Fostering and Evaluating Reflective Capacity in Medical Education: Developing the REFLECT Rubric for...

Evaluating Reflective Writing

Fostering and Evaluating Reflective Capacityin Medical Education: Developing the REFLECTRubric for Assessing Reflective WritingHedy S. Wald, PhD, Jeffrey M. Borkan, MD, PhD, Julie Scott Taylor, MD, MSc,David Anthony, MD, MSc, and Shmuel P. Reis, MD, MHPE

Abstract

PurposeReflective writing (RW) curriculuminitiatives to promote reflective capacityare proliferating within medicaleducation. The authors developed a newevaluative tool that can be effectivelyapplied to assess students’ reflectivelevels and assist with the process ofproviding individualized written feedbackto guide reflective capacity promotion.

MethodFollowing a comprehensive search andanalysis of the literature, the authorsdeveloped an analytic rubric throughrepeated iterative cycles of development,including empiric testing and

determination of interrater reliability,reevaluation and refinement, andredesign. Rubric iterations were appliedin successive development phases toWarren Alpert Medical School of BrownUniversity students’ 2009 and 2010 RWnarratives with determination ofintraclass correlations (ICCs).

ResultsThe final rubric, the Reflection Evaluationfor Learners’ Enhanced CompetenciesTool (REFLECT), consisted of fourreflective capacity levels ranging fromhabitual action to critical reflection, withfocused criteria for each level. The rubricalso evaluated RW for transformative

reflection and learning and confirmatorylearning. ICC ranged from 0.376 to0.748 for datasets and ratercombinations and was 0.632 for the finalREFLECT iteration analysis.

ConclusionsThe REFLECT is a rigorously developed,theory-informed analytic rubric,demonstrating adequate interraterreliability, face validity, feasibility, andacceptability. The REFLECT rubric is areflective analysis innovation supportingdevelopment of a reflective clinician viaformative assessment and enhancedcrafting of faculty feedback to reflectivenarratives.

Editor’s Note: Commentaries on this article appear

on pages 5 and 8.

Fostering reflective capacity withinmedical education helps develop criticalthinking skills,1,2 inform clinicalreasoning,3 and enhance professionalism4

among trainees. Reflection—theexpertise-enhancing, metacognitive, tacitprocess5,6 whereby personal experienceinforms practice7—is integral to coreprofessional practice competencies.8,9

Development of reflective capacity hasbeen highlighted as necessary for effectiveuse of feedback in medical education10,11

and is an essential aspect of self-regulatedand lifelong learning.5,10 Reflection canguide practitioners as they encounter the

complexity that is inherent to clinicalpractice, potentially influencing thechoice of how to act in “difficult ormorally ambiguous circumstances.”12 Inthis vein, the development of reflectivepractice has been associated withenhancing an individual’s character or“virtue,” fostering a “habit of mind,”13

“dispositional tendency,”14 or “medicalmorality”15 with which to approachclinical reasoning and ethical or values-related16 dilemmas that may arise. It alsohelps in developing “phronesis”—adaptive expertise or practical wisdom toguide professionally competent clinicalpractice.13,17 Failure to reflect on one’sown thinking processes, including criticalexamination of one’s assumptions,beliefs, and conclusions, was recentlydescribed as a cognitive component of“physician overconfidence,” acontributing cause of diagnostic error inmedicine.18 In line with this, research hasoffered promising new evidence of anassociation between analytical reflectivereasoning and improved diagnosticaccuracy in challenging cases.1

Definitions of reflective capacity abound,though they generally include review,interpretation, and understandingexperiences to guide future behavior. For

example, Mann and colleagues19 definereflective capacity as “critical analysis ofknowledge and experience to achievedeeper meaning and understanding.”Theoretical pillars of reflective capacityinclude Schon’s20 progression fromknowing-in-action, to surprise,reflection-in-action (“thinking on ourfeet”21), experimentation, and, finally,reflection-on-action (postexperiencereflection), and Boud and colleagues’22

emphasis on addressing feelings in thereflective process. Moon23 introduces thecomponent of meaning making toreflection in learning, and Mezirow24

links premise reflection withtransformative or confirmatory learning,bringing additional depth and breadth toreflection conceptualization. Mann andcolleagues19 describe two overarchingdimensions in models of reflection:iterative and vertical. The iterativedimension of reflection is one triggeredby experience, producing a newunderstanding; the vertical dimensioncombines surface (descriptive) anddeeper (analytic) levels of reflection.

Reflection is not necessarily intuitive,especially in students at initial stages oftheir medical careers. Thus, medicaleducators strive to implement innovative

Please see the end of this article for informationabout the authors.

