studentbmj

Reflection: how do I do it?

You will be expected to reflect on your experiences at medical school and beyond

By: Rhona Knight, Jemima Henstridge-Blows, Helen Stacey, Josiah Knight

Published: 28 October 2013
DOI: 10.1136/sbmj.f6387
Cite this as: Student BMJ 2013;21:f6387

Reflection: what is it?

Reflection is something we do every day. It is an established part of medical education and a
requirement for revalidation with the General Medical Council.[1] It is a focused learning
process, which facilitates the development of insight and understanding, transforming the
learner and guiding future practice. Reflection can take many forms: it can be the individual
quietly pondering over an event; a discussion or debrief with a colleague; a written piece of
work for our own learning; or a formal piece of work for assessment purposes. It can also take
more artistic approaches.

Reflection: why bother?

Reflective practice is a core skill needed in professional medical practice, which enables us to
learn to cope with an ever changing work environmenthence the efforts to integrate it into
the undergraduate curriculum.[2] In an article in JAMA, Ronald M Epstein wrote, Reflection
and self-awareness help physicians to examine belief systems and values, deal with strong
feelings, make difficult decisions and resolve interpersonal conflict.[3] Most doctors value
opportunities to reflect on a patients care with colleagues and appreciate time to discuss areas
of work that they are finding difficult.[4] This emphasis on reflection is not newphilosophers
have long advocated reflective thought. Socrates said, The life which is unexamined is not
worth living,[5] and George Santayana observed, Those who cannot remember the past are
condemned to repeat it.[6]

Reflection: an essential part of the curriculum

Tomorrows Doctors identifies the need for doctors to assess, apply, and integrate new
knowledge; to adapt to changing circumstances; to develop a portfolio including reflections;
and to continually and systematically reflect on practice, and wherever necessary, translate
that reflection into action.[7] As a result, medical schools are using a variety of ways to
encourage reflective practice.
At St Andrews, reflective writing is required regularly from the first year, beginning in freshers
week. Staff encourage analysis of thoughts and feelings, from the first experience in the
dissection room, to peer and self appraisal in group tasks and scenarios. Students are
expected to evaluate encounters with simulated patients and volunteer patients from the
community. Similarly, at Leicester medical school, formalised reflection is found throughout the
course. The use of reflective templates is encouraged in personal development portfolios.
Reflection on patients stories and team roles is a key part of inter-professional learning.
Reflection is also used in the learning and assessment of some student selected components.
In the medical education component, for example, students are required to reflect on their
experiences of teaching and learning before and after the course. They are also encouraged to
keep a reflective learning log throughout the course and to meet once a week in collaborative
reflective groups. Final reflective assignments have included the opportunity to use more
artistic forms of reflection (fig 1 1 ). The skills learnt can be taken on into postgraduate training,
where reflection is a key part of the foundation curriculum, being mentioned 15 times in the
2012 curriculum document,[8] and where reflective learning logs are assessed as part of the eportfolio.

Fig 1 One of a collection of reflective poems. Emma Boothby, University of Leicester

Alternative forms of reflection using multimedia approaches, such as the use of digital
storytelling, are also beginning to be encouraged.[9] [10] An example of this, used for teaching
students about reflection in Leicester, incorporates a digital story created by a general
practitioner registrar and one of his patients, which is based on a series of photos taken by the
patient to document her experiences of healthcare. These photographs and the trainees
interactions with the patient, with the appropriate consent and due attention to confidentiality,
became the basis of a reflective digital story presented with pictures, music, and narrative in
PowerPoint.
The use of digital methods, such as e-portfolios, can also facilitate the sharing of experiences
with a wider audience and over long distances, allowing the reflective work of others to be
seen. This can help in exploring different points of view and understanding different
approaches. With the increasing variety of technological platforms, reflection can be recorded
in numerous formatsfor example, recording oneself on a digital voice recorder or recording,
with permission, a discussion with colleagues and peers. These methods encourage the
development of a more informal style, which can help those who find reflective writing
challenging. The use of videofor example, a consultation with a simulated patientcan also
be a useful reflective device because it provides a record of an experience for analysis.

