The reflective zombie: Problematizing the conceptual framework of reflection in medical education. — TEI-tagged view

Anne De la CroixpersName, Mario VeenpersName (2018date). “The reflective zombie: Problematizing the conceptual framework of reflection in medical education..” Perspectives on Medical Educationtitle·j.

Object of study — how medical educationterm·key has turned the concept of reflectionterm·dom into a teachable and measurable construct

Research question — whether reflectionterm·dom itself can be assessed and measured

Contribution — three messages: embrace diversity in reflectionterm·dom, let students reflect on reflectionterm·dom, and study reflectionterm·dom in everyday interaction

Full text — tagged

The reflective zombieterm·dom: Problematizing the conceptual framework of reflectionterm·dom in medical educationterm·key.

Abstract Reflectionterm·dom is an ambiguous and profoundly complex human activity. We celebrate the developments in teaching and researching reflectionterm·dom in education, yet have identified flaws in the way reflectionterm·dom has been operationalized: medical educationterm·key has translated the age-old concept into a teachable and measureable construct. We fear that in this process of operationalization, the philosophical underpinnings of reflectionterm·dom have been discarded. We illustrate this with a thought experiment about a ‘reflective zombieterm·dom’: students who have been conditioned to follow prescribed thought steps rather than engaging in truly reflective behaviour. In research and assessmentterm·key of reflectionterm·dom, measuring tools might be unable to distinguish reflective zombiesterm·dom from students who authentically reflect. We argue that the instrumental approachterm·dom lies at the root of this problem as it limits the rich concept of reflectionterm·dom and illustrate our point by describing problems related to paradigm (we are looking at reflectionterm·dom in the wrong way), methods (we are using the wrong tools), and epistemics (can we even know what we want to know?). We offer three suggestions for implementing reflectionterm·dom into the curriculum and for research into reflectionterm·dom. First, acknowledge the diversity of reflectionterm·dom and let go of the ‘checklistterm·key approach’. Second, embrace the personal nature of reflectionterm·dom by stimulating awareness of one’s personal reflectionterm·dom styles as part of the reflective process. Third, shift the focus of research to the practice of reflectionterm·dom. We believe that a strong vision on reflectionterm·dom can lead to a balanced curriculum, setting students up for a lifelong learning as a reflective practitionerterm·key.

Keywords: Reflectionterm·dom, Methodology, Assessmentterm·key, Theory Introduction Imagine two third year medical students who are identical in almost every way. They wrote identical reflective reports, for which they both received an A−. They both have an IQ of 130, are generally liked by teachers, and their GPA is 3.7. Additionally, they filled in a questionnaire measuring reflective skills, on which they both scored identically. As medical students, they only differ in one aspect: while one of the students has actually reflected, the other just pretended to do so’. How do we know which is which?

This thought experiment is analogous to Chalmers’ ‘philosophical zombieterm·dom’, which is an exact physical duplicate of a human being, but without consciousness [ 1 ]. The ‘reflective zombieterm·dom’ is someone who displays all the outer traits of reflectionterm·dom, without having actually reflected. In this thought experiment, the most important clue to distinguish the reflective zombieterm·dom from the student who has authentically reflected is their score for the written reflective report and the outcome of the questionnaire. However, this does not help us find out who the zombie is. This symbolizes the central problem we address in this paper: an outcome focus, both in measurement and in assessmentterm·key, has distracted from our understanding of true reflectionterm·dom.

The instrumental approachterm·dom to reflectionterm·dom conditions students to focus on fulfilling the expectations of the assignments, instead of on developing into curious, emotionally intelligent, and critical reflective practitionersterm·key. Students know what phrases and expressions to use to emulate reflectionterm·dom [ 2 ]. They are good at playing the educational game and at gaming the system to succeed and know, for instance, that ‘they like it if you say you cried’ [ 3 ]. Reflective assignments such as portfolios or essays could reward students for doing nothing more than check the boxes of ‘good reflectionterm·dom’, which they can do without actually reflecting. This ‘tends toward an individual, non-collaborative, instrumentalist orientation’ [ 4 ] and has consequences for the way students navigate their way through medical school. On the other hand, versions of the concept of reflectionterm·dom that do not fit into the prescriptive mould of medical educationterm·key’s construct of it, are excluded or not seen at all. For example, a student who, after reflecting, concludes that everything is fine just the way it is. This does not fit into the way of thinking in which reflectionterm·dom should always lead to changes in behaviour.