Correspondence should be addressed to Dr. Wald,Warren Alpert Medical School of Brown University,Department of Family Medicine, 111 Brewster St.,Pawtucket, RI 02860; telephone: (781) 424-2711;fax: (866) 372-7918; e-mail: [email protected].

Acad Med. 2012;87:41–50.First published online November 18, 2011doi: 10.1097/ACM.0b013e31823b55fa

Supplemental digital content for this article isavailable at http://links.lww.com/ACADMED/A68.

Academic Medicine, Vol. 87, No. 1 / January 2012 41

educational methods to promotedevelopment of reflective capacity earlyin the training process. The use ofreflective writing (RW) to facilitatereflective practice is well documented.25–29

Curricula have included RW groups forstudents in clerkships and residencies,journaling, portfolios, video essays, andwhat we have termed “interactive” RW—integration of written feedback fromfaculty to foster learners’ development ofmore sophisticated reflection skills.29

Pedagogic goals of professionaldevelopment, insights into the process ofpatient care, and practitioner well-beinghave been addressed through the small-group RW process.30 RW, a subset ofnarrative medicine, cultivates self-awareness and builds narrativecompetence for clinical encountersthrough the processes of attending,representing, and affiliating that areshared between RW and clinicalpractice.25 RW embodies the“interpretative and narrative”31 qualitiesof practical medical reasoning. Narrativecompetence and emotional self-reflectiveability, which may be cultivated throughRW, can bolster resilience to emotionallychallenging situations32 and promotecapability in challenging communicationencounters, such as breaking bad news.33

Mentors who skillfully support andchallenge learners through noticing thereflective moment, making sense of theexperience (including emotionalresponses), tolerating uncertainty (or“messiness” of clinical practice at the“heart of professional expertise”20), andusing new insights5,34 are an essentialcomponent to developing reflectivecapacity. Their guided written feedbackabout reflective narratives can promote amore in-depth reflective process.35,36 Atthe Warren Alpert Medical School (AMS)of Brown University, students receiveguided, individualized feedback abouttheir RW from interdisciplinaryfaculty29,37–39 during the Doctoringcourse40,41 and family medicineclerkship.42 Faculty use a rigorouslydeveloped tool (the Brown EducationalGuide to the Analysis of Narrative[BEGAN]) to enhance the educationalimpact of their written feedback aboutreflective narratives.43

The proliferation of RW curricula locallyand internationally has created the needfor a valid, reliable evaluative tool thatcan be effectively applied to assess

students’ levels of reflection and thedevelopment of reflective skills withinRW pedagogy. Publications on the utilityof RW in medical education have beenlargely anecdotal or based on studentself-report. Although some suggestassessing students’ levels of reflection toevaluate reflective learning outcomes,44,45

a recent comprehensive review concludedthat measurement of reflection is at anearly stage of development and thatqualitative and exploratory researchapproaches are appropriate for achievingdeeper understanding of this essentialconstruct.19

There are significant limitations andchallenges in applying available codingsystems for analyzing written reflectivejournals to determine the extent and levelof reflection. Proposed criteria for“grading” physiotherapy students’reflective journals,46 for example, lackedclear explication,47 and a reliablestructured worksheet for assessingreflection level48 focused on depth to theexclusion of breadth of reflection.47 Plackand colleagues7 applied a modifiedBloom’s taxonomy to determineachievement of higher-order thinking inreflective journals, yet they onlyindirectly assessed reflection per se.Identification and coding of textualelements of journals for levels ofreflection using Boud and colleagues’22

model was described as relatively difficultand not achieving sufficiently reliableoutcomes.44,46 Plack and colleagues47

broadened coding schema for reflectivejournals by including Schon’s,20 Boudand colleagues’,22 and Mezirow’s 24

theoretical frameworks; however, theschema did not integrate criteria withinreflective levels, and the authorsidentified the need for further refinementof some operational definitions. Inaddition, our review of available criteriafor assessing level of reflection revealedthat existing criteria did not includeMezirow’s24 transformative orconfirmatory learning schemata49; in fact,we encountered a critique of hisreflection levels (as used in currentassessment formats) as inadequatelydescribing the process of reflectivethinking.46 Some recently publishedrubrics for reflective narrative analysis arelimited either in scope50 –52 or in buildinga validity argument.53 Lastly, the factorialvalidity of at least one self-report reflectioninstrument has been questioned.54 In lightof the increased interest in formal

assessment of level of reflection as anindicator of professional development ofmedical students and best teachingpractices,35 we set out to design anempirically tested, concise, “user-friendly” evaluative paradigm stemmingfrom our review of existing qualitativeand quantitative measures andframeworks for reflective capacity.

