examples of reflective writing for doctors

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BMC Med Educ

A systematic scoping review of reflective writing in medical education

Jia yin lim.

1 Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 11, Singapore, 119228 Singapore

2 Division of Supportive and Palliative Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore

Simon Yew Kuang Ong

3 Division of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore

4 Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore

5 Duke-NUS Medical School, National University of Singapore, 8 College Rd, Singapore, 169857 Singapore

Chester Yan Hao Ng

Karis li en chan, song yi elizabeth anne wu, wei zheng so, glenn jin chong tey, yun xiu lam, nicholas lu xin gao, yun xue lim, ryan yong kiat tay, ian tze yong leong, nur diana abdul rahman, crystal lim.

6 Medical Social Services, Singapore General Hospital, Outram Rd, Singapore, 169608 Singapore

Gillian Li Gek Phua

7 Lien Centre for Palliative Care, Duke-NUS Medical School, National University of Singapore, 8 College Rd, Singapore, 169857 Singapore

Vengadasalam Murugam

Eng koon ong.

8 Assisi Hospice, 832 Thomson Rd, Singapore, 574627 Singapore

Lalit Kumar Radha Krishna

9 Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK

10 PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore

Associated Data

All data generated or analysed during this review are included in this published article and its supplementary files.

Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW’s place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed.

A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content analysis. Like pieces of a jigsaw puzzle, the Jigsaw Perspective combined the themes and categories identified from both reviews. The Funnelling Process saw the themes/categories created compared with the tabulated summaries. The final domains which emerged structured the discussion that followed.

A total of 33,076 abstracts were reviewed, 1826 full-text articles were appraised and 199 articles were included and analysed. The domains identified were theories and models, current methods, benefits and shortcomings, and recommendations.

Conclusions

This SSR in SEBA suggests that a structured approach to RW shapes the physician’s belief system, guides their practice and nurtures their professional identity formation. In advancing a theoretical concept of RW, this SSR in SEBA proffers new insight into the process of RW, and the need for longitudinal, personalised feedback and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-022-03924-4.

Introduction

Reflective practice in medicine allows physicians to step back, review their actions and recognise how their thoughts, feelings and emotions affect their decision-making, clinical reasoning and professionalism [ 1 ]. This approach builds on Dewey [ 2 ], Schon [ 3 , 4 ], Kolb [ 5 ], Boud et al. [ 6 ] and Mezirow [ 7 ]’s concepts of critical self-examination. It sees new insights drawn from the physician’s experiences and considers how assumptions may integrate into their current values, beliefs and principles (henceforth belief system) [ 8 , 9 ].

Teo et al. [ 10 ] build on this concept of reflective practice. The authors suggest that the physician’s belief system informs and is informed by their self-concepts of identity which are in turn rooted in their self-concepts of personhood - how they conceive what makes them who they are [ 11 ]. This posit not only ties reflective practice to the shaping of the physician’s moral and ethical compass but also offers evidence of it's role in their professional identity formation (PIF) [ 8 , 12 – 23 ]. With PIF [ 8 , 24 ] occupying a central role in medical education, these ties underscore the critical importance placed on integrating reflective practice in medical training.

Perhaps the most common form of reflective practice in medical education is reflective writing (RW) [ 25 ]. Identified as one of the distinct approaches used to achieve integrated learning, education, curriculum and teaching [ 26 ], RW already occupies a central role in guiding and supporting longitudinal professional development [ 27 – 29 ]. Its ability to enhance self-monitoring and self-regulation of decisional paradigms and conduct has earned RW a key role in competency-based medical practice and continuing professional development [ 30 – 36 ].

However, the absence of consistent guiding principles, dissonant practices, variable structuring and inadequate assessments have raised concerns as to RW’s efficacy and place in medical training [ 25 , 37 – 39 ]. A Systematic Scoping Review is proposed to map current understanding of RW programs. It is hoped that this SSR will also identify gaps in knowledge and regnant practices, programs and assessment methods to guide the design of RW programs.

Methodology

A Systematic Scoping Review (SSR) is employed to map the employ, structuring and assessment of RW in medical education. An SSR-based review is especially useful in attending to qualitative data that does not lend itself to statistical pooling [ 40 – 42 ] whilst its broad flexible approach allows the identification of patterns, relationships and disagreements [ 43 ] across a wide range of study formats and settings [ 44 , 45 ].

To synthesise a coherent narrative from the multiple accounts of reflective writing, we adopt Krishna’s Systematic Evidence-Based Approach (SEBA) [ 10 , 15 , 21 , 46 – 53 ]. A SEBA-guided Systematic Scoping Review (SSR in SEBA) [ 13 – 24 , 50 , 53 – 55 ] facilitates reproducible, accountable and transparent analysis of patterns, relationships and disagreements from multiple angles [ 56 ].

The SEBA process (Fig. 1 ) comprises the following elements: 1) Systematic Approach, 2) Split Approach, 3) Jigsaw Perspective, 4) Funnelling Process, 5) Analysis of data and non-data driven literature, and 6) Synthesis of SSR in SEBA [ 10 , 15 , 21 , 46 – 53 , 57 – 60 ] . Every stage was overseen by a team of experts that included medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore, and local educational experts and clinicians at YLLSoM, Duke-NUS Medical School, Assisi Hospice, Singapore General Hospital, National Cancer Centre Singapore and Palliative Care Institute Liverpool.

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The SEBA Process

STAGE 1 of SEBA: Systematic Approach

Determining the title and background of the review.

Ensuring a systematic approach, the expert team and the research team agreed upon the overall goals of the review. Two separate searches were performed, one to look at the theories of reflection in medical education, and another to review regnant practices, programs, and assessment methods used in reflective writing in medical education. The PICOs is featured in Table 1 .

PICOs inclusion and exclusion criteria

Identifying the research question

Guided by the Population Concept, Context (PCC) elements of the inclusion criteria and through discussions with the expert team, the research question was determined to be: “ How is reflective writing structured, assessed and supported in medical education? ” The secondary research question was “ How might a reflective writing program in medical education be structured? ”

Inclusion criteria

All study designs including grey literature published between 1st January 2000 to 30th June 2022 were included [ 61 , 62 ]. We also consider data on medical students and physicians from all levels of training (henceforth broadly termed as physicians).

Ten members of the research team carried out independent searches using seven bibliographic databases (PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus) and four grey literature databases (Google Scholar, OpenGrey, GreyLit, ProQuest). Variations of the terms “reflective writing”, “physicians and medical students”, and “medical education” were applied.

Extracting and charting

Titles and abstracts were independently reviewed by the research team to identify relevant articles that met the inclusion criteria set out in Table Table1. 1 . Full-text articles were then filtered and proposed. These lists were discussed at online reviewer meetings and Sandelowski and Barroso [ 63 ]’s approach to ‘negotiated consensual validation’ was used to achieve consensus on the final list of articles to be included.

Stage 2 of SEBA: Split Approach

The Split Approach was employed to enhance the trustworthiness of the SSR in SEBA [ 64 , 65 ]. Data from both searches were analysed by three independent groups of study team members.

The first group used Braun and Clarke [ 66 ]’s approach to thematic analysis. Phase 1 consisted of ‘actively’ reading the included articles to find meaning and patterns in the data. The analysis then moved to Phase 2 where codes were constructed. These codes were collated into a codebook and analysed using an iterative step-by-step process. As new codes emerge, previous codes and concepts were incorporated. In Phase 3, codes and subthemes were organised into themes that best represented the dataset. An inductive approach allowed themes to be “defined from the raw data without any predetermined classification” [ 67 ]. In Phase 4, these themes were then further refined to best depict the whole dataset. In Phase 5, the research team discussed the results and consensus was reached, giving rise to the final themes.

The second group employed Hsieh and Shannon [ 68 ]’s approach to directed content analysis. Categories were drawn from Mann et al. [ 9 ]’s article, “Reflection and Reflective Practice in Health Professions Education: A Systematic Review” and Wald and Reis [ 69 ]’s article “Beyond the Margins: Reflective Writing and Development of Reflective Capacity in Medical Education”.

The third group created tabulated summaries in keeping with recommendations drawn from Wong et al. [ 56 ]’s "RAMESES Publication Standards: Meta-narrative Reviews" and Popay et al. [ 70 ]’s “Guidance on the C onduct of N arrative Synthesis in Systematic Reviews”. The tabulated summaries served to ensure that key aspects of included articles were not lost.

Stage 3 of SEBA: Jigsaw Perspective

The Jigsaw Perspective [ 71 , 72 ] saw the findings of both searches combined. Here, overlaps and similarities between the themes and categories from the two searches were combined to create themes/categories. The themes and subthemes were compared with the categories and subcategories identified, and similarities were verified by comparing the codes contained within them. Individual subthemes and subcategories were combined if they were complementary in nature.

Stage 4 of SEBA: Funnelling Process

The Funnelling Process saw the themes/categories compared with the tabulated summaries to determine the consistency of the domains created, forming the basis of the discussion.

Stage 5: Analysis of data and non-data driven literature

Amidst concerns that data from grey literature which were neither peer-reviewed nor necessarily evidence-based may bias the synthesis of the discussion, the research team separately thematically analysed the included grey literature. These themes were compared with themes from data-driven or research-based peer-reviewed data and were found to be the same and thus unlikely to have influenced the analysis.

Stage 6: Synthesis of SSR in SEBA

The Best Evidence Medical Education (BEME) Collaboration Guide and the Structured approach to the Reporting In healthcare education of Evidence Synthesis (STORIES) were used to guide the discussion.

A total of 33,076 abstracts were reviewed from the two separate searches on theories of reflection in medical education, and on regnant practices, programs and assessments of RW programs in medical education. A total of 1826 full-text articles were appraised from the separate searches, and 199 articles were included and analysed. The PRISMA Flow Chart may be found in Fig. 2 a and b. The domains identified when combining the findings of the two separate searches were 1) Theories and Models, 2) Current Methods, 3) Benefits and Shortcomings and 4) Recommendations.

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a PRISMA Flow Chart (Search Strat #1: Theories of Reflection in Medical Education). b PRISMA Flow Chart (Search Strat #2: Reflective Writing in Medical Education)

Domain 1: Theories and Models

Many current theories and models surrounding RW in medical education are inspired by Kolb’s Learning Cycle [ 5 ] (Table 2 ). These theories focus on descriptions of areas of reflection; evaluations of experiences and emotions; how events may be related to previous experiences; knowledge critiques of their impact on thinking and practice; integration of learning points; and the physician’s willingness to apply lessons learnt [ 6 , 73 – 75 ]. In addition, some of these theories also consider the physician’s self-awareness, ability and willingness to reflect [ 76 ], contextual factors related to the area of reflection [ 4 , 77 ] and the opportunity to reflect effectively within a supportive environment [ 78 , 79 ]. Ash and Clayton's DEAL Model recommends inclusion of information from all five senses [ 80 – 83 ]. Johns's Model of Structured Reflection [ 84 ] advocates giving due consideration to internal and external influences upon the event being evaluated. Rodgers [ 39 ] underlines the need for appraisal of the suppositions and assumptions that precipitate and accompany the effects and responses that may have followed the studied event. Griffiths and Tann [ 75 ], Mezirow [ 77 ], Kim [ 85 ], Roskos et al. [ 86 ], Burnham et al. [ 87 ], Korthagen and Vasalos [ 78 ] and Koole et al. [ 74 ] build on Dewey [ 2 ] and Kolb [ 5 ]’s notion of creating and experimenting with a ‘working hypothesis’. These models also propose that the lessons learnt from experimentations should be critiqued as part of a reiterative process within the reflective cycle. Underlining the notion of the reflective cycle and the long-term effects of RW, Pearson and Smith [ 88 ] suggest that reflections should be carried out regularly to encourage longitudinal and holistic reflections on all aspects of the physician’s personal and professional life.

