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Look in the Mirror, What Do You See

Author: Chris Walsh / Codes: CC23, CC24 / Published: 26/07/2017

As many of us are preparing our portfolios for ARCP or revalidation, RCEM’s Head of elearning, Chris Walsh, talks us through why reflection is at the core of our learning.

“Reflection” will be a thrilling topic for many of you, as I know just dropping “reflective practice” into any discussion really gets things going! All joking aside, discussions around reflective learning aren’t going away, nor is the ‘death by tickbox’ feeling that it often engenders. In a very small way this blog hopes to explain what RCEMLearning is trying to do here.

Reflective learning and thinking is an important part of educational practice and there is a vast amount of literature about it. Some of the key points from the existing scholarship are detailed below, but this isn’t exhaustive and other approaches are available:

Believe it or not reflective practice is quite trendy within and beyond med ed. The Open Universitys 2015 Innovating Pedagogy report claimed that the engine of learning is a continuous cycle of engagement and reflection (Sharples et al 2015, p 8). So reflection can be seen as an internal (and at times external) debate about how experience and developing knowledge changes our understanding and approach to things.

One of the most accessible definitions of reflection/reflective practice is provided by Bernard et al (2012) who claim that, Reflection is a cognitive process in which new information and experiences are integrated into existing knowledge structures and mental models, resulting in meaningful learning (p. 281)

Reflection is closely associated with experiential learning, which is knowledge we accrue from real-life situations. One of the most significant models here is Kolbs learning cycle (see image below), where reflection on the learning experience is positioned as the second step on the sequence.

 

Figure 1: Kolbs learning cycle

In The Reflective Practitioner: How Professionals Think in Action, Alexander Schn describes how reflective practice often takes the form of a reflective conversation with the situation (Schon 1983, p.194). This type of internalised contemplative action evidences metacognitive processes (in other words its an attribute shared by many successful learners). It’s an ongoing and ever-shifting internal chat.

It is an essential skill and developmental opportunity for people operating in EM as it offers an opportunity for learners to learn about and reflect upon knowledge in authentic activities (Laurillard 14). This may help offset some of the more abstract elements of reflective practice as the authentic activities should organically present opportunities to reflect on them. Of course capturing the learning point close to the ‘authentic’ moment is very problematic, but more on that later.

This short video by Phillip Dawson provides an excellent overview of the key theories associated with reflective practice. Dawson is talking about reflective practice in a university context but his points about scarcity (of resources and time etc.) parallel with EM. It’s around 12 minutes long and it provides a good mix of the theoretical and practical, without ignoring some of the challenges associated with reflective practice. Specifically Dawson makes two important points:

  • It’s meant to be spontaneous, but that’s hard to capture in portfolios in a way that doesn’t completely diminish the ‘in the moment’ spirit.
  • It should be a springboard, not an end point. To avoid reflection existing in a ‘scholarly echo chamber’ it should be used to engage with literature, evidence and your peers.

Ive attempted to distil some of the most pertinent ideas here to give you a flavour of these debates. Each of these concepts and authors warrant further investigation in their own right so while I apologise for the superficial treatment, I really urge you to check out the links and references to each of them.

How does this relate to Med Ed/EM

Reflective practice is embedded in medical educations learning cultures because it showcases higher-level metacognitive processes, including the ability to contemplate, refine, and improve. It also fulfils key bureaucratic requirements and administrative ones, as illustrated by the GMC guidance. Reflection has to be undertaken for appraisals, portfolio development and so on. It could be argued that the curriculum encodes hierarchies of knowledge, but reflective practice demonstrates how your understanding of these change across a career.

Consistent and informed reflection is a foundational part of lifelong learning that helps emergency physicians self-monitor (Wald et al 2012, Bernard et al 2012). Furthermore Roland and Brazil (2015), two of the most recognised figures within EM education, claim that the development of new institutionally-approved reflective spaces is one of the most pressing demands within the specialitys educational discourse. They also claim that developing the functionality to encourage reflective thinking is critical to underpinning the metacognitive potential represented by movements such as FOAMed (Roland and Brazil 2015).

