Reflection in/and Writing

Journal of General Internal Medicine, 2010

Reflective capacity has been described as an essential characteristic of professionally competent clinical practice, core to ACGME competencies. Reflection has been recently linked to promoting effective use of feedback in medical education and associated with improved diagnostic accuracy, suggesting promising outcomes. There has been a proliferation of reflective writing pedagogy within medical education to foster development of reflective capacity, extend empathy with deepened understanding of patients' experience of illness, and promote practitioner well-being. At Alpert Med, "interactive" reflective writing with guided individualized feedback from interdisciplinary faculty to students' reflective writing has been implemented in a Doctoring course and Family Medicine clerkship as an educational method to achieve these aims. Such initiatives, however, raise fundamental questions of reflection definition, program design, efficacy of methods, and outcomes assessment. Within this article, we consider opportunities and challenges associated with implementation of reflective writing curricula for promotion of reflective capacity within medical education. We reflect upon reflection.

2010

Introduction: Reflective writing, a complex human activity is one of the innovative pedagogies to promote deep learning among medical students and doctors. Despite its potential to facilitate learning, there is limited literature on evaluation of various purposes of reflective writing in medical education. Hence, aim of this study is to develop an instrument and evaluate the perceptions of house officers about benefits of reflective writing. Methods: Mixed method study followed AMEE 87 guidelines for questionnaire development. The study was carried out from Oct 2018-Feb 2019 in a dental college in Islamabad. A 30-items questionnaire was developed by following these steps: (1) conduction of literature review, (2) item development, (3) conduction of cognitive interviews and (4) pilot testing. Coding and interpretation of transcribed data and notes taken during cognitive interviews was done to finalize three main themes (learning, self-regulation and alteration in clinical behavior) identified in literature review. In pilot testing, participants were asked to rate the purposes of reflective writing on a three-point Likert scale (Agree, do not know and disagree). Data was analyzed using SPSS version 22. Results: All of nineteen house officers (n= 3 for cognitive interviews, n= 16 for pilot testing) had previous experience of writing reflections using Gibb's reflective cycle. Thirteen (81%) out of sixteen house officers agreed that reflective writing improves learning, helps in self-regulation and alters clinical behavior, two (13%) did not know about the three themes that were finalized in cognitive interviews and one (6%) did not agree. Discussion and Conclusion: Reflective writing improves learning, helps in self-regulation and alters clinical behavior in the selected house officers. This study may inspire medical education experts to include reflective writing as a part of formal undergraduate medical and dental curriculum to enhance student's learning experience.

