Abstract
Background
Graduate medical education programs employ reflection to advance a range of outcomes for physicians in training. However, the most effective applications of this tool have not been fully explored.
Objective
A systematic review of the literature examined interventions reporting the use of reflection in graduate medical education.
Methods
The authors searched Medline/PubMed, Embase, Cochrane CENTRAL, and ERIC for studies of reflection as a teaching tool to develop medical trainees' capacities. Key words and subject headings included reflection, narrative, residents/GME, and education/teaching/learning. No language or date limits were applied. The search yielded 1308 citations between inception for each database and June 15, 2015. A total of 16 studies, encompassing 477 residents and fellows, met eligibility criteria. Study quality was assessed using the Critical Appraisal Skills Programme Qualitative Checklist. The authors conducted a thematic analysis of the 16 articles.
Results
Outcomes studied encompassed the impact of reflection on empathy, comfort with learning in complex situations, and engagement in the learning process. Reflection increased learning of complex subjects and deepened professional values. It appears to be an effective tool for improving attitudes and comfort when exploring difficult material. Limitations include that most studies had small samples, used volunteers, and did not measure behavioral outcomes.
Conclusions
Critical reflection is a tool that can amplify learning in residents and fellows. Added research is needed to understand how reflection can influence growth in professional capacities and patient-level outcomes in ways that can be measured.
Introduction
Reflection is considered a critical component of learning in graduate medical education (GME).1–4 By reflecting on experiences, residents and fellows develop self-regulated learning skills that can lead to enhanced competence, humanism, and professionalism.1,5–11 Theory supports reflection as a means to advance knowledge, guide future learning, deepen understanding of complex concepts, and explore emotionally challenging situations.1,12–14 However, the impact of reflection on medical trainees and its most effective use in GME remain unclear.
We conducted a systematic review of the literature to evaluate the available evidence on the impact reflection has in GME. Reflection is defined in several ways. For this review, we used the definition by Mann and colleagues,1 which includes a framework for reflection, involving critical thinking, exploration of personal and emotional experiences, and examination of the impact of actions. Our review also focused on studies that measured the effect of reflection on resident/fellow capacities. Our objective was to identify elements of reflection that could support positive change in physicians in training.
Methods
A health sciences librarian trained in systematic reviews (J.N.) developed and conducted searches in Medline/PubMed, Embase, Cochrane CENTRAL, and ERIC through June 15, 2015. The search combined relevant key words and subject headings for the 3 concepts of reflection/narrative, residents/GME, and education/teaching/learning. The search used no language, country, or date limits.
The Figure provides the preferred reporting items for systematic reviews and the flow diagram outlining the review methods. After eliminating duplication, 1308 studies were screened for eligibility using a 2-step process that included only studies in GME and studies that used reflection as an intervention.
Figure.
PRISMA Flow Diagram
A total of 1308 abstracts/titles were screened, which resulted in the exclusion of 1192 articles. Pairs of team members conducted full-text screenings of the 116 remaining articles, which produced 16 eligible studies, for which data were extracted into a standardized template. Conflicts in inclusion and data extraction were resolved through discussion. Following data extraction, team members assessed study quality using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. This checklist focuses on the validity, content, and relevance of the research design, data collection, and analysis. All studies included in the review satisfied CASP criteria. We conducted a thematic analysis that focused on the core areas of interest in the reported study results.
Results
Sixteen studies using reflection in GME were included in the final review. The Table shows details on participants and settings, the interventions, and the outcomes studied. The results of thematic analysis are listed in the “Focus” column of the Table.
Table.
Studies Examining the Impact of Educational Activities Involving Reflection on Residents and Fellows
Impact of Training on the Quality of Reflection
Four studies explored the impact of reflective exercises on the reflective capacity of trainees.3,15–17 George et al15 enrolled 25 second-year family medicine residents in monthly coaching sessions. Residents set goals and entered written reflections in a web-based portfolio. The findings showed deepening reflective ability over time.
Khanum16 created a curriculum of reflective exercises for 24 obstetrics and gynecology residents. Residents completed reflective exercises focusing on learning challenges. While participants varied in reflective ability, as a group they demonstrated deeper reflection over time.
Levine and colleagues17 examined the impact of reflective writing on 32 first-year internal medicine residents from 9 programs. Participants volunteered to write serial narrative reflections over 1 year. The authors focused on meaningful segments in the writing, which showed increased depth of reflection over time.
Impact of Reflection on Learning
Most models of reflection underscore its critical role in the learning cycle: synthesizing learning and discovering connections within an educational experience.1 Six studies described connections between reflection and learning in practice.3,15,17–20
Bernard and colleagues18 investigated the use of a social media platform for reflection in an emergency medicine residency. Reflections from 37 residents and 34 faculty members were analyzed using a constant comparison approach. The value of learning from shared reflections was supported in the analysis.
