Reflective medics

Find time to slow down and think. Paul Stephenson and David Brigden believe it vital to reflect on learning

"There is an art of which every man should be a master—the art of reflection. If you are not a thinking man, to what purpose are you a man at all?"
William Hart Coleridge

Although this quotation may seem unnecessarily harsh, reflection is undoubtedly fundamental to clinical practice. Capacity for reflection is cited as a key attribute for doctors by healthcare regulators throughout the world.^{w1 w2} The need for UK medical students to be aware of reflective practice stems from the General Medical Council (GMC) recommendations, set out in Tomorrow’s Doctors, that students should be able to reflect on practice and be self critical.^w3

The GMC also states that a medical school must make room within its curriculum to allow students time for reflection and personal growth. This is the case at the University of Liverpool, where students are encouraged to reflect on their clinical performance before regular feedback meetings.

So the GMC expects medical graduates to become reflective practitioners. But what exactly does this mean and how can we develop our capacity for reflection?

What is reflection?

Reflection was first proposed as an essential learning tool in the late 1970s^w5; it has been a popular topic of research ever since.^{w6 w7} A definition of reflective learning is “the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and which results in a changed conceptual perspective.”^w8

Reflection therefore requires medical students to question their beliefs or understanding of a situation, with a changed personal stance forming the outcome of this introspection. This can be carried out during or after the event that triggers the reflection. Book work is a necessity of medical education, but to become competent doctors it is essential that students apply theory appropriately in the clinical setting. It has been proposed that reflection can help this process because^w9:

Reflection can promote the growth of the individual—morally, psychologically, emotionally, and cognitively
Reflection can integrate the student’s clinical skills, book work, attitudes, and values
Reflection allows appropriate assimilation of theory, clinical practice, and ethical values.

Why is reflection uncommon in clinical settings? A simple answer is shortage of time. Another barrier may be personal discomfort with exploring emotions, and the possibility that the reflecting student made a clinical error. However, medical students must make time for reflection and try to learn from mistakes.

How to reflect

Reflection has three essential stages.^w5

Awareness—The first stage is triggered by an awareness of uncomfortable feelings and thoughts. This may arise because of some situation or event that does not unfold in the way that we would expect. For example, a usually reliable treatment may have an unexpected negative outcome. Of course, it is also possible for positive outcomes to leave us wondering why things have worked out so well; reflection need not always concern negative experiences. Either way, there is some “out of the ordinary” experience that causes us to begin reflecting.

Analysis—The second stage involves an analysis of the situation that leads to an examination of feelings and knowledge. This may ultimately result in the generation of new knowledge. During the analysis phase it is often a good idea to get the opinion of a colleague.

New perspectives—The final stage involves the development of a new perspective on the situation. The outcome of reflection is therefore to learn something new and to develop professionally.

Skills for reflection

Many of the skills needed do not come easily, so medical students must regularly practise the essential skills needed for reflection.^w6

Self awareness—This involves an honest examination of how the situation has affected the student and how the student has affected the situation. This is not easy, especially in the heat and pressure of the moment, when it can be hard to recall exactly what happened.

Description—This involves having the ability to recognise and recollect salient events. This might entail recalling similar signs and symptoms in patients presenting with a particular disorder.

Critical analysis—This involves examining components of a clinical situation—looking at existing knowledge, challenging assumptions, imagining and exploring alternatives. This encourages the creation of new ideas.

Synthesis—This is the process of integrating new knowledge or experience and making it part of our personal knowledge base. This is particularly important because the outcome of reflection involves the development of a new perspective.

Evaluation—Finally, students must decide whether a change in practice is necessary.

Reflecting in practice

The stumbling block for many students is deciding what they should reflect upon? A vague answer would point medical students towards matters that they find challenging or uncomfortable—that is, in theory awareness must form the first stage in the process of reflection (figure ¹). Because reflection is a student centred activity, the student will most often reflect on an unexpected event by themselves and measure the event against their own internal beliefs or standards.

Skills needed for the process of reflection

Students might also benefit by comparing their internal beliefs and standards against professional guidance (boxes 1 and 2). Professional guidance, such as Duties of a Doctor, might also provide students with a good starting position when considering topics for reflection.^w2 By keeping this guidance in mind when reviewing a clinical experience, students can measure themselves against the standard required of a foundation year doctor—after all this is where medical students are heading. If the student is not meeting prescribed duties, he or she must critically analyse performance and identify areas for improvement.

