2014, 36: 818–820
PERSONAL VIEW
REAL-flection: Genuine reflection on real experiences DEBBI ANDREWS
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
University of Alberta, Canada
Reflection as an education strategy is everywhere these days. It seems that almost every medical education experience has a written reflection attached. Learner portfolios are full of pages and pages of reflections. Some learners find this expectation of reflective practice easy to fulfill. They are already doing it. They journal, they write, they are self-critical. They enjoy the opportunity to incorporate these practices into the study of medicine. Reflection is a characteristic of introverts, and it may be that this is no longer the group from which we are drawing the majority of our learners. Many of my current learners are extroverts. They derive energy from interacting with others. They are action-oriented, often chosen for their people skills. I encountered one brilliant and gregarious young woman who when asked to reflect on her performance said to me, ‘‘That’s my problem. Everyone keeps telling me, ‘Reflect! Reflect!’ I don’t know how to reflect. Please teach me how to do this.’’ She knew it was more than just thinking. She was clearly a good thinker – in fact, she was one of the strongest diagnosticians in her group, but she also knew there was something different about her learning experience, and she wanted to figure it out. I told her that in the conversation we were then having together, she was reflecting. Since that time I have encountered other students, usually in the preclinical years, who don’t know how to reflect and who may or may not realise this. They don’t do very well when asked to reflect about things they have not personally experienced, and find it hard to become engaged in such tasks. For some of them, a reflective exercise based on a prompt like a film or a ‘‘what if’’ question seems to be an assignment to be gamed – you write what you think your instructor wants you to write, find the ‘‘right’’ answer. These students write reflections that sound like essays, always staying with general principles and never touching on their own thoughts and feelings. They complain of having nothing else to contribute, feeling that writing about feelings in such a
situation would be a lie, and promise that they will do better when they have had experience. They insist they cannot pretend to feel something that they have not yet felt. They are missing the point about writing in response to a film of a medical situation. The point is not that they should pretend to be in the situation portrayed and write as if they were that doctor or that patient; the point is that they should react to the situation as their current selves, in their current stage of training and with their current knowledge. This framing needs to be made explicit for some students. The non-reflectors are correct in one regard – we don’t want manufactured reflections. They need to be real. Real encounters happen with real people. They do not need to be big or dramatic encounters but each student must be a participant, not an observer. Ideally this kind of experience should happen early in medical school if we expect pre-clinical reflection to have real meaning and impact for the students. One of our most successful attempts at using reflection with pre-clinical students came from a recent studentorganised elective in childhood developmental disability. A second year student who had worked in a developmental treatment program prior to med school had been discussing those experiences with some peers, and the group expressed concerns about their lack of preparedness for interacting with children with disabilities and their families during clerkship. The students wanted to do something about this. I was asked if I could help organize an elective to address these gaps. The pilot project that emerged consisted of some didactic material about developmental conditions and advice on how to handle behavior. A member of our parent advisory network talked about being a family with a child who had a disability. The clinical piece was a half-day visit to a local intervention program, with a specific assignment: The student would meet a parent and child, do an observation of the child’s development, and interview the
Correspondence: Debbi Andrews, MD, FRCP(C), Associate Professor and Divisional Director, Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, 121 GlenEast, Glenrose Rehabilitation Hospital, 10230 111 Avenue, Edmonton, AB T5G 0B7, Canada. Tel: +780 735 7921; Fax: +780 735 7907; E-mail: [email protected], [email protected]
818
ISSN 0142-159X print/ISSN 1466-187X online/14/90818–3 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.907883
REAL-flection
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
parent about the child’s strengths, weaknesses and challenges. Evaluation was based on attendance, completion of the assignment, and a reflective passage. Neither assignments nor reflections were graded; each student merely received a check mark for items completed, and they were allowed to hand them in without signing their name on the documents. Fourteen students participated and turned in all the materials. The resulting reflections were very rich, and very real. Here is an excerpt from one student (CW), used with permission: Coming into this elective, my goal was to learn about developmental delays as well as improve my abilities to interact with children. Prior to medical school, I had very limited experiences with children, whether it being in formal or social settings. So I hoped to learn more about children in general as well as those with developmental delay as my first step into the world of pediatrics. I was also curious to see how others who work comfortably with children interacted with them. Reflecting back on those intents I had walking into the elective, I’m glad to say that I learned more than I expected. My favorite and most memorable experience in this elective [was] the visit to [the program]. Truthfully, I was slightly anxious about the visit as I have next to no experience interacting with children with developmental delays/disabilities. The first thing that struck me was how normal these kids with developmental delays presented themselves. Personally, I was expecting a room full of kids throwing temper tantrums, with obvious facial features, etc. I was pleasantly surprised by their normal physical appearances but it also made me more curious of each child’s delay that led them to this program. But my second lesson of the day came during my conversation with a parent whose child was enrolled in [the program] . . . I recognized the toll a child with developmental delay/learning disability has on the family. Needless to say, these parents have gained my utmost respect. Walking away from this experience, I can’t say that I’m completely comfortable with children (normal or developmentally delayed) . . . . I hope to build on my existing knowledge in developmental pediatrics during my clinical years. The elective has also given me a different perspective. I often pass[ed] judgement on parents whose children act out defiantly and uncontrollably in public settings. Hearing a parent’s personal struggles and sacrifices for [a] child has provided an insight that will make me think twice before reacting. Note assessing