The Reflection Evaluation for Learners’Enhanced Competencies Tool(REFLECT), a new rubric for evaluatingmedical students’ levels of reflection andthe development of those levels withinRW pedagogy, is an innovative approachto assessing reflection that includesmultiple fundamental domains ofreflection. In this report, we describe thedevelopment of the rubric, presentreliability and validity data, and discussthe rubric’s application and potential usefor enhancing the educational effects ofreflective narratives in medical education.

Method and Results

Preliminary stage: Literature and modelreview

The development of the REFLECT rubricbegan in early 2008 with a comprehensiveanalysis of the literature, includingtheoretical models of reflection, RWpedagogy, elements of reflective practice,and existing assessment modalities inhealth professions education. By October2008, we concluded literature searches inthe PubMed database for relevant articlesfor the years 1995 to 2008 using keywords such as “reflection,” “reflectivepractice,” reflective writing,” “reflectionin medicine,” “reflection in medicaleducation,” and “reflection in healthprofessions education.” We thenconducted ongoing subsequent literaturesearches until late 2010 (to inform thewriting of this article) with “reflection,”“reflective writing,” and “reflectionassessment” used as key words, thougharticles from 2008 to 2010 were notincluded in the literature review for thedevelopment of REFLECT.

We then used snowball technique toextend the literature search fromretrieved articles to other relevantsources. The snowball technique forsampling is a method whereby existingstudy participants suggest, recruit, orassist in recruiting future subjects fromamong their acquaintances or contacts.55

In this case, it refers to careful review of


Academic Medicine, Vol. 87, No. 1 / January 201242

the bibliographies of articles found fromdatabase searches to detect other relevantarticles that may have been otherwisemissed. From our review of the literature,we identified four existing modalities ofreflection assessment: (1) scales (“paperand pencil” forms with responses scoredby respondents), (2) thematic coding(qualitative analysis that codes themes inthe narratives), (3) qualitative analysis(more elaborate qualitative analysismoving beyond themes into models), and(4) analytical instructional rubrics(theory-based delineation of dimensionsor levels of an assessed construct).

We next examined these four approachesfor their utility in the assessment ofmedical students’ RW. Our deliberationswere based on both theoretical andfunctional premises. We usedanonymized analogical datasets ofmedical student RW exercises—sampledanew with each iteration—from the 2009and 2010 Doctoring course and familymedicine clerkship as anchors for thedeliberation. Although our literaturesearch uncovered an existing scale formeasuring “personal reflection,”54 we didnot use it for our analysis given itsintended purpose for students’ self-reported reflective capacity rather thanfor assessment of the construct withinRW. Thematic coding26,27 with soleemphasis on extraction of themes was alsoinadequate for our evaluative aims becausestudents’ reflective levels within RW couldnot be determined with such a method.Similarly, qualitative analysis was deemedinsufficient because of its inability toprovide focused differentiation of reflectivelevels. The fourth approach, the analyticalinstructional rubric,56 is specifically used forassessment. Analytical instructional rubrics

seemed to be the best choice for theassessment of reflective levels becausethey are based on a theoretical frameworkand can be tailor-made for specificpurposes. An instructional rubricdelineates the various dimensions orlevels of an assessed construct, definingbenchmarks for each, and can yieldquantitative scores.57,58 The rubricformat—used for both formative andsummative purposes—may vary, thoughcommon features include quality levelgradations on a continuum of strong toweak work product, as well as a relativelycomplex list of criteria or “whatcounts” in completing a project ormastering a skill.59 Our closeexamination of the four existingapproaches led us to select an analyticalinstructional rubric as the evaluativeparadigm for our own tool.

Iterative development of the initialrubric

Once we had determined which approachto use, we began the process ofdeveloping an actual analyticalinstructional rubric to assess students’reflective narratives. This wasaccomplished through an acceptedmethodology of thorough model review,listing criteria, designating quality levels,creating a rubric draft, and revising thedraft.59 Several iterative cycles ofdevelopment were required.

The first iterative cycle: Initial reflectionrubric. In the first cycle, we constructedan initial reflection rubric based on ourcomprehensive analysis of relevanttheoretical models of reflectionand existing reflection measureinstruments.60 After considering a

broad range of possible elements, wereached consensus on five levels ofreflection with associated criteria basedon the theories of Schon,20 Boud andcolleagues,22 Moon,23 and Mezirow.24

This rubric included the following levels:Level 1: Nonreflective: Habitual Action;Level 2: Nonreflective: ThoughtfulAction; Level 3: Reflective; Level 4:Critically Reflective; and Level 5:Transformative Learning. We developedcriteria or dimensions for each level (e.g.,descriptive versus reflective stance,attending to emotions) based on asynthesis of literature descriptors. Asession aimed at standardization ofscoring on three RW samples followed.Within this session, we presentedrationale for scoring, discussed andresolved scoring discrepancies, andreached consensus about scoring.