The challenges

In the abstract theoretical and pedagogical sense it is hard to disagree with the value that reflective practice represents. However the reality is often quite different; reflection takes time (which theres precious little of), it can all feel a bit tokenistic, and the mandatory nature of it can undermine the authentic and spontaneous nature of whatevers been learnt. My academic background is in arts and humanities, and issues around reflection remind me of (trying to teach) essay writing; writing was a universal requirement but there was an assumption made by faculty, departments and even institutions that essay writing skills and new insights would somehow be picked up via some kind of educational osmosis, but it doesnt happen that way. Its hard to do something youve never really been taught how to do.

Lets not kid ourselves, reflection can also be a massive burden at times. In his recent talk at #theEMEC (2017), Scott Carrington coined reflection as “the dirtiest word in medicine” because of how we have come to resent its’ mandatory nature which can turn such a useful tool into a hollow gesture to tick yet another box in our portfolios.

Another elephant in the room is how it can be configured with assessment paradigms as theres a danger it can become too inspectorial and it assumes a death by tick box function (Hargreaves 2013). An implicit issue here is related to ethics and access to data which is too frequently ignored in discussions about educational technology who gets access to the data? What can it be used for?

Bernard et al. claim that assessment should focus on the process and not the content of the reflection. But how can you assess process and not content? I cant offer any tangible solutions to this at the moment but the tensions between reflection as process and assessment as a system need much further thought.

The table below represents a very crude attempt to capture some of the problems in the reflection-assessment dichotomy:

As a College we need to do more work to encourage and facilitate other modes of reflection. If the value of reflection rests in the spontaneity of the metacognitive moment, then why not encourage reflection by voice memo, Twitter feeds, vlogging, etc. Of course we once again confront here the lag between reality of educational practice and the conservatism of assessing/credentialing bodies who validate that practice.

From an educational and pedagogical perspective the importance of reflecting in the moment, fluently, and honestly represents top-of-the-range metacognitive functions. In other words its what good learners do on a consistent basis. Logistically, administratively, and perhaps even ethically, its a different matter though. Irrespective of mode its hard to shake off the feeling that its another form to complete and another password to remember. Moreover, if it’s not possible to capture the insights close to the learning moment, theres a danger its educational worth could be diluted and distorted.

The next steps are challenging but doable. We need to find a system thats easy to use, that captures the authenticity of the learning and the transparency of the process without feeling technologically or administratively cumbersome. We also need to get better at showcasing good examples.

So plenty to reflect on here

References/Further Reading

  1. Bernard, B.W., Gorgas, D., Greenberger, S., Jacques, A., Khandelwal, S. (2012). The use of reflection in Emergency Medicine Education. Academic Emergency Medicine 19(8), pp. 978-982
  2. GMC. (2016). Reflecting on your practice.
  3. Hargreaves, J. (2003). So how do you feel about that? Assessing reflective Practice. Nurse Education Today (24): pp. 196201
  4. Kolb, D. (1993). The process of experiential learning. In Culture and process of adult learning. M. Thorpe, R. Edwards, and A. Hanson (Eds). (London, Routledge): pp. 138-156.
  5. Laurillard, D. (2002). Rethinking university teaching: a conversational framework for the effective use of learning technologies. (London, RoutledgeFalmer).
  6. Roland, D. and Brazil, V. (2015). Top 10 ways to reconcile social media and traditional education in emergency care. Emergency Medicine Journal (32): pp. 819-822.
  7. Schon, D., A. (193). The Reflective Practitioner: How Professional Think in Action. New York: Basic Books.
  8. Sharples, M., Adams, A., Alozie, N., Ferguson, R., FitzGerald, E., Gaved, M., McAndrew, P., Means, B., Remold, J., Rienties, B., Roschelle, J., Vogt, K.,Whitelock, D., Yarnall, L. (2015). Innovating Pedagogy 2014: Open University Innovation Report 4. (Milton Keynes: The Open University).
  9. Wald, H. S., Borkan, J. M., Scott, T., Julie, A., Reism, S. P. (2012). Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing. Academic Medicine 87(1): pp. 41-50

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