[BLOG] Reflecting upon ‘Reflection’

‘Reflection’ is a significant component of medical training and practice, yet it can be regarded as difficult, unrewarding and time-consuming. Joel Cunningham considers how we can change our perception of reflective practice to make it easier and more productive in our professional development.

With thanks to @mikedavis8702 for thoughts from #DEMEC2015.

‘Reflection’ is omnipresent in modern day medical education and practice. It is considered a mandatory component of both undergraduate training and postgraduate E-portfolios, and it is integral to Consultant and GP revalidation (NHS England 2013; Nath 2014).

It is difficult to find any literature about the proportion of meaningful engagement of reflective practice within the medical profession. However, the current qualitative evidence base in the field has proposed clear benefits for medical students and practitioners: making meaning of complex situations, enabling learning from experience and improving the supervisor/trainee relationship (Mann et al. 2009).

Within the medical community, reflective practice can hold a reputation for sending shivers down the spine of medical students and giving trainees sleepless nights whilst trying to complete the prescribed number of Reflections before their annual appraisals[i]. Even senior doctors can struggle (Garner 2013). Why?

It is first important to try to consider what the term means. Many definitions are offered within literature (Mann et al. 2009; Aronson 2011), but it is difficult to actually put them into the context of day-to-day practice. In my mind, there are two forms: Reflection, and reflection. The capitalisation of the ‘R’ carries a significant difference.

The formalised, externalised and documented form is a Reflection. This entails mental exploration of a significant event and its consequences, alongside consideration and discussion of the implications for one’s future practice. It is usually written within a structured, lengthy, and usually eponymous, ‘model’. At worst, it can be viewed as an internal inquisition. It can leave you staring at a computer screen whilst re-living a difficult decision or a challenging situation. Unfortunately, a computer screen is rarely a reassuring companion on the journey of Reflection. The blank white spaces can be accusatory and demanding and it is little wonder that Reflection can be an unsatisfying experience in this context.

How about changing the scribe? During one of my medical school clinical attachments, I participated in a research study where I was asked to record reflections using a Dictaphone. For me, a blank Dictaphone was a more stern master than a computer screen, and frequently 20 minutes of contemplation would yield precious few minutes with my finger on the ‘record’ button.

One of the best way methods of Reflection that I have encountered is using a blank page. As long as you make sure you cover the important points (what happened, how did you feel, what should or shouldn’t you change the next time it happens?) then the absence of an approved model of Reflection shouldn’t matter. Different people prefer different methods - tutors, supervisors and e-portfolios should accept that.

One of the struggles whilst writing Reflections comes from the fear of judgement by tutors or supervisors who may read them. This is a twofold cause for anxiety: one could be judged on the event itself, as well as on one’s ability to Reflect. The process of self-assessment be slowed along the way by multiple neuropsychological barriers (Epstein et al 2008). Perhaps this goes someway to explain why we are reluctant to publish self-appraisals of situations when we felt challenged. It is sometimes difficult to remember that, in reality, Reflections never count towards grades and should only be used as tools to support our development.

What about reflection? In my mind, this version is the internal and informal consideration of the events of the day, with subsequent thoughts about “how to do it better next time”. For me, this is the time at the end of the shift; the tube journey home or time spent cooking a meal. It’s an unofficial video-action replay of the highlights and low-lights, and it comes with tacit acknowledgement of the lessons learnt. It allows you to consider your performance during the course of that shift. It is a natural process, frequently subconscious, and one that we have all used since childhood to refine our social and life skills. Does this happen in everyone? Even if not demonstrably, it’s difficult to imagine how someone can progress through life without this tool.

Our reflections can also frequently be out loud, with friends, family or colleagues. My FY2 year was out of town and I shared a house with a group of brilliant colleagues. We would occasionally share our more challenging experiences around the dinner table[ii]. Sometimes these were answered with reassurances and suggestions, and sometimes with similar stories and consensus conclusions. Sometimes, the questions which were asked by the group were very different from those that came from within.

Balint groups are the professional version of this – regular meetings of a group of doctors where challenging situations are discussed and reflected upon together. My experience of a Balint group as a medical student was limited by my lack of clinical experience at the time, but I could appreciate that they are much more responsive and dynamic than a blank Reflection proforma.

The value of reflective practice (in both senses) is based on its ability to deconstruct complex experiences and recognise points for self-development. The barriers lie in both the challenges of self-assessment and in the difficulties with documentation. If we acknowledge that reflection is a natural process that use in many parts of our life on a daily basis (“How can I do that differently next time?”) then the challenge is just to apply it to our clinical practice and find a suitable medium to share it with those who want to see it.

TOP TIPS:

• Divide the process into two parts:
  1. What happened and how can I learn from this experience?
  2. What components and thoughts do I feel comfortable with sharing with my supervisors?
• Try out different ways to document your Reflections – typed or handwritten, a blank page or a structured model, or even recorded. Which one suits you?
• Try to discuss challenging experiences with a close friend or trusted colleague[iii] – they can provide support, reassurance and occasionally a completely different perspective for you to consider.

References/Further Reading

1. Aronson, L., 2011. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher, 33(3), pp.200–205.
2. Garner A. 2013. “I ‘don't reflect on my practice'? GMC, what do you think I’ve been doing for the last 43 years?”. British Medical Association. Available at: https://www.bma.org.uk/news-views-analysis/work/2013/august/jumping-through-hoops-for-revalidation [accessed 6th March 2016]
3. Mann, K., Gordon, J. & MacLeod, A., 2009. Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education, 14(4), pp.595–621.
4. Nath V, Seale B, Kaur M. 2014. “Medical Revalidation: From Compliance to Commitment”. The King’s Fund. London. Available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/medical-validation-vijaya-nath-mar14.pdf [accessed 6th March 2016]
5. NHS England (Revalidation Support Team). 2013. Medical Appraisal Guide; A guide to medical appraisal for revalidation in England (Ver 4). NHS England. Available at: https://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/02/rst-medical-app-guide-2013.pdf [accessed 6th March 2016]

Footnotes

[i] Note: this tactic is understandably actively discouraged by Training Boards and we do not endorse it!

[ii] Fully anonymised.

[iii] Again, anonymised!