Theories and models referred for implementation - iterative stages of reflection

Regnant theories shape assessments of RW (Table 3 ). This extends beyond Thorpe [ 96 ]’s study which categorises reflective efforts into ‘non-reflectors’, ‘reflectors’, ‘critical reflectors’, and focuses on their process, structure, depth and content. van Manen [ 97 ], Plack et al. [ 98 ], Rogers et al. [ 99 ] and Makarem et al. [ 100 ] begin with evaluating the details of the events. Kim’s Critical Reflective Inquiry Model [ 85 ] and Bain’s 5Rs Reflective Framework [ 101 ] also consider characterisations of emotions involved. Other models appraise the intentions behind actions and thoughts [ 85 ], the factors precipitating the event [ 101 ] and meaning-making [ 85 ]. Other theories consider links with previous experiences [ 100 ], the integration of thoughts, justifications and perspectives [ 99 ], and the hypothesising of future strategies [ 98 ].

Theories and models referred for assessment - vertical levels of reflection

Domain 2: Current methods of structuring RW programs

Current programs focus on supporting the physician throughout the reflective process. Whilst due consideration is given to the physician’s motivations, insight, experiences, capacity and capabilities [ 25 , 96 , 112 – 116 ], programs also endeavour to ensure appropriate selection and training of physicians intending to participate in RW. Efforts are also made to align expectations, and guide and structure the RW process [ 37 , 116 – 122 ]. Physicians are provided with frameworks [ 76 , 79 , 105 , 123 , 124 ], rubrics [ 99 , 123 , 125 , 126 ], examples of the expected quality and form of reflection [ 96 , 115 , 116 ], and how to include emotional and contextual information in their responses [ 121 , 127 – 129 ].

Other considerations are enclosed in Table 4 including frequency, modality and the manner in which RW is assessed.

Current methods of structuring RW programs

Domain 3: Benefits and Shortcomings

The benefits of RW are rarely described in detail and may be divided into personal and professional benefits as summarised in Table 5 for ease of review. From a professional perspective, RW improves learning [ 96 , 112 , 119 , 147 , 157 , 170 , 179 , 185 – 192 ], facilitates continuing medical education [ 119 , 128 , 173 , 174 , 193 – 195 ], inculcates moral, ethical, professional and social standards and expectations [ 118 , 156 , 160 ], improves patient care [ 29 , 120 , 129 , 131 , 135 , 142 , 194 , 196 – 199 ] and nurtures PIF [ 150 , 157 , 172 , 191 , 200 ].

Benefits of RW programs

From a personal perspective, RW increases self-awareness [ 114 , 127 , 137 , 161 , 166 , 179 , 185 , 202 , 216 ], self-advancement [ 9 , 131 , 134 , 150 , 168 , 174 , 195 , 205 , 217 , 229 ], facilitates understanding of individual strengths, weaknesses and learning needs [ 112 , 119 , 150 , 152 , 170 , 218 , 219 ], promotes a culture of self-monitoring, self-improvement [ 130 , 172 , 173 , 185 , 193 , 198 , 201 , 210 , 211 ], developing critical perspectives of self [ 193 , 223 ] and nurtures resilience and better coping [ 154 , 160 , 206 ]. RW also guides shifts in thinking and perspectives [ 148 , 149 , 156 , 203 , 207 , 208 ] and focuses on a more holistic appreciation of decision-making [ 37 , 118 , 126 , 174 , 177 , 194 , 196 , 199 , 200 , 224 – 226 ] and their ramifications [ 37 , 112 , 116 , 130 , 131 , 141 , 154 , 179 , 193 , 194 , 196 , 204 , 207 , 218 , 230 ].

Table 6 combines current lists of the shortcomings of RW. These limitations may be characterised by individual, structural and assessment styles.

Shortcomings of RW programs

It is suggested that RW does not cater to the different learning styles [ 220 , 232 ], cultures [ 190 ], roles, values, processes and expectations of RW [ 114 , 129 , 135 , 138 , 142 , 209 , 227 , 234 ], and physicians' differing levels of self-awareness [ 29 , 79 , 119 , 176 , 188 , 226 , 231 , 236 ], motivations [ 29 , 119 , 136 , 138 , 157 , 161 , 167 – 169 , 176 , 181 , 193 , 196 , 226 , 232 , 233 ] and willingness to engage in RW [ 37 , 114 , 136 , 149 , 160 , 183 ]. RW is also limited by poorly prepared physicians and misaligned expectations whilst a lack of privacy and a safe setting may precipitate physician anxiety at having their private thoughts shared [ 129 , 149 , 209 , 231 ]. RW is also compromised by a lack of faculty training [ 143 , 145 , 239 ], mentoring support [ 37 , 50 , 119 , 133 , 196 ] and personalised feedback [ 50 , 114 , 136 , 167 , 229 ] which may lead to self-censorship [ 37 , 114 , 136 , 149 , 160 , 183 ] and an unwillingness to address negative emotions arising from reflecting on difficult events [ 114 , 168 , 176 , 193 , 230 ], circumventing the reflective process [ 118 , 142 , 165 , 196 ] .

Variations in assessment styles [ 9 , 115 , 157 , 161 , 166 , 193 , 209 ], depth [ 29 , 105 , 118 , 126 , 177 , 207 ] and content [ 37 , 114 , 136 , 149 , 169 , 183 , 196 ], and pressures to comply with graded assessments [ 114 , 115 , 118 , 129 , 138 , 143 , 149 , 155 , 157 , 209 , 232 , 237 , 238 ] also undermine efforts of RW.

Domain 4. Recommendations

In the face of practice variations and challenges, there have been several recommendations on improving practice.

Boosting awareness of RW

Acknowledging the importance of a physician’s motivations, willingness and judgement [ 37 ], an RW program must acquaint physicians with information on RW’s role [ 128 ], program expectations, the form, frequency and assessments of RW and the support available to them [ 130 , 132 , 150 , 154 , 242 ] and its benefits to their professional and personal development [ 96 , 227 ] early in their training programs [ 115 , 220 , 242 , 243 ]. Physicians should also be trained on the knowledge and skills required to meet these expectations [ 1 , 37 , 135 , 151 , 160 , 215 , 244 , 245 ].

A structured program and environment

Recognising that effective RW requires a structured program. Recommendations focus on three aspects of the program design [ 132 ]. One is the need for trained faculty [ 9 , 115 , 219 , 220 , 230 , 233 , 242 , 246 ], accessible communications, protected time for RW and debriefs [ 125 ], consistent mentoring support [ 190 ] and assessment processes [ 247 ]. This will facilitate trusting relationships between physicians and faculty [ 30 , 114 , 168 , 196 , 231 , 233 ]. Two, the need to nurture an open and trusting environment where physicians will be comfortable with sharing their reflections [ 96 , 128 ], discussing their emotions, plans [ 127 , 248 ] and receiving feedback [ 9 , 37 , 79 , 114 , 119 , 128 , 135 , 173 , 176 , 179 , 190 , 237 ]. This may be possible in a decentralised classroom setting [ 163 , 190 ]. Three, RW should be part of the formal curriculum and afforded designated time. RW should be initiated early and longitudinally along the training trajectory [ 116 , 122 ].

Adjuncts to RW programs

Several approaches have been suggested to support RW programs. These include collaborative reflection, in-person discussion groups to share written reflections [ 128 , 131 , 138 , 196 , 199 , 231 , 249 ] and reflective dialogue to exchange feedback [ 119 ], use of social media [ 149 , 160 , 169 , 194 , 204 , 230 ], video-recorded observations and interactions for users to review and reflect on later [ 133 ]. Others include autobiographical reflective avenues in addition to practice-oriented reflection [ 137 ], support groups to help meditate stress or emotions triggered by reflections [ 249 ] and mixing of reflective approaches to meet different learning styles [ 169 , 250 ].

In answering the primary research question, “How is reflective writing structured, assessed and supported in medical education?” , this SSR in SEBA highlights several key insights. To begin, RW involves integrating the insights of an experience or point of reflection (henceforth ‘event’) into the physician’s currently held values, beliefs and principles (henceforth belief system). Recognising that an ‘event’ has occurred and that it needs deeper consideration highlights the physician’s sensitivity . Recognising the presence of an ‘event’ triggers an evaluation as to the urgency in which it needs to be addressed, where it stands amongst other ‘events’ to be addressed and whether the physician has the appropriate skills, support and time to address the ‘event’. This reflects the physician’s judgement . The physician must then determine whether they are willing to proceed and the ramifications involved. These include ethical, medical, clinical, administrative, organisational, sociocultural, legal and professional considerations. This is then followed by contextualising them to their own personal, psychosocial, clinical, professional, research, academic, and situational setting. Weighing these amidst competing ‘events’ underlines the import of the physician’s ability to ‘balance’ considerations. Creating and experimenting on their ‘working hypothesis’ highlights their ‘ability’, whilst how they evaluate the effects of their experimentation and how they adapt their practice underscores their ‘ responsiveness ’ [ 2 , 5 , 74 , 75 , 77 , 78 , 85 – 87 , 90 ].

The concepts of ‘ sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’ spotlight environmental and physician-related factors. These include the physician’s motivations, knowledge, skills, attitudes, competencies, working style, needs, availabilities, timelines, and their various medical, clinical, administrative, organisational, sociocultural, legal, professional, personal, psychosocial, clinical, research, academic and situational experiences. It also underlines the role played by the physician’s beliefs, moral values, ethical principles, familial mores, cultural norms, attitudes, thoughts, decisional preferences, roles and responsibilities. The environmental-related factors include the influence of the curriculum, the culture, structure, format, assessment and feedback of the RW process and the program it is situated in. Together, the physician and their environmental factors not only frame RW as a sociocultural construct necessitating holistic review but also underscore the need for longitudinal examination of its effects. This need for holistic and longitudinal appraisal of RW is foregrounded by the experimentations surrounding the ‘working hypothesis’ [ 2 , 5 , 72 , 74 , 77 , 84 – 86 , 90 ]. In turn, experimentations and their effects affirm the notion of regular use of RW and reiterate the need for longitudinal reflective relationships that provide guidance, mentoring and feedback [ 87 , 90 ]. These considerations set the stage for the proffering of a new conceptual model of RW.

