The use of reflection in medical
education:
AMEE Guide No. 44
JOHN SANDARS
The University of Leeds, UK
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Twelve tips for teaching reflection at
all levels of medical education
LOUISE ARONSON
University of California, USA
2
Learning
Professionalism
Clinical
reasoning
3
But how??
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Reflection in the education context
• A process in which thoughts are ‘turned back’
so that they can be interpreted or analyzed.
• Outcome: increased understanding or
awareness which can be used in future when
faced with a similar event.
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Definitions
• Reflection (Dewey 1938):
‘an active, persistent and careful consideration of any belief or
supposed form of knowledge in the light of the grounds that
support it and the further conclusion to which it tends’.
• Reflection (Boud et al. 1985):
‘a generic term for those intellectual and affective activities in
which individuals engage to explore their experiences in order to
lead to a new understanding and appreciation’.
• Reflection (Moon 2004):
‘a form of mental processing with a purpose and/or anticipated
outcome that is applied to relatively complex or unstructured ideas
for which there is no obvious solution’.
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Critical reflection
• Process of analyzing, questioning, and
reframing an experience in order to make an
assessment of it for the purposes of learning
(reflective learning) and/or to improve
practice (reflective practice).
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A medical mistake
A superficial, educationally ineffective
reflection:
Description of the events or a description
accompanied by reasons such as the
team/clinic was busy and other people failed
in their responsibilities.
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A medical mistake
A more useful and deeper reflection :
- How and why decisions were made
- Underlying beliefs and values of individuals and
institutions
- Assumptions about roles, abilities and responsibilities
- Similar past experiences
- Contributing hospital circumstances and policies
- Frank discussion with team members
- Explicit notation of lessons learned and creation of a
specific, timely, and measurable plan for personal or
system change to avoid future similar errors
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“Reflective learning” goals
• Meaningful learning
• Practice improvement
• Help learners integrate (1) new learning with
existing knowledge; (2) affective with
cognitive experience; and (3) past with
present or present with future practice
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Reflection process
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• Reflection is a metacognitive process that
occurs before, during and after situations
with the purpose of developing greater
understanding of both the self and the
situation so that future encounters with the
situation are informed from previous
encounters.
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Metacognition
‘thinking about thinking’
effective reflection
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Reflection before, during and after
Reflection before an action
Approaching situations with
a particular learning goal
Greater personal growth
and learning
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Future action
Reflection is a process with a definite purpose
Making sense of a situation will not improve
practice unless these insights can change
future responses to situations.
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Approaches to
Reflection in medical education
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1. Reflection for learning
Experiential learning
Experience must be interpreted and
integrated into existing knowledge structures
to become new or expanded knowledge.
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Experiential learning cycle
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2. Reflection to develop a therapeutic
relationship with patients
Recognition and understanding of the
personal belief and value systems of the
clinician or patient.
Differences between these systems can
produce a strong emotional reaction in the
clinician, which in turn can influence their
decision making and subsequent actions.
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3. Reflection to develop professional practice
Integration of knowledge and skills
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Self-regulated learning and reflection
• Self-regulated learners use metacognitive
processes to select, monitor and evaluate
their approach to a task.
• Reflection can be considered as a selfregulated learning activity.
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Guided reflection
• Support of another person: a peer group
member, a supervisor or mentor to facilitate
reflection.
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Ethical aspects of reflection
Confidentiality
Who has access to the reflection and for what
purpose?
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The educational impact of
reflection
Reflection is associated with a deeper
approach to learning that allows new learning
to be integrated with existing knowledge and
skills.
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Educational strategies to
develop reflection
a) Motivation for reflection
reflection for personal growth and
professional development.
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Clear goals
Internal factors
External factors
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Goal setting
Initially provide information about the nature
and outcomes of reflection, including its
importance for professional practice and
lifelong learning.
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Internal factors
Self-efficacy and ease of the task
Motivation can be increased by
encouragement and by gradually increasing
the reflective tasks, such as beginning with
only noticing and then introducing the
complete reflective process.
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External factors
• Educational environment within which
reflection is expected to occur
• Assessment drives learning
• Assessed portfolio for personal and
professional reflective learning
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b) Metacognitive skills for reflection
Noticing
Processing
Altered action
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1. Noticing
• Recognition of when your existing mental
models and personal theories are being
challenged by the experience of an event.
• Before, during or after
• Without an initial awareness no reflection can
occur.
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Noticing can be developed by using
several techniques
(i) Self monitoring
• Increased awareness by constant selfmonitoring of thoughts and emotions.
• Mindfulness has its roots in Eastern
philosophical-religious traditions.
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• Becoming mindful requires deliberate and
non-judgemental attention to the immediate
thoughts and emotions: regular self-recording
(by the use of written or audio diaries and
logs).
