Reflection in medicine

Models of reflection

Many models of reflection exist.¹² Such models of reflection can provide a foundation for building learning activities that might help improve reflective abilities. (Table 1^{1,2,4,6–8,13} shows the levels of reflection of several models.) To describe reflection, several models use a scale that goes from superficial to deeper reflection or learning, with the deeper levels seemingly harder to achieve.¹² Moon's last step implies the process of integrating learning into existing cognitive structure, which leads to changes in attitude and behaviour.⁷

Three of the models describe reflection as an iterative process (Table 1^{1,2,4,6–8,13}): models from Kolb¹³ and Schön,⁶ who are widely known in education, and Boud and colleagues.² These 3 models share the “surprise” concept or the idea that new experiences are triggers for reflection.

These different models can be used in various settings to teach ourselves, students, peers, and health care teams to be reflective practitioners and reflective teams. The aim of reflective activities should be to move learners from the lower levels of reflection to the higher levels and then to application. If a cycle model is used, then the next step should start from this application to trigger a new reflective cycle. All these models are descriptions of the same phenomenon. The practitioner, facilitator, or teacher could choose 1 model, become familiar with it, and then use it to build reflective activities.

Table 2 lists examples of questions that can be used in a variety of settings to move learners along the reflection continuum. Noticing questions are useful in the clinical setting, after observing a learner with a patient or after a case discussion. Processing questions might require step-ping back, a little like “reflection–on–action,”⁶ and might be more useful in grand rounds, group case discussions, or Balint groups.¹⁴ Future action questions are used during end–of–case discussions or encounters between educational supervisors and their pupils as they plan the next clinical activities and inform future learning. In morbidity and mortality committees, processing and future action questions are useful to help move reflection beyond simple discussions of cases and blame.

There are many activities that can foster reflection (Table 3). Although there are the obvious ones such as keeping learning portfolios or writing reflective essays, other opportunities do exist, and not all reflective activities need to be completed individually. For example, we sometimes use reflective log sheets to record daily reflection with our more advanced learners instead of the usual daily–assessment sheets that clinical supervisors use. Recording daily reflection can help residents learn to self–assess. The contents of reflective log sheets are discussed with clinical super-visors, providing further opportunity for reflection. Residents can make reflective log sheets a part of their portfolios, and they can later refer to them to feed their reflection and their discussions with their educational supervisors, as well use them to build their learning plans. Another reflective activity we use in our setting is the practice-based small group learning program of the Foundation for Medical Practice Education.¹⁵ This program is designed to facilitate reflection through case–based discussions of residents' cases and log sheets. These log sheets, which include commitment-to–change practice statements, are completed at the end of each module and are revisited at a later period to discuss whether the planned changes were made and what the facilitators and barriers to implementing those changes were. All of these activities are even more effective if the facilitator in a group, or the educational supervisor in an individual encounter, uses judicious questions to help learners move along the reflection continuum, through the steps of noticing and processing, in order to inform future actions.⁵ The scales can also be used to build tools to assess the level of reflection in written work or during group discussions.

A real tool

What we reflect on, how we reflect, and what happens after reflection can vary. Reflection can occur when a learner reflects on an individual, group, or organizational aspect of clinical practice, education, policy, or research. It can also occur when a team reflects on how it functions as a group. As such, using simple tools such as questionnaires or reflective essays to assess the process of reflection might only capture part of the process, and the process should not be abandoned for the perceived lack of a robust measurement.

Reflection is not an abstract concept. It is an important tool in the practice of medicine, as Epstein and Hundert explain in their article on professional competence: Professional competence is “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.”¹⁶ This statement gives us a reason to continue to reflect on our actions and teach our trainees to reflect.