Medical students’ perspectives of reflection for their professional development

Abstract

Background

Reflection is a critical component of learning which plays a significant role in improving knowledge and skills. It is a metacognitive process that aims to create a deeper understanding of the situation. This study sought to explore the perspectives of medical students concerning the role of reflection in their professional development.

Methodology

This qualitative content analysis study was undertaken with 20 medical students across different year levels in 2023. Participants entered the study by purposive sampling. Data was collected through individual semi-structured interviews. Interviews were audio recorded and transcribed verbatim. Collected data was analyzed based on the steps proposed by Graneheim and Lundman. Data analysis was performed using MAXQDA-10 software.

Results

A total of 168 primary codes were extracted. After removing duplicate codes and merging similar codes, finally 54 codes were extracted, which were placed in 3 main themes and 7 subthemes. They encompassed: self-awareness (self-acceptance, metacognitive self-exploration, semantic perception); professional competence (self-directed learning, professional commitment); and reflection culture (organizational climate, educational structure).

Conclusions

Findings revealed that the most important aspect of reflection is the recognition and acceptance of individual identity, along with the metacognitive awareness of how to know, especially in the early years, and understanding the meaning of behaviors and relationships over time. Students explained the undeniable impact of reflection on individual and self-directed learning and the development of professional commitment during their studies. The findings of this study, specifically major themes from reflection culture narratives, provide us with a better understanding of the lack of a positive organizational atmosphere, inappropriate educational structure and intensive clinical rotations, as well as lack of trust between students and medical teachers, which negatively impact on or hinder professional development. It seems that by faculty development initiatives, mentoring, group reflection sessions, reflective practices can turn into an opportunity to improve the quality of education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06401-2.

Background

The aim of Medical Education is to assist students in becoming proficient professionals by helping them to gain the knowledge and skills, as well as the essential attributes of being a medical professional. It is one of the tasks of medical schools to prepare the novice into a proficient medical doctor by inculcating a professional identity in the long run [1]. A vital part of developing as a medical professional, which is also accentuated by the Accreditation Council for Graduate Medical Education (ACGME), is the ability of medical students to reflect. Medical students as future doctors need to reflect in order to function professionally when faced with complex cases [2]. The ACGME has been established globally as a valuable framework, but the developing countries such as Iran which have distinct medical education systems and diverse sociocultural values and practices, have not significantly engaged with the implementation of an equivalent competency framework. However, the principles of reflective practice are increasingly being recognized as vital for fostering medical professionalism and competence among students, and this issue has been emphasized in the medical education curriculum in Iran [3, 4]. It is essential to note that the direct application of the ACGME framework in Iran must be approached with careful consideration. The Iranian medical education system has its own historical and cultural nuances that influence how reflective practice is perceived and implemented. Moreover, recent studies indicate a growing recognition of the need for reflective practice within Iranian medical curricula [5].

Reflection is defined as “critical thinking, exploration of personal and emotional experiences, and examination of the impact of actions” [6]. Merriam-Webster defines reflection as ‘‘a thought, idea, or opinion formed or a remark made as a result of meditation [7].’’ There are abundant definitions for the term “reflection” in Medical Education [8]. We have to bear in mind that it has various meanings depending on the context. Reflection, as a critical component of learning, plays a significant role in the training of medical professionals, especially medical students. Reflection has been recognized as a crucial component to foster professional development, clinical skill acquisition, ethical awareness, and the integration of theoretical knowledge with practical experience [9]. Reports signify that reflection can enhance clinical reasoning [10] and student performance [11]. By the same token, intangible skills such as professionalism, empathy and humanism can be augmented by the use of reflection [12].

Professional development in the field of medical education encompasses the ongoing acquisition of knowledge, skills, and competencies that augment a medical professional’s capacity to deliver high-quality patient care. Within this context, reflection is of paramount importance, as it allows medical students to critically assess their experiences, assimilate new information, and enhance their practice. Reflection transcends mere retrospective contemplation; it constitutes an active process that promotes profound learning and personal development [13]. Professional identity development refers to the process by which medical students come to comprehend their roles within the healthcare sector. This process involves the integration of personal values and experiences with established norms and ethical standards in medicine. Reflection, significantly shaped by interactions with mentors, colleagues, and patients, is instrumental in this developmental journey. It cultivates a sense of belonging and informs ethical decision-making, thereby influencing how individuals conceptualize their responsibilities within the healthcare environment [14]. The study conducted by Mann et al. underscores the substantial role of reflective practice in the development of professional identity among medical students. Engaging in structured reflection enables students to express their values, comprehend the intricacies of clinical practice, and cultivate a sense of professionalism [6].

