Reflection Reflective journals and electronic portfolios are becoming increasingly popular within undergraduate and graduate medical education. I’m starting to be a believer in this learning approach, which teaches learners about professional development and life-long learning principles. Academic Medicine just published a great qualitative paper proposing a conceptual model for reflection.

What is “reflection”?

In an Medical Teacher article by Sandars, the author defines reflection broadly as:

“a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.”

Study question

In educational activities intended to foster reflection, what cognitive and emotional processes occur when students engage in reflection?


Starting 1997, MS1s and MS3s at Baylor Medical School completed 3 Clinical Practice Instruments (CPI) assessing attitudes about patient-centered care, beliefs about psychosocially oriented practice, and stress levels in uncertain situations. After students received their scores, as well as how they compared to their class, they were asked to reflect on the experience.

In 2000, a focus group from each medical school class was interviewed (MS1-MS4) about their experience specifically in the areas of:

  • Self- knowledge and values
  • Abilities and behaviors
  • Attitudes and beliefs

This study group used the recorded focus group interviews. Internal validity of this qualitative study was addressed by having multiple investigators analyze the findings.



The investigators found underlying elements that recur in reflection activities:

  • The educational activity
  • The presence or absence of dissonance
  • Processing through reconciliation or preservation
Permeating these themes is the concept that students have internal and external ideals.
  • Internal ideals: the learner’s own perception about her/himself, or ideals of what a physician should be

  • External ideals: other people’s view of the learner, or perception of what a physician should be, according to the teacher or exercise activity

Are you as confused by the abstractness of this summary as I am!? Here are some concrete examples which helped me understand:

This exercise was for students to reflect on the CPI activity and their scores.

  • Student A received scores which demonstrate that she is a below-average listener and communicator, which takes her by surprise. After some contemplation, she can understand where these scores are coming from. She decides to be more cognizant of patient interactions in future encounters. This is an example of Activity –> Dissonance (between internal and external ideals) –> Reconciliation (acceptance and change of internal ideals).

  • Student B received scores which demonstrate that he is a below-average listener and communicator, which takes him by surprise. After some contemplation, he believes the results and study tool to be flawed. This is an example of Activity –> Dissonance –> Preservation (diminishes or discounts the external ideal).

  • Student C received scores which are congruent with his perceptions of himself. This is an example of Activity –> No Dissonance.

Conceptual model when building reflection exercises

The authors recommend that reflection exercises should be designed with the following questions in mind:

  1. Is the ideal implied by the activity explicitly articulated to students?
  2. Can the activity elicit emotion?
  3. Will the activity engender dissonance?
  4. What is the preferred pathway (reconciliation or preservation)?
  5. If reconciliation is the preferred pathway, how can it be facilitated?

The investigators used this conceptual model to revise the CPI reflection activity. They added a “framing session” AFTER the students completed the CPI exercise but BEFORE the scores were released. This helped to address question #1 and #5 above.

During the framing session, the students were asked to think about the ideal qualities of a physician, relevance of the CPI activity, and how their values are changing during medical school. This made them think about their “internal ideals” and the overall purpose of the reflection exercise.



Thompson BM, Teal CR, Rogers JC, Paterniti DA, & Haidet P (2010). Ideals, Activities, Dissonance, and Processing: A Conceptual Model to Guide Educators’ Efforts to Stimulate Student Reflection. Academic medicine : journal of the Association of American Medical Colleges, 85 (5), 902-908 PMID: 20520048

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD