Reflection or ‘pre‐reflection’: what are we actually measuring in reflective practice?

The concept of reflective learning is not new, but has roots in what might now be regarded as classical texts on adult learning, self-directed learning and professional practice.1–3 Professionals are expected to understand how they perform and to use this information to plan their professional development, building on strengths and addressing weaknesses. Through continuous cycles of reflection and adjustment in practice, professionals maintain or improve their practice over potentially long careers. A lack of ability to reflect or adapt may result in poor insight and poor performance in practice.4 Evidence that this idealised reflective process can occur is emerging, at least for experienced doctors. In a recent study, assessment feedback that was inconsistent with self-perception was shown to provoke reflection,5 although, in a related study, emotional reactions to negative multi-source feedback interfered with its acceptance.6 The concept of reflective learning has roots in classical texts on adult learning, self-directed learning and professional practice Two papers in this issue7,8 further highlight the challenges faced in teaching and assessing reflective practice within medical curricula. The first suggests that, although measures of reflection exist in postgraduate medical education, such measures may not relate to strategies that aim to improve clinical practice.7 The second highlights the difficulties encountered in teaching reflective practice to undergraduate health professional students, but, importantly, also identifies three teaching strategies that might facilitate reflective learning. These are: supporting self-insight; creating a safe environment, and encouraging students to take responsibility.8 Most educators, including the authors of these two papers, agree that reflective practice is important and should be fostered in learners. Within the health professions, nurse education has arguably led the way: it has a longer tradition of formal reflective learning and perhaps better acceptance by students.9 The obvious next question is: when and how should we foster reflective practice in medical education? The most common current answer is: from the beginning, in written learning portfolios. There is an ongoing surge in attempts to ‘teach’ reflective practice in medical schools, often from the earliest stage, sometimes by delivering lectures on how to reflect. Students are often asked to write reflective assignments on curriculum components such as early clinical experiences, interprofessional learning or clinical cases that raise ethical or professional issues. These essays are then marked, usually formatively in a manner that provides students with constructive feedback on how to improve their reflective writing, but, in some schools, in which they are summatively marked, their content contributes to pass/fail decisions. However, although teachers are generally positive about the use of reflection in learning portfolios to drive learning, there is only limited evidence that this actually happens, particularly at undergraduate level.10 Many students are confused about how to approach these tasks, de-motivated by what they may perceive as onerous ‘paperwork’, and concerned about the use of resulting scores in pass/fail decisions.11,12 Further, reflective practice may be more powerful in relation to certain activities (such as critical incidents)13 and may vary with medical specialty and the age of the practitioner.14 Indeed, the value of reflective portfolios may depend strongly on their structure, on how their use is modelled by tutors and on how their content and process are assessed.15,16 For example, reflection may be more meaningful when reflective essays are discussed in small peer groups or tutor meetings,17 perhaps through the use of questions that provoke reflection.18 Although teachers are generally positive about the use of reflection in learning portfolios to drive learning, there is only limited evidence that this actually happens Experience in our medical school has raised questions about just how well we should expect junior medical students to perform in written reflective assessments. Most students entering medical school are aged 18–22 years and their ability to reflect, not to mention their ability to capture reflections in writing, may not properly develop until the later stages of either their personal maturity or their professional careers. Many students struggle with the concept and present poor reflective essays. Others, motivated to obtain high marks, compile large portfolios and seek assistance in how to write reflectively. Unfortunately, the latter strategy often includes using websites that offer sentence structures and keywords that suggest reflection and potentially attract good marks. A likely result is that some students’ reflective essays indicate neither reflective ability nor even genuine reflection. We find many to be rather formulaic, which suggests that their writers have followed a script. We have even had students ask for the topic of their reflective essays in advance of the experience they will be required to reflect on, stating that they want to get started on the reflective essay! This raises the possibility that reflection is being recorded before the events that are designed to trigger the reflection (our in-house term for this process is ‘pre-flection’) and that some learners may even approach these events with the aim of making the experience fit the pre-flection. However, the literature is surprisingly silent on gamesmanship in reflective activities. Many medical students struggle with the concept of reflection; others compile large portfolios and seek assistance in how to write reflectively There is an urgent need to determine what it is we are trying to foster and to measure. Is reflective practice a single, stable construct? Is it a skill set that can be taught? Is it measurable, such that reflective practice can be assessed along the lines of other components of competence in medicine, as illustrated in Miller’s pyramid?19 That is, should the skill set be deconstructed, taught in stages that reflect the acquisition of understanding of professional practice and assessed in terms of ‘knows how’, ‘shows how’ and ‘does’? How can insight and the taking of responsibility be taught and assessed? Is reflection something that should be assessed other than in writing, such as through verbal discussion? What about students with personality types or learning preferences that do not naturally support reflective practice?3,20,21 Can they become reflective practitioners, or are they at greater risk of becoming poor performers who lack insight into their own strengths and weaknesses? Is there a ‘minimal standard’ of reflective ability that is required to be a competent professional? If so, should reflective ability be formally assessed at entry to medical school? Alternatively, should the emphasis on reflective practice be deferred until postgraduate training? Are less reflective students at greater risk of becoming poor performers who lack insight into their own strengths and weaknesses? The literature still provides few clear answers to these questions, which may therefore be best utilised in informing a research agenda for understanding, fostering and measuring reflective practice. The stakes are too high to allow attractive but unclear concepts to determine the outcomes of basic medical education.