David Kolb’s Experiential Learning Theory (ELT), developed in 1980s, forms the theoretical framework of this study. This theoretical framework not only served as a foundational literature base for this study, but it was also used in the development of interview guide, as well as analyzing and interpreting the findings of the study. According to Kolb’s Experiential Learning Theory, learning constitutes a process through which experiences are transformed into knowledge. Kolb delineates four distinct stages within the learning cycle: Concrete Experience, Reflective Observation, Abstract Conceptualization, and Active Experimentation. In the initial stage, learners participate in specific experiences or activities. The subsequent stage, Reflective Observation, prompts individuals to contemplate these experiences, analyzing what occurred and the underlying reasons. During the third stage, Abstract Conceptualization, learners develop concepts and generalizations informed by their reflections. Finally, in the fourth stage, Active Experimentation, learners implement the newly acquired concepts in real-world contexts to evaluate their applicability [15]. This cyclical framework emphasizes that learning transcends mere information absorption; it necessitates active engagement with experiences, reflective thought, and the practical application of acquired knowledge. Reflection constitutes an essential element of Kolb’s experiential learning model, especially within the Reflective Observation phase. This phase encourages learners to engage in critical analysis of their experiences, facilitating the recognition of both achievements and opportunities for enhancement. Schön reinforces this perspective by asserting the importance of reflection in professional practice. He differentiates between two types of reflection: reflection-in-action, which occurs during the execution of an activity, and reflection-on-action, which takes place post-activity. Both modalities of reflection play a crucial role in enhancing a practitioner’s ability to derive lessons from their experiences, thereby promoting a more profound understanding of their professional practice [16].

In the context of medical education, reflection plays a crucial role in fostering professional development. It is essential for medical students to not only acquire theoretical knowledge but also to cultivate the capacity to effectively apply that knowledge within clinical environments. Kolb’s experiential learning model posits that engaging in reflective practice enables students to refine their clinical competencies, enhance their decision-making abilities, and develop a more profound understanding of patient care. Moon asserts that reflective practice in educational contexts prompts students to critically evaluate their experiences, thereby leading to improved learning outcomes. This perspective is consistent with the objectives of professional development, as it is imperative for medical practitioners to engage in ongoing reflection on their practice to enhance patient care and adapt to emerging challenges [17].

In our context, medical students are taught the medical knowledge as well as the clinical skills through real hands-on experiences. We believe that experience alone does not guarantee learning. In order to boost learning, students’ experience must be interpreted and integrated into existing knowledge. This can be obtained if medical students find the opportunity to reflect on their learning. Sandars state that the context of medical practice is challenging and medical doctors are faced with a wide variety of complex circumstances. In this vein, proficient doctors can make the right decisions to tackle these complicated and poorly-defined situations through a process of reflection [18].

Literature is replete with studies on reflection and there is convincing evidence on the role of reflection in the professional development of medical students. In this respect, research findings show that reflection can improve diagnostic thinking [19], professional identity [20], and humanism aspects of medical care [21]. A systematic review by Winkel et al. on interventions reporting the use of reflection in graduate medical education in 2017 revealed that reflection can result in comfort with learning in complex situations, engagement in learning, deepening professional values as well as improved attitudes [22]. There exists a paucity of research within the Iranian context regarding the examination of reflective practices aimed at enhancing students’ professional development. Nevertheless, the investigation conducted by Farajpour et al. emphasizes the significant importance of reflection in medical education, illustrating that early exposure to clinical settings encourages students to critically assess their experiences and emotional responses. Through reflective practices, students gained deeper insights into their personal and professional development, enhancing their understanding of patient care and their evolving identities as healthcare providers [23].

Relevant students on reflection have also been conducted concerning the opinions of students towards reflection with diverse results. For instance, some studies highlight that students consider reflection as a valuable tool for their training [24, 25]. While, some studies indicate that students perceived reflection as a time-consuming task [26, 27].

Students as the main stakeholders of the teaching-learning process can shed light on reflection activities and understanding their perspectives of reflection are valuable. In our context, the perspective of medical students who are engaged with reflection needs more investigation to advance our perspectives. The purpose of the present study was to analyse the medical students’ perspectives of reflection activities in terms of their professional development in Yazd University of Medical Sciences, Yazd, Iran.

Methodology

Research design

This qualitative study used a conventional content analysis approach. Qualitative content analysis is one of numerous methods used to analyze textual data emphasizing participant’s perspectives. Its goal is to provide knowledge and understanding of the phenomenon under study [28].

This study employed a basic qualitative approach to the study design [29]. The Consolidated criteria for Reporting Qualitative research Checklist (COREQ) has been used in the reporting of this study [30].

Research team

The research team consisted of scholars holding Ph.D. degrees in Medical Education, each with a robust background in qualitative research methodologies. Both scholars are faculty members at Medical Universities in Iran, where they have cultivated a deep understanding of the intricacies of medical education within the local context. Their extensive expertise in research design and execution is complemented by their roles as assistant professors, where they not only teach but also mentor students in research practices. In addition, their active engagement in the academic community in Iran ensures that they remain informed about the latest developments and challenges in medical education, further enriching the research process. This blend of academic rigor and practical experience positions the research team to effectively investigate the themes of reflection and professional development among medical students, ensuring that the findings are relevant and applicable to the Iranian educational context.