There are many educators who are stimulating students to reflect meaningfully, by holding group conversations [ 5 ], or by designing writing tasks that can indeed change ‘the attitudes, values, beliefs, and assumptions of individual participants’ [ 6 ]. This is the case for many higher education courses, yet we wish to strengthen these developments by critically elaborating on three flaws in current thinking about reflectionterm·dom in medical educationterm·key (research) specifically. We join critical calls for a new conceptual approach [ 2 , 7 – 9 ], and highlight existing practices that might help us to teach and study reflectionterm·dom in a way that is congruent with its original goals.

Reflectionterm·dom through the keyhole Reflectionterm·dom is part of many higher education programs. In this essay, we focus on reflectionterm·dom in medical educationterm·key. A lot happens in the development of young medical students to medical professionals. They learn to carry great responsibilities for a diverse group of patients, under stress, in multidisciplinary teams, with complex administrative systems. Crucial aspects in this development are the ability to learn from experiences and grow as a professional, and the ability to monitor one’s own thoughts and feelings in relation to the often-challenging circumstances. These abilities are often incorporated into the medical curriculum under the term ‘reflectionterm·dom’ [ 10 ].

Most broadly defined, reflectionterm·dom is ‘looking for the meaning of an event, the meaning of a history’ [ 11 ]. This can take place in many ways and can involve thought, experiences, emotions, the body, and others. Reflectionterm·dom is generally thought to involve one’s relation to both the inner and outer world. It is about surprise, doubt, and out of the box thinking. There is a fundamental role for emotions—so much so, that the distinction between feeling and thought may be artificial [ 12 ]. By introducing the idea of the ‘reflective practitionerterm·key’, the field of medical educationterm·key adopted an age-old concept: Socrates (470–399 BC), Hippocrates (460–370 BC), Aquinas (1225–1274), Hegel (1770–1831), Descartes (1596–1650), and Confucius (551–479 BC) have all eloquently formulated the need for deep thought and reflectionterm·dom.

However, medical educationterm·key journals give the impression that reflectionterm·dom was invented in 1933, and that all that matters is whether it has three steps or four [ 13 ]. Taking its characteristic instrumental approachterm·dom [ 14 , 15 ] medical educationterm·key has translated the complex and rich concept into a construct that is inconsistent with its philosophical underpinnings [ 8 , 9 ]. Reflectionterm·dom has become an ambiguous notion [ 16 ] that can be assessed by checkliststerm·key, requiring a uniform way of teaching, and guidelines for what counts as ‘proper’ reflectionterm·dom. Medical educationterm·key research seems preoccupied with three issues: finding a uniform definition or model of reflectionterm·dom, finding a singular way to measure it, and developing a fool proof way of adding reflectionterm·dom to the medical curriculum [ 10 ]. As some have noted, this is ironic, given that Dewey conceptualized reflectionterm·dom in education as an antidote to this step-by-step outlining of desired thought processes [ 16 – 18 ].

We fear that certain aspects of teaching and researching reflectionterm·dom in medical educationterm·key could stimulate zombie-like learning behaviour—which is frustrating for teachers and students alike. The focus on outcomes can lead to ‘poor reflectionterm·dom, lack of engagement from students and low-confidence and apathy of staff’ [ 19 ]. We see three key problems with reflectionterm·dom as it is currently approached in medical educationterm·key (research), to do with paradigms, methods, and epistemics.

Problems with reflectionterm·dom in medical educationterm·key The paradigm problem In the middle of the night, a police officer sees a drunken person crawling on the sidewalk under a streetlamp, looking for his lost keys. She offers the drunk man to help him look, and asks where he lost his keys. The man points at a spot 15 yards away. When the officer proposes to look there, the man answers: ‘but there is no light over there’. This famous joke illustrates the ‘streetlight effectterm·dom’: we tend to look for answers where it is easy for us to see, rather than where they might actually be found [ 20 ]. In medical educationterm·key, knowledge about reflectionterm·dom is sought after in quantitative research, and in terms of measurability. This is not because reflectionterm·dom is necessarily ‘found’ here, but because that is where medical educationterm·key, with its strong ties to cognitive and behavioural sciences [ 15 ], often tends to ‘look for things’. Luckily, qualitative research is slowly more accepted and embraced in medical educationterm·key.

When the static light beam of medical educationterm·key shines on reflectionterm·dom, it shows up as a way of thinking that can be broken down into systematically teachable steps. It seems neatly orderable. However, if we turn the beam into a searchlight and shine on actual educational practice, we find that reflectionterm·dom is often messy, unpredictable and intensely personal [ 5 , 21 ]. But the reality of the classroom—the interactions between teacher and students, and students amongst themselves—is a place where researchers hardly ever look. A different paradigm can open up spaces to look for knowledge about reflectionterm·dom based on how it occurs in practice.

The methods problem The translation of reflectionterm·dom into the realm of medical educationterm·key has brought with it two demands: to measure reflectionterm·dom, and to assess it. These two activities are requirements of medical educationterm·key, but is reflectionterm·dom itself actually assessable and measurable? There are certainly aspects of reflectionterm·dom that can be counted: number of hours spent on writing an essay, the types of words and sentences used, the extent to which students are rated or rate themselves as empathic (scale 1–5). But ‘not everything that counts can be counted, and not everything that can be counted counts’ [ 22 ]. Do the measurable features of reflectionterm·dom tell us anything about its essence?

The sociologist Maslow said: ‘I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail’ [ 23 ]. We know how to make validated checkliststerm·key and questionnaires, we know how to draw conclusions from the data we derive from these tools, and we know how to extract publishable information out of these tools. Rich definitions of reflectionterm·dom might not translate to research methods that match its complexity and personal nature. Reflectionterm·dom involves (at least) cognition, emotions, the body, language, consciousness, and experiences. But when we study it, we get out our ‘hammer’ in the shape of psychometrics, and thereby reduce the phenomenon to a series of quantitative measurements. However, it is exactly these measuring tools that eliminate the human nature of reflectionterm·dom, and make it impossible for us to filter out the ‘reflective zombieterm·dom’. After all, both zombie and authentically reflecting students, would answer ‘yes’ to the question: ‘I take a close look at my own habits of thinking’ from the GRAS reflectionterm·dom questionnaire [ 24 ].

The epistemic problem At the root of the measurement issue lies an epistemic problem. Reflectionterm·dom is often formulated as a private experience, a ‘silent dialogue between me and myself’ [ 25 ]. But if this is true, how can another person judge if I have reflected, and if so, how deeply I reflected? We cannot know another’s innermost thoughts and feelings. For instance, we generally find it unacceptable to tell someone else ‘you are not hungry’ or ‘you don’t have a headache’, because we are unable to access another’s private experience. Yet this is precisely what we ask our educators, and we ask our researchers to score the quality of reflectionterm·dom. This dilemma touches on the basic problem of epistemics: how to access the phenomenon under study. When it comes to ‘territories of knowledge’ [ 26 ], or ‘knowables’ [ 27 ], one might wonder: who are we to deny that someone has reflected? A student could have the most profound emotional experiences and insights into their professional identity, but might lack the language to express it, or might be so caught up in this process that they do not feel the need to express it.