We obtained full formal institutionalreview board approval from theMemorial Hospital of Rhode Island priorto narrative analyses to allow cycles ofempirical testing on actual examples ofrandomly selected medical students’ RW.We applied the initial rubric to a datasetof all 93 second-year students’ self-selected “best” RW “field notes” collectedfor evaluation (2008 –2009). Three ratersapplied the initial reflection rubric tocode subsets of these field notes, with anoverlap of 10 randomly selected notes forreliability calculation, and interraterreliability was determined on these 10overlapping notes using intraclasscorrelation (ICC; see Table 1). Thedistribution of students in each reflectionlevel, according to our coding, was asfollows: Level 1 � 0, Level 2 � 17, Level3 � 38, Level 4 � 28, and Level 5 � 10.

Table 1Interclass Correlation (ICC) Estimates Computed for Each Iteration of theREFLECT (Reflection Evaluation for Learners’ Enhanced Competencies Tool)Rubric in Five Pilot Tests of the Rubric, Developed at Warren Alpert MedicalSchool (AMS) of Brown University, Providence, Rhode Island, 2009–2010

Date of pilottest

Rubriciteration Sample

Number ofraters

ICC singlemeasures

Cronbachalpha

1: July 2009 1 10 narratives from the Doctoring course, year 2, AMS 3 0.748 0.899...................................................................................................................................................................................................................................................................................................................2: December 2009 2 10 narratives from the Doctoring course, Year 2, and

family medicine clerkship, years 3–4, AMS3 0.455 0.715

...................................................................................................................................................................................................................................................................................................................3: January 2010 2 10 narratives from the general surgery clerkship,

University of Alberta3 0.376 0.644

...................................................................................................................................................................................................................................................................................................................4: February 2010 3 10 narratives from the family medicine clerkship,

years 3–4, AMS3 0.508 0.756

...................................................................................................................................................................................................................................................................................................................5: April 2010 3 60 narratives from the Doctoring course, year 2, AMS 4 0.632 0.774



The second iterative cycle: TheREFLECT rubric. Next, we set out tomodify the rubric on the basis of insightsgained from further literature review(including review of literature gleanedfrom the original search, plus new searchresults), application of the initialreflection rubric to students’ reflectivenarratives, and feedback obtained whenwe presented our initial findings atconferences. We reached consensus aboutdefinitions for four reflection levelsretained from initial rubric and twopossible outcomes of the reflectiveprocess, as well as more precisedelineation of criteria presented as acontinuum of development. The fourlevels carried over from the initial rubricwere Nonreflective: Habitual Action;Nonreflective: Thoughtful Action;Reflective; and Critically Reflective. Thetwo possible learning outcomes requireachievement of the Critically Reflectivelevel and were defined as transformativelearning and confirmatory learning.

We refined and elaborated criteria formastering each of the four levels: voiceand presence, description of conflict ordisorienting dilemma (insight andreflection), attending to emotions, andcritical analysis and meaning making. Wealso identified attention to assignment asan optional “minor” criterion to beaddressed when relevant. During thisiteration, we named the rubric REFLECT.

Using three raters, we applied the seconditeration rubric to a sample of 10 newreflective narratives from the second-yearDoctoring course and the family medicineclerkship and a sample of 10 field notesfrom a general surgery clerkship and againdetermined interrater reliability using ICC(see Table 1).

Third iteration. After improving the tooland retesting it during the seconditeration, we further reevaluated, refined,and redesigned the REFLECT in a thirditeration. To empirically test the tool anddetermine its interrater reliability, weapplied the rubric to a sample of 10family medicine clerkship reflectivenarratives. We then applied the rubric toall 92 second-year Doctoring coursestudents’ self-selected “best” reflectivenarratives (2009 –2010). We scored allnarratives independently, and then fourraters independently scored 60 narratives,randomly split into batches of 10. Eachnarrative was scored independently by

two raters, and we computed ICCs forthe six combinations.

Present iteration. The present iterationof the REFLECT was informed bymethodological consultation withadditional content and psychometricexperts and further close reading of therelevant literature. Our aim was to moreprecisely calculate interrater reliabilitydata and to deliberate the role of theREFLECT rubric in formative versussummative assessment. Given ourprimary emphasis on analyzing quality ofreflection within RW in a developmentalcontext, we decided to omit assignednumbers for reflection “levels” toencourage use of the rubric for formativerather than summative purposes(Appendix 1).

