REAL-flection: Genuine reflection on real experiences

Abstract

Reflection as an education strategy is everywhere these days. It seems that almost every medical education experience has a written reflection attached. Learner portfolios are full of pages and pages of reflections. Some learners find this expectation of reflective practice easy to fulfill. They are already doing it. They journal, they write, they are self-critical. They enjoy the opportunity to incorporate these practices into the study of medicine. Reflection is a characteristic of introverts, and it may be that this is no longer the group from which we are drawing the majority of our learners. Many of my current learners are extroverts. They derive energy from interacting with others. They are action-oriented, often chosen for their people skills. I encountered one brilliant and gregarious young woman who when asked to reflect on her performance said to me, ‘‘That’s my problem. Everyone keeps telling me, ‘Reflect! Reflect!’ I don’t know how to reflect. Please teach me how to do this.’’ She knew it was more than just thinking. She was clearly a good thinker – in fact, she was one of the strongest diagnosticians in her group, but she also knew there was something different about her learning experience, and she wanted to figure it out. I told her that in the conversation we were then having together, she was reflecting. Since that time I have encountered other students, usually in the preclinical years, who don’t know how to reflect and who may or may not realise this. They don’t do very well when asked to reflect about things they have not personally experienced, and find it hard to become engaged in such tasks. For some of them, a reflective exercise based on a prompt like a film or a ‘‘what if’’ question seems to be an assignment to be gamed – you write what you think your instructor wants you to write, find the ‘‘right’’ answer. These students write reflections that sound like essays, always staying with general principles and never touching on their own thoughts and feelings. They complain of having nothing else to contribute, feeling that writing about feelings in such a situation would be a lie, and promise that they will do better when they have had experience. They insist they cannot pretend to feel something that they have not yet felt. They are missing the point about writing in response to a film of a medical situation. The point is not that they should pretend to be in the situation portrayed and write as if they were that doctor or that patient; the point is that they should react to the situation as their current selves, in their current stage of training and with their current knowledge. This framing needs to be made explicit for some students. The non-reflectors are correct in one regard – we don’t want manufactured reflections. They need to be real.