How to reflect: do, review, plan

Models of reflection are usually cyclical,[11] [12] [13] and most can be crystallised into three
stagesdo, review, and plan.[14] You can enter the cycle at any point and repeat the process
as you revisit the experience in different contexts, contributing to your continuous professional
development.

Stage 1: Dothe experience

Examples of this could be going to a lecture, meeting a patient, preparing for and taking an
examination, having a difficult encounter with a consultant, or getting good feedback from a
ward clerk.

Stage 2: Reviewthe reflection

During this stage, you try to make sense of your experience. This stage is best divided into
three parts.

Part 1: recollect the experience in detail

What happened?
What were you thinking and feeling?
What did you notice?
What else was happening? Were you thinking about work, home, study, or health?
What might others there have noticed, thought, and felt?
What might someone looking in have seen?

Part 2: looking beneath the surface

This part of reflection encourages you to consider the experience in more depth. This includes
considering possible answers to the question why?
Why did the experience play out the way it did?
Why did I react, think, and feel the way I did?
Why did others react, think, and feel the way they did?
What went well? What went less well? Why?
It is at this stage that connections may emerge: with past experiences; the curriculum; other
disciplines and perspectives; art, film, literature, and other humanities; professional
responsibilities; and your values and beliefs, as well as those of others.
Not all people learn best through words, and it is this part of reflective practice that is
particularly open to the use of art, dance, drama, creative writing, and music. Facilitated
reflection often encourages learners to look more broadly and deeply than they would alone.

Part 3: identifying insights

In this part you try to crystallise those light bulb moments that have emerged from your
reflection. Questions to help you identify these include:
What have I learnt about the situation?
What eureka moments have there been?
What have my emotional reactions told me about myself and how I relate to others?
What have I learnt about the way I think, learn, and act?
What have I learnt about me as a person, my values, and my beliefs?
What have I learnt about others?
What has challenged me?
What have I learnt about medicine, the role of the doctor, and me as a future doctor?

Stage 3: Planwhat next?

This part encourages you to identify how you might approach a similar situation in the future.
Whereas the first two stages are often done informally as we mull over our day and talk with
colleagues, this stage benefits from taking time to formally identify and write down your key
learning points, what changes you need to implement, and what other actions you need to take
forward.
There is something about writing things down that makes them more likely to happen, and
when you review what you have written at a later stage you can see how you have fulfilled
your plans and consider how they have helped. This formal process can be aided by a
template. Medical schools often provide their own templates (fig 2 2 ). In the template, brief
notes on the experience, reflections, and future actions can be made, taking care to ensure
patient confidentiality.

Fig 2 Reflective learning template

In the days of smart phones and iPads, a template can be accessible in seconds so making
time in a busy schedule to reflect formally is not that difficult. Reflective notes can be made in
time snatched in the coffee room, on the bus home, in the few minutes before a lecture starts,
or as you wait to do something on the ward. It really doesnt take too long, so you can get into
the habit of recording the evidence of reflective learning on a daily basis and upload your
findings on to electronic learning portfolios if needed. Hyperlinks to relevant documents or
websites can also be added, and these can become a good revision or reference source.
Evidence of further reading, reflection, and other learning resources can also be added at a
later stage and, if required, the notes in the template can be used to help complete more
detailed reflective assessments.

Reflection: is it worth it?

Helen, Jemima, and Josiah:
Initially we approached reflection with hesitation because it was difficult to appreciate its
relevance and importance amid the demands of the course. As we persisted and practised our
reflective skills, we have begun to see the value of routine reflection. Having a record of past
experiences and approaches enables us to develop. It is not the writing of a piece but the
subsequent application of what has been learnt that is the reason for reflection. Most
importantly, reflection should be constructive. Medical schools should produce medical
students who have the ability and desire to reflect independently.