Bethune and Brown19 used case-based reflective exercises with 57 family medicine residents. Eight of these residents participated in semistructured interviews on the impact of reflection, and reported reflection informed their strategies for future learning and influenced patient interactions.
George et al15 also assessed goal setting using a web-based portfolio. The authors attributed the residents' increasingly complex learning goals to a learning process driven by reflection.
Levine et al17 also assessed for enhanced learning through reflections, with residents demonstrating increased self-awareness and a reconsideration of their core values. The authors concluded that reflection served the following multiple functions for residents: a venue for expressing emotions, a forum for clarifying learning goals, and a source of motivation to improve.
Toy and colleagues20 explored the impact of reflection on learning goals for clinical behaviors. Sixteen obstetrics and gynecology residents engaged in monthly reflection and goal setting. Participants increased their number of logged procedures and documented cases, which the authors interpreted as evidence of increased engagement in learning.
Miller Juve3 also examined self-directed learning by residents engaged in writing reflections. No change was seen between pre- and posttest, yet participants reported that reflective practice would aid their future learning.
These studies suggest that the act of engaging in reflection might motivate future clinical behavior in practice.
Impact of Reflection on Developing Professionalism
Seven studies explored reflection as a means to develop residents' professionalism.2,5,18,19,21–23 Four studies examined individual-level professionalism, and 3 looked at professional connections within a community of care.
Bethune and Brown19 explored 8 family medicine graduates' perceptions of the role of reflective exercises in training. Respondents reported that reflection influenced their developing professional identities by encouraging personal insights and offering a different perspective on patient interactions, potentially enhancing the development of their professional identity.
Kung and colleagues2 developed a professionalism and ethics curriculum for 30 radiology residents that consisted of 6 reflective sessions. Using a pre-/posttest design, the authors found no changes in self-reported professionalism overall, although there were some positive changes in concepts of accountability, honor, integrity, enrichment, and duty.
Adams and colleagues5 introduced Balint training to 16 obstetrics and gynecology residents. While pre- and posttest assessments did not show significant changes, participants reported that reflection produced valuable insights about patient care and a sense of community building.
Maurer et al21 studied 52 internal medicine and 8 psychiatry residents engaged in narrative medicine sessions on a geriatric rotation. Pretests and posttests revealed an improvement in residents' knowledge, skills, and attitudes about geriatric care.
Nothnagle and colleagues22 studied 22 family medicine residents enrolled in seminars that used reflection to promote self-directed learning and professionalism. A thematic analysis of semistructured interviews and field notes revealed residents believed the sessions enabled community building and practical application of professional values.
The analysis by Bernard et al18 also showed shared reflection as a positive influence in approaching challenging cases.
DasGupta and colleagues23 introduced monthly reading and discussion sessions for 18 pediatrics residents and 16 community health workers as part of a community medicine rotation. Residents and community health workers reported increased understanding of other perspectives, medical culture, and the importance of diversity.
Studies on the impact of reflection on individual professionalism produce mixed findings. At the same time, participants reported that reflection helped them solidify professional values and, combined with clinical activities, reflection appeared to positively influence connections within a community of practice.
Impact of Reflection on Empathy and Communication Skills
Five studies examined whether participation in structured reflection improved trainees' communication skills and empathy toward patients.12,17,24–26
Learman et al24 studied 32 obstetrics and gynecology residents to assess the quality of resident reflections and performance. Participants completed case-based reflection exercises, which were scored by faculty. This showed a correlation between the depth of residents' reflection and the quality of communication skills (rated by allied health professionals and medical students).
Ballon and Skinner25 studied reflective elements in an addiction curriculum for 28 psychiatry residents. A postrotation questionnaire revealed increased comfort with difficult content, and participants also reported increased comfort providing critical feedback to patients.
Winkel and colleagues26 instituted a narrative medicine curriculum consisting of 6 reflective writing seminars for 18 obstetrics and gynecology residents. Pre-/posttest surveys measuring burnout and empathy showed no significant differences. Residents enjoyed the sessions, but reported that they did not believe the sessions would affect their interactions with patients.
Epner and Baile12 introduced a “difficult conversations” seminar for 26 first-year oncology fellows. Fellows participated in monthly sessions led by peers using dramatic techniques, reflective writing, and Balint-type discussion groups. Analysis of written reflections and surveys revealed fellows valued the curriculum and felt it enhanced their communication skills.
A study of narrative reflections by 32 internal medicine interns by Levine and colleagues17 showed improved self-awareness. Residents reported the reflections served as an emotional outlet and motivated them to improve their connections with patients.