Physicians deal with complex and ill-structured problems and must reflect in order to function professionally while adapting to their patients' needs. This qualitative single case study explores the meaning and use of reflection in the professional preparation of physicians within the medical school of a Midwestern University. Along with a review of the types of reflection assessed and an analysis of Epstein's (1999) Levels of Mindfulness in guided student reflections, faculty and administrators were interviewed to learn more about their perspectives related to reflection. Assessing reflection in medical education is complicated by a lack of agreement about definitions and goals. Although scientific reflection and clinical reflection are more heavily assessed in written evaluations, faculty tended to discuss personal reflection (learning from experience) more during interviews. Most interviewees focused on one aspect of the phases of reflection (trigger, critical analysis, or outcome) rather than the entire process. Some were particularly uncomfortable with the idea of assessing an internal process. The use of Level of Mindfulness was useful in assessing quality and focus of students' written narratives, however the levels do not work well as a continuum for this purpose and proved to be too broad to detect more subtle shifts in thinking across time. In addition, encouraging students to tell stories seems to stimulate deeper reflection. Using common definitions can help facilitate meaningful opportunities for reflection into the curriculum. x This study explores the meaning and use of reflection in the professional preparation of physicians. This qualitative single case study examines the use of reflection within the medical school of a Midwestern University designated a Research University (Very High Research Activity) by the Carnegie Foundation. Along with a review of existing evaluations and an analysis of guided student reflections, I interviewed faculty tutors and medical education deans to learn more about their perspectives. The goal was to produce a thick description of the use of reflection at this medical school. Specifically I investigate how faculty define reflection in the first 2 years of this medical school's curriculum, and how students' written reflections relate to ratings of reflective ability given by faculty. This study aims to answer the following question: How is the concept of reflection used in the educational preparation of physicians? The following sub- questions help to answer the larger question: 1. How is reflection defined and evaluated in the first 2 years of the medical school curriculum? a. What are faculty and administrators' beliefs and values related to reflection? b. What types of reflection are assessed: scientific, clinical, personal (Aukes et al., 2007)? Why were these items chosen? 2. What is the relationship between faculty's perceptions of a student's reflective ability (as demonstrated in scores received on tutor evaluations) Reflection in Medical Education 7 of their portfolio, students complete guided reflection exercises after the first and second years and in the middle of the third year. These questions focus on personal strengths and weaknesses and future goals related to the graduation characteristics. In addition, second year students provide artifacts of their competency in each of the eight characteristics. Throughout the first 2 years, tutors provide numerical ratings as well as comments to students for various areas of performance including self-reflection, problem solving ability, and group interactions. These evaluations provide an artifact of faculty thinking related to reflection by means of what was included and excluded from the evaluation. Unfortunately, students of any program sometimes receive contrary messages. They may read about the importance of patient centered care in program materials but receive other messages in the day-to-day activities of professional preparation. This informal or hidden curriculum does not always support students building communication and relationship skills (Dobie, 2007). And with so many different definitions of reflection, it may not be abundantly clear which, whose, and how these definitions are being incorporated into the curriculum and lived by the students and faculty. This dissertation explicitly analyzes the espoused and lived values of the faculty, administrators, and students at one particular medical school to help understand how those involved (students, faculty, and administrators) have interpreted and used reflection to train medical students. Reflection in Medical Education 8 Conceptual Context This section outlines conceptual frameworks supporting this research including types and levels of reflection. In addition, I provide definitions used and assumptions made related to this research. Types of Reflection Aukes et al. (2007) outline three types of reflection in medicine: clinical, scientific, and personal. Scientific reflection and clinical judgment are most emphasized and may be called problem solving, decision-making, or critical thinking. The authors describe personal reflection as reflection-ON-experienceemphasizing sense-making in medical practice. Personal reflection tends to be seen as a personality trait or private attitude outside of the medical tool kit (Coulehan , 2005). In this study, the items faculty developed to assess reflection were coded according to which of the three types of reflection they assess. Epstein (1999) does not limit reflection to scientific reasoning, clinical decisions, or personal experiences. Instead he speaks of the mindful practitioner as one who "attends, in a nonjudgmental way, to his or her own physical and mental processes during ordinary everyday tasks to act with clarity and insight," (p. 2) and suggests that mindfulness is integral to competence. Epstein expands the idea of reflective practice and highlights the interdependence of action, cognition, memory and emotion proposing the following Levels of Mindfulness: 0) Denial & Externalization-the problem as "out there", person may avoid responsibility or reflection. Reflection in Medical Education 9 1) Imitation/Behavioral Modeling-takes some responsibility, but uses external behavioral standard to resolve situation. 2) Curiosity/Cognitive Understanding-makes decisions based on cognitive models. Reflects to generate hypotheses but ignores personal knowledge, tacit knowledge, and emotions. 3) Curiosity/Emotions and Attitudes-shows curiosity about feelings, thoughts, and behaviors without labeling them as good or bad. 4) Insight-shows understanding about the nature of a problem, how to attempt to solve the problem, and the interconnectedness of practitioner and knowledge. 5) Generalization/Incorporation and Presence-uses insight to generalize. Incorporates new behaviors and attitudes and shows compassion. Mindfulness can be applied to any aspect of medical practice. As can be seen from the levels, mindfulness is more than critical thinking related to symptoms and diagnoses or personal reflection on feelings. Rather it is a global approach to medical practice. For this study, I use Epstein's (1999) levels of mindfulness to analyze student narratives related to performance and progress in the first 2 years of medical school. Blocks-The units by which the studied medical school divides academic years. Each year consists of four ten week blocks-Eight weeks of instruction, one week of evaluation, one week off. Clerkship-A course occurring in the third and fourth years of medical training usually focused on a specialty area and lasting 2 to 8 weeks. PBL-Problem Based Learning is an educational approach in which students learn by attempting to solve a problem. In the curriculum being studied, small groups are presented a new case every week and must diagnose the patient and develop an appropriate treatment approach. Tutor-Educator that facilitates the problem based learning group process without lecturing or providing the group answers. Mindfulness-Nonjudgmental attention to physical and mental processes of everyday tasks in order to gain insight and inform actions . Clinical Reasoning (doctor as expert)-Problem-and patient-oriented understanding, judgment and decision making. The key function of clinical reasoning is to solve a problem. This is reflection related to solving a patient's problem. Scientific Reflection (doctor as scholar)-Critical appraisal of literature and one's own practice, ground in evidence and clinical epidemiology (Sackett, Haynes, Guyatt, & Tugwell, 1991). The key function of scientific reflection is optimizing scientifically-based clinical decisions or evidence-based medicine. This is a more technical view of reflection. Personal Reflection (doctor as person)-Consideration of experience (own and others) in order to make sense/meaning. Aukes et al. (2007) calls this Reflection-on-Experience. Attends to the process of sense making about practice, thoughts, emotions, and beliefs. Reflection in Medical Education 11 In this section I make explicit assumptions I have made related to this research. First, multiple constructed realities exist (Denzin & Lincoln, 2000). Using a qualitative approach (specifically a case study) allows a multifaceted view of reflection in medical education to emerge that would be difficult to achieve with a national survey of medical schools. Second, knower and known shape each other (Denzin & Lincoln, 2000). I tried to remain aware of my position in relation to this research at all times. Chapter three outlines the ways in which I formally monitored my influence on this research. Third, although reflection is an internal process, I have assumed that cognitive processes and behavior are connected therefore evidence of reflection can be observed. Fourth, I assumed that programs assess/evaluate what they value. Therefore, written evaluations used by this medical...