Participants and research context

This qualitative study was conducted with 20 medical students (10 males and 10 females) across different year levels at Shahid Sadoughi University of Medical Sciences in Yazd in 2023. Participants were chosen using non-probability, purposive sampling technique. In order to obtain a comprehensive understanding of the diverse perspectives of medical students regarding reflection and professional development practices, participants were deliberately selected from different academic year levels. In this regard, participants from different stages of the medical program, including basic science (n = 5), physiopathology (n = 4), clinical training (n = 5), and clinical internship (n = 6) were recruited in the study. All the recruited students had already participated in a reflection workshop and had experience of reflection during their medical training. The reflection workshop was conducted in the semester prior to the data collection phase of our research, specifically in the spring of 2023. This timing was deliberately selected to provide participants with the opportunity to engage with the principles of reflection and professional development just before their participation in the study. Through their involvement in the workshop, students acquired essential knowledge and skills pertinent to reflective practice, thereby enhancing their capacity to contribute substantively to the discussions during the data collection phase. The medical education in Yazd Medical University is 7 years long, reflecting the standard framework for medical training in Iran. This program begins with 2.5 years of basic sciences, followed by 1 year dedicated to physiopathology, providing students with a strong foundational knowledge essential for clinical practice. After completing these initial phases, students enter a clinical training period lasting 2 years, where they gain hands-on experience in various medical specialties. This is followed by a 1.5-year internship period, allowing students to apply their knowledge in real-world healthcare settings. This structure aims to equip future physicians with the necessary competencies to address the unique health challenges faced in Iran, while also aligning with national educational standards and regulations.

Inclusion and exclusion criteria

The selection of student participants for the study was based on specific criteria: (1) enrollment in the medical education program at various academic levels at Shahid Sadoughi University of Medical Sciences, (2) participation in the reflection workshop held in the semester preceding data collection, and (3) a demonstrated willingness to engage in the study and provide informed consent. In contrast, students experiencing psychological or emotional distress were excluded from participation. Additionally, individuals who lacked adequate time or willingness to partake in the interview process were also excluded from the study.

Ethical considerations

This study was part of a research project at Yazd University of Medical Sciences with the ethical code IR.SSU.REC.1402.048. Before initiating each interview, written, voluntary, informed consent was granted from participants and they had the freedom to opt out of the research. The purpose of the research was explained to participants before each interview and they were thoroughly informed that the interviews were an attempt to share thoughts and experiences of reflection. Additionally, the condition of using data was explained to participants and they were assured of the confidentiality and anonymity. Each interview was audio-taped, with the participants’ permission and conducted at a time and place convenient to participants.

Data collection and analysis

Data collection was conducted using in-depth individual semi-structured interviews. Data saturation finalized the final number of participants. In this respect, sampling continued until no new information or data was added to the previous obtained data. Totally, 20 interviews were conducted. Interviews were done by one of the members of the research team (SH), who has experience in conducting qualitative studies and has worked as a director of staff development unit for several years in the hospital.

In order to collect data, an exploratory interview guide was developed based on the theoretical frameworks underpinning the study, as well as the exploratory characteristics of the research. The interview guide commences with a welcoming introduction delineating the study’s objectives. Demographic inquiries are included to collect background information, while the primary, follow-up, and exploratory questions probe into participants’ comprehension and experiences of reflection. Specifically, participants were asked interview questions: (1) to explore their perspectives of reflection; (2) to elaborate on experiences (positive and negative) of reflection during their medical training; and (3) to perceive the relevancy of reflection in their learning and professional development. If participants provided answers that were vague or needed more detailed explanations, follow up questions were asked. Questions such as “Please explain more” and “Do you want to add anything else?” were asked to obtain more information (the interview guide is provided in the electronic supplementary material section). A concluding summary question is provided to elicit additional insights, and the guide concludes by expressing gratitude to participants, while also offering the opportunity for further communication regarding any post-interview inquiries. To ensure the validity of the interview guide, it was disseminated to four specialists in the field of Medical Education who possess significant professional and research expertise. Their feedback was considered, and modifications were implemented as deemed necessary. Prior to the commencement of the interviews, a pilot test was administered involving two student participants to assess the coherence of the questions, the length of the interview, and the participants’ understanding. Following the pilot testing, no modifications were made to the interview guide.

Each interview lasted 25–50 min and was transcribed verbatim. We performed a qualitative content analysis of the data [31] based upon themes emerging from the texts. Data analysis was done in an interactive process. After each interview, a member of the research team (AB) transcribed each interview and it was checked for correctness by another member of the team (SH) by reading the transcript, whilst listening to the audio-tape. Content analysis of the transcripts was then undertaken using the approach proposed by Graneheim and Lundman [32]. Therefore, data was generated by following these steps: (A) determining the content and unit of analysis; (B) determining the semantic units or coding units; (C) summarizing and abstracting; E) categorizing the codes into subcategories; and F) forming main categories from subcategories. Data was analyzed using MAXQDA distributed by VERBI GmbH in Berlin, Germany version 10.