how this student prior experiences,
reflects setting
for action, goals and
expressing expectations of what will be found in the program visit: ‘‘Prior to medical school, I had very limited experiences with children, whether it being in formal or social settings. So I hoped to learn more about children in general as well as those with developmental delay . . .’’ The student then reflects in action, commenting on what is happening right there in the program: ‘‘The first thing that struck me was how normal these kids with developmental delays presented themselves . . . .’’ Finally, there is reflection on action, a review of what has occurred with a plan for future. ‘‘I hope to build on my existing knowledge in developmental pediatrics during my clinical years.’’ I don’t know that the student deliberately set out to follow Donald Schon’s three-step model of reflective practice – the instructions we gave were very general – but I couldn’t ask for a better example of this model in use. They were all like that – all fourteen reflective passages contained rich reflections and profound insights. It occurred to me that the difference here was engagement. All the students reported being excited to visit the program and being moved by the parents’ stories. The experiences were real. They were worth reflecting on. We will be repeating the elective next year. The students told us they wanted more of those interactive experiences. If, as with CW, they had come when children had settled in and were improving, they wished they could have seen the transformation. If they had come earlier before the children had mastered some of the strategies being taught, the students wished that they could come back and see how the children improved. Even in a period of a few hours, ‘‘their family’’ had become important to them; they felt connected and wanted to continue the relationship. This is what it would be like when they were the doctors. Lessons learned? Don’t assume that all students can reflect. Some will need guidance. Honour that request. Make sure that students know that it is reflection on their current experience, taking into account current feelings and abilities, that is the backbone of a strong reflective habit. Students reflect more deeply when they have been engaged in an experience so . . . Keep it real!
Notes on contributor DEBBI ANDREWS, MD, FRCP(C) is an Associate Professor and Director of the Division of Developmental Pediatrics at the University of Alberta
819
D. Andrews
in Edmonton, Alberta, Canada. She is highly involved in medical education at all learner levels and a published author of poetry, essays and short stories.
Acknowledgements
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
I would like to acknowledge my student collaborator, Sarah Riedlinger, MD candidate, Class of 2015, and all the students
820
who participated in this elective for their gracious permission to describe their experiences, especially CW who allowed generous excerpts from a personal reflection. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.
PERSONAL VIEW
REAL-flection: Genuine reflection on real experiences DEBBI ANDREWS
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
University of Alberta, Canada
Reflection as an education strategy is everywhere these days. It seems that almost every medical education experience has a written reflection attached. Learner portfolios are full of pages and pages of reflections. Some learners find this expectation of reflective practice easy to fulfill. They are already doing it. They journal, they write, they are self-critical. They enjoy the opportunity to incorporate these practices into the study of medicine. Reflection is a characteristic of introverts, and it may be that this is no longer the group from which we are drawing the majority of our learners. Many of my current learners are extroverts. They derive energy from interacting with others. They are action-oriented, often chosen for their people skills. I encountered one brilliant and gregarious young woman who when asked to reflect on her performance said to me, ‘‘That’s my problem. Everyone keeps telling me, ‘Reflect! Reflect!’ I don’t know how to reflect. Please teach me how to do this.’’ She knew it was more than just thinking. She was clearly a good thinker – in fact, she was one of the strongest diagnosticians in her group, but she also knew there was something different about her learning experience, and she wanted to figure it out. I told her that in the conversation we were then having together, she was reflecting. Since that time I have encountered other students, usually in the preclinical years, who don’t know how to reflect and who may or may not realise this. They don’t do very well when asked to reflect about things they have not personally experienced, and find it hard to become engaged in such tasks. For some of them, a reflective exercise based on a prompt like a film or a ‘‘what if’’ question seems to be an assignment to be gamed – you write what you think your instructor wants you to write, find the ‘‘right’’ answer. These students write reflections that sound like essays, always staying with general principles and never touching on their own thoughts and feelings. They complain of having nothing else to contribute, feeling that writing about feelings in such a
situation would be a lie, and promise that they will do better when they have had experience. They insist they cannot pretend to feel something that they have not yet felt. They are missing the point about writing in response to a film of a medical situation. The point is not that they should pretend to be in the situation portrayed and write as if they were that doctor or that patient; the point is that they should react to the situation as their current selves, in their current stage of training and with their current knowledge. This framing needs to be made explicit for some students. The non-reflectors are correct in one regard – we don’t want manufactured reflections. They need to be real. Real encounters happen with real people. They do not need to be big or dramatic encounters but each student must be a participant, not an observer. Ideally this kind of experience should happen early in medical school if we expect pre-clinical reflection to have real meaning and impact for the students. One of our most successful attempts at using reflection with pre-clinical students came from a recent studentorganised elective in childhood developmental disability. A second year student who had worked in a developmental treatment program prior to med school had been discussing those experiences with some peers, and the group expressed concerns about their lack of preparedness for interacting with children with disabilities and their families during clerkship. The students wanted to do something about this. I was asked if I could help organize an elective to address these gaps. The pilot project that emerged consisted of some didactic material about developmental conditions and advice on how to handle behavior. A member of our parent advisory network talked about being a family with a child who had a disability. The clinical piece was a half-day visit to a local intervention program, with a specific assignment: The student would meet a parent and child, do an observation of the child’s development, and interview the