To begin, the Krishna Model of Reflective Writing (Fig. 3 ) builds on the Krishna-Pisupati Model [ 10 ] used to describe evaluations of professional identity formation (PIF) [ 8 , 10 , 24 , 251 ]. Evidenced in studies of how physicians cope with death and dying patients, moral distress and dignity-centered care [ 46 , 54 ], the Krishna-Pisupati Model suggests that the physician’s belief system is informed by their self-concepts of personhood and identity. This is effectively characterised by the Ring Theory of Personhood (RToP) [ 11 ].

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Krishna Model of Reflective Writing

The Krishna Model of RW posits that the RToP is able to encapsulate various aspects of the physician’s belief system. The Innate Ring which represents the innermost ring of the four concentric rings depicting the RToP is derived from currently held spiritual, religious, theist, moral and ethical values, beliefs and principles [ 13 , 51 , 53 , 252 ]. Encapsulating the Innate Ring is the Individual Ring. The Individual Ring’s belief system is derived from the physician’s thoughts, conduct, biases, narratives, personality, decision-making processes and other facets of conscious function which together inform the physician’s Individual Identity [ 13 , 51 , 53 , 252 ]. The Relational Ring is shaped by the values, beliefs and principles governing the physician’s personal and important relationships [ 13 , 51 , 53 , 252 ]. The Societal Ring, the outermost ring of the RToP is shaped by regnant societal, religious, professional and legal expectations, values, beliefs and principles which inform their interactions with colleagues and acquaintances [ 13 , 51 , 53 , 252 ]. Adoption of the RToP to depict this belief system not only acknowledges the varied aspects and influences that shape the physician’s identity but that the belief system evolves as the physician’s environment, narrative, context and relationships change.

The environmental factors influencing the belief system include the support structures used to facilitate reflections such as appropriate protected time, a consistent format for RW, a structured assessment program, a safe environment, longitudinal support, timely feedback and trained faculty. The Krishna Model of RW also recognises the importance of the relationships which advocate for the physician and proffer the physician with coaching, role modelling, supervision, networking opportunities, teaching, tutoring, career advice, sponsorship and feedback upon the RW process. Of particular importance is the relationship between physician and faculty (henceforth reflective relationship). The reflective relationship facilitates the provision of personalised, appropriate, holistic, and frank communications and support. This allows the reflective relationship to support the physician as they deploy and experiment with their ‘working hypothesis’. As a result, the Krishna Model of RW focuses on the dyadic reflective relationship and acknowledges that there are wider influences beyond this dyad that shape the RW process. This includes the wider curriculum, clinical, organisational, social, professional and legal considerations within specific practice settings and other faculty and program-related factors. Important to note, is that when an ‘event’ triggers ‘ sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’, the process of creating and experimenting with a ‘working hypothesis' and adapting one's belief system is also shaped by the physician’s narratives, context, environment and relationships.

In answering its secondary question, “ How might a reflective writing program in medical education be structured? ”, the data suggests that an RW program ought to be designed with due focus on the various factors influencing the physician's belief system, their ‘sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’, and their creation and experimentation with their ‘working hypothesis’. These will be termed the ‘physician's reactions’ . The design of the RW program ought to consider the following factors:

Recognising that the physician’s notion of ‘ sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’ is influenced by their experience, skills, knowledge, attitude and motivations, physicians recruited to the RW program should be carefully evaluated
To align expectations, the physician should be introduced to the benefits and role of RW in their personal and professional development
The ethos, frequency, goals and format of the reflection and assessment methods should be clearly articulated to the physician [ 253 ]
The physician should be provided with the knowledge, skills and mentoring support necessary to meet expectations [ 76 , 79 , 105 , 123 , 124 , 254 , 255 ]
Training and support must also be personalised
Recognising that the physician’s academic, personal, research, administrative, clinical, professional, sociocultural and practice context will change, the structure, approach, assessment and support provided must be flexible and responsive
The communications platform should be easily accessible and robust to attend to the individual needs of the physician in a timely and appropriate manner
The program must support diversity [ 207 ]
The reflective relationship is shaped by the culture and structure of the environment in which the program is hosted in
The RW programs must be hosted within a formal structured curriculum, supported and overseen by a host organisation which is able to integrate the program into regnant educational and assessment processes [ 9 , 115 , 219 , 220 , 230 , 233 , 242 , 246 ]
The faculty must be trained and provided access to counselling, mindfulness meditation and stress management programs [ 249 ]
The faculty must support the development of the physician’s metacognitive skills [ 256 – 259 ], and should create a platform that facilitates community-centered learning [ 173 , 176 ], structured, timely, personalised open feedback [ 119 , 135 , 179 , 237 ] and support [ 128 , 131 , 138 , 196 , 199 , 231 , 249 ]
The faculty must be responsive to changes and provide appropriate personal, educational and professional support and adaptations to the assessment process when required [ 207 ]
To facilitate the development of effective reflective relationships, a consistent faculty member should work with the physician and build a longitudinal trusting, open and supportive reflective relationship
The evolving nature of the various structures and influences upon the RW process underscores the need for longitudinal assessment and support
The physician must be provided with timely, appropriate and personalised training and feedback
The program’s structure and oversight must also be flexible and responsive
There must be accessible longitudinal mentoring support
The format and assessment of RW must account for growing experience and competencies as well as changing motivations and priorities
Whilst social media may be employed to widen sharing [ 149 , 155 , 160 , 169 , 194 ], privacy must be maintained [ 120 , 189 ]

On assessment

Assessment rubrics should be used to guide the training of faculty, education of physicians and guidance of reflections [ 37 , 116 – 122 ]
Assessments ought to take a longitudinal perspective to track the physician's progress [ 116 , 122 ]

Based on the results from this SSR in SEBA, we forward a guide catering to novice reflective practitioners (Additional file 1 ).

Limitations

This SSR in SEBA suggests that, amidst the dearth of rigorous quantitative and qualitative studies in RW and in the presence of diverse practices, approaches and settings, conclusions may not be easily drawn. Extrapolations of findings are also hindered by evidence that appraisals of RW remain largely reliant upon single time point self-reported outcomes and satisfaction surveys.

This SSR in SEBA highlights a new model for RW that requires clinical validation. However, whilst still not clinically proven, the model sketches a picture of RW’s role in PIF and the impact of reflective processes on PIF demands further study. As we look forward to engaging in this area of study, we believe further research into the longer-term effects of RW and its potential place in portfolios to guide and assess the development of physicians must be forthcoming.

Acknowledgements

The authors would like to dedicate this paper to the late Dr. S Radha Krishna and A/Prof Cynthia Goh whose advice and ideas were integral to the success of this review and Thondy and Maia Olivia whose lives continue to inspire us.

The authors would also like to thank the anonymous reviewers, Dr. Ruaraidh Hill and Dr. Stephen Mason for their helpful comments which greatly enhanced this manuscript.

Abbreviations

Authors’ contributions.

All authors were involved in data curation, formal analysis, investigation, preparing the original draft of the manuscript as well as reviewing and editing the manuscript. All authors have read and approved the manuscript.

No funding was received for this review.

Availability of data and materials

Declarations.

All authors have no competing interests for this review.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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To some doctors reflective writing may come easily. The majority, however, are not likely to approach this section of their revalidation or training portfolio with relish. But, valued or not, reflection is an essential practice for today’s doctor.

A reflective practitioner is capable of standing back and observing their actions, identifying patterns, and improving their practice as a consequence. By critiquing cases—challenging or routine—the reflective doctor can achieve the ultimate aim: improved patient care. As well as enabling the clinician to make better decisions for future patients, it can also be personally beneficial 1 and may help to avoid stress, poor job satisfaction, and burnout. 2 3

With that in mind, here are our top 10 tips for transforming trainee and appraisal portfolio entries into an invaluable tool.

1 Write, write, and write some more

Time can change perspective on clinical encounters and documenting as you go along is a useful way to capture that change. Some events continue to develop after the initial writing—an ongoing record may show how the situation has affected you and others over time, thus providing deeper clarity.

2 Read examples

Reflective writing is notoriously difficult to quantify and therefore assess. Reading examples can improve the quality of your reflections. Jenny Moon, an expert in performing and teaching reflective writing, has written a series of reflections on the same event, with varying levels of reflectivity. She highlights the difference between describing what happened compared with reflecting on it. 4

3 Find something meaningful

The literature suggests that reflecting for the sake of it probably doesn’t produce valuable results. More useful reflection will evolve from an event that held some meaning for you. Try using a broad base to select your topic. Simply asking the questions “what went well?” and “what could have been done differently?” provides a sound starting point for reflection. 5

4 Discussion

Good quality reflective work will include other people’s opinions too. Discussions with colleagues involved in the situation could reveal new aspects. This technique is vital to develop the empathetic clinician. Creating an open and safe culture for discussing rather than ignoring difficult situations improves staff wellbeing and patient care.

5 It’s not really about what happened but how it made you feel

Try not to dwell too much on the actual events, instead focus on the emotional impact for you and others involved. Don’t fall into the trap of providing intricate and irrelevant details—the colour of the registrar’s shirt probably won’t matter in the long run. If you are stuck for what to write, just answer the question, “How did it make me feel?”

6 Explore the uncomfortable

If it makes you uncomfortable then you are probably onto something. Why doesn’t it sit right? Why don’t you want to discuss it with others? Questioning the whys of your emotional response is the key to finding patterns in your practice and this insight may change your approach in the future. Doctors have been hard wired to cut the waffle and stick to the facts but going against the grain in this situation will add layers to your account and strengthen the quality of your reflection.

7 Creative writing

Literature suggests that reflective practice is linked closely with creative writing. Creative writing gives writers the opportunity to explore scenarios they may not have come across but that could be useful in the future should that situation arise. 6 The creation of characters can help the writer develop empathy with others and is a platform from which to explore what someone very different may think or feel.

Fun is not a word commonly associated with reflective practice. Challenge yourself to enjoy the process—after all, medicine doesn’t often give you a chance to get to know yourself (rather than your patients) better. Asking the question “Why?” could become both interesting and therapeutic, rather than yet another box ticking exercise.

9 Personal Development Plan

Reflection will help you identify the areas where you need to focus your learning. This will improve your PDP from a list of vague, timeless goals to specific, achievable objectives with a detailed strategy of how and when they will be completed.

10 Evidence of change

Reflection is ultimately meaningless if it doesn’t facilitate change. If you have identified changes you need to make, return later and provide details of the improvement. This might take the form of an audit or responding to feedback from patients or colleagues. Record it all in your portfolio and reflect again—has the cycle been successful or is more work needed?

Reflection is a personal experience and the best results will happen when the user creates their own process and style. However, following the tips above should give a sound base on which to build and complete those portfolio and appraisal entries.

No competing interests.

↵ Johns C, Burnie S. Becoming a reflective practitioner. Wiley-Blackwell, 2013 .
↵ Kristiansson MH, Troein M, Brorsson A. We lived and breathed medicine - then life catches up: medical students’ reflections. BMC Med Educ 2014 ; 14 : 66 . doi:10.1186/1472-6920-14-66 . pmid:24690405 . OpenUrl
↵ Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 2005 ; 20 : 559 - 64 . doi:10.1007/s11606-005-0102-8 . pmid:16050855 . OpenUrl CrossRef PubMed Web of Science
↵ Moon J. Using story. Routledge, 2010 .
↵ Johna S. The Power of Reflective Writing: Narrative Medicine and Medical Education. permj 2013;17:84-85. doi: 10.7812/tpp/13-043
↵ Hampshire AJ, Avery AJ. What can students learn from studying medicine in literature? Med Educ 2001 ; 35 : 687 - 90 . doi:10.1046/j.1365-2923.2001.00969.x . pmid:11437972 . OpenUrl CrossRef PubMed Web of Science

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Reflection in clinical practice: guidance for postgraduate doctors in training

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Emma Richardson, Gordon Jackson Koku, Harjinder Kaul, Reflection in clinical practice: guidance for postgraduate doctors in training, Postgraduate Medical Journal , Volume 99, Issue 1178, December 2023, Pages 1295–1297, https://doi.org/10.1093/postmj/qgad063

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Reflection is a cyclical process [ 1] of understanding and analysis of one’s professional experiences, with the aim of self-improvement within future practice, if a similar event is encountered [ 2]. Reflection is also understood to have a critical role within the learning cycle [ 2] and clinicians should feel confident when engaging in its practice, as it allows them to focus not only on increasing their medical knowledge, but also on advancing nonclinical skills [ 1] such as communication, multidisciplinary work, and leadership and management. Additionally, reflection is considered essential in continuing professional development [ 3] and this skill must be developed and practised by postgraduate doctors in training (PDiT), and indeed all clinicians, during their professional career.

There are many different theories that guide the practice of reflection. An example is the Kolb cycle [ 4], which is an experimental learning theory that describes how each stage supports the next, for effective learning. There are four stages in the Kolb cycle, all of which must be completed. These are concrete experience, reflective observation, abstract conceptualization, and active experimentation.

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12 Reflective practice prompts for health professionals

February 16, 2018 by Anne Marie Liebel

[This post available as a podcast episode here .]

I have heard “reflective practice” mentioned a few times, in the years I have been talking with physicians, medical educators, and public health professionals.

Dr. Tasha Wyatt, of the Educational Innovation Institute at the Medical College of Georgia, explained to me:

“Physicians are trained–very much so–to gather data, to make decisions. And reflective practice is a way to slow down that process.”

Reflective practice is certainly a term that gets thrown around. It sometimes elicits groans.

If I could say one thing about the term “reflective practice” in my experience as an educator…it would not be a nice thing to say.

A bad reputation

Let me be clear: I am a reflective practitioner. Critical reflection is the engine of my practice. I have spent most of my time in higher education trying to rescue “reflective practice” from its own reputation in my students’ imaginations.

That’s not to say this reputation is undeserved. From where I stand, there are some punitive, reductive, top-down things going on under the guise of “reflective practice.”

And I’m hearing similar statements from the health sector.

A broad spectrum

Reflective practice is a broad spectrum that covers many different understandings of and approaches to reflection (and practice).

This has advantages and disadvantages. Flexibility is essential in an approach that generally is an alternative to practices that are more didactic or directive.

There seems to be support of reflection as a skill. Health professionals all require critical-thinking and problem-solving skills, and reflective practice has been used to support these. Reflection is used to increase metacognition. It is sometimes invoked as a way to connect theory to practice, or to enhance communication. Professionals reflect in classes, in continuing education, or in communities of practice; alone, in dyads, or in small groups.

examples of reflective writing for doctors

Yet this literature review points out the variation in what reflective practice means, and how it is facilitated and assessed, in medical education. This literature review finds similar results in pharmacy education, pointing out the conflicting interpretations and applications of the term ‘reflective practice.’ I highly recommend both these literature reviews for references on reflective practice in health professions.

Both also cite Donald Schön, whose highly-influential books The Reflective Practitioner and Educating the Reflective Practitioner describe and analyze reflection-in-action across multiple professions and professional contexts.

In Educating the Reflective Practitioner , Schön explains why:

[T]he problems of real-world practice do not present themselves to practitioners as well-formed structures. Indeed, they tend not to present themselves as problems at all but as messy, indeterminate situations. Often, situations are problematic in several ways at once. These indeterminate zones of practice—uncertainty, uniqueness, and value conflict—escape the canons of technical rationality. It is just these indeterminate zones of practice, however, that practitioners and critical observers of the professions have come to see with increasing clarity over the past two decades as central to professional practice. (p. 4)

What I want to share here is a key tool in reflective practice: questioning or problem-posing as a way to begin to investigate and address the “problems of real-world practice.”

“Problems of real-world practice”

If I hear ‘what could you have done differently?’ posed as a ‘reflective practice’ question one more time, I’ll scream.

So instead, I’m going to give you twelve prompts that you can ask yourself when you wish to engage in some critical reflection.

These questions are designed to get at your taken-for-granted beliefs and actions. They encourage you to problematize structures, processes, and practices (as these authors do), accepting current arrangements not as given or natural but as politically and historically situated (as these authors point out).

These questions are aimed at those times when you are educating—a patient, or a student. But they can have broader applicability. Overall, they are designed to encourage you to take a critical view of the customary practices and conventional arrangements in your practice context.

After each, there always is a follow-up question: what implications does this have for your practice? In other words, why might this matter to you and your work with patients?

Which patients tend to draw your attention? Why do you think this is? Which patients tend to escape your notice? Why do you think this is?
Are there patients you find it difficult to get along with , or relate to, or reach? How do you feel about this?
What information or knowledge are you assuming patients have when they meet with you? Where would they have acquired this knowledge or information? How have you responded when they do not appear to have this knowledge or information ?
What’s presenting a challenge to you recently when it comes to patient education, that you did not think would present a challenge?
Did anything a patient did or said surprise you today? What was it? Why was it surprising to you? How can you let patients surprise you more often? Have you surprised yourself lately? How?
What’s going on around you that piques your curiosity this week? That you’d like to give more time and attention to, if you could?
When you meet with a patient, how are you talking to this person? What do you tend to think of people in this social group ? How might your conversational dynamics be based on biases and stereotypes?
If you broke down the time you spent this week on different tasks and put it on a chart or graph, what would it look like? To what extent does this match your idea of a successful or productive use of your time?
What have you done this week that you were proud of, no matter how simple it might sound?
Are there times you are unsure of what you are communicating to a patient or colleague? How do you deal with this?
If you could wave a magic wand and give yourself the insights, knowledge, dispositions or skills you need in order to succeed this week, what would you give yourself?
What clever hacks , little-known tricks, or productivity boosts have you discovered lately? What might these be telling you about yourself, or your context?

Again, the important question at the end of each set is always: what implications does this have for your practice?

“Is reflection safe?”

Reflection is an important process for any profession. Yet, at the same time, health care providers are held to such high expectations that reflection can seem risky, as recent events in the UK illustrate.

“Is reflection safe?” Dr. Wyatt wondered aloud, as we were talking. “If so, under what conditions? If not, under what conditions?”

Of course, no one can eliminate the stress and messiness of practice. Reflection, when critically oriented, is designed to press into–and not deny–the stress and messiness of practice. It is an irreplaceable, powerful tool that invites professionals to imagine other possible practices, roles, and relationships.

If you are interested in taking your language use seriously, why not start with your metaphors ? This workshop shows you how to break down the metaphors you use, understand their cognitive and affective aspects, and evaluate them in use. On demand, right on this site .

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Open access
Published: 09 January 2023

A systematic scoping review of reflective writing in medical education

Jia Yin Lim 1 , 2 ,
Simon Yew Kuang Ong 3 , 4 , 5 ,
Chester Yan Hao Ng 1 , 2 ,
Karis Li En Chan 1 , 2 ,
Song Yi Elizabeth Anne Wu 1 , 2 ,
Wei Zheng So 1 , 2 ,
Glenn Jin Chong Tey 1 , 2 ,
Yun Xiu Lam 1 , 2 ,
Nicholas Lu Xin Gao 1 , 2 ,
Yun Xue Lim 1 , 2 ,
Ryan Yong Kiat Tay 1 , 2 ,
Ian Tze Yong Leong 1 , 2 ,
Nur Diana Abdul Rahman 4 ,
Min Chiam 4 ,
Crystal Lim 6 ,
Gillian Li Gek Phua 2 , 5 , 7 ,
Vengadasalam Murugam 2 , 5 ,
Eng Koon Ong 2 , 4 , 5 , 8 &
Lalit Kumar Radha Krishna 1 , 2 , 4 , 5 , 9 , 10

BMC Medical Education volume 23 , Article number: 12 ( 2023 ) Cite this article

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Conclusions

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Introduction

Teo et al. [ 10 ] build on this concept of reflective practice. The authors suggest that the physician’s belief system informs and is informed by their self-concepts of identity which are in turn rooted in their self-concepts of personhood - how they conceive what makes them who they are [ 11 ]. This posit not only ties reflective practice to the shaping of the physician’s moral and ethical compass but also offers evidence of it's role in their professional identity formation (PIF) [ 8 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. With PIF [ 8 , 24 ] occupying a central role in medical education, these ties underscore the critical importance placed on integrating reflective practice in medical training.

Perhaps the most common form of reflective practice in medical education is reflective writing (RW) [ 25 ]. Identified as one of the distinct approaches used to achieve integrated learning, education, curriculum and teaching [ 26 ], RW already occupies a central role in guiding and supporting longitudinal professional development [ 27 , 28 , 29 ]. Its ability to enhance self-monitoring and self-regulation of decisional paradigms and conduct has earned RW a key role in competency-based medical practice and continuing professional development [ 30 , 31 , 32 , 33 , 34 , 35 , 36 ].

However, the absence of consistent guiding principles, dissonant practices, variable structuring and inadequate assessments have raised concerns as to RW’s efficacy and place in medical training [ 25 , 37 , 38 , 39 ]. A Systematic Scoping Review is proposed to map current understanding of RW programs. It is hoped that this SSR will also identify gaps in knowledge and regnant practices, programs and assessment methods to guide the design of RW programs.

Methodology

A Systematic Scoping Review (SSR) is employed to map the employ, structuring and assessment of RW in medical education. An SSR-based review is especially useful in attending to qualitative data that does not lend itself to statistical pooling [ 40 , 41 , 42 ] whilst its broad flexible approach allows the identification of patterns, relationships and disagreements [ 43 ] across a wide range of study formats and settings [ 44 , 45 ].

To synthesise a coherent narrative from the multiple accounts of reflective writing, we adopt Krishna’s Systematic Evidence-Based Approach (SEBA) [ 10 , 15 , 21 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. A SEBA-guided Systematic Scoping Review (SSR in SEBA) [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 50 , 53 , 54 , 55 ] facilitates reproducible, accountable and transparent analysis of patterns, relationships and disagreements from multiple angles [ 56 ].

The SEBA process (Fig. 1 ) comprises the following elements: 1) Systematic Approach, 2) Split Approach, 3) Jigsaw Perspective, 4) Funnelling Process, 5) Analysis of data and non-data driven literature, and 6) Synthesis of SSR in SEBA [ 10 , 15 , 21 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 57 , 58 , 59 , 60 ] . Every stage was overseen by a team of experts that included medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore, and local educational experts and clinicians at YLLSoM, Duke-NUS Medical School, Assisi Hospice, Singapore General Hospital, National Cancer Centre Singapore and Palliative Care Institute Liverpool.

The SEBA Process

STAGE 1 of SEBA: Systematic Approach

Determining the title and background of the review.

Identifying the research question

Inclusion criteria

Extracting and charting

Titles and abstracts were independently reviewed by the research team to identify relevant articles that met the inclusion criteria set out in Table 1 . Full-text articles were then filtered and proposed. These lists were discussed at online reviewer meetings and Sandelowski and Barroso [ 63 ]’s approach to ‘negotiated consensual validation’ was used to achieve consensus on the final list of articles to be included.

Stage 2 of SEBA: Split Approach

The Split Approach was employed to enhance the trustworthiness of the SSR in SEBA [ 64 , 65 ]. Data from both searches were analysed by three independent groups of study team members.

Stage 3 of SEBA: Jigsaw Perspective

Stage 4 of SEBA: Funnelling Process

The Funnelling Process saw the themes/categories compared with the tabulated summaries to determine the consistency of the domains created, forming the basis of the discussion.

Stage 5: Analysis of data and non-data driven literature

Stage 6: Synthesis of SSR in SEBA

The Best Evidence Medical Education (BEME) Collaboration Guide and the Structured approach to the Reporting In healthcare education of Evidence Synthesis (STORIES) were used to guide the discussion.

a PRISMA Flow Chart (Search Strat #1: Theories of Reflection in Medical Education). b PRISMA Flow Chart (Search Strat #2: Reflective Writing in Medical Education)

Domain 1: Theories and Models

Many current theories and models surrounding RW in medical education are inspired by Kolb’s Learning Cycle [ 5 ] (Table 2 ). These theories focus on descriptions of areas of reflection; evaluations of experiences and emotions; how events may be related to previous experiences; knowledge critiques of their impact on thinking and practice; integration of learning points; and the physician’s willingness to apply lessons learnt [ 6 , 73 , 74 , 75 ]. In addition, some of these theories also consider the physician’s self-awareness, ability and willingness to reflect [ 76 ], contextual factors related to the area of reflection [ 4 , 77 ] and the opportunity to reflect effectively within a supportive environment [ 78 , 79 ]. Ash and Clayton's DEAL Model recommends inclusion of information from all five senses [ 80 , 81 , 82 , 83 ]. Johns's Model of Structured Reflection [ 84 ] advocates giving due consideration to internal and external influences upon the event being evaluated. Rodgers [ 39 ] underlines the need for appraisal of the suppositions and assumptions that precipitate and accompany the effects and responses that may have followed the studied event. Griffiths and Tann [ 75 ], Mezirow [ 77 ], Kim [ 85 ], Roskos et al. [ 86 ], Burnham et al. [ 87 ], Korthagen and Vasalos [ 78 ] and Koole et al. [ 74 ] build on Dewey [ 2 ] and Kolb [ 5 ]’s notion of creating and experimenting with a ‘working hypothesis’. These models also propose that the lessons learnt from experimentations should be critiqued as part of a reiterative process within the reflective cycle. Underlining the notion of the reflective cycle and the long-term effects of RW, Pearson and Smith [ 88 ] suggest that reflections should be carried out regularly to encourage longitudinal and holistic reflections on all aspects of the physician’s personal and professional life.

Domain 2: Current methods of structuring RW programs

Current programs focus on supporting the physician throughout the reflective process. Whilst due consideration is given to the physician’s motivations, insight, experiences, capacity and capabilities [ 25 , 96 , 112 , 113 , 114 , 115 , 116 ], programs also endeavour to ensure appropriate selection and training of physicians intending to participate in RW. Efforts are also made to align expectations, and guide and structure the RW process [ 37 , 116 , 117 , 118 , 119 , 120 , 121 , 122 ]. Physicians are provided with frameworks [ 76 , 79 , 105 , 123 , 124 ], rubrics [ 99 , 123 , 125 , 126 ], examples of the expected quality and form of reflection [ 96 , 115 , 116 ], and how to include emotional and contextual information in their responses [ 121 , 127 , 128 , 129 ].

Other considerations are enclosed in Table 4 including frequency, modality and the manner in which RW is assessed.

Domain 3: Benefits and Shortcomings

The benefits of RW are rarely described in detail and may be divided into personal and professional benefits as summarised in Table 5 for ease of review. From a professional perspective, RW improves learning [ 96 , 112 , 119 , 147 , 157 , 170 , 179 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 ], facilitates continuing medical education [ 119 , 128 , 173 , 174 , 193 , 194 , 195 ], inculcates moral, ethical, professional and social standards and expectations [ 118 , 156 , 160 ], improves patient care [ 29 , 120 , 129 , 131 , 135 , 142 , 194 , 196 , 197 , 198 , 199 ] and nurtures PIF [ 150 , 157 , 172 , 191 , 200 ].

From a personal perspective, RW increases self-awareness [ 114 , 127 , 137 , 161 , 166 , 179 , 185 , 202 , 216 ], self-advancement [ 9 , 131 , 134 , 150 , 168 , 174 , 195 , 205 , 217 , 229 ], facilitates understanding of individual strengths, weaknesses and learning needs [ 112 , 119 , 150 , 152 , 170 , 218 , 219 ], promotes a culture of self-monitoring, self-improvement [ 130 , 172 , 173 , 185 , 193 , 198 , 201 , 210 , 211 ], developing critical perspectives of self [ 193 , 223 ] and nurtures resilience and better coping [ 154 , 160 , 206 ]. RW also guides shifts in thinking and perspectives [ 148 , 149 , 156 , 203 , 207 , 208 ] and focuses on a more holistic appreciation of decision-making [ 37 , 118 , 126 , 174 , 177 , 194 , 196 , 199 , 200 , 224 , 225 , 226 ] and their ramifications [ 37 , 112 , 116 , 130 , 131 , 141 , 154 , 179 , 193 , 194 , 196 , 204 , 207 , 218 , 230 ].

Table 6 combines current lists of the shortcomings of RW. These limitations may be characterised by individual, structural and assessment styles.

It is suggested that RW does not cater to the different learning styles [ 220 , 232 ], cultures [ 190 ], roles, values, processes and expectations of RW [ 114 , 129 , 135 , 138 , 142 , 209 , 227 , 234 ], and physicians' differing levels of self-awareness [ 29 , 79 , 119 , 176 , 188 , 226 , 231 , 236 ], motivations [ 29 , 119 , 136 , 138 , 157 , 161 , 167 , 168 , 169 , 176 , 181 , 193 , 196 , 226 , 232 , 233 ] and willingness to engage in RW [ 37 , 114 , 136 , 149 , 160 , 183 ]. RW is also limited by poorly prepared physicians and misaligned expectations whilst a lack of privacy and a safe setting may precipitate physician anxiety at having their private thoughts shared [ 129 , 149 , 209 , 231 ]. RW is also compromised by a lack of faculty training [ 143 , 145 , 239 ], mentoring support [ 37 , 50 , 119 , 133 , 196 ] and personalised feedback [ 50 , 114 , 136 , 167 , 229 ] which may lead to self-censorship [ 37 , 114 , 136 , 149 , 160 , 183 ] and an unwillingness to address negative emotions arising from reflecting on difficult events [ 114 , 168 , 176 , 193 , 230 ], circumventing the reflective process [ 118 , 142 , 165 , 196 ] .

Domain 4. Recommendations

In the face of practice variations and challenges, there have been several recommendations on improving practice.

Boosting awareness of RW

A structured program and environment

Adjuncts to RW programs

The concepts of ‘ sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’ spotlight environmental and physician-related factors. These include the physician’s motivations, knowledge, skills, attitudes, competencies, working style, needs, availabilities, timelines, and their various medical, clinical, administrative, organisational, sociocultural, legal, professional, personal, psychosocial, clinical, research, academic and situational experiences. It also underlines the role played by the physician’s beliefs, moral values, ethical principles, familial mores, cultural norms, attitudes, thoughts, decisional preferences, roles and responsibilities. The environmental-related factors include the influence of the curriculum, the culture, structure, format, assessment and feedback of the RW process and the program it is situated in. Together, the physician and their environmental factors not only frame RW as a sociocultural construct necessitating holistic review but also underscore the need for longitudinal examination of its effects. This need for holistic and longitudinal appraisal of RW is foregrounded by the experimentations surrounding the ‘working hypothesis’ [ 2 , 5 , 72 , 74 , 77 , 84 , 85 , 86 , 90 ]. In turn, experimentations and their effects affirm the notion of regular use of RW and reiterate the need for longitudinal reflective relationships that provide guidance, mentoring and feedback [ 87 , 90 ]. These considerations set the stage for the proffering of a new conceptual model of RW.

Krishna Model of Reflective Writing

Belief system

Recognising that the physician’s notion of ‘ sensitivity’, ‘judgement’, ‘willingness’, ‘balance’, ‘ability’ and ‘responsiveness’ is influenced by their experience, skills, knowledge, attitude and motivations, physicians recruited to the RW program should be carefully evaluated

To align expectations, the physician should be introduced to the benefits and role of RW in their personal and professional development

The ethos, frequency, goals and format of the reflection and assessment methods should be clearly articulated to the physician [ 253 ]

The physician should be provided with the knowledge, skills and mentoring support necessary to meet expectations [ 76 , 79 , 105 , 123 , 124 , 254 , 255 ]

Training and support must also be personalised

Contextual considerations

Recognising that the physician’s academic, personal, research, administrative, clinical, professional, sociocultural and practice context will change, the structure, approach, assessment and support provided must be flexible and responsive

The communications platform should be easily accessible and robust to attend to the individual needs of the physician in a timely and appropriate manner

The program must support diversity [ 207 ]

Environment

The reflective relationship is shaped by the culture and structure of the environment in which the program is hosted in

The RW programs must be hosted within a formal structured curriculum, supported and overseen by a host organisation which is able to integrate the program into regnant educational and assessment processes [ 9 , 115 , 219 , 220 , 230 , 233 , 242 , 246 ]

Reflective relationship

The faculty must be trained and provided access to counselling, mindfulness meditation and stress management programs [ 249 ]

The faculty must support the development of the physician’s metacognitive skills [ 256 , 257 , 258 , 259 ], and should create a platform that facilitates community-centered learning [ 173 , 176 ], structured, timely, personalised open feedback [ 119 , 135 , 179 , 237 ] and support [ 128 , 131 , 138 , 196 , 199 , 231 , 249 ]

The faculty must be responsive to changes and provide appropriate personal, educational and professional support and adaptations to the assessment process when required [ 207 ]

To facilitate the development of effective reflective relationships, a consistent faculty member should work with the physician and build a longitudinal trusting, open and supportive reflective relationship

Physician’s reactions

The evolving nature of the various structures and influences upon the RW process underscores the need for longitudinal assessment and support

The physician must be provided with timely, appropriate and personalised training and feedback

The program’s structure and oversight must also be flexible and responsive

There must be accessible longitudinal mentoring support

The format and assessment of RW must account for growing experience and competencies as well as changing motivations and priorities

Whilst social media may be employed to widen sharing [ 149 , 155 , 160 , 169 , 194 ], privacy must be maintained [ 120 , 189 ]

On assessment

Assessment rubrics should be used to guide the training of faculty, education of physicians and guidance of reflections [ 37 , 116 , 117 , 118 , 119 , 120 , 121 , 122 ]

Assessments ought to take a longitudinal perspective to track the physician's progress [ 116 , 122 ]

Based on the results from this SSR in SEBA, we forward a guide catering to novice reflective practitioners (Additional file 1 ).

Limitations

Availability of data and materials

All data generated or analysed during this review are included in this published article and its supplementary files.

Abbreviations

Reflective Writing

Professional Identity Formation

Ring Theory of Personhood

Best Evidence Medical Education

Structured approach to the Reporting In healthcare education of Evidence Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Systematic Scoping Review

Systematic Evidence-Based Approach

Yong Loo Lin School of Medicine

Population, Intervention, Comparison, Outcome, Study Design

Realist And Meta-narrative Evidence Syntheses - Evolving Standards

Wang Y-H, Liao H-C. Construction and validation of an analytic reflective writing scoring rubric for healthcare students and providers. 醫學教育. 2020;24(2):53–72.

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The authors would also like to thank the anonymous reviewers, Dr. Ruaraidh Hill and Dr. Stephen Mason for their helpful comments which greatly enhanced this manuscript.

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Lim, J.Y., Ong, S.Y.K., Ng, C.Y.H. et al. A systematic scoping review of reflective writing in medical education. BMC Med Educ 23 , 12 (2023). https://doi.org/10.1186/s12909-022-03924-4

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EXAMPLES OF REFLECTION

BEHIND THE TABS/BUTTONS AT THE BOTTOM OF THIS PAGE you can find two in-depth examples of reflection . Furthermore, you can find 3 more examples on the GMC website here (by clicking the text).

Benefits of and barriers to reflection

Reflection has many benefits and is used for a wide variety of reasons:

to validate prior learning.
to attend to the grounds or the justification of our beliefs.
for problem solving.
to reflect on the content of a problem.
to think about the processes involved in a practice.
to examine the basis of our perspectives.
to develop greater productivity, greater satisfaction.
to enhance flexibility and to improve our leadership skills.
to develop feelings of greater congruity about ourselves and our working practices.
to acknowledge immediate feelings, followed by later thoughtful scrutiny.
to reinforce good practice.

However, reflection can be a daunting concept initially.

Barriers to reflection can include:

fear of the unknown.
worry about what you might find.
admission of error and losing face.
feelings of being emotionally drained.
pressure to change things.
sense of being too old to learn new things.
the culture of ‘winging it.’
a sense of isolation.

It is no wonder that many of us shy away from doing it.

CLICK THE TABS/BUTTONS BELOW TO VIEW EXAMPLES

A failed kidney transplant patient, he had spent large part of his life in and out of hospital even though he was only seven. He knew all about doctors and nurses, blood tests and operations. He did not like being in hospital and he did not like being told what to do.

On the morning in question, I needed to take a blood sample from him. I introduced myself as I had not met him before. He looked at me suspiciously and told me he wanted to eat his lunch first. I thought this was a reasonable request and said I would come back.

When I came back, he said he did not want his blood taken. I explained why it had to be done. There then followed every excuse he could think of as to why he should not have his blood taken then. He wanted to play some more first. He wanted his mum to have her blood taken first. He wanted another doctor to do it. He wanted to go to the toilet first. I dealt with each argument, but he became increasingly distressed. He swore and shouted, cried, and tried running away.

I was a terribly busy that shift and could have done without this, but something made me curious about this child’s behaviour.

His mother said we should go ahead. The minute the needle touched his skin, he was quiet. He stopped crying and calmly watched the blood enter the specimen tube.

I asked him why he had been so distressed. He said he had to make a fuss ‘so that I would be careful.’ I said I could understand his logic but that perhaps in future he did not need to make quite so much fuss. I have to say I admired him in a way for his strategy.

I thought I dealt with this situation well by letting the patient eat his lunch and coming back later and I was glad that I asked him why he had been so distressed, because I learned something from that. However, I could feel myself getting angry with him and only just managed to control that.

When I thought back over this case later that evening, I recalled talking to a parent of a sick child a few months ago and she said how much she hated her powerlessness. She said she felt as though she and her daughter were victims in the machinery of the healthcare system. That comment stayed with me, and I wondered today if this child’s behaviour over the blood sample was driven by the need to exert some power over what was being done to him.

I realized that we would do well to remember how vulnerable patients feel, and that we need to earn our patient’s trust and it is often best to tread carefully at the start.

When I am working with patients in future, I will endeavour to give them as much choice as possible over their care, even down to when I take their blood. I would like to look at the patient feedback forms and see whether there is scope to ask them about choices in their care.

Situation: ITU resident on night shift

We had a fifty-one-year old gentleman with NASH who had presented with haematemesis on our ITU outreach list. He had presented on the Friday with a litre of haematemesis witnessed in A&E. There was no gastro on call over the weekend, so he was waiting for his scope on Monday. Soon after starting my night shift, I was asked by the med reg to come and see him as he had just had another episode of haematemesis of about 1L.

When I got there, he had just been reviewed by the surgical registrar and looked unwell. As I went to examine him, he vomited again- about 1.5L over my shoes and on to the floor. I asked for help, assessed what kind of IV access he had and squeezed the bag of blood that was up. A nurse soon arrived and the surgical reg. I asked them to fast bleep the anaesthetist on call and someone went to look for a Sengstaken-Blackemore tube.

The SB tube was put down which stopped the bleeding and more blood was ordered. The plan was to take the patient to theatre and do an OGD. I left the patient with the surgical registrar and the anaesthetists and went back to the unit. They would contact me if there was any deterioration and we made a bed available for the patient post-theatre.

A few hours later, I was called by the medical registrar on call to say that they were in the process of trying to get the patient transferred to the tertiary centre Liver ITU. The SB tube balloon had been pulled out and the surgeons on call could not band varices and there were no gastroenterologists available. I went back to the ward to assess the situation.

The patient now had an arterial line and a CVP line. The SB tube was back in place. The patient was still receiving blood and blood products. I spoke to the tertiary centre and they accepted the patient for transfer. It was decided that the patient should be intubated for transfer and that it was best to do this on the ward rather than transferring him up to the unit first. The surgical registrar, medical registrar, anaesthetic SHO and registrar and the ITU consultant (over the phone) were all involved in this decision.

There was delay in intubation so that after the SB tube had been removed, the patient vomited blood again and then arrested (PEA). It was a difficult intubation but successful and the SB tube was then re-sited. The patient received 3 cycles of CPR with adrenalin and atropine with return of spontaneous circulation. The initial BP was 100 systolic. The patient’s daughter (a paediatrician) arrived soon after the start of the resuscitation but did not stay for long to observe.

The situation was again discussed with the tertiary centre and consultants at home (anaesthetic, medical, ITU) and with the staff present (anaesthetists, surgical reg, medical reg, site managers, nurses) and it was felt that although the patient was unstable, transfer to a unit with staff to do oesophageal banding was the only option that offered some chance of survival. There were conflicting opinions about this, but this was the consensus that was reached.

The patient however was not able to maintain his BP (Blood Pressure), despite boluses of adrenalin and ongoing transfusion. The BP was barely maintained at 70 systolic. The situation was re-assessed, and it was decided that transfer was no longer an option. The family had not yet been spoken to. I was nominated to speak to family, with the medical registrar.

The family (wife, daughter, son) understood that the situation was serious and that we had tried to get the patient stable enough for transfer to a specialist unit but that this had not been possible. They wanted active treatment but understood that this was likely to be futile. I explained that the patient could either be brought up to ITU for ongoing support but that the outcome was likely to be poor. The alternative was to keep the patient comfortable on the ward. The family decided that they wanted the patient to be kept comfortable on the ward.

The situation was then again discussed with the members of staff present and with consultants over the phone. The consensus was that treatment should be stopped and the patient kept on the ward. He died soon thereafter with his family at the bedside.

MY EVALUATION

Things that went well: good communication between different members of staff, good decision-making process, patient’s best interests always foremost, dignified death at the end.

Areas for improvement: awareness of ward nursing staff of seriousness of situation, hospital logistics (availability of SB tube), delay in intubation, out of hours gastroenterology availability.

This case left me with a feeling of slight unease; whilst I knew we had done all we could – and we had facilitated a calm and dignified death at the end of the process, I just felt like we could have been slicker in our management. I was frustrated by the nursing staff who did not seem to grasp how ill the patient was. I could feel myself getting angry with the lack of availability of the equipment and the out of hours gastro cover system. I felt like I was doing my absolute best for this patient but around me the staff and the hospital infrastructure were taking it all at a much more casual pace. We work hard and intensively and when that is not matched by the system or other colleagues it can be infuriating.

I have treated patients with similar problems before and have also been with patients at the end of their life. I think the reason this case affected me was because I felt overpowered not just by the inevitability of the patient’s death, but also by the small inefficiencies of the hospital system.

Identify learning points

Communication between everyone involved in case is vital - staff present but also other centres and consultants over the phone, consensus in decision making is important and not easy, but sometimes we cannot always offer patients the care they need or we would like to offer.

Establish follow up actions

The equipment issue is something I can do something about so I intend to do process mapping on such essential pieces of kit, and ensure that there is a system in place to have all kit kept fully stocked and up to date for future cases.

I have spoken to my consultant about the equipment project and he suggested I could submit the results as a Quality improvement Project to the department.

Benefits of Reflective Writing in Health Care through the Vivid Lens of House Officers

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Introduction: Reflective writing, a complex human activity is one of the innovative pedagogies to promote deep learning among medical students and doctors. Despite its potential to facilitate learning, there is limited literature on evaluation of various purposes of reflective writing in medical education. Hence, aim of this study is to develop an instrument and evaluate the perceptions of house officers about benefits of reflective writing.

Methods :Mixed method study followed AMEE 87 guidelines for questionnaire development. The study was carried out from Oct 2018-Feb 2019 in a dental college in Islamabad. A 30-items questionnaire was developed by following these steps: (1) conduction of literature review, (2) item development, (3) conduction of cognitive interviews and (4) pilot testing. Coding and interpretation of transcribed data and notes taken during cognitive interviews was done to finalize three main themes (learning, self-regulation and alteration in clinical behavior) identified in literature review. In pilot testing, participants were asked to rate the purposes of reflective writing on a three-point Likert scale (Agree, do not know and disagree). Data was analyzed using SPSS version 22.

Results: All of nineteen house officers (n= 3 for cognitive interviews, n= 16 for pilot testing) had previous experience of writing reflections using Gibb's reflective cycle. Thirteen (81%) out of sixteen house officers agreed that reflective writing improves learning, helps in self-regulation and alters clinical behavior, two (13%)did not know about the three themes that were finalized in cognitive interviews and one (6%) did not agree.

Discussion and Conclusion: Reflective writing improves learning, helps in self-regulation and alters clinical behavior in the selected house officers. This study may inspire medical education experts to include reflective writing as a part of formal undergraduate medical and dental curriculum to enhance student's learning experience.

Reflective writing, critical thinking, self-regulation, clinical behavior.

Introduction

Medical education help students to acquire knowledge, skills and attitudes necessary for the medical health profession ( Schei, Fuks and Boudreau, 2018 ). Therefore, it is the responsibility of medical teachers to introduce right pedagogy among their students ( Sukhato et al. , 2016 ). Reflective writing is one of the latest pedagogies being used in medical education. It is a complex human activity ( Anne de la Croix, 2018 ). It has been proliferating in educational programs to enhance development of reflective capacity, to extend empathy by deep understanding of patient’s experiences of their illness and to promote practitioner well-being ( Boud and Walker, 1998 ; Wald and Reis, 2010 ). Hence, the ultimate goal of medical education is to produce knowledgeable, up to date and skillful professionals with undertaking of maintaining and developing expertise over the period of their lifelong career ( Swanwick, 2014 ).

Reflection is a metacognitive process in which a person is engaged in attentive, critical, exploratory and iterative interactions with his thoughts and actions to change them, hence it is powerful equipment of experiential learning ( Fragkos, 2016 ; Larsen, London and Emke, 2016 ; Asiah Mohd Sharif, 2017 ). Attention to self and critical reflection on the situation are two necessary elements for continued competence (Sanders, 2015; Fragkos, 2016 ). Reflective writing engages one in the process of deep understanding and continuous learning ( Jorwekar, 2017 ). It can improve individual’s specific learning situation to have greater self-awareness, professional expertise, critical thinking and resilience, therefore provide improved service to clients ( Jorwekar, 2017 ). Active thinking is only possible when we reflect upon events about what we have done good or bad, how differently we have done it and how it can be done in a better way ( Chesterman, 2014 ). However, ‘reflective zombie’ is the term used in the literature for those students who just follow the steps of the thought process they are being told rather to engage themselves in authentic reflection process ( Anne de la Croix, 2018 ).

Several frameworks have been developed and are used for reflective practice to enhance student’s learning experience and professional development. John Dewey in 1938, Schon in 1983, Kolb in 1984 and Driscoll in 1994 introduced various models for reflection ( Donald A. Schon, 1984 ). Whereas the most useful framework is given by Gibbs in 1988 and he introduced a structured reflective cycle consisting of organised stages ( Gibbs, 1988 ; Priddis and Rogers, 2017 ).

Reflective practice in teaching is used as a self-assessment tool. It is also useful for professional development, enhancing student’s learning experience and improving memory as it is used to recall previous experience ( Larsen, London and Emke, 2016 ). Usually reflective diaries, portfolios, blogs, journals, poetry, some short stories, novels or books are used for written reflections ( Korthagen, 1993 ). Most of the work on reflective writing has been done in nursing ( Moattari, 2007 ) and Larsen et al . (2016) stated that it is rarely a formal part of the daily work of medical education or practice. Checklists, portfolios and other tools that are being used to encourage reflection that are isolated from original theories of reflection and reflective practice, hence the main essence of reflection has been lost ( Larsen, London and Emke, 2016 ). Despite the importance of reflective writing, there is general lack of awareness of different purposes of reflection for learning. Literature search revealed a gap that there is a need of in-depth inquiry regarding reflection. Hence, there is a need to develop an instrument that can evaluate various purposes of reflective writing ( Mann, 1999 ; Mann et al. , 2007 ; Fragkos, 2016 ).

Mix method study with sequential qualitative and quantitative components following guidelines of AMEE 87 for questionnaire development in educational research was carried out over five months (Oct 2018-Feb 2019) in one of the dental colleges in Islamabad. Selected house officers had previous experience of reflective writing during their rotation in the Prosthodontic department.

Data Collection: Approval of the study was obtained from Institutional Review Board Committee of the institute. A purposive sampling (n=19) of house officers was done for cognitive interviews and later pilot testing. The participants selection was based on their written reflections according to Gibb’s Reflective Cycle during their routine rotation in the Prosthodontic department (reflective writing is compulsory part of their logbook in Prosthodontics rotation only). For cognitive interviews, three categories of house officers were selected (average, above average and below average) based on their undergraduate academic record of final professional examination provided by the administration upon request. The purpose of choosing three categories of house officers was to get maximum input of their responses to finalize items. Participants were informed about the research implication and their participation was voluntary. Informed consent was taken before cognitive interviews and the pilot testing. House officers who participated in cognitive interviews were excluded in pilot testing.

Questionnaire : A 30-items questionnaire (Supplementary File 1) was developed by following these steps: (1) conduction of literature review, (2) item development, (3) conduction of cognitive interviews from three house officers and (4) pilot testing. The initial questionnaire had 32 items under four themes emerged from literature review (learning, self-regulation, alteration in clinical behavior and organizational skills) which were then reduced to 30-items under three themes after cognitive interviews. The first theme was “learning” which comprised of seven items. The second theme “self-regulation” included fourteen items and the third theme was “alteration in clinical behavior” that comprised of nine items.

Three-point Likert scale (agree, do not know and disagree) was used to ask participants to rate the purposes of reflective writing. The rationale behind using three-point Likert scale was to get clear responses. House officers at early career may have been unable to distinguish between the narrow boundary of strongly agree and agree or vice versa. This was evaluated in the cognitive interviews and during discussion about the points of Likert scale.

Data collection technique for cognitive interviews and pilot testing: After an informed consent and appropriate briefing, data was first collected from cognitive interviews from three selected house officers for quality assurance procedure. The technique used was a mixture of think aloud and concurrent verbal probing as it better identifies potential errors ( Artino et al. , 2014 ). A newly developed questionnaire was then distributed among sixteen house officers for pilot testing.

Data Analysis: For cognitive interviews,coding and interpretation of transcribed data and written notes taken during the interview was done for alterations in the items. For pilot testing, the data was analyzed using SPSS version 22. Frequencies were calculated for all items as well as the items under three themes (learning, self-regulation and alteration in clinical behavior).

Ethics approval for this study was granted on 20th November 2018 by Dr. Hina Mahmood, Secretary, Institutional Review Board Committee of Dental Section, Islamabad Medical and Dental College, Islamabad (Ref IMDC/DS/OG/280).

Results/Analysis

Among nineteen participants of the study, three participated in cognitive interviews and remaining sixteen participated in pilot testing (100% response rate). See Table 1 :

Table 1. Participant’s demographics

Cognitive Interviews:

The decision of rephrasing, omitting and repositioning the statements of few items was done after conduction of cognitive interviews. See Table 2 :

Table 2. Results of cognitive Interviews from three participants

Pilot Testing:

Thirteen (81%) out of sixteenrespondent house officers agreed that reflective writing improves learning, helps in self-regulation and alters clinical behavior. Two (13%) did not know about the three themes that were finalized in cognitive interviews and one (6%) did not agree. Sixteen house officers (100%) agreed that reflection helps in understanding self and situation, monitoring own work progress, setting goals and meeting them in time. See Table 3 :

Table 3. Frequencies and percentages of three themes originated from literature review and confirmed in cognitive interviews

The present study has evaluated the perceptions of house officers about the various purposes of reflective writing. Majority of the house officers (13/ 16; 81%) in pilot testing agreed that reflective writing does enhance learning, helps in self-regulation and alters clinical behavior.

Frenk et al . (2010) stated that outdated and static curricula without addition of innovative methods for students learning is the reason for production of ill-equipped graduates from underfinanced institutions as it mismatches professional competencies, patient and population priorities ( Julio Frenk, Lincoln Chen, Zulfiqar A Bhutta, Jordan Cohen, Nigel Crisp, 2010 ). In medical education, various learning theories have been provided in literature and reflective practice in health care education is one of those learning theories ( Dacre, 2001 ). Mostly reflections have been explored in nursing and limited data is available for the reflective writing in medical and dental schools ( Moattari, 2007 ). Previously, it has been explored that writing reflections every day for two consecutive weeks had positive learning influence on medical students analyzing their clinical performance ( Larsen, London and Emke, 2016 ).

In our study fourteen (88%) house officers agreed that reflection improves learning. It does improve learning due to critical thinking ( Jorwekar, 2017 ). A systematic review stated that reflective writing is related to learning, professional identity development, and critical thinking in medical and health professions students ( Fragkos, 2016 ). Thirteen house officers (81%) agreed that reflection increases desire for more theoretical knowledge and learning new practical skills. Personal knowledge incorporates knowledge of skills and practices and personal understandings of people and situations ( Michael Eraut, 2010 ). Nine studies in a systematic review reported that reflections in clinical portfolios helped in measurable change in student skills and attitudes and one study reported a change in student behavior ( Buckley et al. , 2009 ).

Reflective practice leads to deeper understanding from experience or situation and enable us to understand our strengths, acquisition of knowledge, skills, attitudes and values ( Fragkos, 2016 ). In our study, fourteen (88%) house officers agreed that reflection enables one to think about one’s strengths and weaknesses. While doing clinical work one may think of the strengths and weaknesses of the particular situation and for the next time those weaknesses can be managed for the better output. Comparing with our study, sixteen (100%) house officers agreed that reflection helps in developing understanding of the self and present situation so that future encounters with the similar situation are informed from the previous encounters. Hence, another important aspect of reflective practice is enhancement of patient care for the health professionals ( Fragkos, 2016 ). We also had similar finding in our study where twelve (75%) house officers agreed that reflection helps in better care of patients.

Reflection also leads to motivation and self-directed learning ( Fragkos, 2016 ). Reflective practice maximizes deep and life-long learning ( Hargreaves, 2016 ). In our study fourteen (88%) participants agreed that reflection has marked effect on self-directed and lifelong learning and twelve (75%) agreed that it improves depth of knowledge. Jorwekar (2017) stated that self-directed learning is the important aspect of adult learning in medical education. Reflection not only increases skill and knowledge but also helps students in communication. Reflection is the strategy by which attitude and communication among students can be inculcated. Present medical education needs to include such methods which can assure strong communication skills ( Jorwekar, 2017 ). Hence communication between health care professional and patient is very important. In our study twelve (75%) agreed that reflection improves communication skills. One more advantage of reflection is that it also changes student’s behavior ( Fragkos, 2016 ). If one reflects on the clinical experience, one can reduce medical errors by changing clinical behavior, learning new knowledge and practical skills ( Fragkos, 2016 ). In our study thirteen (81%) agreed that reflection alters clinical behavior and it reduces treatment errors.

Reflective writing strategy if used regularly and effectively with supervision, can have various roles and benefits among doctors and undergraduate medical students. It may help them in becoming better future health care professionals by inculcating the habit of life-long learning ( Taranikanti et al. , 2019 ). Limited studies are available in the literature that have evaluated the main purposes of reflective writing in depth. Reflective writing shall be included in the undergraduate curriculum from the initial phase of medical school due to its vast benefits as shown in our study.

Limitations: We only used four out of seven steps to develop questionnaire as it served the purpose of our study ( Artino et al. , 2014 ). We obtained only the response process validity from potential respondents through cognitive interviews. Moreover, the study could have been expanded to include multiple institutes with large sample size and to compare the differences in different cohorts of house officers working in different institutional settings.

