The reflective zombie: Problematizing the conceptual framework of reflection in medical education

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 effect’: 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 education, knowledge about reflection is sought after in quantitative research, and in terms of measurability. This is not because reflection is necessarily ‘found’ here, but because that is where medical education, 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 education.

When the static light beam of medical education shines on reflection, 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 reflection 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 reflection based on how it occurs in practice.

The translation of reflection into the realm of medical education has brought with it two demands: to measure reflection, and to assess it. These two activities are requirements of medical education, but is reflection itself actually assessable and measurable? There are certainly aspects of reflection 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 reflection 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 checklists 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 reflection might not translate to research methods that match its complexity and personal nature. Reflection 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 reflection, and make it impossible for us to filter out the ‘reflective zombie’. 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 reflection questionnaire [24].

At the root of the measurement issue lies an epistemic problem. Reflection 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 reflection. 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.

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

Rather than pushing every student’s reflection into the same mould, we feel that diversity in reflection 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 reflection do not necessarily point to authentic inner reflection. To think of an assessment system that is more authentic, would require some ‘letting go’ of checklists and uniformity, especially considering the culture of examination in medical education [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 assessment in the area of reflection: 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 assessment, 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 reflection 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 reflection in curricular design and educators who are skilled at coaching students and giving effective feedback.

There is a need to look at reflection differently, and to use different data when studying reflection. 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 reflections, without a predetermined format. We ought to recognize that sharing reflection 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 reflection 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 reflection upon reflection’ [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 reflection, but to use them pragmatically: ‘All models are wrong, but some are useful’ [39].

Finally, teaching should be focused on creating conditions that foster reflection, rather than trying to teach directly ‘how to reflect’. Strictly speaking, reflection 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 reflection 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 education to create such an environment’. We want to motivate students to turn reflection into a lifelong practice, instead of just another assignment they have to complete to get their degree. Therefore, part of the reflection curriculum should be for everyone ‘to work out his or her own system for engaging in reflection’ [41]. Working out which way of reflecting works best for oneself is actually a crucial part of the reflective process. It is necessary if reflection 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.

When it comes to future research on reflection, we propose to describe how reflection actually takes place in practice, rather than prescribe what counts as ‘good reflection’. 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 reflection in a group session [5, 21]. We found that groups of doctors in training naturally find their own structure in group reflection 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 reflection in medical education as an interactional activity. As mentioned before, formal assessment tools such as checklists 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’ reflection than approaches that aim to objectify reflection. What we are trying to say here is that there is a contrast between ‘objectively’ trying to assess reflection and human contact, interaction, and intuition.

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 reflection in medical education 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 participation’, 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 reflection as a mandatory point of the curriculum, despite its drawbacks and potential negative aspects. Making reflection mandatory also communicates to students that reflection 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].