Correspondence: Debbi Andrews, MD, FRCP(C), Associate Professor and Divisional Director, Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, 121 GlenEast, Glenrose Rehabilitation Hospital, 10230 111 Avenue, Edmonton, AB T5G 0B7, Canada. Tel: +780 735 7921; Fax: +780 735 7907; E-mail: [email protected], [email protected]
818
ISSN 0142-159X print/ISSN 1466-187X online/14/90818–3 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.907883
REAL-flection
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
parent about the child’s strengths, weaknesses and challenges. Evaluation was based on attendance, completion of the assignment, and a reflective passage. Neither assignments nor reflections were graded; each student merely received a check mark for items completed, and they were allowed to hand them in without signing their name on the documents. Fourteen students participated and turned in all the materials. The resulting reflections were very rich, and very real. Here is an excerpt from one student (CW), used with permission: Coming into this elective, my goal was to learn about developmental delays as well as improve my abilities to interact with children. Prior to medical school, I had very limited experiences with children, whether it being in formal or social settings. So I hoped to learn more about children in general as well as those with developmental delay as my first step into the world of pediatrics. I was also curious to see how others who work comfortably with children interacted with them. Reflecting back on those intents I had walking into the elective, I’m glad to say that I learned more than I expected. My favorite and most memorable experience in this elective [was] the visit to [the program]. Truthfully, I was slightly anxious about the visit as I have next to no experience interacting with children with developmental delays/disabilities. The first thing that struck me was how normal these kids with developmental delays presented themselves. Personally, I was expecting a room full of kids throwing temper tantrums, with obvious facial features, etc. I was pleasantly surprised by their normal physical appearances but it also made me more curious of each child’s delay that led them to this program. But my second lesson of the day came during my conversation with a parent whose child was enrolled in [the program] . . . I recognized the toll a child with developmental delay/learning disability has on the family. Needless to say, these parents have gained my utmost respect. Walking away from this experience, I can’t say that I’m completely comfortable with children (normal or developmentally delayed) . . . . I hope to build on my existing knowledge in developmental pediatrics during my clinical years. The elective has also given me a different perspective. I often pass[ed] judgement on parents whose children act out defiantly and uncontrollably in public settings. Hearing a parent’s personal struggles and sacrifices for [a] child has provided an insight that will make me think twice before reacting. Note assessing
how this student prior experiences,
reflects setting
for action, goals and
expressing expectations of what will be found in the program visit: ‘‘Prior to medical school, I had very limited experiences with children, whether it being in formal or social settings. So I hoped to learn more about children in general as well as those with developmental delay . . .’’ The student then reflects in action, commenting on what is happening right there in the program: ‘‘The first thing that struck me was how normal these kids with developmental delays presented themselves . . . .’’ Finally, there is reflection on action, a review of what has occurred with a plan for future. ‘‘I hope to build on my existing knowledge in developmental pediatrics during my clinical years.’’ I don’t know that the student deliberately set out to follow Donald Schon’s three-step model of reflective practice – the instructions we gave were very general – but I couldn’t ask for a better example of this model in use. They were all like that – all fourteen reflective passages contained rich reflections and profound insights. It occurred to me that the difference here was engagement. All the students reported being excited to visit the program and being moved by the parents’ stories. The experiences were real. They were worth reflecting on. We will be repeating the elective next year. The students told us they wanted more of those interactive experiences. If, as with CW, they had come when children had settled in and were improving, they wished they could have seen the transformation. If they had come earlier before the children had mastered some of the strategies being taught, the students wished that they could come back and see how the children improved. Even in a period of a few hours, ‘‘their family’’ had become important to them; they felt connected and wanted to continue the relationship. This is what it would be like when they were the doctors. Lessons learned? Don’t assume that all students can reflect. Some will need guidance. Honour that request. Make sure that students know that it is reflection on their current experience, taking into account current feelings and abilities, that is the backbone of a strong reflective habit. Students reflect more deeply when they have been engaged in an experience so . . . Keep it real!
Notes on contributor DEBBI ANDREWS, MD, FRCP(C) is an Associate Professor and Director of the Division of Developmental Pediatrics at the University of Alberta
819
D. Andrews
in Edmonton, Alberta, Canada. She is highly involved in medical education at all learner levels and a published author of poetry, essays and short stories.
Acknowledgements
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 05/12/15 For personal use only.
I would like to acknowledge my student collaborator, Sarah Riedlinger, MD candidate, Class of 2015, and all the students
820
who participated in this elective for their gracious permission to describe their experiences, especially CW who allowed generous excerpts from a personal reflection. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.
