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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.

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.

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 ].

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.

Reflective and feedback performances on Thai medical students' patient history-taking skills

Affiliations.

• 1 School of Medicine, Walailak University, 222 Taiburi, Tha Sala, Nakhon Si Thammarat, 80161, Thailand. [email protected].
• 2 School of Medicine, Walailak University, 222 Taiburi, Tha Sala, Nakhon Si Thammarat, 80161, Thailand.
• 3 School of Nursing and Health Science, University of Dundee, Dundee, DD1 4HJ, UK.
• PMID: 31088550
• PMCID: PMC6518691
• DOI: 10.1186/s12909-019-1585-z

Background: Reflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated.

Methods: In this retrospective study, we assessed RP and feedback performances on Thai medical students' patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students' reflective performance and categorised them into one of the six stages of Gibbs' reflective cycle; their feedback performances were analysed using Pendleton's model. We investigated the correlations between students' overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students' opinions of the RP teaching method were also collected.

Results: All (n = 48) students participated in our study. The students' mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs' reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students' highest Gibbs' reflection levels and their history-taking OSCE scores.

Conclusions: RP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students' achievement of better reflection performances.

Keywords: Feedback; History taking; Reflective practice; Thai.

• Attitude of Health Personnel
• Clinical Competence / standards*
• Educational Measurement
• Knowledge of Results, Psychological*
• Medical History Taking / standards*
• Retrospective Studies
• Self-Assessment
• Students, Medical*
• Young Adult