REFLECT rubric application

The process of applying the REFLECTrubric to a reflective narrative consists offour steps:

1. Read the entire narrative.

2. Fragmentation: Zoom in to details(phrases/sentences) of the narrative toassess the presence and quality of allcriteria (see Appendix 1). Determinewhich level each criterion represents.

3. Gestalt: Zoom out to consider overallgestalt of the narrative (while taking intoconsideration the detailed analysis ofStep 2). Determine which level thenarrative as a whole achieves. If theCritical Reflection level is achieved,determine whether either or bothlearning outcomes (transformative orconfirmatory learning) were alsoachieved.

4. Defend the assignment of level andlearning outcomes with examplesfrom the text. Do not “read betweenthe lines.”

A sample reflective narrative andREFLECT rubric analysis is presented inAppendix 2. Another example can beseen in Supplemental Digital Appendix 1,http://links.lww.com/ACADMED/A68.

Statistical analyses

We applied single-measure ICCs61 to alldatasets and computed ICCs for eachiteration of the REFLECT in the pilotdevelopmental phases (Table 1). We usedSPSS version 11.0 (IBM Corporation,Armonk, New York) to calculate ICCs.An ICC is used to measure

ordinal/continuous data for interraterreliability for two or more raters whendata may be considered interval. It mayalso be used to assess test–retestreliability. An ICC may be conceptualizedas the ratio of between-groups varianceto total variance. In single-measurereliability, individual ratings constitutethe unit of analysis (i.e., single-measurereliability provides the reliability for asingle judge’s rating). Single-measureICC is the more conservative estimateand can represent how much agreementone rater will have with other raters. Wechose to use ICCs because the levels inrubric iterations are ordinal data wheregradations are interpretable, with no“natural zero.” Each application of thedeveloping rubric involved at least threeraters.

As demonstrated in Table 1, we observedvariation in the ICCs. The noted decreasebetween iterations 1 and 2 may beattributed to insufficient training of theraters and/or lack of clarity in definitionsof levels and criteria. Some of the ensuingvariation may be due to the use ofdifferent samples of field notes, each ofwhich may have had different qualities, aswell as the small sample sizes in iterations1 to 4. In addition, further variation maybe attributed to the alterations in thecriteria for the rubric’s rating scale, whichoccurred as part of the iterative process ofscale development. The current iterationis likely a more stable ICC because itincludes 60 field notes, though this is stilla relatively small sample. Internalconsistency measured by Cronbach alphais also reported in Table 1 and rangesfrom 0.644 to 0.899.

Discussion

RW initiatives within medical educationhave prospered as medical educators arecalled on to prepare students to becomereflective clinicians.3,62 Increasing use ofsuch pedagogy has led to interest informal assessment of achieved level andqualities of reflection within narrative.The rationale for conducting theory-informed evaluation of RW includesobtaining a deeper understanding of theprofessional development of students,designing best teaching practices, andevaluating curriculum outcomes andeffectiveness. Although written essaymethodology may tap into importantcompetencies such as empathy, personalreflection, and professionalism, effective



http://links.lww.com/ACADMED/A68

assessment of RW can be challenging.32

We obtained encouraging results in easeof application and interrater reliabilitywith the REFLECT rubric.

We deliberately chose an analytic rubricevaluation paradigm because it promotesa theory-informed evaluation of RW andsupports learning and metacognition(“the act of monitoring and regulatingone’s thinking”).59 The content validity ofthe resulting framework is sound giventhe iterative process of instrumentdevelopment we employed. Additionally,the components of the rubric (levels ofreflection, criteria defining each level, andoutcomes) are grounded in the reflectionliterature. Rubric levels capturedevelopmental progression from habitualaction to critical reflection. Criteria foreach level are based in theory and clearlyexplicated. Fundamental, core processesof the reflection construct, includingpresence, recognizing “disorienting”dilemmas, critical analysis ofassumptions, attending to emotions, andderiving meaning from the exercise, areall assessed with the rubric. An additionaldistinguishing feature of the REFLECT isthe two possible learning outcomes ofcritical reflection—new understanding(transformative learning) and/orconfirming one’s frames of reference ormeaning structures (confirmatorylearning). Both of these delineatedoutcomes have relevance for gaininginsight to guide present and futurebehavior.