Rhona:
Reflection is part of my everyday professional life as a general practitioner and an educator. In
preparing a lecture on reflection, I reflect on what happened at last years lecture. After the
difficult consultation with the woman with dementia and her family, I reflect on what happened.
In both cases, I look beneath the surface of what worked and what didnt work, at peoples
reactions, and their feedback. I consider other related areas, what I have read since, and
conversations I have had. I consider and plan what to do next time. I review, plan, and do.
Formal reflection gives me the opportunity to spend protected time in a structured way,
learning from my experiences; this leads to increased practical and professional wisdom.
Rhona Knight, portfolio general practitioner and senior clinical educator1, Jemima Henstridge-Blows, second
year medical student2, Helen Stacey, second year medical student2, Josiah Knight, second year medical
student2
1

University of Leicester, Leicester, UK, 2St Andrews Medical School, St Andrews, UK

Competing interests: Dr Knight reports one of the co-authors is her son, and the two others are
his colleagues at university. The final year students who provided two of the figures were part
of a SSC she led at the University of Leicester in 2012.
Provenance and peer review: Commissioned; not externally peer reviewed.

References
. General Medical Council. The good medical practice framework for appraisal and revalidation. 2012.
www.gmcuk.org/static/documents/content/GMC_Revalidation_A4_Guidance_GMP_Framework_04.pdf.
. Lachman N, Pawlina W. Integrating professionalism in early medical education: the theory and
application of reflective practice in the anatomy curriculum. Clin Anat 2006;19:456-60.
. Epstein RM. Mindful practice. JAMA 1999;282:833-9.
. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a
systematic review. Adv Health Sci Educ 2009;14:595-621.
. Plato. Apology. Jowett B, transl. Pennsylvania State University.
http://www2.hn.psu.edu/faculty/jmanis/plato/apology.pdf.
. George Santayana (1863-1952). Internet Encyclopedia of Philosophy. 2006.
www.iep.utm.edu/santayan/.
. General Medical Council. Tomorrows doctors. 2009. www.gmcuk.org/TomorrowsDoctors_2009.pdf_39260971.pdf.
. Academy of Medical Royal Colleges. Foundation programme curriculum. 2012.
www.aomrc.org.uk/publications/statements/doc_details/9468-foundation-programmecurriculum-2012.html.
. Sandars J, Homer M. Reflective learning and the net generation. Med Teach 2008;30:877-9.
. Murray C, Sanders J.Reflective learning for the net generation student.Newcastle University.
www.medev.ac.uk/newsletter/article/247/.
. Kolb DA. Experiential learning: experience as the source of learning and development. Prentice Hall,
1984.
. Schn D. The reflective practitioner: how professionals think in action. Temple Smith, 1983.
. Moon JA. A handbook of reflective and experiential learning: theory and practice. Falmer, 2004.
. Sandars J. The use of reflection in medical education: AMEE guide no 44. Med Teach 2009;31:68595.

Cite this as: Student BMJ 2013;21:f6387

Responses to this article

3 Feb 2014
Emilie Green (NE Thames / Foundation year 1 doctor) says:

'Reflection' was obligatory at medical school, and was often viewed as a pointless hoop to jump through. As
a doctor, there is no one breathing down my neck to reflect, yet I find myself doing it anyway.

A consultant surgeon recently advised my foundation doctor colleagues and me to read a book entitled
'How doctors think' by Jerome Groopman. This book facilitates the reflection process, and has helped me
with a specific issue that I have encountered since starting work.

There are occasionally patients that it is difficult to form a smooth professional relationship with, which is
to be expected given that individuality is what makes humans human. However, this difficulty in developing

a 'bond' with such patients concerned me as I felt that it may subconsciously have a negative effect on the
care that I provide.

Groopman talks of being fixated on a certain way of thinking about a patient who may be viewed in a
negative light by clinicians. For example, doctors may attribute abdominal pain to be of psychological origin
if a patient continually complains of this symptom despite extensive investigation with no definitive
conclusion. They may therefore miss an organic cause due to the 'boy who cried wolf' phenomenon.

Doctors should therefore be able to constantly challenge their thought process and clinical practice, so as
not to provide inadequate care to patients that don't fit neatly into the ideal doctor-patient relationship. As
long as doctors are self-aware of their bias regarding a particular 'difficult' patient, the cycle of poor care
provision may be broken.