11. Ik neem verantwoordelijkheid voor mijn uitspraken

12. Ik wijs anders denken af

13. Ik kan een ervaring vanuit verschillende standpunten bekijken

14. Ik neem de uitspraken die ik doe voor mijn rekening

15. Ik kan eigen opvattingen ter discussie stellen

16. Ik ben me bewust van mijn grenzen

17. Ik betrap me er wel eens op dat ik moeite heb een ethisch standpunt toe te lichten

18. Ik ben me bewust van culturele invloeden op mijn opvattingen

19. Ik wil mijzelf begrijpen

20. Ik ben me bewust van de emotionele lading die informatie voor anderen kan

hebben

21. Ik betrap me er wel eens op dat ik moeite heb alternatieve oplossingen te

bedenken

22. Ik kan me in de situatie van een ander inleven

23. Ik heb zicht op de emoties die mijn denken beïnvloeden

Appendix 2: Oefenstof tot doordenken / Food for reflection

Oefenstof tot doordenken / Food for reflection Reflecteren is een werkwoord. Hieronder staan losse tekstfragmenten met serieuze en lichtvoetige reflecties, vanuit verschillende invalshoeken, over uiteenlopende onderwerpen, binnen en buiten het domein van het medisch onderwijs. Waarschuwing: lees ze vooral niet achter elkaar door. Neem wat van uw gading is en laat de rest liggen. Ze zijn bedoeld om op andere gedachten te komen – hetzij van anderen of van uzelf. ® Wat zijn reflectieve / mindful dokters? Een van de beste artikelen over reflectieve en mindful dokters is nog steeds dat van Ronald Epstein: ‘Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit.(…) In contrast, mindlessness may account for some deviations from professionalism

and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.’ Epstein, R.M. Mindful practice, JAMA, 1999; 282: 833−839. ® Wie naar binnen kijkt, wordt zich bewust. Wie naar buiten kijkt, droomt. – Carl Jung ® The uncertainty of the expert


‘When physicians shift from a theoretical discussion of medicine to its practical applications, they do not acknowledge the uncertainty inherent in what they do. Katz argues that while uncertainty itself imposes a significant burden on the physicians, the greater burden is “the obligation to keep these uncertainties in mind and acknowledge them to patients.” He observes that “the denial of uncertainty, the proclivity to substitute certainty for uncertainty, is one of the most remarkable human psychological traits. It is both adaptive and maladaptive, and therefore it both guides and misguides.” Physicians’ denial of awareness of uncertainty serves similar purposes: it makes matters seem clearer, more understandable, and more certain than they are; it makes action possible. There are limits to living with uncertainty. It can paralyze action. This is a core reality of the practice of medicine, where – in the absence of certitude – decisions must be made.’ (p. 153) Jerome Groopman. How doctors think, Boston, New York: Houghton Mifflin Company 2007. ® Think like a man of action and act like a man of thought. – Henri Bergson ® Geestelijke oefeningen De uitdrukking ‘geestelijke oefeningen’ brengt de hedendaagse lezer enigszins van de wijs. Allereerst is het vandaag de dag niet meer zo gepast om het woord ‘geestelijk’ te gebruiken. Maar we moeten ons toch bij het gebruik van deze term neerleggen. Omdat andere mogelijke adjectieven of benamingen, zoals ‘psychisch’, ‘moreel’, ethisch’, intellectueel’, ‘beschouwend’ of ‘’de ziel betreffende’, niet alle aspecten omvatten van de werkelijkheid die we willen beschrijven. We zouden natuurlijk van denkoefeningen kunnen spreken, omdat het denken zichzelf bij deze oefeningen om zo te zeggen als materie beschouwt en probeert zichzelf te veranderen. Maar het woord ‘denken’ maakt onvoldoende duidelijk welke belangrijke plaats de verbeeldingskracht en het gevoelsleven bij deze oefeningen innemen. Om dezelfde reden kunnen we niet volstaan met intellectuele oefeningen’, hoewel de intellectuele aspecten (definitie, indeling, redering, lezen, onderzoek, retorisch versterking) hierin een grote rol spelen.’ (blz. 17-18). Pierre Hadot, Oefeningen van de geest. Het antieke denken en de kunst van het leven. Amsterdam: Ambo 2005. ® Ken uzelf Erkenne dich! - Was hab ich da für Lohn? Erkenn ich mich, so muß ich gleich davon. (Know thyself? If I knew myself I would run away.)