Access to reflectionterm·dom requires externalizationterm·key: it is not enough to reflect—one must demonstrate reflectionterm·dom. When medical students demonstrate the ‘skill’ of reflectionterm·dom, they must open up private thoughts to observation and assessmentterm·key. They might prefer to reflect in abstract terms while listening to music, or might reflect by talking about their experiences to friends, yet medical educationterm·key asks these students to verbalize reflectionsterm·dom, which could force students to worry about words, structure, etc. The same issue occurs in research: asking someone to report on their reflectionterm·dom is not a way to measure that original reflectionterm·dom, but is itself an exercise of ‘reflectionterm·dom on reflectionterm·dom’. Externalizationterm·key changes the very nature of private reflectionterm·dom, as there is now an audience. When we ask students to reflect for their teachers, their reflectionterm·dom will be different from their ‘silent dialogue’. We know students’ learning behaviour is driven by assessmentterm·key. The reflectionterm·dom will change even more if there are checkliststerm·key and requirements for ‘good reflectionterm·dom’, possibly resulting in reflective products filled with socially desirable phrases.

Mandatory reflective products can lead to a learning environment in which it is more advantageous for students to demonstrate behaviours that fit the expectations of ‘reflecting’, than it is to invest in an authentic search for meaning. We feel like this view of reflectionterm·dom is needlessly limited and limit ing and are worried about a possible zombie apocalypse due to excessive interest in measurement. So, how do we stop it and move forward in a more meaningful way?

How to prevent zombies?

The rich concept of reflectionterm·dom has been translated into a step-wise process that can easily be assessed and measured within the confines of the medical educationterm·key paradigm. But this process excludes many other forms of legitimate reflectionterm·dom, and it adds a performative dimension to reflectionterm·dom that makes it impossible to know the difference between authentic reflectionterm·dom and ‘acting reflectively’. This is too bad, because reflectionterm·dom may be the deciding factor if we want students to truly become medical professionals rather than merely acting professionally [ 28 ]. We do not pretend to have all the answers, but are motivated to join the discussion about different ways forward. Existing developments provide exciting and suitable ideas for incorporating reflectionterm·dom in medical educationterm·key and offer starting points for fostering true reflectionterm·dom in the curriculum. The three most important messages are: accept and embrace diversity in reflectionterm·dom, reflect on reflectionterm·dom, and shift the research focus to the messiness of everyday interactions.

Embrace diversity, let go of checkliststerm·key!

If we accept and embrace the diversity of ways in which people reflect, we can move away from a prescriptive focus that defines reflectionterm·dom in advance, and aims to measure or assess. A more informative venture would be to describe all the productive ways in which reflectionterm·dom in medical educationterm·key can occur. This would also include non-Western practices and philosophies [ 4 ]. Since reflectionterm·dom is deeply personal, assessing reflectionterm·dom also requires a personal element. Ironically, current work on reflectionterm·dom aims to exclude subjectivity as much as possible from the assessmentterm·key process. Laura Shemtob, a medical student from London, eloquently argues the need for a more personalized approach to reflectionterm·dom: ‘Reflective practice has been integrated into my medical educationterm·key through portfolios, essays, and longitudinal pathways, but my own reflectionterm·dom does not follow any of these templates’ [ 29 ].

Rather than pushing every student’s reflectionterm·dom into the same mould, we feel that diversity in reflectionterm·dom needs to be appreciated, and medical school can become the place to talk about personal ways of reflecting. After all, the zombie metaphor we use is not meant as a way of blaming students, but it is a thought experiment to dispute behaviourism. We argue that outer traits which look like reflectionterm·dom do not necessarily point to authentic inner reflectionterm·dom. To think of an assessmentterm·key system that is more authentic, would require some ‘letting go’ of checkliststerm·key and uniformity, especially considering the culture of examination in medical educationterm·key [ 9 ]. It requires the recognition that some learning objectives, like reflective ones, might be better left unassessed. Alternatively, we might want to advance the idea of ipsative assessmentterm in the area of reflectionterm·dom: assessing the way in which an individual has improved compared to his/her earlier work, or ‘a summative judgement that reflects the learner’s progress rather than outcomes and level of achievement’ [ 30 ]. While this is still a form of assessmentterm·key, it could be used as a way of creating learning conditions that suit individual students’ needs and wishes, and thus creating an encouraging context in which we hope reflectionterm·dom might flourish. We can imagine that students formulate their own learning objectives, based on their preferences on how to reflect. We realize this is an ambitious goal that requires a structural integration of reflectionterm·dom in curricular design and educators who are skilled at coaching students and giving effective feedback.

