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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Tuesday 30 August 2011

Reflection on Reflection

Our dear Royal College has decided to formalise, nay, mandate reflective practice from every Fellow. It is now embedded into ongoing professional development. This news may have completely passed you by, but this is official as of 1st Jan 2011. We are now required to provide evidence of reflective learning. More specifically, this is required by the RCR for “online CPD activities (and all Category II CPD activities)”. We are not alone, the RCR is one in a long line of UK Royal Colleges who have introduced such a system.

Some will have read this and made a PFFFFFFFTT noise as they involuntarily spat their drink across the room. This is quite understandable. Working in the NHS inexorably turns innate medical scepticism into abject cynicism. And the longer one works in the NHS, the more hard-bitten one becomes. Hence anyone pushing a particular way of thinking, behaving or working in the NHS comes in for a hard time, particularly when extra work is being proposed. At best, such idea-mongers are viewed with an arched eyebrow and pursed lips as we attempt to discern their hidden agenda. At worst, there is open hostility with, shall we say, lapses into the vernacular.

Reflective practice is considered a Good Thing. Educational mantra has us believe that critically looking at our emotions, experiences and actions can lead to valuable insights. It follows that such revelations about our strengths and weaknesses can only lead to improvement.

Reflection has the oldest of educational roots. Socrates boldly stated “the unexamined life is not living”, believing the sole purpose of life is personal and spiritual growth. His method of self-examination through dialogue has stood the test of time. Modern notions about formal reflection are founded on an extensive literature spanning four decades. Reflection is heavily emphasised in educational circles: go on a Teaching Course and you’ll not only learn the names of Schön & Kolb but also be expected to spend time metaphorically navel gazing.

Many doctors think little of reflection. Some are openly hostile, convinced it is an utter waste of time; tree-hugging nonsense for folk who don’t know what they are doing. Some are ambivalent; they can see possible merit but don’t do it and resent being told to do so. Even those who espouse its benefits secretly rarely engage in formal reflective practice.

The author hugs a tree

Amidst this angst and politics lies a paradox; reflection itself cannot be reflected on. It has gained such pre-eminence as an ideology that it cannot be questioned; it is now firmly part of the educational hegemony. Anyone daring to question its importance is seen as a scholastic luddite, a pedagogical heretic and educational dinosaur. Not a good state of affairs.

However, there are serious and weighty criticisms of reflective practice. For starters, if you spend all your time examining your life, you leave no time to live it. One analogy is driving whilst always looking in the rear view mirror. This is a very real problem; if reflection is overtly emphasised then it paradoxically inhibits learning.

Another persistent problem is how to define reflection. Critics have said that it is indistinguishable from “thinking”. Which we all do. If a term can mean anything, it means nothing.

The other worry is overvaluing the products of reflection. Solipsism (the view that the self is all that can be known to exist) can lead to some seriously distorted or even frankly wrong views. Such ‘bad’ knowledge can drive out the good. One analogy here is that spinning your wheels in the mud is more likely to lead to entrenched ruts than real progress.

Whilst this debate may (or may not) be incredibly interesting and entertaining there is a trump card. One of the fundamental flaws of reflection is the absolute lack of evidence that reflective practitioners are any better than their peers. Quite why this should be is a matter of debate. There is some evidence that reflection is a symptom of good learning; an epiphenomenon. Hence it should not be a goal in itself.

The RCR should be bold - drop mandatory reflection in professional education. The contribution of reflection is marginal, it is ideologically driven, and sometimes counterproductive. As experts in our field, most of us have got there quite happily without the need for formalized reflection. And we certainly don’t like to be told to do something with no evidence behind it.


Credit - I am very grateful to James Atherton for this very wise article, ironically providing much material on which to reflect.