– Johann Wolfgang von Goethe® Seven guidelines of wisdom


‘Doctors are expected to be wise. Nowadays people can access knowledge without our help. They want more from us than just correct decision making, and we expect wisdom of one another. The commonest complaint about doctors in trouble is that they lack insight. Yet we receive no training in wisdom. We assume that it is randomly distributed and partly genetic, like musical ability. (…) Here at last are some guidelines. 1. Mix the generations: In modern Britain the only time that the generations mingle is at weddings. In hospital, consultants teach registrars, registrars teach juniors, and students teach one another. Intergenerational discourse should be reintroduced. Don't assume the flow of wisdom will be one way. 2. Take time for reflection: "Reflective practice" is a cliché in nursing journals but not in ours. If anyone passing my door sees me sitting and thinking I feel guilty. The only place where you could stare thoughtfully through the window used to be the train, but modern electronics have stopped even that. 3. Converse with lay people: This is hard. Many lay people have fixed attitudes to our profession, ranging from awe to resentment. Many doctors encourage these feelings. Concealing your calling is no help. We must converse as equals. 4. Dare to be unoriginal: Today's NHS is constantly seeking novelty. Its jargon has a six week shelf life. In this context it takes nerve to point out the obvious. Wisdom is old fashioned though it can be repackaged under a snappy title like "clinical governance." 5. Move around: This is increasingly difficult. Long ago undergraduates could move around Europe, but medical schools' seamless curricula now make this impossible. Regions are doing the same for specialist registrars. And consultants stay put. 6. Keep your sense of humour: Seriousness belongs in the consulting room. Outside, be a jester, whose job is to deflate pomposity. Good jokes depend on insight. Think of all the books called The wit and wisdom of . . . . 7. Stop reading articles with "guidelines" in the title: Whoever heard of a wise person reading numbered guidelines? Or writing them?’ James Owen Drife (professor of obstetrics and gynaecology). BMJ 2000;320:1349. ® Het medisch onderwijs is te belangrijk om alleen aan artsen over te laten. ® Spiegels ‘Mirrors are meaningless until someone looks into them. Thus, a history of the mirror is really the history of looking, and what we perceive in these magical surfaces can tell us a great deal about ourselves. (..) The mirror appears throughout the human drama as a means of self-knowledge or self-delusion. We have used the reflective surface both to reveal and to hide reality, and mirrors have found their


way into religion, folklore, literature, arts, magic and science.’ Mark Pendergrast. A history of the human love affair with reflection, New York, Basic Books, 2003. ® Mirrors should reflect a little before throwing back images. – Des Beaux-Arts ® Als een psycholoog zichzelf een spiegel voorhoudt, gebruikt hij het liefst een one-way screen. ® Ontwikkeling van competenties De medische en persoonlijke competentie van de dokter zijn bepalend voor de medische professionaliteit. De ontwikkeling van medische expertise begint vanaf de medische opleiding en wordt bevorderd door problem based learning (PBL) (Henk Schmidt, 1990). De ontwikkeling van persoonlijke competentie begint vanaf de geboorte. Een niet gering verschil. De persoonlijke competentie wordt niet automatisch bevorderd of gehinderd door een problem based life. Van belang is hoe life-events door de persoon in kwestie worden geïnterpreteerd. Processen als hechting, veiligheid, scholing, vrijwaring van armoede, en succesvol ervaringsleren spelen daarbij een belangrijke rol – ook tijdens de ontwikkeling van de medische competenties. ® Lastige vragen Reflecteren is de kunst van het vragen stellen. Om er wat in te komen, zou u enkele ‘lastige vragen’ van Max Frisch eens kunnen proberen: . Kent u de wereld door te kennen of te voelen? . Overtuigt uw zelfkritiek u? . Hebt u gevoel voor humor als u alleen bent? . Wie zou u liever nooit zijn tegengekomen? . Wat staat uw geluk in de weg? . Waarvoor bent u dankbaar? . Beschouwt u zichzelf als een goede vriend? . Houdt u van iemand? Waaruit leidt u dat af? . Wanneer bent u opgehouden te denken dat u wijzer werd, of denkt u dat nu nog? Leeftijd opgeven. Hoe oud zou u willen worden? . Welke hoop hebt u opgegeven? Het Dagboek 1966-1971 van de Zwitserse schrijver Max Frisch begint met ‘lastige vragen’. Aparte editie: Max Frisch. Lastige vragen, Amsterdam: Meulenhof 1995. ® Verantwoorden


