English and Reflective Writing Skills in Medicine

A Guide for Medical Students and Doctors

Clive Handler, Charlotte Handler, Deborah Gill

• Publisher: CRC Press
• Year: 2017
• ISBN:
  9781315346380
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

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 clearly, concisely, and accurately. Sections on English writing skills, alongside anonymised successful and unsuccessful examples of reflected essays, explore both the principles and practice of effective writing. This clear, practical book is a valuable resource for medical undergraduates and postgraduates, whether English be their first or an additional language.

CHAPTER 1 Reflective practice and written reflection in medicine

In this chapter we outline what “reflection” in education has come to mean and why reflective practice is seen as important in education for the professions. We look at reflective writing, outlining when and why it is used in medicine and medical education and what constitutes good reflective writing. We have used the current guidance for medical students at UCL Medical School as a framework for answering questions such as: What is a good incident to use as a focus for reflection? What does a good piece of reflective writing look like? What framework should I use to construct a good piece of reflective writing?

As reflective practice tutors who regularly read reflective pieces and give students what we hope is useful feedback, we have also made suggestions about what constitutes useful feedback for students as they develop this complex cognitive and expressive skill, and we highlight the debate concerning whether you can “mark” reflection.

By exploring these areas we hope to draw the reader’s attention to the fact that reflection, reflective practice and reflective writing are difficult concepts to define clearly for both teachers and learners, and that this lack of clarity sometimes leads teachers to adopt loose definitions and provide vague guidance, leaving learners struggling to understand the usefulness of reflective activities or what is required of them.

Finally, throughout the chapter we offer some frameworks for novices that may be helpful in understanding the purpose of reflective practice so they can improve their attempts at reflection and reflective writing.

WHAT IS REFLECTION?

In the last few decades, reflection and reflective practice have become an accepted organising framework for professional preparation and practice (Boud and Walker 1998) and consequently activities to encourage the development of reflective abilities have become established components of contemporary education for all professions, including medicine. But what exactly is reflection?

Definitions of reflection in the context of learning are plentiful in the literature; however, the term “reflection” may be used to refer to a wide array of cognitively and philosophically distinct methods and attitudes (Van Manen 1995).

In medical education a frequently used definition is one by Moon that suggests:

Reflection is a form of mental processing . . . that we use to fulfil a purpose or to achieve some anticipated outcome. It is applied to relatively complicated or unstructured ideas for which there is not an obvious solution and is largely based on the further processing of knowledge and understanding and possibly emotions that we already possess.

(Moon 1999: 5)

Other useful definitions refer to reflection as when individuals purposefully explore experiences that bring about changes in perspective and understanding:

Reflection refers to all those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations.

(Boud et al. 1985: 19)

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.

(Boyd and Fales 1983: 99)

The idea of reflection as a contributor to the enhancement of practice has its foundations in the work of John Dewey (1933). He first described reflection in terms of “thinking about thinking”. Dewey wrote extensively about “reflective thought”; thoughts and reflections provoked by an event that arouses a state of doubt, perplexity or uncertainty, and that leads the individual to search for possible explanations or solutions.

Donald Schön (1983) coined the term “reflective practice” and argued that professionals in their everyday practice face unique and complex situations that are unsolvable by the “technical rationality” approaches that had been the dominant paradigm in professional and scientific learning since the nineteenth century. Schön suggests professional practice is largely based upon tacit knowledge (knowing-inaction) and that professionals increasingly engage in “reflective conversation with the situation” as practice becomes stable. Schön also proposes that practitioners go on to reflect on action; a more extended and sustained review that occurs later on, after the event, and provides opportunities to learn from the earlier decision-making process or reflection-in-action (1987).

REFLECTIVE PRACTICE AND EDUCATION FOR THE HEALTH PROFESSIONS

It is generally assumed that reflective practice, and thus the notion of the preparedness of health professionals to think critically and to engage themselves in reflection upon their professional activities, will contribute to the improvement of their performance (Mamede and Schmidt 2004). The result of this assumption is that reflection is regarded as a core skill in professional competence (Epstein and Hundert 2002). However, it has been argued that reflective theory and practice has little irrefutable evidence of effectiveness in the health professions (Burton 2000).

The emphasis by the General Medical Council (GMC) for doctors to develop and practise reflection suggests the fundamental aim of reflection and reflective practice within medical education is to ultimately improve patient care (GMC 2006).

Undergraduate medical education has thus, unsurprisingly, embraced a reflective practice component. However, as Schön postulates, being critically self-aware is an acquired skill and cognitive restructuring of knowledge comes with experience and is characteristically an expert act (Ericsson and Charness 1994). It is unsurprising, therefore, that medical students find the practice of reflection difficult and struggle with creating meaning from the process.

As educators we are often unclear as to what we are asking students to do when they undertake reflective practice, and to what end. The fact that students often entitle their written work “reflective practise”, as opposed to the term reflective practice used by their teachers and curriculum designers, is an interesting one: do they not know the difference between the spelling of the word as a noun as opposed to a verb? Or are they seeing this as practising a skill, much like one might practise taking blood, rather than as a distinct activity or behaviour in itself, purposeful in its own right?

It is worth noting that reflective practice has been adopted in the health professions in modern times beyond its original intention of the examination of personal experience to be used as an aspect of “proof” of professional development; one of the many facets of modern medicine whereby the actions of professionals have become “rooted in the public and political as well as the private and personal” (Bolton 2001: 5). This has some implications for the “honesty” of reflections, limiting what practitioners of all levels of experience are prepared to share either verbally or in writing.

In the process of reflection, individuals use a number of personal and cognitive skills: self-awareness, description, critical analysis and evaluation; it is important that we acknowledge the difficulty most learners will have in being reflective in the way we expect them to be, and in articulating this new way of thinking.

A practical and explanatory description of purposeful reflection that could usefully be shared with novices might include the following.

Acknowledging the purpose

A deliberate act where an individual explores their experiences and becomes more “mindful” of an event, in order to arrive at new understandings and appreciations.

Selecting an event

Choosing an incident that has been significant to you: preferably one that remains “unsorted” to some extent and where deeper “reflection-on-action” may help you to understand your own motives and actions and the motives and actions of others. This does not have to be a major incident or an alarming event: simply an episode that sticks in the mind and cannot easily be put aside.

Description

Giving a description that provides enough of the detail that makes the incident worthy of reflection but recognising this is the first stepping stone to the reflection: it is not the whole act.

Critically analysing the description

Being honest in how the event affected you as an individual and the impact that may have had within the event.

Stepping back and exploring and challenging assumptions and conclusions: considering alternative explanations of events than those initially reached.

Being self-aware, accepting that there may be other ways of thinking about your actions or omissions.

Evaluation

To develop new perspectives on the event and to acknowledge what you have learned from it and how you might behave or think differently in the future....

Table of contents

• Cover Page
• Half title
• title
• copy
• foreword
• preface
• About the authors
• List of contributors
• Preface
• 1 Reflective practice and written reflection in medicine
• 2 How to write good English
• 3 The essays
• 4 Self-assessment exercises
• Index