Let students reflect on reflectionterm·dom There is a need to look at reflectionterm·dom differently, and to use different data when studying reflectionterm·dom. Looking for meaning in an event or experience can take on many shapes and forms. We applaud initiatives where students themselves choose a way to share or show reflectionsterm·dom, without a predetermined format. We ought to recognize that sharing reflectionterm·dom can be a valuable reflective activity in itself, and not just a means to an end [ 5 , 31 ]. Luckily, this already happens in many places and could include written reports, audio logs, group discussions, but could also be art, creative writing, meditation, film, poetry, or other ways of expressing oneself [ 32 – 35 ]. These examples show that there is a role for the arts and humanities in medicine [ 36 , 37 ], though it is not yet widely recognized. This could also prevent reflectionterm·dom becoming overly focusing on the self [ 8 ], which can have negative consequences such as rumination, ‘becoming blocked from taking action, loss of spontaneity, pessimism, and falling into a bottomless pit of reflectionterm·dom upon reflectionterm·dom’ [ 38 ].

We recommend universities not to stick to one model or protocol, but try different ones and see which are the ones that suit your group and personal teaching style. We do not suggest banning all models of reflectionterm·dom, but to use them pragmatically: ‘All models are wrong, but some are useful’ [ 39 ].

Finally, teaching should be focused on creating conditions that foster reflectionterm·dom, rather than trying to teach directly ‘how to reflect’. Strictly speaking, reflectionterm·dom is not something that can be taught, but a human faculty that each of us possesses to some degree, and which can be stimulated. We need to create the best environment for reflectionterm·dom to emerge. According to Driessen [ 40 ]: ‘A learning environment and a portfolio that values a reflective dialogue with a trusted person in an open and safe way, is probably the way to go. However, it is a long road for medical educationterm·key to create such an environment’. We want to motivate students to turn reflectionterm·dom into a lifelong practice, instead of just another assignment they have to complete to get their degree. Therefore, part of the reflectionterm·dom curriculum should be for everyone ‘to work out his or her own system for engaging in reflectionterm·dom’ [ 41 ]. Working out which way of reflecting works best for oneself is actually a crucial part of the reflective process. It is necessary if reflectionterm·dom is not to be just one more mandatory exercise, but a gateway to lifelong learning that doctors are able—and motivated—to continue into their professional practice.

Shift the research focus to the practice of reflectionterm·dom When it comes to future research on reflectionterm·dom, we propose to de scribe how reflectionterm·dom actually takes place in practice, rather than pre scribe what counts as ‘good reflectionterm·dom’. Studies where students use a personal audio log, for example, can enrich our understanding of workplace learning, simply by describing what students say [ 42 ]. As we showed in previous studies, looking at conversational data can show how participants construct their reflectionterm·dom in a group session [ 5 , 21 ]. We found that groups of doctors in training naturally find their own structure in group reflectionterm·dom sessions, in a way that is not prescribed by their teachers and despite a lack of rules on how to reflect.

We feel there are strong advantages to approaching reflectionterm·dom in medical educationterm·key as an interactional activity. As mentioned before, formal assessmentterm·key tools such as checkliststerm·key cannot establish objectively which of the two students in our thought experiment truly reflected. However, their teachers probably would not need more than ten minutes with either student to get an idea of who truly reflected and who did not. The nature of teachers’ interactions with students, and the role of teachers’ intuition, can unveil more about the students’ reflectionterm·dom than approaches that aim to objectify reflectionterm·dom. What we are trying to say here is that there is a contrast between ‘objectively’ trying to assess reflectionterm·dom and human contact, interaction, and intuition.