Among these studies, there is insufficient evidence to assess the impact of reflection on empathy or patient communication. Participants reported improved awareness and attitudes toward their patients, but studies did not assess whether changes in attitudes resulted in a measurable changes in resident skills for interacting with patients.
Reflection and Trainee Comfort With Complex or Difficult Situations
Two studies explored whether reflection increased trainee comfort with complex or challenging situations.12,25
In the study by Ballon and Skinner25 psychiatry residents on an addiction rotation used reflective journaling to explore stereotypes and stigmas regarding addictive disorders. Participants reported feeling more comfortable and effective in engaging with patients after the rotation.
An Epner and Baile12 study of a “difficult conversations” seminar series for oncology fellows revealed increased fellow skills in handling complex and difficult communication contexts.
The small number of studies in this area offered limited support for reflection as a means of exploring challenging content with physicians in training. The findings suggest reflection creates a forum where these difficult subjects can be safely explored, increasing comfort and readiness when these issues are encountered in clinical practice.
Discussion
The opportunity to learn through reflection has potential in GME, with a limited number of heterogeneous studies suggesting reflection as a teaching tool for several key teaching topics and contexts. Collectively, the 16 studies suggested reflection has a positive impact on empathy, increases comfort with learning in complex situations, and enhances engagement in the learning process. Reflection also appears to enhance learning of complex subjects, deepen professional values, and improve attitudes and comfort when learners explore difficult subjects.
Established models of reflection propose that personal growth occurs over time, as experiences are examined to produce new understanding that informs future practice. In addition to this horizontal dimension of reflection, there appears to be a vertical dimension, in which superficial reflective capacity can expand into deeper reflection with critical synthesis.1 Studies included offered some evidence that this vertical reflective capacity may develop with practice. However, most studies did not include comparison groups, and natural maturation may have been a confounder.
Studies that looked at the role of reflection in enhancing residents' learning found that graduates who received instruction in reflection continued to engage in reflective practice after training. This is consistent with Schön's reflective practice1 and Moon's concept that reflection is the path from superficial to deep learning.1
Studies that examined the impact of reflection on professionalism did not show changes after reflection, but participants reported changes in their beliefs. Changes may have occurred, but they were not detected with the available measures. Studies that used reflection in a community of practice suggested it as a possible antidote to the “hidden curriculum” that can undermine professional values in the learning environment.
Theoretical links between reflection and empathy are based on physicians' willingness to self-assess, coupled with their ability to accurately read patient cues.27 Studies in this area found participants had positive perceptions of the impact of reflection on their attitudes and communication skills, but there was no difference in measured empathy or communication skills.
Limitations of this review include the small number of original studies, lack of comparison groups, reliance on self-reporting, and use of instruments that lack validity evidence. Most notably, studies in the review did not measure the impact of reflection on professional behaviors, resident learning, or patient outcomes. Most used volunteers, which may limit generalizability to settings where learners are required to participate in reflection.
In addition, the review itself may have inadvertently excluded studies, which might have altered the conclusions. Finally, providing formal opportunities for reflection in clinical education may influence physician wellness—an important issue facing educators—but to date no studies have addressed this topic.
Future research could assess contexts that promote reflection, and the value and outcomes of engaging learners not naturally drawn to reflection is a critical topic for future study.
Conclusion
Reflection offers the potential to enhance and deepen learning, empathy, and professionalism in residents and fellows. This systematic review revealed a small body of relevant literature that supports reflection as a habit that can be developed, a tool that can clarify professional values and build community, and a way to help learners process complex subject matter. In contrast, the influence of reflection in developing empathy and communication skills was not clear in the studies reviewed.