Annals of Family Medicine, 2017

All of us have an “inner life” that forms the core of who we are. It shapes and is shaped by our actions and experiences. During physician training, attention to residents’ inner life requires a focus on their beliefs and emotions as well as their ethical and spiritual development, topics often considered to be outside the realm of clinical training and practice. We suggest that written reflections, as part of medical residency curriculum, can allow residents to explore their inner lives. The depth and range of residents’ explorations show the value of adding brief, protected time for residents to explore their hopes, joys, struggles, and feelings, and to develop meaning from their experiences with patients.

Journal of medical education and curricular development

Reflection has become an important tool for physicians and other medical practitioners. However, many forms of reflection exist in the health care literature, with each having particular implications for successful clinical practice. Very little attention has been given to whether reflection is a vital part of narrative medicine and which forms of reflection might be compatible with this approach to patient care. In this article, the most common types of reflection are compared and discussed, specifically regarding their potential role in narrative medicine. Reflection that encourages practitioners to focus on the various perspectives shared within a medical encounter is both in line with the tenets of narrative medicine and has important consequences for patient empowerment.

Reflective Practice, 2014

Reflection is thinking about, pondering upon something that we have learnt. It is something that one consciously looks at in great depthcontemplating, analyzing in order to learn from it. Reflection aids everyday life in formal learning and informal learning. Reflection is used widely in the field of education, especially healthcare curricula throughout the world in which clinical practice is a huge component. This study aims to identify whether there is an improvement in students' clinical grades with the use of a reflective journal. Before students were exposed to clinical posting, they underwent a Workshop on Reflective Writing to teach them how to write a reflective journal. They were introduced to Kolb's four-stage model of reflection: concrete experience, reflective observation, abstract conceptualization and active experimentation. The students were asked to write a minimum of three journal entries each week, but they were encouraged to write as much as possible. Students were then sent on clinical placement. A one-to one interview with each student revealed that students felt that writing reflective journals improved their clinical practice. Findings revealed that there was improvement in their clinical practice. Hence knowledge of reflective writing is fundamental to healthcare educators, and they themselves need to be reflective practitioners.

BMC Medical Education

Background Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW’s place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed. Methods A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content anal...

2020

Purpose Reflective writing (RW) curriculum initiatives to promote reflective capacity are proliferating within medical education. The authors developed a new evaluative tool that can be effectively applied to assess students' reflective levels and assist with the process of providing individualized written feedback to guide reflective capacity promotion. Method Following a comprehensive search and analysis of the literature, the authors developed an analytic rubric through repeated iterative cycles of development, including empiric testing and determination of interrater reliability, reevaluation and refinement, and redesign. Rubric iterations were applied in successive development phases to Warren Alpert Medical School of Brown University students' 2009 and 2010 RW narratives with determination of intraclass correlations (ICCs). Results The final rubric, the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), consisted of four reflective capacit...

The purpose of this article is to analyze some models of expert decision and their impact on the clinical practice. We have analyzed decision-making considering the cognitive aspects (explanatory models, perceptual skills, analysis of the variability of a phenomenon, creating habits and inertia of reasoning and declarative models based on criteria). We have added the importance of emotions in decision making within highly complex situations, such as those occurring within the clinical practice. The quality of the reflective act depends, among other factors, on the ability of metacognition (thinking about what we think). Finally, we propose an educational strategy based on having a task supervisor and rectification scenarios to improve the quality of medical decision making. de decisiones; Toma de decisiones clínicas; Seguridad del paciente; Práctica profesional