Trustworthiness

Validity and accuracy of data was provided on the basis of Goba and Lincoln’s criteria [33]. To ensure the credibility of the data, member-checks were used. In this regard, the extracted codes were shared with participants and modifications were applied to the data. Furthermore, in order to reduce subjectivity, a reflexive journal was maintained to facilitate the bracketing of biases. This approach contributed to obtaining more profound insights and, as a result, enhanced the credibility of the study. To establish dependability, two experts in qualitative research, reviewed codes and categorizations. In terms of confirmability, an external observer experienced in qualitative research verified and validated data collection and analysis processes. For transferability, an attempt was made to capture all details, from sampling to collecting and analyzing data, as much as possible. Researchers also documented comprehensive and thick description of the entire research process to allow the applicability and pertinence of the study’s outcomes to different contexts.

Results

The study participants included 10 males and 10 females with the mean age of 24 years from different stages of the medical program at Shahid Sadoughi University of Medical Sciences in Yazd in 2023. All participants were Iranian and Muslim. In terms of their family status, 4 were married, 2 were engaged, and 14 were single. The content analysis technique revealed 168 primary codes which were categorized into three main themes and seven sub-themes within the concept of reflection. As can be seen in Table 1, the identified main themes included: [1] self-awareness; [2] professional competence; and [3] reflection culture.

Table 1.

The main themes and sub-themes obtained from interviews at shahid sadoughi university

Main themes	Sub-themes
1. self-awareness	1.1. self-acceptance
	1.2. metacognitive self-exploration
	1.3. semantic perception
2. professional competence	2.1. self-directed learning
	2.2. professional identity formation
3. reflection culture	3.1. organizational climate
	3.2. educational program structure

Self-awareness; I accepted my real self as I am

Self-awareness constitutes a critical component of reflective practice, especially within the framework of medical education and professional development. It encompasses the capacity of individuals to identify and comprehend their own thoughts, emotions, and behaviors, along with the effects these have on others. In the context of medical training, self-awareness is essential for fostering empathy, refining communication skills, and ultimately improving the quality of patient care [17]. Research shows that individuals who have a clear understanding of themselves tend to exhibit higher levels of confidence and creativity. This self-awareness also leads to improved decision-making, stronger interpersonal connections, and enhanced communication skills. Additionally, individuals who possess this level of self-awareness are less likely to engage in deceitful or unethical behavior, and are more likely to excel in their professional roles and leadership positions [34].

Self-acceptance; Reflection made me accept myself as I am

Self-acceptance plays a crucial role in maintaining mental health. Failure to embrace oneself can lead to various emotional problems, such as uncontrolled anger and depression [35]. Majority of participants emphasized the significance of self-reflection in recognizing their skills and accepting themselves unconditionally.

“Through self-reflection on my learning process and the skills I possess, as well as those I lack, I gradually come to accept myself as I am. I observe that some of my peers struggle to acknowledge their deficiencies in truly understanding concepts, relying instead on rote memorization without practical application” (P.4. clinical training level).

This reflection underscores the role of self-awareness in promoting acceptance, enabling individuals to acknowledge their shortcomings rather than overlook them. Furthermore, it addresses a more pervasive concern within educational settings, wherein certain students may refrain from engaging with the material on a deeper level.

Another participant stated:

“Upon entering the university, I viewed university as an extension of high school where learning was solely based on textbooks and lectures, I gradually realized the need to reassess my study habits and learning approach. Reflecting on the discrepancy between studying anatomy and physiology, I recognized the necessity of seeking out diverse sources to properly grasp the material. This process of reevaluation allowed me to embrace my strengths and weaknesses, ultimately guiding me towards a more effective and self-aware approach to learning” (P.6. basic science level).

This assertion highlights the significant impact of reflection within academic environments, stressing that self-acceptance extends beyond mere recognition of one’s present condition; it also involves a proactive commitment to personal development and the modification of learning approaches.

Metacognitive self-exploration; I started to explore about myself

John Flavell first coined the term metacognition in the late 1970s and defined it as “cognition about cognitive phenomena” or, in simpler words, “thinking about thinking” [36]. Self-exploration is defined as the mindful, and enduring practice of identifying and challenging one’s assumptions and actions in light of new information arising from exposure to new surroundings and the passage of time [37]. Participants in this study highlighted the transformative impact of metacognitive self-exploration on their learning experiences. One student reflected on her academic journey, stating:

“After three years of studying medicine, I observed that while some students excel in exams, they may struggle to explain the material or apply it in real-world scenarios. Through exposure to reflection from a senior student, I gradually learned to assess my own learning process and identify areas for improvement over time” (P.11. physiopathology level).

This quotation illustrates the importance of peer influence and reflective practices in fostering metacognitive awareness, enabling students to critically evaluate their understanding and application of knowledge.

Another student at the clinical level stated:

“In my initial year at university, I discovered that my study techniques were inadequate during the first mid-term exams. I am now appreciative of this realization as I progress through my clinical coursework. The use of concept maps has proven to be extremely beneficial in improving my studying methods. Had I not taken the time to reflect on my learning strategies early on, I would have likely encountered numerous challenges at present” (P.8. clinical training level).