References
- 1. Mann K, Gordon J, MacLeod A. . Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009; 14 4: 595– 621. [DOI] [PubMed] [Google Scholar]
- 2. Kung JW, Slanetz PJ, Huang GC, et al. Reflective practice: assessing its effectiveness to teach professionalism in a radiology residency. Acad Radiol. 2015; 22 10: 1280– 1286. [DOI] [PubMed] [Google Scholar]
- 3. Miller Juve AK. Reflective Practice and Readiness for Self-Directed Learning in Anesthesiology Residents Training in the United States [dissertation]. Portland: University of Oregon; 2012. http://pdxscholar.library.pdx.edu/open_access_etds/235/. Accessed May 11, 2017. [Google Scholar]
- 4. Wittich CM, Reed DA, McDonald FS, et al. Perspective: transformative learning: a framework using critical reflection to link the improvement competencies in graduate medical education. Acad Med. 2010; 85 11: 1790– 1793. [DOI] [PubMed] [Google Scholar]
- 5. Adams KE, O'Reilly M, Romm J, et al. Effect of Balint training on resident professionalism. Am J Obstet Gynecol. 2006; 195 5: 1431– 1437. [DOI] [PubMed] [Google Scholar]
- 6. Hildebrand C, Trowbridge E, Roach MA, et al. Resident self-assessment and self-reflection: University of Wisconsin-Madison's five-year study. J Gen Intern Med. 2009; 24 3: 361– 365. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Branch WT., Jr. The road to professionalism: reflective practice and reflective learning. Patient Educ Couns. 2010; 80 3: 327– 332. [DOI] [PubMed] [Google Scholar]
- 8. Shapiro J, Kasman D, Shafer A. . Words and wards: a model of reflective writing and its uses in medical education. J Med Humanit. 2006; 27 4: 231– 244. [DOI] [PubMed] [Google Scholar]
- 9. Carraccio C, Englander R. . Evaluating competence using a portfolio: a literature review and web-based application to the ACGME competencies. Teach Learn Med. 2004; 16 4: 381– 387. [DOI] [PubMed] [Google Scholar]
- 10. Leung FH, Ratnapalan S. . A framework to teach self-reflection for the remedial resident. Med Teach. 2011; 33 3: e154– e157. [DOI] [PubMed] [Google Scholar]
- 11. Clandinin DJ, Cave MT. . Creating pedagogical spaces for developing doctor professional identity. Med Educ. 2008; 42 8: 765– 770. [DOI] [PubMed] [Google Scholar]
- 12. Epner DE, Baile WF. . Difficult conversations: teaching medical oncology trainees communication skills one hour at a time. Acad Med. 2014; 89 4: 578– 584. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Cohen-Katz JL, Miller WL, Borkan JM. . Building a culture of resident well-being: creating self-reflection, community, & positive identity in family practice residency education. Families Systems Health. 2003; 21 3: 293– 304. [Google Scholar]
- 14. Holmboe E. . Bench to bedside: medical humanities education and assessment as a translational challenge. Med Educ. 2016; 50 3: 275– 278. [DOI] [PubMed] [Google Scholar]
- 15. George P, Reis S, Dobson M, et al. Using a learning coach to develop family medicine residents' goal-setting and reflection skills. J Grad Med Educ. 2013; 5 2: 289– 293. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Khanum Z. . Effectiveness of reflective exercises for obstetrics and gynaecological residents. J Coll Physicians Surg Pak. 2013; 23 7: 468– 471. [PubMed] [Google Scholar]
- 17. Levine RB, Kern DE, Wright SM. . The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ Theory Pract. 2008; 13 5: 723– 733. [DOI] [PubMed] [Google Scholar]
- 18. Bernard AW, Kman NE, Bernard RH, et al. Use of a secure social media platform to facilitate reflection in a residency program. J Grad Med Educ. 2014; 6 2: 326– 329. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Bethune C, Brown JB. . Residents' use of case-based reflection exercises. Can Fam Physician. 2007; 53 3: 470– 476. [PMC free article] [PubMed] [Google Scholar]
- 20. Toy EC, Harms KP, Morris RK Jr, et al. The effect of monthly resident reflection on achieving rotation goals. Teach Learn Med. 2009; 21 1: 15– 19. [DOI] [PubMed] [Google Scholar]
- 21. Maurer MS, Costley AW, Miller PA, et al. The Columbia Cooperative Aging Program: an interdisciplinary and interdepartmental approach to geriatric education for medical interns. J Am Geriatr Soc. 2006; 54 3: 520– 526. [DOI] [PubMed] [Google Scholar]
- 22. Nothnagle M, Reis S, Goldman RE, et al. Fostering professional formation in residency: development and evaluation of the “forum” seminar series. Teach Learn Med. 2014; 26 3: 230– 238. [DOI] [PubMed] [Google Scholar]
- 23. DasGupta S, Meyer D, Calero-Breckheimer A, et al. Teaching cultural competency through narrative medicine: intersections of classroom and community. Teach Learn Med. 2006; 18 1: 14– 17. [DOI] [PubMed] [Google Scholar]
- 24. Learman LA, Autry AM, O'Sullivan P. . Reliability and validity of reflection exercises for obstetrics and gynecology residents. Am J Obstet Gynecol. 2008; 198 4: 461.e1– e8. [DOI] [PubMed] [Google Scholar]
- 25. Ballon BC, Skinner W. . “Attitude is a little thing that makes a big difference”: reflection techniques for addiction psychiatry training. Acad Psychiatr. 2008; 32 3: 218– 224. [DOI] [PubMed] [Google Scholar]
- 26. Winkel AF, Hermann N, Graham MJ, et al. No time to think: making room for reflection in obstetrics and gynecology residency. J Grad Med Educ. 2010; 2 4: 610– 615. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Halpern J. . Empathy and patient-physician conflicts. J Gen Intern Med. 2007; 22 5: 696– 700. [DOI] [PMC free article] [PubMed] [Google Scholar]