Dit zijn inderdaad ‘lastige vragen’. ‘Maar gaat het wel om een antwoord? Max Frisch (…) meent van niet. Hij maakt onderscheid tussen een vraag beantwoorden en je tegenover een vraag verantwoorden. (…) Als je een vraag moet beantwoorden, kun je zeggen dat je het antwoord niet weet; je kunt ook verwijzen naar iemand die het antwoord wel weet; ook kun je zeggen dat je voor het zoeken van het antwoord nu geen tijd hebt, of dat het je niet zo interesseert.’ Als je de vraag afdoende heb beantwoord, is daarmee de kous af en heeft het geen zin de vraag opnieuw te stellen. ‘Maar als je je tegenover een vraag moet verantwoorden, dan kun je je daaraan niet onttrekken. De ernst en het belang van de vraag verplichten je daartoe. In die zin zijn waarachtige vragen lastige vragen. (…) Als je je verantwoordt, dan tast die verantwoording de vraag niet aan. Na verantwoording blijft de vraag bestaan.’ Jos Kessels, Erik Broers, Pieter Mostert. Vrij ruimte: filosoferen in organisaties. klassieke scholing voor de hedendaagse praktijk. Amsterdam: Boom 2002; 64. ® Who reflects too much will accomplish little. – Wilhelm Tell ® Met paradoxale vragen of situaties kom je er met ‘ja’ of ‘nee’ niet uit. U kunt dan altijd nog ‘mu’ (Japans) of ‘ja ja’ (Gronings) zeggen. Dat bevestigt noch ontkent de vraag, het overstijgt uw manier van (dualistisch, exclusief) denken. De kunst van het omgaan met paradoxen is niet ze op te lossen, maar te laten bestaan. ® Without some courage, one cannot write a sensible remark about oneself. – Wittgenstein ® Poëzie stelt vragen ‘De poëzie die mij het liefst is, is begrijpelijk en stelt desondanks vragen. Onbegrijpelijke poëzie stelt valse vragen, stelt hoofdzakelijk de vraag: wat betekent dit allemaal? Na veel moeite blijkt het antwoord: niets. Goede poëzie stelt juist vragen die ik perfect begrijp, maar waarop ik geen antwoord weet. Met dat niet-weten kan ik uren bezig zijn. Goede poëzie gaat om de interpretatie van wat duidelijk is. Het is duidelijk, maar ik weet niet wat ik ermee moet. Er staat wat er staat, maar wat moet ik erbij voelen?’ Herman de Coninck. Intimiteit onder de melkweg: over poëzie. Amsterdam: De Arbeiderspers 1994; 18. ® The greatest discovery of my generation is that man can alter his life simply by altering his attitude of mind. – William James ® Stokpaardjes