The REFLECT rubric is currently usedwithin AMS for structured RWparadigms within the Doctoring courseand family medicine clerkship, though wecould envision its application forproducts of spontaneous in-class RWassignments as well. Written feedbackabout students’ RW is currently standardwithin the Doctoring course and thefamily medicine clerkship curricula, andfaculty can use the BEGAN43 and/orREFLECT rubric tools to formulate thiswritten feedback. Faculty assess overall“level” of reflection for research purposes,but students do not receive this informationas feedback. Faculty do not assess quality ofwriting, in keeping with recent evidence of alack of significant relationship between qualityof writing and reflective content.63

Recently reported rubrics for “grading”RW exhibit similarities and differenceswith REFLECT. O’Sullivan and

colleagues50 used a similar statisticalapproach in the development of theirreflection rubric, yet this rubric does notinclude various reflection domains.Kember and colleagues52 introduce a“transitional” phase between each of fourreflection categories, though thesecategories are not elaborated. McNeilland colleagues51 offered a relativelycursory grading system without clearreference to theoretical underpinnings,and Devlin and colleagues’53 rubric isdescribed as a feedback rubric, based onone typology. In general, we propose thatthe REFLECT rubric achieves a morecomprehensive assessment than theserecent rubric design efforts, increasing itscredibility within an increasing pool ofinstruments for a similar purpose.

The process of rubric developmentinvolved refining a pilot rubric throughfurther immersion in the literature,application of the rubric to variousdatasets, and discussion until consensuswas reached on specific criteria. The ICCscores at the present iterationdemonstrate acceptable interraterreliability. Feasibility of scoring andacceptability to both raters and studentsare promising based on feedback fromfaculty development workshops and usein student instruction. We have receivedpositive feedback about the REFLECTrubric for formative assessment ofstudents’ RW from faculty developmentworkshops locally, nationally, andinternationally. Further investigations,including feedback queries for studentsand faculty at AMS and multiinstitutionalcollaboration, are planned. Thegeneralizability of the REFLECT rubric ispotentially limited, given its developmentand testing within a single institution, butwe are currently undertaking efforts toimprove generalizability by using therubric within various health professionscurricula at multiple institutions. Wehope to soon complete and distribute arubric “codebook” containing illustrativeexamples of rubric application tonarratives to enhance feasibility andpromote generalizability. Futuredirections include assessments oflongitudinal reflective narratives atvarious stages of the professional lifecycle and analysis of variables such aswriting prompt design on rubric results.

We note some limitations to our work.Although we provide ample contentevidence, further support from studies

with larger samples will be required toestablish robust internal structurevalidity. In addition, we recommendtesting this rubric against other validatedreflection evaluation tools.

We propose the use of the REFLECT rubricas a developmental tool within medicaleducation. It is designed to help guide ourlearners toward achieving greater breadthand depth of reflective capacity within thedevelopmental trajectory of becomingreflective practitioners.62 Such formativeassessment and feedback may help fosterexpertise, promoting more effective self-evaluation64 and self-directed learning,65

as well as more thoughtful approaches topatient care.66 Although our efforts atstandardization have yielded promisingpsychometric properties, we recommendusing the REFLECT rubric for formativerather than summative assessment. Incontrast to “quantifying” or “grading,”which may risk a lack of reflectiveauthenticity by encouraging moreformulaic approaches to reflection,67 weenvision the REFLECT rubric asproviding qualitative anchors to helpeducators both assess development ofreflective capacity dimensions andformulate constructive, individualizedfeedback to students’ reflectivenarratives. At this time, we countercalls for rubrics to be used forquantitative and summative assessmentof learners.68 We urge caution in thisregard because such use may provecounterproductive, potentiallyinhibiting the development of reflectivecapacity within interactive RW.

We plan to study the use of the REFLECTrubric to enhance the educational impactof RW feedback. We hope to examineboth faculty’s and students’ perspectiveson the effectiveness of rubric applicationfor feedback formulation and promotionof reflective capacity. Given the currentemphasis in medical education onmeasurable objectives, future research todetermine the extent to which what isbeing measured in text is a valid indicatorof reflective activity and how this predictsor correlates with professionalism issuesis of interest. Further research is neededto explore concurrent validity throughthe use of reflection scales,54 thematicanalyses,26 and/or measures of reflectivepractice outcomes. We propose theinclusion of our rubric paradigm withinsuch an approach as a means ofenhancing “state of the art” reflection



assessment. The study of medical schoolsthat teach reflective practice has beensuggested to determine whether they aremore likely to produce physicians whoare able to improve patient care.69 Thus,the connection between medicaleducation modalities such as RW-enhanced reflective capacity and qualityclinical outcomes69 warrants furtherinvestigation.