This study confirms that reflective writing enhances learning, helps in self-regulation and alters clinical behavior of dental house officers in the preliminary findings from pilot testing. The results of this study may inspire medical educationists in Pakistan to include reflective writing as a part of formal undergraduate and postgraduate medical and dental curriculum to develop the habit of reflection and to enhance student’s learning experience so that they may gain more knowledge and improve their practice.

Take Home Messages

• Reflective writing should be made mandatory for dental students going through clinical clerkships and house officers as this will help to inculcate a habit of reflective learning for the future professional life.

• The importance and purpose of reflective writing needs to be emphasized from the beginning of medical education.

Notes On Contributors

Anbreen Aziz is a Dental Health Professional in the Department of Medical Education at Hazrat Bari Sarkar (HBS) Dental College, Islamabad, Pakistan.

Usman Mahboob is Director of Institute of Health Professions Education & Research (IHPER) at Khyber Medical University (KMU) Peshawar, Pakistan.

Tayyaba Saleem is a Clinical Professor and Head of Department of Prosthodontics and Dental Health Professional in the Deprtment of Medical Education at Dental section of Islamabad Medical and Dental College (IMDC), Islamabad, Pakistan.

Declarations

The author has declared that there are no conflicts of interest.

Ethics Statement

Ethics approval for this study was granted on 20th Novemeber 2018 by Dr. Hina Mahmood, Secretary, Institutional Review Board Committee of Dental Section, Islamabad Medical and Dental College, Islamabad (Ref IMDC/DS/OG/280).

External Funding

This article has not had any External Funding

Acknowledgments

The authors wish to thank the management of IMDC dental section for permission to conduct this research.

Bibliography/References

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Open peer review.

This review has been migrated. The reviewer awarded 4 stars out of 5

What a beautiful piece of research. Reflective writing and its study through the perception of house officer learners is an outstandibg topic. The topic is by Far the deepest technique to tackle deep learning. I am particularly happy with the methodology an adsition might be called for for a longitudinal study on these learners to establish achievement and attainment .

Competing Interests: No conflicts of interest were disclosed.

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COMMENT ON THIS REPORT

This review has been migrated. The reviewer awarded 5 stars out of 5

THANKS FOR THE INVITE TO REVIEW THIS ARTICLE. The research article adapted mixed method study design which is a commendable work and the methodology, scientific approach, qualitative analysis, expression of the results were clear and kudos to the entire team of authors for doing a fantastic work on the usually non practiced but recommended by the medical educators worldwide. The study concludes that reflective writing enhances learning, helps in self-regulation and alters clinical behavior of dental house officers. My questions to the authors: 1. Is this writing the reflection daily / weekly / regular activity among dental house officers?2. Did the participants had any formal training / workshops in medical education to write reflection? 3. I got fascinated with the qualitative results of cognitive interviews - its surprising that the dental house officer not even having post graduate degree how come they were able to give so many responses clearly (Close to final responses)??? - Please clarify????

Thank you for sharing this interesting study. The authors reported the perceptions of house officers on the significance of reflective writing on their learning, self-regulation and alteration of clinical behaviors. The manuscript is well-organized, and the discussion is coherent and structured. Good job! Participants of the study reported that reflection alters clinical behavior and it reduces treatment errors. This point may be a venue for a future study to investigate ‘how’ reflective writing actually contribute to improved learning and better clinical practice using examples from their clinical practice. Yet, perhaps instead of house-officers, dentists might be recruited to provide evidence on how reflection advances their practice. Another point related to the application of reflection models. As you know, there’s no such thing as one model fits all in medical education. For instance, ‘each’ institutional design model, (e.g. Gagne, Merrill, ADDIE, 4C/ID, …etc.) can be used for particular types of session, based on different contextual variables. Likewise, it would be interesting for the authors plan a future study on how and why to select the appropriate framework for reflection (e.g. Gibbs, Kolb, Schön, Driscol, …etc.). This would provide a valuable hands-on manual for reflection. I hope my comments would motivate you to plan a series of future studies, inspired by this one. Good luck!

It is a very interesting manuscript. I read it with much interest. Reflective writing became an integral part of the medical education, especially in workplace-based settings. Reflective writing in medical education is followed in many ways, including logbooks or work diaries or portfolios. The literature review in this article is up to date, and references are relevant. But I am a little bit confused with the research methodology. I have read the previous reviewers' comments and authors' replies. I am not aware of AMEE's guide for the development of the questionnaire. If I were the author, I would have called the first three interviews as pilot testing for developing questionnaire, and other 16 interviews are as part of the actual study (Just a thought). The other comment which is a surprise time that there was no mention of Kolb's reflective learning theory in the entire manuscript. The discussion has drawn appropriately based on results. Thank you.

Note on Title, Abstract and ReferencesThe title of this paper is well articulated that provides what the paper tends to explore and establish. The abstract serves all the required information of the paper so that the paper can be visualized. The references are up to date with recent findings of researchers though few have been used from 80s and 90s publications but not yet irrelevant.Note on Introduction and Methodology:The introduction of this paper is evidence based, orderly and argumentative. But the authors could have provided a research question that fosters a hypothesis and this could have provided a directed objective without its tacit expression of all these.The methodology provided detail of the way and procedures of the research which is imitable, adaptable for any researcher from any corner of the world.Note on Results and Discussion: The results and discussions of this paper is vivid and clear. The strength of this paper is to have triangulated the quantitative and qualitative study. The table is vivid and there is no discrepancy of interpretation with the scope of the paper. The authors could have added few suitable graphs in order to make the results more readable. Conclusion:The authors have firm conviction on the limitation of the research which is praiseworthy and honest approach. The concluding remark is very knit and condensed that explains the results and discussions in a nut shell. Thanks for the effort for gifting such a well-constructed paper.

this article informs us of a very important dimension to medical education. reflective learning is important for our generation of learners and should be encouraged everywhere. I'm motivated and encouraged by this article.

This is an interesting article on reflective writing and its use in health professions education. Reflective writing is being increasingly used though as the authors mention it may not always be used correctly. I was not aware of the term ‘cognitive interviewing’. The authors can explain this in detail for the benefit of the readers. Gibb’s reflective cycle can also be explained briefly. I assume there were two main objectives for this paper. The first was to examine the evidence in favor of reflective writing in health professions education. The second was to develop a questionnaire through review of literature and the process of cognitive interviewing and pretest the same. The authors can reframe the manuscript so that these two objectives are kept separate in my opinion.A description of how exactly the process of cognitive interviewing was used to develop the questionnaire can be provided. Tables 2 and 3 do describe this process but may need greater clarification for readers. What were the parameters examined during pre-testing of the questionnaire? Did this result in any modification of the instrument? Are three respondents enough for the purpose of cognitive interview? The questionnaire developed by the authors can be shown in the Appendix. Some reorganization may be required to further strengthen the flow and development of ideas.

Reviewer Status

Alongside their report, reviewers assign a status to the article:

Reviewer Reports

P Ravi Shankar , American International Medical University
Felix Silwimba , University of Lusaka
Sateesh Babu Arja , Avalon University School of Medicine
Mohamed Al-Eraky , University of Dammam
BALAJI ARUMUGAM , TAGORE MEDICAL COLLEGE AND HOSPITAL
Samar Ahmed , Ain Shams University Faculty of Medicine

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Examples of reflection
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Boud Keogh & Walker's (1985:19) definition: 'Reflection in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciation'. Definitions of Reflective Writing.
A systematic scoping review of reflective writing in medical education
Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing ...
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Quick guide to reflective practice. What you need to know to be a reflective practitioner. Reflection is a core part of medical practice as well as an ethical duty, outlined in paragraph 13 of the GMC's 'Good medical practice' (2024). Formal reflective writing is an increasingly important aspect of medical training and professional development.
Developing Reflective Practice: A Guide for Medical Students, Doctors
The process of reflective practice is promoted as a quality improvement exercise to facilitate analysis of behaviors and the formation of action plans for improvements. It is best graphically described twice in this book as the 6-step Gibbs Framework/reflective cycle, which concludes with an "action plan.".
Reflective practice for doctors and medical students
For example, "What can I learn from or do differently next time" There are lots of techniques to explore. Find out more about the 'WHOA!' model of reflection developed by Warwick Medical School or writing a reflective diary. Read more in The reflective practitioner - guidance for doctors and medical students.
PDF Stories at work: reflective writing for practitioners
relieved by this writing and discussion process. Positive findings have resulted from research into a "framework that has allowed doctors to reflect on and evaluate their emotional responses to everyday practice through writing an 'emotional diary"'.2 This is the substance of reflective practice, a term
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Reflection in clinical practice: guidance for postgraduate doctors in
Prior to writing a reflection. It is recommended that PDiTs discuss and reflect on their experiences with a trained supervisor or appraiser . The Gold Guide suggests that educational supervisors should assist in developing the PDiT's skills of self-reflection and self-appraisal, as these will be required throughout their professional career.
English and Reflective Writing Skills in Medicine
ABSTRACT. Reflective writing is an established and integral part of undergraduate medical curricula, and also features in postgraduate medical education and revalidation. This book guides and teaches medical students - and all medical and paramedical staff - through the process of writing reflective essays and less formal reflective pieces ...
Reflecting on your practice
Steps involved in writing reflection in practice. 1) Description of the activity. Include the date of the activity and what made you have selected this example to reflect on. 2) Perception. Describe the way that you perceived the event taking place. Think about why things happened in the way that they did. One of the most challenging aspects of ...
Reading the Self: Medical Students' Experience of Reflecting
Purpose . To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors.
Developing Reflective Practice: A Guide for Medical Students, Doctors
The ability to reflect on practice is a fundamental component of effective medical practice. In a sector increasingly focused on professionalism and patient-centred care, Developing Reflective Practice is a timely publication providing practical guidance on how to acquire the reflective skills necessary to become a successful clinician. This new title draws from a wide range of theoretical and ...
12 Reflective practice prompts for health professionals
Reflective practice is a broad spectrum that covers many different understandings of and approaches to reflection (and practice). This has advantages and disadvantages. Flexibility is essential in an approach that generally is an alternative to practices that are more didactic or directive. There seems to be support of reflection as a skill.
A systematic scoping review of reflective writing in medical education
Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW's place in medical training, a ...
Reflective Writing
to attend to the grounds or the justification of our beliefs. for problem solving. to reflect on the content of a problem. to think about the processes involved in a practice. to examine the basis of our perspectives. to develop greater productivity, greater satisfaction.
Reflective writing in undergraduate medical education: A qualitative
The aim of this study was to identify the types of reflective writing produced by a cohort of medical students undertaking a clinical psychiatry module as part of their undergraduate medical programme at a University in the Republic of Ireland. A random sample of 80 reflective essays were selected for review.
PDF the reflective practitioner
principles for effective reflective practice and includes a number of templates and examples.5 This should be considered alongside this guidance. ... This skill is often developed by writing structured reflections, commonly with ... supervisors and appraisers to help them develop skills in evaluating the quality of reflection. Doctors in ...
Benefits of Reflective Writing in Health Care...
Introduction: Reflective writing, a complex human activity is one of the innovative pedagogies to promote deep learning among medical students and doctors. Despite its potential to facilitate learning, there is limited literature on evaluation of various purposes of reflective writing in medical education. ... Consider the following examples ...