‘Ik hoef de lezer, als hij er een STOKPAARD op na houdt, niet te vertellen – dat een mens aan zijn hele lijf geen gevoeliger lid heeft.’ Laurence Sterne. Het leven en de opvattingen van de heer Tristram Shand. Amsterdam: Athenaeum-Polak & Van Gennep 1990. ® Es gibt viele Menschen, die sich einbilden, was sie erfahren, das verstünden sie auch. – Johann Wolfgang von Goethe ® Reflectief denken en handelen ‘One can think reflectively only when one is willing to endure suspense and to undergo the trouble of searching. To many persons both suspense of judgment and intellectual search are disagreeable, they want to get them ended as soon as possible. They cultivate over-positive and dogmatic habits of mind, or feel perhaps that a condition of doubt will be regarded as evidence of mental inferiority. It is at the point where examination and test enter into investigation that the difference between reflective thought and bad thinking comes in.’ John Dewey. How we think: a restatement of the relation of reflective thinking in the educative process. Chigago: Henry Regnery 1933; 176. ® Als iemand in een (sollicitatie)gesprek zegt, ‘Ik heb veel ervaring’, is de meest logische reactie: ‘Èn, hebt u er iets van geleerd?’ ® Schaamte der gevoelens ‘Ik ben een nogal ouderwets en geremd iemand die moeite heeft om over zichzelf te vertellen. Of misschien ben ik juist wel een vooruitstrevend iemand, misschien verdwijnt in een volgend tijdperk de mode wel zich in het openbaar bloot te geven. Ik weet niet met wat voor inwendige reserves mensen overblijven die zo graag onthullingen doen. Je moet toch iets voor jezelf bewaren. Sommigen van mijn ervaringen probeer ik te verwerken in mijn gedichten. Soms lukt me dat, soms ook niet. Maar er zonder meer, direct over spreken is niet mijn rol.’ Wisława Szymborska. In: Anna Bikont en Johanna Sczęsna, Wisława Szymborska. Prullaria, dromen en vrienden. Biografie. Breda: De Geus 2007; 9. ® Geen mens is intelligent genoeg om zijn eigen domheid te begrijpen. – Matthijs van Boxsel ® Er is oordeelvermogen voor nodig om te weten wanneer we vooroordelen moeten handhaven en wanneer we ze moeten prijsgeven. – Theordore Dalrymple ® Edward de Bono over eenvoud


- Een deskundige is iemand die erin is geslaagd om beslissingen en beoordelingen

eenvoudiger te maken, omdat hij weet waar hij op moet letten en wat hij buiten beschouwing moet laten.

- Eenvoud is simplistisch als je het nog niet begrijpt; eenvoud is eenvoudig als je het hebt begrepen.

- Het vermogen om concepten uit te lichten, te preciseren en opnieuw vorm te geven is cruciaal voor het proces van vereenvoudiging.

- Decentralisatie kan leiden tot eenvoud wat betreft werking, maar tot grotere complexiteit wat betreft beheer.

- Het is essentieel om duidelijk te stellen waar, waarom en in wiens belang naar eenvoud wordt gezocht.

- In plaats van meer technologieontwerpen, zijn er meer ontwerpen voor ‘waardeconcepten’ nodig. De technologie kan bijna elke waarde die wij bedenken leveren – we hebben een achterstand in het bedenken van waarde.

- Sommige regels hoeven niet te worden opgevolgd – maar het is verstandig ze in je achterhoofd te houden.

Edward de Bono, Eenvoud. Amsterdam: Uitgeverij Nieuwezijds 1998. ® ‘Vraag en antwoord Een van de grondgedachten van de georganiseerde industriële vormgeving is dat het produkt het antwoord moet zijn op een vraag. Vanzelfsprekend kan men een antwoord niet juist formuleren, wanneer men de vraag niet heeft verstaan. Het zich bewust maken van de vraag moet dus de eerste stap in de richting van de conceptie van het produkt zijn, dat is een nog belangrijker bezigheid dan het maken van een schetstekening, moeilijker misschien ook, doch het resultaat ervan kan zijn dat die schetstekening niet vlotter tot stand komt, dan toch met grotere kans op succes gemaakt kan worden.’ Wim Gilles, Industriële vormgeving, de productanalyse, 1957. In: Het ontstaan der dingen. Schetsen, modellen en prototypes. Museum Boijmans Van Beumingen Rotterdam / NAi Uitgevers Rotterdam 2003. ® In plaats van met kijkcijfers kunnen talkshows op tv beter met de volgende criteria beoordeeld worden. Mensen met beperkt verstand praten over andere mensen. Mensen met gemiddeld verstand praten over gebeurtenissen. Mensen met verstand praten over ideeën. ® The greatest danger for most of us is not that our aim is too high and we miss it, but that it is too low and we reach it. – Michelangelo. ® Humor en anamnese