Conclusions

RW and its assessment may enhance ourunderstanding of the professionaldevelopment of physicians and helpguide pedagogic initiatives aimed atsupporting this process. Metacognitiveskills including reflection as well asdimensions of professionalism ineffective patient care (such as self-awareness, empathy, and insight), andphysician well-being can potentially befostered through RW exercises.30 We arehopeful that longitudinal investigationsof RW exercises using the REFLECTrubric will assist educators as well aslearners as they reflect on the efficacy ofsuch curriculum initiatives. In essence,the use of the REFLECT rubric as part ofthe assessment tool kit has the potentialto broaden the question of “How dodoctors think?”70 to “How can we helpdoctors to think?” As interdisciplinaryinterest continues to grow in RW and therole of reflective capacity in health carepractice, increased rigor in theorybuilding, curricula implementation,assessment, and outcome research iscalled for in order to demonstrateauthenticity and sustainability of suchconstructs. Such efforts can help realizethe promise of RW as a vehicle forpromoting reflective capacity and its rolein building professional identity, as wellas for guiding development of medicalexpertise, leading to the formation ofmindful, compassionate, and competentpractitioners.

Acknowledgments: The authors gratefullyacknowledge Dr. Jonathan White for use ofnarratives in determination of rubric reliability,Drs. David Cook and William McGaghie for theircomments on statistical design, and Dr. RitaCharon for insightful dialogue on rubricapplication. The authors also gratefullyacknowledge Tina Charest, MD, and EugeneCone for the use of their reflective narratives.

Funding/Support: None.

Other disclosures: None.

Ethical approval: This study was reviewed andapproved by the institutional review board of theMemorial Hospital of Rhode Island.

Dr. Wald is clinical associate professor of familymedicine, Warren Alpert Medical School of BrownUniversity, Providence, Rhode Island.

Dr. Borkan is professor and chair, Department ofFamily Medicine, Warren Alpert Medical School ofBrown University, Providence, Rhode Island.

Dr. Taylor is associate professor of family medicineand director of clinical curriculum, Warren AlpertMedical School of Brown University, Providence,Rhode Island.

Dr. Anthony is assistant professor of familymedicine and director of medical student education,Warren Alpert Medical School of Brown University,Providence, Rhode Island.

Dr. Reis is professor and immediate past chair,Section of Family Medicine and Department ofMedical Education, Ruth and Bruce Rappaport Facultyof Medicine, Technion-Israel Institute of Technology,Haifa, Israel, and adjunct clinical professor of familymedicine, Warren Alpert Medical School of BrownUniversity, Providence, Rhode Island.

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Appendix 2REFLECT (Reflection Evaluation for Learners’ Enhanced Competencies Tool)Rubric Applied to a Reflective Narrative From a Third-Year Student in the FamilyMedicine Clerkship at Warren Alpert Medical School of Brown University,Providence, Rhode Island

Reflective Narrative

Writing Prompt

“Sick people need physicians who can understand their disease, treat their medical problems, and accompany them through their illness.” RitaCharon, MD, PhD

Reflect on a patient care experience(s) in which you learned something new about the role of a primary care physician. Include a description of theexperience(s) of the patient encounter. Some dynamics to consider:

● Longitudinal physician–patient relationship

● Being there for the patient, alleviating or sharing the suffering, preserving our empathy over time

● Responsibility and service

Were any of your assumptions challenged or validated? Did you gain any insights about yourself (cognitive and/or emotional)? How might yourexperience(s) change your practice of medicine?

Student Narrative

Sitting on a small green stool about a foot away from the patient, the doctor furrowed his brow. It had been a particularly long day, filled withpatients asking for early refills on pain medications. Now, Donna* had come in having an asthma attack and we were trying to discuss hermedications.

“I don’t know the name of it,” Donna said. “It’s round and green.”

“Are you sure it’s green?”

“Oh yeah, I’m sure it’s green. I can see it in my head right now. Round and green. Dark green.”

“Are you sure it’s not purple? And does it look like a flying saucer?”

The doctor was sure that his patient was on Advair which came in a dispenser that could be described as round, but was definitely not green. Donnawas sitting on the exam table, her face and her eyes, teary since the attack, were a matching shade of red. The records indicated that Donna wastaking Advair on a daily basis and Albuterol for acute attacks. Donna, however, was describing a green round device that didn’t sound like anythingthat the doctor and I were familiar with.

“I take the green circle thing whenever I have an attack and that hasn’t been for awhile. Then I take the other medicine every day.”

“Hold on,” said the doctor reaching for the door. He rustled through his closet outside the exam room for awhile and then returned, holding anAdvair discus. “Do you take anything that looks like this?” he questioned.

“Ohhhhh, yeah!!! That’s it, that’s the thing. That’s the thing I take whenever I have an attack.”

“This … is the green circle?” I asked incredulously.

“Oh, well … I guess it’s purple.”

Oh, Jesus, I thought. This was ridiculous. This lady has no idea what medications she’s taking and it sounds like she’s been taking them completelywrong. There’s no way the doctor didn’t explain to her that Advair was for daily use and Albuterol was for acute attacks. And the discus wasobviously not green! How did she not bring her medications list in with her, or better yet, the medications themselves so she could tell us how shetook them?