• Record should be made as soon as possible
after the event.
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• The self-monitoring techniques may feel
artificial at the beginning but gradually it
becomes a routine and subconscious process.
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(ii) Feedback from others
Individuals self-rate themselves higher and in a more
positive light than when rated by others.
Behaviour represents underlying beliefs
Non-verbal behaviour (tone of voice or facial expression), is
often a more powerful indicator of beliefs and can be
readily observed by others.
Feedback from colleagues and patients, supervisor or
mentor : anonymously.
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(iii) Critical incidents and significant event
analysis.
‘Moments of surprise’ when an action
unexpectedly happens
valuable opportunity for reflection.
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2. Processing
• There are several techniques and these
depend on the intention of reflection:
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(i) Reflection for learning
• Do I have the information or skills to deal with
this situation?
• Do I need to have further information or skills
to deal with this situation, either now or in the
future?
• What is the underlying reason why the
identified issue was not resolved?
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(ii) Reflection to develop a
therapeutic relationship
• Communicative doctor-patient relationship
through compassion and care.
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• What am I feeling and what are my emotions?
• Why do I feel like this?
• Are there other situations in my life or my
encounters with others when I feel the same?
• Can I explain why I feel this way?
• What are the consequences of these emotions
for me and for others?
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3. Future action
• Aim of reflection is to inform future actions so
that they can be more purposive and
deliberate.
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Reflective storytelling and writing
• Information, opinions and emotions.
• Integral aspect of many stories is reflection on
an experience with the development of new
insights.
• Teller should notice and make sense of an
experience.
• Therapeutic aspect: learner to release
emotion, an essential part of the reflective
process.
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Assessment of reflection
• Judgment about the standard
• Formative assessment is an integral aspect of
giving feedback and it also offers the
identification of further learning needs.
• Summative assessment occurs after a period
of study and this may be required for
reflection.
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Common problems encountered
with reflection in medical education
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1. Low engagement in reflection
• Self-regulated learning :
‘goal’
‘will’ (the motivation)
‘skill’ (the monitoring of strategies)
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• Internal factors
Intrinsic interest in the activity
Self-efficacy (a self-belief in being able to
achieve the task)
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• External factors
Support and encouragement by the
organisation
Role of facilitators
Confidentiality
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2. Difficulties with the phases of reflection
• Noticing phase
A reluctance to give feedback.
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• Processing phase
Presence of strong emotions that the event has
produced in the learner.
Often the most important events, such as a
missed diagnosis, that can stimulate reflection
are also those that are associated with the most
powerful emotions, such as anger or sadness.
Recognise and release these emotions, they can
block further reflection.
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3. Lack of integration of reflection in overall
teaching and learning approach
A process that is disconnected from the
educational process.
Reflection should become an integral part of
each session and the overall curriculum.
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Instructional methods for reflection
• In class or at home
• Oral or written
There are no data for the superiority or
inferiority of any approach
Oral reflection is most suitable during a
surprising or troubling experience
• Reflection-on-action: after the event.
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Structured or
Unstructured approach?
• Majority of learners produce reflections which
are largely anecdotes devoid of learning.
• Structured approaches to help learners reflect
in deeper and more educationally meaningful
ways.
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A structured prompt makes explicit
the components of critical reflection:
• Discussion of processes and assumptions as well
as actions and thoughts
• Consideration of the role of associated emotions
and relevant past experiences
• Solicitation of feedback and review of relevant
literature where appropriate
• Explicit notation of lessons learned
• Creation of a plan to improve future behavior and
outcomes
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Arguments against structured
reflections
• Structure limits and distorts the very response
the exercise is designed to elicit
• It risks encouraging mindless ‘‘recipe
following’’ rather than insightful analysis.
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Create a conducive learning
environment
• Positive learning climate through the use of an
authentic context and creation of a safe and
supportive environment for reflection.
• Educators can increase authenticity by
modeling reflection and encouraging other
faculty to incorporate reflection into their
practice and teaching.
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Teach learners about reflection before
asking them to do it
• Define reflection for your learners
• Provide them with evidence of the educational
and practice-related benefits of reflection
• Outline the components of good critical
reflections: (1) linking past, present, and future
experience; (2) integrating cognitive and
emotional experience; (3) considering the
experience from multiple perspectives; (4)
reframing; (5) stating the lessons learned; (6)
planning for future learning or behavior.
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Provide feedback and follow-up
• Feedback can be individual, group, faculty, or
peer.
• Shared reflection is better than individual and
self assessment is often inaccurate.
• In reflection, others often see things the
reflector cannot see.
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Make this exercise part of a larger
curriculum to encourage
reflection
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Although the world
is full of suffering…
it is also full of
overcoming it.
Helen Keller
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