Een bijzondere aspect van het empirisch vermogen van de dokter is gevoel voor humor. Dat komt omdat het (glim)lachen om een opmerking of situatie ook een intersubjectieve instemming en afstemming tussen mensen uitdrukt. Humor houdt een reflectieve verwijzing in naar wat Alfred Schütz de voorraad van ‘alledaagse kennis’ noemt: humor onthult een stukje van de structuur van de gedeelde sociale leefwereld (Alfred Schutz. Der sinnhafte Aufbau der sozialen Welt, 1967. Zie hoofdstuk 6). Humor kan dus fungeren en gebruikt worden voor het verfijnen van anamnese en communicatie. Als een dokter humor op deze manier weet te hanteren, als onderdeel van zijn communicatief empirisch vermogen, gaat het uitdrukkelijk niet om grappig zijn, de ‘clini-clown’ uithangen, of om patiënten aan het lachen te krijgen. Het gaat om een reflectieve milde beroepshouding, waardoor een verstandhouding met de patiënt wordt opgebouwd waarin betere informatie kan worden uitgewisseld. ® Mijn dokter zegt dat ik heel goed op de placebo’s reageer. ® If you can't change the circumstances, change your perspective. – Unknown ® Advies om bij de hand te hebben voor studenten en docenten die ongeduldig en ongelukkig worden als anderen niet zo snel en slim zijn als zij: Sei nicht ungeduldig, wenn man deine Argumenten nicht gelten lässt. – Johann Wolfgang von Goethe ® Schaatsen en reflecteren ‘Het was werkelijk goddelijk zoals hij hier voortgleed – dat woord kwam ook bij hem op: goddelijk. De bewegingen van het schaatsen waren iets wat hoorde: prachtig om naar te kijken, heerlijk om zelf te doen – schaatsen moest door God persoonlijk zijn bedacht. Maar eigenlijk, nu hij erover nadacht, bewees de goddelijkheid van het schaatsen juist dat God niet bestond. Want als je een wereld moest scheppen, en je kreeg de vrije hand zoals God had gehad, dan zou je, om schaatsen te kùnnen bedenken, toch wel heel veel eerst moeten bedenken. Water, kou, vriezen. (..) En dan moest je nog bedenken dat je botten van dieren kon slijpen (..) pas dàn was schaatsen mogelijk, dit eindeloze goddelijke glijden, afduwen en glijden, zonder dat het moeite kostte, in het donker van de Ransdorper Die.’ Tim Krabbé. Drie Slechte Schaatsers, Amsterdam: Prometheus 2004. ® ‘Werken aan de grenzen van het weten’ komt in de praktijk meestal neer op ‘werken aan de grenzen van het meten’.


® ‘Product: het doel Elke ontwerper zal u daarop antwoorden dat het materiaal, evenals de constructie waar het direct mee samenwerkt, evenals de werkwijze die het verlangt, evenals de afwerking die het toestaat en de kleur waarin het gebracht kan worden, ondergeschikt is aan het product. Dat het een van de middelen is om dat product te doen beantwoorden aan die steeds weer terugkerende criteria van: 1. functionaliteit – geschiktheid voor het gebruiken 2. rationaliteit – geschiktheid voor de vervaardiging 3. begeerlijkheid – geschiktheid voor de verkoop.’ Wim Gilles, Polytechnisch tijdschrift, oktober 1955. In: Het ontstaan der dingen. Schetsen, modellen en prototypes. Museum Boijmans Van Beumingen Rotterdam / NAi Uitgevers Rotterdam 2003. ® How awful to reflect that what people say of us is true! – Logan Pearsall Smith ® Competence, like truth, beauty and contact lenses, is in the eye of the beholder. – Laurence J. Peter, The Peter Principle ® Het biljartspel ‘Het is dan ook logisch, dat het beoefenen van het biljartspel door vele doktoren wordt voorgeschreven aan patiënten, die in hun dagelijks leven zittende arbeid moeten verrichten. Met de gezonde lichamelijke bewegingen, die in het biljartspel liggen opgesloten, verbindt zich ook een afzonderlijke geestelijke prikkeling, welke in het wikken der kansen en in de mathematische berekening van de loop der ballen ligt. Het feit, dat men tot op zeer hoge leeftijd dit spel, dat meer souplesse dan kracht vraagt, kan blijven beoefenen, vraagt onze bijzondere aandacht. (…) De verklaring is deze: het biljartspel is een spel van de hersenen en van de hand, die beide bij de normale mens tot op hoge leeftijd blijven functioneren.’ A.W.H. van Haaren, J.E. van der Hoek jr., Het biljartspel. Amsterdam-Antwepen: Kosmos 1965. De reeks Weten en Kunnen nr. 257. ® Reflecteren is denken over denken ‘Een man staat in een café en het barmeisje vraagt of hij zich wel goed voelt, hij ziet er een beetje merkwaardig uit. Hij zegt dat dat wel kan kloppen, hij is namelijk aan het denken. Waarover, vraagt het barmeisje. Over denken, zegt de man. Dat kan niet, zegt het barmeisje. ‘Mensen kunnen niet alleen denken over denken, je moet ergens over denken, ontbijt, of bier, of seks, of de regering, maakt niet uit, maar je moet met iets beginnen, toch? Anders zou je een gedachte hebben over een gedachte over een gedachte over een gedachte … mij niet gezien!’ Stefan Themerson. Logica, Etiketten, en Vlees. Amsterdam: De Bezige Bij 1979.