You cannot study reflectionterm·dom directly, but you can study language and interaction. Whatever feelings and thoughts we share, feature in our conversations as words, gestures, silences and facial expression. Interesting answers can be found in conversations between medical educators and students, between peers, or in study groups. Studies like our previous ones could be used to analyze what reflectionterm·dom is for different people, and data can be used to spark discussions among educators about facilitating reflectionterm·dom and to help teachers create a discursive environment in which reflectionterm·dom can occur. We feel that talk in the educational context can hold interesting answers about the nature of reflectionterm·dom and how students learn from it.

Reflecting on the reflective zombieterm·dom So far, we have focused on the zombie student in our initial thought experiment who did not reflect authentically. But what about the other student, who did reflect and may have experienced benefits and insights from writing the report and filling in the questionnaire? We aimed to suggest ways in which the richness of reflectionterm·dom in medical educationterm·key can be enhanced—but this does not mean that we should abandon approaches that work, even if they only work for some of the students. For example, there might be some merit in ‘going through the motions’. One of our colleagues stressed this point when talking about becoming a doctor. She did not feel competent and confident when she had just graduated and when she started her practice. She felt like she was faking it. What helped her through were tips and tricks, and some good acting. By doing what she felt was expected of her, she gained insights, and confidence. She learned, she added her own twists, and found her identity as a family doctor—she faked it until she made it. ‘Emotional labour’, the process of displaying emotions that are expected in the workplace, may start out as acting and gradually become authentic [ 43 ]. Although ‘deep acting’ is preferred, ‘surface acting’ can play an important role in daily practice. This idea mirrors the thought that one always takes on a certain role in interactions to influence how one is perceived [ 44 ]. It bears resemblance to ‘legitimate peripheral participationterm’, in which newcomers to a specific community of practice behave in a way that is expected in that community, yet they might not have internalized it—it is not yet authentic behaviour [ 45 ]. However, it might offer some students a starting point into the journey to having insights about their own behaviour, being open to emotions, and so on. This is also an argument for keeping reflectionterm·dom as a mandatory point of the curriculum, despite its drawbacks and potential negative aspects. Making reflectionterm·dom mandatory also communicates to students that reflectionterm·dom is part of their job description, and that it is their individual responsibility to bring this into practice—even if it is impossible for educators to tell them how to do so [ 46 ].

Conclusion The issues touched upon in this essay are valid for all higher education courses in which reflectionterm·dom has a place, yet focused on medical educationterm·key. We all want doctors to be critically thinking, emotionally developed and empathic—and above all, reflective. Recent work has shown inspiring and promising approaches to teaching and studying reflectionterm·dom. However, many interpretations of reflectionterm·dom do not do justice to the theoretical underpinnings of reflective thought. As Fendler and colleagues have pointed out [ 18 ], if reflectionterm·dom is cast in the same formal terms of the paradigm it is translated into, it incorporates the methodological habits of that paradigm and loses its power to interrupt and question. The tendency to treat reflectionterm·dom as something to measure and to structure contradicts the very nature of reflective thought. The instrumental approachterm·dom demands that we look for answers where they cannot be found, using tools that do not unlock new insights, making claims about students’ thinking that might not be warranted. A false sense of security may be found in the instrumental approachterm·dom that leads to extensive checkliststerm·key, but if this is our sole focus we risk doing the opposite of what reflectionterm·dom is meant to achieve: being genuinely curious and exploring one’s self and one’s experiences, leading to lifelong learning. Reflectionterm·dom is essential to medical educationterm·key and should be woven into the fabric of the curriculum by acknowledging diversity, fostering a reflective culture, and describing behaviour rather than prescribing.

Biographies Anne de la CroixpersName is an assistant professor at the the VUmc School of Medical Sciences and the LEARN! Academy, VU University, Amsterdam. She is a teacher, teacher trainer, and researcher whose work focuses on interaction and communication in higher education and healthcare settings.

Mario VeenpersName is an educational researcher and philosopher at the department of General Practice at the Erasmus University Medical Center, Rotterdam and the institute for Medical Educationterm·key Research Rotterdam (iMERR). His interests are medical educationterm·key, interactions addressing medical, psychological or philosophical topics, group interaction, and discursive approaches to reflectionterm·dom and critical thinking.

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