Reflection is an important part of training, appraisal and revalidation for doctors based in the UK. However, for many doctors the very thought of reflection can cause feelings of frustration, non-engagement or even rejection. Where did we go wrong?
Learning objectives
1. Consider the definition of reflection used in medicine
2. Understand how reflection can be assessed
3. Encourage you to read Meditations by Marcus Aurelius
Oh no! A patient has complained about your refusal to supply antibiotics for a cold. Wow! This would make a really good entry in your learning portfolio:
“That men of a certain type should behave as they do is inevitable. To wish it otherwise were to wish the fig-tree would not yield its juice. In any case, remember that in a very little while both you and he will be dead, and your very names will quickly be forgotten.”
You have to respond to the complaint in writing. You feel annoyed that this will take up time that could be spent with other patients. Today you will miss lunch or seeing your children after work because the response has to be formulated outside of your normal working hours. Nevermind, there is some solace that the experience will allow a great portfolio entry to discuss with your appraiser/supervisor:
“Put from you the belief that ‘I have been wronged’, and with it will go the feeling. Reject your sense of injury, and the injury itself disappears.”
The patient has written a scathing online review about your negligence and lack of empathy. He recommends other patients petition for you to be stripped of your medical licence. You know that you can’t remove the review and that in replying to it you may indeed validate the criticism. Moreover, you can’t breach patient confidentiality and could only respond in the most generic and vague terms that it would seem robotic, adding credibility to the claim that you lack empathy. Well, at least you have more to write in your portfolio:
“Soon you will have forgotten the world, and soon the world will have forgotten you.”
The three quotes above are taken from the writings of Marcus Aurelius, Roman Emperor from 161 to 180 AD. Considered the last of the ‘Five Good Emperors’, he wrote a series of personal notes collectively known as the Meditations. Some have considered this work the epitome of reflective writing.
Questions
How would you define good reflection?
Would Marcus Aurelius be considered a good reflector using your definition?
Boyd and Fales (1983) defined reflection as a”the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self and which results in a changed conceptual perspective”.
But what is “internal examining”? This involves an active process and that (cough…) an unexamined passive process is not sufficient to properly reflect. You just have to spend some dedicated time to think or write about what happened to truly reflect.
It might be that you decide that some things just aren’t worth the time reflecting properly on. However, the current emphasis on reflection may make some doctors feel that they should be reflecting on (almost) everything. Understandably this might result in some individuals believing that they can’t be ‘reflectors’. Yet, the case could easily be made that any learning must involve reflection. Doctors have a lot of learning to do and therefore all doctors must be reflectors. Thats right, even orthopods (sorry, I feel bad now, I’m going to take a moment to think about what I just wrote and in the meantime feel free to replace orthopaedics with any speciality of your choice).
Questions
Are there particular medical specialities you associate with reflective practice?
What characteristics would you associate with a reflective practitioner?
Some of the terms you may have mentioned could have included:
1. Thoughtful
2. Observant
3. Listeners
4. Cautious
5. Considerate
Hold on a second. Aren’t these attributes that all doctors in all specialities should be aspiring to? Are some doctors just better at showing they can reflect?
So how do you show that you can reflect? Active internal examination isn’t enough; reflection must be documented in order to be assessed and almost exclusively this comes down to written evidence. The following is taken from a Royal College of General Practitioners (RCGP) document called ‘Hallmarks of good practice in information recording in the ePortfolio’:
Questions
How would the last great emperor Marcus score against these criteria?
How would your last piece of reflective writing score?
The writings which constitute the Meditations are thought to have been personal and never intended for public viewing. Marcus Aurelius wrote and reflected for himself. You have to reflect and write for someone else. Perhaps the understanding that there is a difference between personal reflection and shared reflection is a reason why there is hostility toward the issue in medicine. The natural reflective process can feel corrupted by the artificial need to demonstrate that you have reflected. This can all seem like a chore rather than an enlightening process for the person involved. Marcus may not have approved, but then again he was a stoic.
“All things are in the process of change, You yourself are ceaselessly undergoing transformation, and the decay of some of your parts, and so is the whole universe.”
What is your experience of reflection in medicine? Please consider sharing your thoughts in the comments section below.
Summary
Reflection should be a process that comes easily to doctors who are good learners. However, the mandatory requirements of training and licensing have changed the everyday meaning of the term in medicine. Doctors have to undergo a dual process of reflection: active personal reflection (whether that be written or in your own head) and verifiable shared reflection subject to scrutiny (written in a portfolio). Openness about this distinction may help some doctors who feel reflection has become a burden. Alternatively, stoicism might be an option.
Further resources
Hallmarks of good practice in information recording in the ePortfolio (courtesy of the RCGP WPBA Standards Group)
http://www.rcgp.org.uk/-/media/Files/GP-training-and-exams/WPBA/RCGP-Hallmarks-of-good-practice-information-recording-ePortfolio.ashx?la=en (direct download)
‘Wrestle to be the man philosophy wished to make you’: Marcus Aurelius, reflective practitioner.
http://www.tandfonline.com/doi/full/10.1080/14623940903138266
Further thoughts by Seamus Sweeny about his article linked directly above
https://amedicaleducation.wordpress.com/2015/09/29/wrestle-to-be-the-man-philosophy-wished-to-make-you-marcus-aurelius-reflective-practitioner-reflective-practice-10-4-2009-429-436-part-1/?wref=tp
UNEXAMINED MEDICINE 
Reblogged this on A Medical Education and commented:
Sati Heer-Stavert very kindly asked my permission to link to the paper I wrote a while back on Marcus Aurelius, stoicism and reflective practice – here is the post that has result which I am very impressed by! Certainly Sati has provided an excellent framework to prompt students and learners to reflect on what reflection means and what the obstacles to it are….
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Hi. “The rcgp guide to supporting info for appraisal and revalidation 2016” has a definition/interpretation on reflection. Probably worth a mention as a source of further info.
The piece you have written certainly gives a different angle with which to approach reflection (especially with trainees and reluctant reflector appraisees!)
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Hi Sav. The RCGP guide is a great idea for further reading and useful in preparing for appraisals. It can be found here: http://www.rcgp.org.uk/revalidation/~/media/Files/Revalidation-and-CPD/2016/RCGP-Guide-to-Supporting-Information-2016.ashx
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