This reflection emphasizes how early metacognitive awareness can lead to the adoption of effective study strategies, significantly enhancing academic performance.

Semantic perception; I understood the meaning of the behavior and words of others

The concept of semantic perception is often discussed in psychology and philosophy [38, 39]. It has also been explored in educational contexts and semantic web technologies [40]. Some experts in the field of education propose that semantic perception functions as the sixth human sense, and they state that the inherent nature of semantic perception has a physiological basis. Semantic perception is unique for each person. The sixth sense of perception is explicitly used to sense and identify a variety of semantic relationships in observations and spoken language [41].

We chose to name this subtheme “semantic perception” after considering feedback from students regarding the behavior of medical teachers and other observations within the university setting.

Participants expressed their experience as follows:

“In the initial stages of my time at the hospital, I lacked an understanding of various behaviors and their impact on patients. During clinical rounds, I observed patients becoming visibly uncomfortable when surrounded by a group of students and teachers at their bedside. Despite noticing signs of distress such as changes in facial color and embarrassment, I failed to grasp the significance of these reactions. Reflecting on these experiences afterwards, I realized the stress and difficulty our presence caused for patients. This realization led me to question why some teachers did not prioritize the well-being of patients. I now take the initiative to communicate with patients beforehand, explain procedures, and offer reassurance to alleviate their anxiety. By seeking permission before conducting physical examinations, I have found a sense of fulfillment in ensuring patients’ comfort and well-being” (P.16. clinical internship level).

This reflection illustrates how developing semantic perception can enhance empathy and improve patient interactions, ultimately fostering a more compassionate healthcare environment.

Another participant expressed:

“Upon gaining insight into the concept of reflection, I came to comprehend the significance of human behavior and the qualities of an effective teacher. In our classroom, a teacher used a unique approach to address misbehavior by invoking a sense of shared fatigue, followed by reciting a poem and sharing a personal anecdote with a moral lesson. This method effectively transformed a disruptive student into a well-behaved one. While some of my peers attributed this success to the teacher’s patience, I recognized the value of reflection in uncovering the deeper meaning behind the teacher’s actions. This experience underscored the importance of reflecting on our surroundings to extract valuable educational insights” (P.7. basic science level).

This statement emphasizes the notion that semantic perception transcends isolated interactions, encompassing a comprehensive understanding of broader educational dynamics. It accentuates the significance of reflection in identifying effective pedagogical strategies.

Professional competence

Literature provides a comprehensive definition of competence as: “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served [42].”

Self-directed learning; I set a learning plan for myself

Self-directed learning, as identified in the extracted codes, encompasses intrinsic motivation, the setting of personal objectives, and self-regulation. One student shared her insights on the impact of self-reflection in her learning process:

“Initially, I doubted my ability to grasp the complex subjects within the medical field. Despite feeling anxious, I reassured myself that if I had been accepted into this field, I possessed the necessary capabilities. Through continuous introspection, I established a goal, devised a study plan, and diligently practiced. Seeking guidance from experienced individuals in the field further aided my success” (P.12. clinical training level).

This reflection accentuates the significance of self-efficacy and systematic planning in addressing initial uncertainties and improving educational results.

A fellow student who participated in an internship and completed the final clinical rotation shared his perspectives on the impact of reflection on his academic achievements. He noted that despite hearing about the importance of reflection from various sources—peers, teachers, and online platforms— it was not until he experienced it firsthand in the emergency department that he truly understood its efficacy.

“During my first experience performing a nasogastric tube insertion, I engaged in reflective practices before, during, and after the procedure, identifying areas for improvement and subsequently enhancing my skills through targeted practice. This approach yielded positive outcomes, prompting me to incorporate reflection into my learning process for other procedures with great success. I now advocate for self-reflection as a valuable tool for personal growth and emphasize the role of individual accountability in my academic journey” (P.3. clinical internship level).

This statement points out the transformative power of reflection in skill acquisition and the importance of taking ownership of one’s learning process.

Professional identity formation; reflection helps to understand professional values

Professional values and ethics are the moral principles and beliefs that individuals rely on to determine the ethical standards and conduct expected in a professional setting. They serve as a guiding framework for ethical decision-making and behavior in the workplace [43]. One student reflected on his experiences in the hospital, noting:

“I noticed overlooked situations in the hospital, but by reflecting on them, valuable lessons can be learned. In one of my rotations, a medical teacher prescribed medication for a child without considering the potential interactions with his asthma medication. Despite the lack of serious consequences, the teacher admitted fault and apologized, prompting differing reactions from students. Through deep contemplation, I gained valuable insights from this experience” (P.18. clinical internship level).

This reflection highlights how recognizing and analyzing mistakes can lead to important learning opportunities, reinforcing the significance of ethical considerations in clinical practice.

The perspectives of specific students suggest that contemplating unprofessional conduct can strengthen dedication to one’s field.