Students should also start reflective practice early in their career. Reflection can be carried out alone or with others—the opportunities to reflect are vast. The most effective form will be a matter of personal preference. Often simply thinking through the unexpected event will suffice if relevant lessons are learnt. Talking with colleagues can also be of great benefit. A “reflection diary” will help guide progress, providing confidence to face mistakes and learn from them and equally to be aware of unexpected positive experiences.^w10 In addition, a written record of reflection helps students to build a portfolio of experiences and evidence of active learning. It is worth noting that evidence of reflective practice should be given by foundation year doctors in the United Kingdom when presenting their foundation learning portfolios.^w11 In reflection it is important to be self critical. A reflective portfolio should include examples of problems faced, mistakes made, and subsequent improvements to practice. A portfolio that shows that everything is perfect all the time might arouse suspicion: none of us can honestly say that everything we do always works out perfectly.^w12

Box 1: Example of reflection using Duties of a Doctor as a framework^w2

Scenario

A medical student was asked if he could cannulate a patient in the emergency department. Keen to practise this clinical skill, the student accepted the task despite the fact that he had only previously practised on a plastic arm with variable success. The student’s first attempt was unsuccessful. Nevertheless, keen to appear competent, the student attempted cannulation four more times before finally accepting defeat and asking a nurse for help.

When the nurse arrived, she found that the patient had already sustained notable bruising because of the repeated attempts at cannulation. The nurse was angry with the student and said he should wait outside, “You’ve done quite enough damage for one morning.” The student was upset by his failure to cannulate the patient as well as the nurse’s remark. How might the student reflect on this clinical incident?

Duties breached (among others)

(1) He did not make the care of his patient his first concern; he seemed more concerned with creating a good impression with the other staff of the emergency department.

(2) He did not provide a good standard of practice and care; in particular he did not accept the limits of his own competence.

(3) He felt guilty that he did not respect the patient’s dignity; he should not have subjected a patient to such an ordeal.

Possible outcomes of reflection

(1) Be more open and honest with other healthcare professionals in the future. In this instance it would have been best to admit at the start that he hadn’t cannulated in a clinical setting before and request adequate supervision.

(2) Ask a senior colleague to provide supervision and advice at his next opportunity for cannulation.

(3) Be more respectful of patients in the future. Remorse from this experience of guilt could serve to motivate.

Box 2: The duties of a doctor registered with the General Medical Council^w4

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care
Keep your professional knowledge and skills up to date
Recognise and work within the limits of your competence
Work with colleagues in the ways that best serve patients’ interests
Treat patients as individuals and respect their dignity:
— Treat patients politely and considerately
— Respect patients’ right to confidentiality
Work in partnership with patients:
      — Listen to patients and respond to their concerns and preferences
      — Give patients the information they want or need in a way they can understand
      — Respect patients’ right to reach decisions with you about their treatment and care
      — Support patients in caring for themselves to improve and maintain their health
Be honest and open and act with integrity
      — Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
      — Never discriminate unfairly against patients or colleagues
      — Never abuse your patients’ trust in you or the public’s trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References w1-w12 are on student.bmj.com.

Paul Stephenson third year medical student ¹University of Liverpool
David Brigden professor of health sciences education
Email: p.stephenson@liv.ac.uk
Student BMJ 2008;16:156-157 | 17

w1 Australian Medical Council. Goals and Objectives of Basic Medical Education. http://www.amc.org.au/GoalsBasicMed.asp (accessed 10 December 2007).
w2 Good Medical Practice USA. Duties of a Doctor. https://gmpusa.org/DODSum.asp (accessed 10 December 2007).
w3 General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: GMC, 1993. (updated 2003)
w4 General Medical Council. Good Medical Practice. London: GMC, 2006.
w5 Atkins S, Murphy K. Reflection: a review of the literature. J Adv Nurs 1993; 18: 1188-92.
w6 Schutz S. Reflection and reflective practice. Community Practitioner 2007; 80: 26-29.
w7 Mamede S, Schmidt H. The structure of reflective practice in medicine. Medical Education 2004; 38: 1302–6.
w8 Boyd EM, Fales AW. Reflective learning: key to learning from experience. Journal of Humanistic Psychology 1983; 23: 99-117.
w9 Branch WT Jr, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med 2002; 77: 1185-8.
w10 Raw J, Brigden DN, Gupta R. Reflective diaries in medical practice. Reflective Practice 2005; 6: 165-9.
w11 Modernising Medical Careers. Foundation Learning Portfolio. NHS, 2005.
w12 Brigden DN. Constructing a Learning Portfolio. BMJ 1999; 319: 2.