My mentor discussed how to take her medications with her again and then scheduled a follow-up appointment with her so that they could makesure she understood.

“Wow, I really dropped the ball on that one,” he said as we were walking back to his office.

“Excuse me?” I said, unable to hold in my disbelief. He dropped the ball? It was the patient who had dropped the ball! She had fairly serious asthmaand didn’t know what medications she was on!

“I obviously didn’t communicate well with her the first time she was here. She really didn’t know much about her medications.”

“Well, didn’t you tell her that the Advair was for daily use and then Albuterol for whenever she had an attack?”

“Of course, but obviously something I said didn’t register with her. It’s the job of a family physician to not only tell the patients what medications totake, but to make sure you’re communicating in a way that is effective. To be honest, I don’t think she’s going to do a much better job taking themedications after today. It’s hard to remember anything when 10 minutes before you couldn’t breathe. That’s why I’m having her come back sosoon.”

I thought about that patient on my drive home. I usually consider myself to be sensitive to the needs of my patients. I think I’m pretty darn good attalking to them, empathizing with them, and expressing myself in a way that they understand. But that day, after dealing with what felt like drugseeker after drug seeker, I had been frustrated and completely unable to relate to this woman. I don’t know if I would have thought to have herreturn in a calmer state to go over her medications. I’m embarrassed to say that I might have written her off as someone who just didn’t care.

From this experience I was reminded of just how complicated the job of a family physician truly is. Sure, many times the diagnosis isn’t difficult, butthere is so much more to family medicine than diagnosis. Communication is so crucial to doing the job right. While I may be a good communicatorand try hard to empathize with patients, there is obviously so much left for me to learn. Even my mentor, who has been practicing for almost 25years, is still improving. Patients are as individual as their diseases. If a physician is not continuously working on communicating more effectively, nomatter how brilliant he/she may be, the patient is being done a disservice.

(Appendix continues)



Appendix 2, Continued

REFLECT Rubric Application ProcessWriting Spectrum: The learner is reflecting on herself in the situation as well as the mentor, demonstrating Reflection on Action. There is clear“movement beyond reporting or descriptive writing to reflecting, i.e., attempting to understand, question, or analyze the event” for Reflection level.The narrative describes grappling with a more nuanced view of a family physician. The writer appears to be on the cusp of criticalreflection–transformative learning level. The importance of “communication,” for example, is identified and described, though some moreelaborated concrete examples of how this could be realized and integrated in future practice might have been helpful, possibly contributing to morecomprehensive meaning making. Overall Level: Reflection.Individual CriteriaPresence: An authentic voice permeates the writing and there is a sense of bringing the full self to the situation. Thus, the narrative fully conveys“being there.” The reader is brought into the exam room through provision of details and then into the writer’s “head.” The writer engages thereader in a powerful, meaningful way. Level: Critical Reflection.Description of conflict or disorienting dilemma: The disorienting dilemma regarding perceived responsibility for such a medication mishappoignantly emerges (“unable to hold in my disbelief, my mentor dropped the ball? It was the patient who had dropped the ball!”). The potentialconflicts within a developing professional identity (i.e., the “expert” not always getting it right, exuding competence while remaining open toimproving with humility in approach, considering broader communications issues and issues of responsibility) are impressively identified, though thechallenging of assumptions could be further elaborated. The dilemma of preserving clinical empathy within “dealing with what felt like drug seekerafter drug seeker” is implied. Level: Reflection.Attending to Emotions: “I had been frustrated” (“and completely unable to relate to this woman”) is an opening phrase, a reflective trigger.Critical analysis might include (1) considering how feelings of frustration or anger toward patients could arise out of one’s own vulnerability and/or(2) how self-awareness of emotional state can help maintain provision of quality care, potentially preventing/minimizing emotional distancing. “I’membarrassed to say that I might have written her off as someone who just didn’t care”—self-reflective and authentic revelation. There could befurther consideration of (attending to) patient’s emotional state (e.g., emotional upheaval, such as anxiety, in the clinical encounter potentiallydisrupting information processing). Level: Reflection.Critical Analysis and Meaning Making: Salient themes include importance of individualized communication, humanizing of mentor,dedication to lifelong learning within the profession. Enhanced appreciation of “staying on one’s toes,” reflecting in action to ascertain patient“being on board” is described, and assumptions are beginning to be challenged. Though there is room for further elaboration of “communication”for more comprehensive meaning making, the student has introduced several notable elements and appears to have examined the dilemma onseveral levels. Level: Reflection–Critical Reflection.

* Patient’s name has been changed.



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