“A sixth-year medical student described an encounter with a teacher who had a financial interest in a laboratory kit manufacturing company and would order unnecessary tests for numerous patients. Despite many patients facing financial struggles, they placed trust in the doctor and proceeded with the tests. Observing this behavior prompted me to reflect on how certain individuals compromise the reputation of the profession and prioritize personal gain. This experience solidified my resolve to avoid replicating such behavior in my future career” (P.5. clinical internship level).

This reflection emphasizes the significance of integrity and accountability within the field of medicine, illustrating how the observation of unethical conduct can reinforce an individual’s dedication to professional values.

Reflection culture; conditions should be favorable for reflection

Reflection culture denotes an environment that actively encourages and values reflective practices, prompting individuals to engage in critical analysis of their experiences and decision-making processes. This culture facilitates ongoing learning and enhancement, prioritizing open communication and providing support for the exchange of insights [44]. The student’s behavior is significantly affected by the educational environment, and the educational environment is related to the success, satisfaction, motivation, and fulfillment of the student’s goals, as well as his knowledge, skills, and attitude [45].

Learning climate

The concept of learning climate encompasses the comprehensive environment in which educational activities occur. It comprises various elements, including faculty support, open lines of communication, psychological safety, and collaborative interactions among students. A favorable learning climate fosters increased engagement and enables students to feel secure in articulating their thoughts and reflecting on their experiences [46]. The educational environment plays a crucial role in shaping students’ readiness to participate in open discussions regarding their understanding and reflections. One student articulated:

“When asked by teachers or older students whether I understand a procedure or topic, I pretend that I know to avoid judgment. Instead, I actively seek to improve my understanding by utilizing online resources and collaborating with peers” (P.13. clinical internship level).

This statement highlights the pressure students feel to appear knowledgeable, which can hinder honest communication and learning.

Another student studying physiopathology shared his experience:

“When I first learned about metacognition in high school and understood the benefits of reflection in learning and error correction, I later learned in university to keep my reflections to myself and not discuss them with others. This shift in perspective towards sharing personal reflections was found to be unpleasant, leading me to believe that it was best to refrain from sharing the results of my reflections with others” (P.2. physiopathology level).

This reflection highlights the ways in which the academic setting may inhibit vulnerability and openness, both of which are crucial for facilitating effective learning.

Educational program structure

The structure of an educational program encompasses the systematic arrangement of a curriculum, which includes its content, sequencing, instructional methodologies, and evaluation techniques. Within the context of medical education, this structure is designed to enhance the acquisition of critical knowledge and competencies, thereby fostering student engagement and optimizing learning outcomes [47]. To foster effective reflective practices, managers and educational planners must create conducive environments for students. The overwhelming volume of course materials, intense and repetitive programs, and high academic demands can significantly hinder medical students’ ability to engage in meaningful reflection.

One student expressed her discontent with the circumstances, stating:

“The demanding nature of the internship stage requires students to manage various responsibilities in both clinical settings and academic environments. I question whether the rigorous curriculum and practical experiences permit sufficient time for reflection” (P.9. clinical internship level).

This highlights the concern that a packed schedule may leave little room for introspection, an essential component of learning.

Another student echoed this sentiment, noting:

“Although teachers stress the significance of reflection, there is often a lack of time for it, especially since there typically isn’t much time beforehand. Nonetheless, there are brief moments during the procedure where self-reflection on one’s performance is possible, provided that the circumstances are conducive and there is no added pressure from being monitored by a teacher or resident” (P.14. clinical internship level).

This observation underscores the need for a supportive environment that allows for reflection, particularly in high-pressure situations.

Discussion

The purpose of this study was to investigate the perspectives of medical students regarding the role of reflection on their professional development. Participants enumerated 3 main themes and 7 subthemes as the following: self-awareness (self-acceptance, metacognitive self-exploration, semantic perception); professional competence (self-directed learning, professional identity formation); and reflection culture (organizational climate, educational program structure). It is essential to note that the majority of the primary themes and subthemes derived from participant interviews encompassed abstract concepts. Consequently, to ensure a uniform understanding of these abstract notions, the definitions of these concepts were elucidated in the results section, drawing upon credible sources.

