Few things seem to irritate doctors and medical students so much as mandatory reflection. Compared to bullying bosses, the lack of sleep and an unstoppable tide of human suffering, the amount of bitterness harboured at being forced to write down ‘reflections’ may seem crazily out of proportion, but I share their frustration. I say this because I am enthusiastic about reflection, but dismayed by the ways it has been handled in medical education and clinical practice.
The assumptions underlying medicine and reflection
To justify any kind of reflection we need to begin with questions like, ‘What is medicine (for)?’ The philosophical foundations of our practice are rarely examined in the formal medical curriculum, but in the hidden curriculum of real-life experience we learn that medicine is a moral practice, guided by science and shaped by culture. It is impossible to escape from the inherent moral ambiguity, scientific uncertainty and cultural conflicts that arise.
These conflicts result in cognitive dissonance – a state of internal inconsistency that some people thrive on, but most are left feeling anxious and uncomfortable, especially when their own values and beliefs are challenged. It may be possible to ignore or suppress the dissonance, but without serious thinking, it can lead to anxiety and burnout or an entrenchment of attitudes, and a lack of critical self and social-awareness.
This brings me to the first problem with mandatory reflection. The dissonance that is frequently the trigger for reflective writing often requires the author to acknowledge their anxiety and reveal their vulnerability. If they are going to do that, then they need to be confident that their writing with be treated seriously and sensitively. In reflective writing problems are identified and explored and though there may be resolution, resolution is not the aim and is rarely the outcome.
Reflection as a supervisory process
Before I help my students with their reflective writing for the first time, conscious that they might be less than enthusiastic, I ask them whether they found it useful before. They often say that they valued time spent talking with their tutor about what they had written, but did not appreciate handing in a piece of writing which was returned with little more than a grade and some comments in the margins. I have learned over the years to treat reflective writing as a process of supervision.
I teach second year medical students to supervise one another using a modified Balint approach . They read aloud a 500 word reflective piece they have written about a patient-experience to a small group of fellow students and myself. They say why the experience mattered to them, any thoughts they had while they were reading it out, and any help they would appreciate from the group. While the writing is an example of ‘reflection on action’, that is, a retrospective view of events, thinking about the writing, whilst reading it aloud demonstrates ‘reflection in action’ . While reading, students often notice things they no longer agree with, or ideas that are less clear than they were when they wrote them down. They make clarifications and comment as they go along and after they have finished reading.
I teach the group to listen. They listen for phrases, and think about why a particular phrase was used. The listen for cues – points of significance, and think about what makes them significant and for whom. They listen for contexts that are there and those that are missing, and think about how these change the significance or meaning of what they have heard. Reflective writing is full of attempts to interpret events, so they listen for examples and think about the significance of one interpretation among other possibilities. They listen to find out what role the narrator plays in the narrative – second year medical students rarely play the role of heroic doctor, but more frequently feel like an imposter playing the part of a trusted professional. They listen for the feelings and emotional content of both the writing and the reader. They listen to what needs are being expressed in the writing and reading. They listen to their own response and how that feels. For those that are keen to learn more I suggest some introductory papers on narrative medicine [3–7].
Close listening is a teachable skill and I find it extremely rewarding to join in with their discussions and share in their progress. After doing this for the last two years, I believe now that empathy can be taught, and it starts by learning how to listen .
After the work has been read aloud, the narrator sits back and the group discusses what they have listened to without directing their comments to the presenting student or making judgements. To show that they have listened they are encouraged to quote phrases and describe their interpretations. I help the group to identify themes and to think about areas that could be explored in more detail and to think about how they can relate to the work. Students need help to identify potential blind spots, like issues of power . Reflection becomes critical reflection when it includes,
considerations of the creation by social and systemic factors of contexts that implicitly or explicitly influence one’s beliefs and behaviours .
After a few minutes the presenting student, who has been listening, is invited back into the group to respond. We all take turns to present our reflective writing, including myself, so that the students can see that I am willing to share my own difficulties and am interested in their responses.
The depth and quality of their conversation often shows a startling maturity and their ability to help one-another to think seriously about their work comes naturally and improves rapidly. After the first session they rewrite their piece, taking into account the discussion and then at a later session, re-present their work to the group in the same way. This gives them the opportunity to learn about trust and continuity. They learn to trust the group (or not) because of the way they handle their reflective writing. Treated sensitively they grow in confidence and their subsequent writing is deeper. Rewriting their work and re-presenting it, reveals the transformative nature of reflection and dialogue and helps them to learn how consultations can transform stories. They learn that reflective practice is an on-going social process rather than a competency or solipsistic introspection.
A reflective culture
The majority of medical students and doctors are naturally self-critical and sensitive to criticism. The aim of reflective practice should be to create a supportive culture in which all professionals are encouraged to think seriously with one-another about what is going on in every-day practice. Without a just culture clinicians will be afraid to talk about important issues for fear of criticism or recrimination . In discussing their study about patient-centred behaviour in medical students, Bombeke et al. concluded that,
Raising students awareness of their personal attitudes might be a better learning goal than teaching ‘better attitudes’ because students may resist attempts to force them to be patient-centred .