® Dermatologie is het vakgebied waar lichaam en geest elkaar op de huid zitten. ® Oecumenische gedachte: Zoveel mogelijk water in elkanders wijn proberen te doen. – Wim Kan ® It takes 15.000 casualties to train a major general. – Ferdinand Foch ® Ervaring

In een konstruktie met veel kwaliteit steekt evenredig veel ervaring. Langdurig en herhaald gebruik door tal van meesters heeft deze ervaring aangedragen. Een beginneling die een goede konstruktie voor het eerst gebruikt komt in kontakt met deze ervaring. Hij kan twee wegen bewandelen om de ervaring eigen te maken: Zelf trachten het juiste gebruik uit te vinden, of zich in dat gebruik door een meester laten instrueren. Dick Raaijmakers. De Methode. Uitgeverij Bert Bakker, Amsterdam, 1985.

® Een leugen kan ook wel eens niet waar zijn (Huis de Beurs). ® ‘There is an underlying rhythm to all text. Sentences crash and fall like the waves of the sea, and work unconsciously on the reader. Punctuation is the music of language. As a conductor can influence the experience of a song by manipulating its rhythm, so can punctuation influence the reading experience, bring out the best (or worst) in a text. (..) A delicate world of punctuation lives just beneath the surface of your work, like a world of microorganisms living in a pond. They are missed by the naked eye, but if you use a microscope you’ll find they exist.’ Noah Lukeman, A dash of style. The art and mastery of punctuation. New York: Norton 2006: 14. ® Student: Reflecteren is zo’n natuurlijk proces, dat doe ik zonder erbij na te denken.

Graduate School for Health Research SHARE This thesis is the first one published within the research program Research in Medical Education of the Graduate School for Health Research SHARE. More information regarding the institute and its research can be obtained from our internet site: www.rug.nl/share. Recent dissertations from the Graduate School for Health Research SHARE: Zuurmond RG (2008) The bridging nail in periprosthetic fractures of the hip; incidence, biomechanics, histology and clinical outcomes Supervisor: prof dr SK Bulstra Co-supervisors: dr AD Verburg, dr P Pilot Wynia K (2008) The Multiple Sclerosis Impact Profile (MSIP), an ICF-based outcome measure for disability and disability perception in MS: development and psychometric testing Supervisors: prof dr SA Reijneveld, prof dr JHA De Keyser Co-supervisor: dr LJ Middel Van Leeuwen RR (2008) Towards nursing competencies in spiritual care Supervisors: prof dr D Post, prof dr H Jochemsen Co-supervisor: dr LJ Tiesinga Vogels AGC (2008) The identification by Dutch preventive child health care of children with psychosocial problems : do short questionnaires help? Supervisors: prof dr SA Reijneveld, prof dr SP Verloove-Vanhorick Hinnen SCH (2008) Distress and spousal support in women with breast cancer Supervisors: prof dr R Sanderman, prof dr AV Ranchor, prof dr M Hagedoorn Nijhuis BGJ (2007) Team collaboration in Dutch paediatric rehabilitation Supervisors: prof dr K Postema, prof dr H Nakken, prof dr JW Groothoff Co-supervisors: dr HA Reinders-Messelink, dr ACE de Blécourt Kort NP (2007) Unicompartmental knee arthroplasty Supervisor: prof dr SK Bulstra Co-supervisors: dr JJAM van Raay, dr AD Verburg Weert E van (2007) Cancer rehabilitation – effects and mechanisms Supervisors: prof dr K Postema, prof dr R Sanderman Co-supervisors: dr CP van der Schans, dr JEHM Hoekstra-Weebers, dr R Otter

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