A prominent theme identified in the research is self-awareness. Green’s study, which explored the significance of self-awareness and reflection within social care practices, revealed that when healthcare professionals, such as doctors and social workers, engage in reflective practices to enhance their self-awareness, it fosters their professional development and improves their methodologies [48]. This ongoing enhancement can elevate the quality of health services provided, which is particularly crucial in the Iranian healthcare context, where systemic challenges and resource limitations can impact patient care. Similarly, Nesbit’s research posits that, three essential meta-skills—self-awareness, self-reflection, and self-regulation—are crucial in facilitating self-development during the managerial learning process. The study emphasizes the pivotal role of self-reflection skills within the proposed model of self-development [49]. It is essential to comprehend the significance of self-awareness for medical students, as it contributes to their personal development and improves their ability to deliver empathetic and culturally competent care. This capability is particularly vital in a diverse society such as Iran. The subtheme of self-acceptance can be viewed as various aspects of attaining self-awareness. Certain scholars argue that unconditional self-acceptance serves as a more effective alternative to self-esteem [50]. Findings from the current study indicate that one of the roles of reflection is manifested through self-awareness, particularly in the context of self-acceptance. This is especially pertinent in the Iranian context, where societal pressures may impact students’ self-perception and mental well-being. Additionally, research has demonstrated a positive correlation between self-acceptance, mindfulness, and individuals’ mental well-being [35, 50]. In light of the growing concerns regarding the mental health of medical students worldwide, it is imperative to investigate whether analogous patterns are observable in Iran. Research has demonstrated that medical students in Iran encounter considerable stress and mental health difficulties, which may adversely impact their academic achievements and interactions with patients [51]. Consequently, promoting self-acceptance through reflective practices may act as a mitigating factor against burnout and anxiety. The findings of our research align closely with those of previous investigations. For instance, a study involving 231 psychology students from two public universities in the southeastern United States revealed a reciprocal and positive relationship between reflection and self-acceptance. This particular study addresses the critical issue of rumination and its connections to reflection, self-acceptance, and empathy [52]. A significant concern raised by educators in the fields of medicine and psychology is that students may experience cognitive errors in their information processing, rather than engaging in genuine reflection. It is essential for students to remain vigilant and avoid becoming ensnared by their own cognitive biases, which can lead to discriminatory practices in patient care. In the Iranian context, where cultural and social biases may influence healthcare delivery, enhancing self-awareness and reflection can help combat these biases and promote equitable treatment for all patients. Additional subthemes encompassed metacognitive self-exploration and semantic perception, with their definitions provided in the results section. Numerous studies have indicated a connection between these concepts and reflection, highlighting their beneficial effects on the learning process [53, 54]. Incorporating these insights into medical education will enhance the preparedness of future healthcare professionals to effectively manage the complexities associated with patient care in Iran and other contexts.

The second primary theme encompasses two subthemes that, according to the analyzed data, signify professional competence. Malcolm Knowles and Fisher characterize self-directed learning as a process wherein individuals recognize their learning needs, establish learning objectives, identify necessary content and resources, select and apply suitable learning strategies, and assess the outcomes and implications of their learning [55]. Abili et al. have distilled the attributes of self-directed learners, as articulated by experts, into several key characteristics: motivation, goal orientation, self-efficacy, locus of control, and self-regulation. Furthermore, the internal factors that effectively foster self-directed learning among learners include self-control, self-management, motivation, and a passion for learning and problem-solving, all aimed at achieving optimal results [56]. The researchers acknowledge that a fundamental skill associated with self-directed learning is self-reflection [57], a finding that was also corroborated by the data analysis conducted in the current study. The students’ reflections, enriched by their lived experiences, led to the development of their professional identity. According to Cruess RL et al., professional identity is conceptualized as a self-representation that evolves over time through the internalization of the medical profession’s characteristics, values, and norms, ultimately resulting in individuals who think, act, and feel like physicians [58]. Jarvis-Selinger e al. further describe the formation of professional identity as an adaptive growth process that unfolds on two distinct levels: the individual level, which encompasses psychological development, and the collective level, which pertains to the individual’s socialization [59]. The Oxford English Dictionary defines socialization as “the process by which a person learns to function within a particular society or group by internalizing its values and norms [60]. In the context of Iran, the culture surrounding medical education is frequently characterized by hierarchical structures and a predominance of passive teaching methodologies. Despite efforts to promote meaningful learning across various settings, these characteristics may hinder the development of self-directed learning and critical reflection among students [61]. This hierarchical approach may restrict students’ opportunities to participate in reflective practices, which are vital for the development of professional identity. The results of this study indicate that promoting a culture of reflection within medical education in Iran is essential for cultivating proficient healthcare practitioners. Moreover, the integration of reflective practices into the curriculum can help in promoting patient-centered care and increase the health level of Iranian society [4]. The behaviors, speech, and other attributes of teachers, along with the surrounding events, contribute to shaping students’ professional identities, facilitating a gradual acquisition of professionalism. As indicated by the findings, these two subthemes collectively constitute the overarching category of professional competence. Researchers have proposed that to attain this objective, essential modifications must be incorporated into the curriculum, alongside the integration of pertinent learning objectives. Furthermore, strategic planning for the implementation and assessment of these changes is imperative. Evidence indicates that one of the most effective pedagogical approaches for this purpose is reflective writing, particularly through the utilization of narrative reflections [58, 62]. The ramifications of this research reach beyond the immediate results, underscoring the urgent need for a transformative strategy in medical education within Iran and the wider Middle Eastern region. By cultivating an environment that promotes reflection and self-directed learning, educators can more effectively equip students to address the challenges of the medical profession and improve the quality of healthcare services in their communities.