Nobody, least of all someone who is either overly or insufficiently self-critical, likes to be told that their reflective writing is not good enough. Judgments about reflective writing may be taken as (and may well be) judgments of character, which educators and others make at their peril. Reflective capacity is a core feature of professionalism and students are unhappy with being judged on this too [14,15].
In their paper about Assessment as Practice, Jordan and Putz describe inherent, discursive and formal types of assessment . We make inherent assessments all the time, as I did by recognising the progress my students made with their reflective writing in our sessions together,
Fundamental is the fact that in-a-glance, on-the-fly mutual assessments underlie all of human sociality and, in fact, the solidarity of all social species. They occur routinely, effortlessly, and unavoidably as part of any non-solitary human activity where people rely on a shared sense of purpose. It is how newcomers become full members of communities of practice.
Formal assessments of reflective writing risk transforming a social process into a finished product, but it is obvious to my students that reflection is always open-ended.
In their narrative review of supervision in medical education, Ng et al. ask, rhetorically,
What difference might it make to consider reflection as more than tool or technique? Reflective practice as a way of being transcends traditional assessment; it is an orientation through which one practices, continually challenges one’s own assumptions, and builds new knowledge .
Rita Charon , in A Sense of Story, or Why Teach Reflective Writing, says,
The duty of the teacher is not to judge and rate but rather to read and tell what is seen. Reflection fulfills difficult missions of medical education in teamwork, peer learning, trust and care.
In learning to listen, reflect and respond to each other, students learn how to listen empathically and interact not only with one-another, but with patients. It helps students develop not just self-critical faculties, but social and political awareness. They learn a little of what it is like to reveal their vulnerabilities and have someone else respond with skill and empathy.
We worry that in our commitment to bring reflective writing to our students we might hurry to provide our schools with what we think they want, like quantified markers of individual learner’s achievements. This impulse perhaps distorts and squanders the potential deep dividends of the work of reflective writing. We might remember that it is a profound achievement to equip our students – and ourselves – with the capacity to tell and listen to stories.
We should pay more attention to nurturing reflective practices instead of devising formal assessments of reflective writing. Medicine might be more humane for doing so.
References and further reading
1 Launer J. Moving on from Balint : embracing clinical supervision. Br J Gen Pract 2007;45:182–3.
2 Schön DA. The Reflective Practitioner: How Professionals Think in Action. Basic Books 1983. http://books.google.ca/books/about/The_Reflective_Practitioner.html?id=ceJIWay4-jgC&pgis=1 (accessed 7 Aug2014).
3 Greenhalgh T. What Seems to be the Trouble?: Stories in Illness and Healthcare. Radcliffe Publishing 2006. http://books.google.co.uk/books/about/What_Seems_to_be_the_Trouble.html?id=_GFjwtQgaA0C&pgis=1 (accessed 2 Dec2014).
4 Greenhalgh T, Hurwitz B. Narrative based medicine: Why study narrative? BMJ 1999;318:48–50. doi:10.1136/bmj.318.7175.48
5 Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust. JAMA 2001;286:1897. doi:10.1001/jama.286.15.1897
6 DasGupta S. Stories Matter: Narrative, Health and Social Justice. 2012;5:1–4.http://www.conexionpediatrica.org/index.php/conexion/article/viewFile/258/308
7 Launer J. Patient choice and narrative ethics. Postgrad Med J 2014;90:484. doi:10.1136/postgradmedj-2014-132866
8 Afghani B, Besimanto S, Amin A, et al. Medical students’ perspectives on clinical empathy training. Educ Health (Abingdon) 2011;24:544.http://www.educationforhealth.net/article.asp?issn=1357-6283;year=2011;volume=24;issue=1;spage=544;epage=544;aulast=Afghan (accessed 22 Sep2014).
9 Donetto S. Medical students’ views of power in doctor-patient interactions: the value of teacher-learner relationships. Med Educ 2010;44:187–96. doi:10.1111/j.1365-2923.2009.03579.x
10 Ng SL, Kinsella EA, Friesen F, et al. Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review. Med Educ 2015;49:461–75. doi:10.1111/medu.12680
11 Dekker PS. Just Culture: Balancing Safety and Accountability. Ashgate Publishing, Ltd. 2012. http://books.google.com/books?hl=en&lr=&id=hntr2Ok3Ed0C&pgis=1 (accessed 7 Aug2014).
12 Bombeke K, Symons L, Debaene L, et al. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ 2010;44:662–73. doi:10.1111/j.1365-2923.2010.03627.x
13 Birden H, Glass N, Wilson I, et al. Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach 2013;35:e1252–66. doi:10.3109/0142159X.2013.789132
14 Finn G, Garner J, Sawdon M. ‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study. Med Educ 2010;44:814–25. doi:10.1111/j.1365-2923.2010.03743.x
15 Brainard AH, Brislen HC. Viewpoint: learning professionalism: a view from the trenches. Acad Med 2007;82:1010–4. doi:10.1097/01.ACM.0000285343.95826.94
16 JORDAN B, PUTZ P. Assessment as practice: Notes on measures, tests, and targets. Hum Organ;63:346–58.http://cat.inist.fr/?aModele=afficheN&cpsidt=16172270 (accessed 9 Feb2015).
17 Charon R, Hermann MN. A Sense of Story, or Why Teach Reflective Writing? Acad Med 2013;87:5–7. doi:10.1097/ACM.0b013e31823a59c7.A