Issue 21 / 16 June 2014

RELECTION has become something of a buzzword in modern medicine. Clinical reflection has been defined as “paying critical attention to the practical values and theories which inform everyday actions, by examining practice reflectively and reflexively”.

Reflective behaviour is undoubtedly of paramount importance for health professionals, as it is intrinsic to the ability to self-regulate.

To teach this attribute, Australian medicals schools often use mandatory reflective essay writing. However, the value of mandatory essays as a teaching method on reflection has recently been called into question.

In research published in the MJA, and provocatively titled “ ‘They liked it if you said you cried’: how medical students perceive the teaching of professionalism”, Australian medical students were questioned on several aspects of the way professionalism was taught in the medical curriculum, including reflective writing.

The researchers found that students would “game the system” by learning the style of reflective essay that attracted high marks from assessors. They concluded that a less formal approach to reflective teaching should be considered.

The debate that followed in the letters section of the Journal included responses from clinical doctors and academics alike, but there were few perspectives from medical students regarding the study conclusions.

As a final year medical student, the MJA article drove home hard as I begin to consider what topic I should discuss in my next reflective essay.

It was argued in one Journal letter in response to the research that being forced to reflect by writing mandatory assignments is artificial. The author’s position was that reflection is not a teachable quality.

I agree and this is in accordance with the definition of clinical reflection as a reflexive, or automatic, action. The ability to reflect is better defined as a behaviour rather than a skill.

To argue that reflection is not a teachable quality is not to say that students’ ability to clinically reflect shouldn’t be fostered. The ability to reflect in a clinical setting is vital for good practice, and as an attribute it should be well developed when we enter the workforce as junior doctors.

However, mandatory reflective essays are often written in circumstances where students are hoping to score good marks.

Reflection as a behaviour is not unique to medicine, and not even unique to professionals. We have all had bad experiences that we contemplate for hours or days following, considering how outcomes may have been altered.

This is true reflection, an almost unconscious method of learning by considering previous experiences and forming solutions to apply to similar situations in the future.

This is essentially a fundamental learning process, sometimes referred to as “action learning”. Taking this further, reflection is an essential function, not a learned one, that has an evolutionary basis as a vital characteristic for survival.

Most university curricula today employ a “problem-based learning” approach, where a clinical scenario is discussed by students facilitated by a clinical educator, with the goal of eliciting important points from the scenario.

Perhaps adopting this approach could help to refine reflective skills. For example, clinical students could be asked to record real cases to discuss as a group and reflect on the pertinent points relating to good clinical and ethical practice.

Regular group discussions throughout the university curriculum may facilitate refinement of students’ clinical skills by stimulating real reflective experiences, which would encourage greater student engagement than reported in reflective essay writing.

University programs effectively teach many components of professionalism, and these efforts should be commended.

Reflection is not teachable, though it may be refined by experience — not by writing long essays, but in real world situations and learning experiences.  

Mr Allister Howie is a medical student at the Launceston Clinical School, University of Tasmania, Launceston.

3 thoughts on “Allister Howie: Reality reflection

  1. Graham Row says:

    Thank you Allister for elegantly exposing  another naked emperor in medicine. Generations of practitioners in the past indeed “learned professionalism” by observing good and bad examples of professional behaviour encountered in every day practice.  Informal discussion with teachers, mentors, and colleagues at tea breaks and in common rooms developed the skill and judgement to distinguish good from bad and right from wrong. Keeping minutes and creating documents is for bureaucrats. This was both “reflective” and educational.  Writing reflective essays did not work for the Australian cricket team.  Why should it work for Australian doctors and doctors in training?

  2. Dr Alisdair Barnes says:

    I agree with what Allister has said. However, the formalising of reflection within the medical course can be helpful. For instance, automatic reflection may primarily be negative, blaming, brooding… while writing about a situation or discussing it with peers and mentor/teacher may lead to problem solving and action to change circumstances that may prevent a similar problem in the future. If I had had this teaching approach when I was a medical student (1970s-80s), I’m sure I would have avoided a few awful situations as a resident doctor. As a relatively anxious, introverted young student and doctor I wasn’t comfortable bringing up problems in an informal setting. And I wasn’t aware that other people had had similar problems and I could learn from them: back in the day, our teachers and professors gave out the perception that they never made mistakes. 

  3. Jane Doe says:

    There is plenty of literature that demonstrates the benefit of reflective practice, however assessing a student on this skill not only encourages an exaggerated response to a clinical scenario, but also manipulation of the facts to impress a marker. The exercise becomes little more than creative writing. I do agree with ExperiencedGP that reflective writing can be an opportunity to debrief, however when you are writing within a word limit in response to a marking rubric, the priority is to pull out a decent mark. 

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