The last main theme addresses two critical aspects: the structure of the educational program and the organizational climate, both of which significantly influence the culture of reflection. The model developed by researchers, grounded in learning theories and encompassing various types of reflection—namely, reflection on action and reflection in action—along with principles of feedback pertinent to adult learning, delineates the roles of both teachers and learners at each phase. Notably, during the organizational phase of the model, it is underscored that teachers not only need to possess reflective capabilities but also must facilitate opportunities within the educational program’s framework that enable students to reconsider their learning experiences. Such activities may be conducted through formal or informal educational initiatives, including small group discussions and collective reflection [63]. A significant concern raised by students pertains to the curriculum’s structure, which inadequately allocates time for reflection, consequently relegating this critical aspect to a lower priority within the medical education framework. A systematic review examining the challenges and issues associated with clinical medical education in Iran indicates that the structure of the curriculum presents considerable obstacles. These challenges encompass subpar clinical rounds, insufficient learning skills, restricted educational opportunities, inadequate training methodologies and ineffective assessment methods, among others. Such deficiencies impede effective learning and critical engagement with clinical scenarios [64]. The integration of reflective practices within medical education is crucial, as reflection fosters self-awareness and facilitates deeper learning, thereby enhancing clinical competencies and patient care. By addressing these challenges through reflective strategies, it is possible to cultivate a more effective educational environment for future healthcare professionals in Iran. Educational administrators and planners must incorporate structured opportunities for reflection within the curriculum, employing appropriate scientific methodologies for both teaching and assessment [63, 65]. The importance of this issue is reinforced by the emerging discourse surrounding competencies in medical students, particularly regarding their ability to reflect on feedback received from clinical training simulators, highlighting the necessity for teachers to prioritize this element in their teaching practices [66]. Sweet’s research indicates that the items categorized under the first theme represent a fundamental form of reflection, which encompasses a self-awareness regarding one’s behavior [53]. This reflection can manifest in various temporal contexts, such as contemplating past experiences (reflection-on-action), engaging with current actions (reflection-in-action), or anticipating future actions (reflection-for-action) [67]. Conversely, the items identified in the second primary theme are characterized as critical reflection. This form of reflection involves an individual undertaking a deliberate examination and assessment of a specific experience, ultimately resulting in a transformation of their viewpoints on the matter at hand. The findings suggest that structured reflection, particularly the critical reflective inquiry model proposed by Kim, is the most effective approach for fostering reflection in clinical learning environments. For optimal outcomes, it is crucial for teachers to recognize the significance of reflection in the learning process and to employ thoughtfully designed guiding questions that facilitate students’ comprehension and articulation of shifts in their thinking, thereby emphasizing their profound learning experiences [68].

The present study has its own limitations. First, although data saturation was achieved with 20 participants, the specific focus on medical students in one Medical University, limit the generalizability of research findings. However, the maximum variation sampling across different year levels ensured a wide range of perspectives, and a well-documented research process enhances the transferability of the findings to similar settings. We recommend conducting multicenter studies regarding the topic under investigation. By the same token, the subjective nature of qualitative research may invoke bias in the data collection, analysis, and interpretation. In this regard, researchers tried to stay away from personal assumptions as much as possible. Furthermore, the results of this study rely on self-reported data from participants, which may be influenced by recall bias or social desirability bias. Nevertheless, the semi-structured format of the interviews, the incorporation of open-ended questions, and the interviewer’s proficiency in eliciting detailed responses contributed to the reduction of these potential biases. Despite these limitations, this study offers significant contributions to the understanding of the role of reflection within medical education, underpinned by a robust theoretical framework and a rigorous qualitative methodology, while emphasizing the perspectives of medical students. The results may serve to enhance educational practices and facilitate the professional growth of future healthcare practitioners.

Conclusion

The perspectives of medical students regarding the significance of reflection in their professional development reveal elements of the hidden curriculum. It appears that students critically evaluate the behaviors, dialogues, communications, strategies, and decisions of their teachers, assimilating experiences and knowledge based on prior learning and contextual factors. Given the critical nature of this subject, it is essential for clinical teachers to be mindful of their role as models and to engage in thoughtful planning. Additionally, fostering a conducive educational environment that encourages medical students to engage in reflective practices can significantly enhance their professional development. Furthermore, it is crucial to instruct students on distinguishing reflection from detrimental cognitive patterns such as overthinking, rumination, obsession, excessive analysis, and anxiety about the future, ensuring that mindfulness training helps them avoid these mental pitfalls.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

All authors participated in drawing up the study. SH, and AB coordinated the conceptualization and planning of methodological aspects. SH carried out the interviews and AB helped in data curation. Both authors took part in data analysis, discussion and drafting the article.

Funding

This study was financially supported by Yazd University of Medical Sciences through Grant No 14949.

Data availability

The datasets generated and analysed during the current study are not publicly available due to considering ethical principles and respecting the privacy of participants but are available from the corresponding author on reasonable request.

Declarations

Ethical approval

This study was approved by the ethics committee of Yazd University of Medical Sciences (IR.SSU.REC.1402.048). Written informed consent was also granted from participants.

Consent for publication

Not applicable.

Clinical trial number

Not applicable.

Competing interests

The authors declare no competing interests.