An appraisal of students' awareness of "self-reflection" in a first-year pathology course of undergraduate medical/dental education

As Confucius said, "By three methods may we learn wisdom: first, by reflection, which is the noblest; second, by imitation, which is the easiest; and third, by experience, which is the most bitter". Dating back to ancient Greece, the 'noble' process of reflection has developed into an effective teaching/learning tool capable of enhancing education, decision-making, critical thinking, and self-concept. Innovation, problem-solving, autonomy, and critical thinking are all necessary skills in healthcare professionals [1]. When performed correctly, reflective writing develops these indispensable attributes, encouraging the writer to create meaning from events that have transpired to guide future choices [2]. As with any skill, the ability to productively reflect requires practice; therefore, implementation of activities exercising this skill early in one's healthcare career should increase student engagement and prepare doctors/dentists-in-training to be competent in these skills in their respective chosen profession.

Now, over 2,500 years after the time of Confucius, the young population is reflecting more than ever. Though not in an academic setting, social media networks such as facebook, myspace and twitter are based on users recording their thoughts and actions, and commenting on what others have written. Despite what is often a daily ritual of recording and discussing (ie "social reflection"), in an academic context, students often struggle with the reflective process. Studies have shown low-levels of reflection in residents and medical students, suggesting that the cognitive processes required to enhance learning through reflection may not be intuitive and suggests a role for active educational interventions [3]. A true reflective process is multidimensional including recognition, implementation and application with a view to increase the depth of understanding. Such increases may involve an evaluation of performance, consideration of events causing these outcomes, and affective and behavioral reactions leading to single-, double- and triple-loop learning [4, 5]. The concept of reflection, though widely mentioned in medical education literature, often describes similar processes under different terms. The main approaches to reflection in medical education are threefold: a) reflection for learning, b) reflection to develop a therapeutic relationship and c) reflection to develop professional practice. Reflection can also be considered primarily as a self-regulated learning activity [5]. In contrast to "social reflection", accurate definition of "academic reflection" is recently articulated as twelve tips for teaching reflection at all levels of medical education by Aronson. These twelve tips are: "1) define reflection 2) decide on learning goals for the reflective exercise, 3) choose an appropriate instructional method for the reflection, 4) decide whether you will use a structured or unstructured approach and create a prompt, 5) make a plan for dealing with ethical or emotional concerns, 6) create a mechanism to follow-up on learners' plans, 7) create a conducive learning environment, 8) teach learners about reflection before asking them to do it 9) provide feedback and follow-up, 10) assesses the reflection, 11) make this exercise part of the larger curriculum to encourage reflection, and 12) reflect on the process of teaching reflection" [6]. With these criteria taken into account to maximize reflection effectiveness, the ultimate goal is the creation of a mindful practitioner, with new initiatives encountered by students acting as building blocks towards this end [3]. As such, identification of specific facets that make up an effective "self-reflection" is important. The awareness of these skills in first-year medical/dental students will facilitate and guide the development of self-reflective exercises that can be specially tailored to suit students' needs to create a firm foundation towards this final objective.

In this research paper we share our experience of an explicit initiative to implement a self-reflection assignment in the first-year pathology Med 102 course. We were interested in determining the extent of students' awareness and understanding of the reflective process and meaning of 'self-reflection' within their learning environment in this early stage of their education.

In the academic years 2007-2008, a total of 95 students (66 medical and 29 dental) and in 2008-2009 a total of 110 students (84 medical and 26 dental) at the University of Saskatchewan were introduced to a self-reflection assignment as part of their pathology course. Students' age ranged from 19 to 34 (mean 23 years) and past educational history ranged from two years of post-secondary to a Master's degree. This wide age range is due to the fact that students in this province are eligible to apply following 2 completed university years. Successful applicants in this category are usually a minority comprising 10-15% of the overall selected candidates. The College of Medicine at the University of Saskatchewan follows a CASE-based (Cooperative, Active, Self-directed, and Experiential learning) integrated four-year curriculum. A balanced composite curricular design including facets of horizontal, vertical and diagonal integration of pathology teaching in the first three years is adopted as the best practice plan for the instruction of pathology within this integrated medical curriculum [7]. The first year courses are attended by both medical and dental students thus promoting opportunities for inter-professional exchanges. The first year pathology, MED 102, is related to the teaching of general pathological concepts serving as a foundation to the upcoming systemic pathology taught in second (MED 202) and third (MED 302) year courses. The MED 102 first year pathology course provides students with an overview of basic concepts and principles of general pathological conditions as applicable to real life practices of medicine and dentistry with horizontal integration to the introductory first year Form and Functions course (a comprehensive vertically integrated histology, embryology, anatomy and physiology course that is run as modular units). The MED 202 (second year) and 302 (third year) courses are horizontally integrated with the teachings of the various scheduled clinical systems with ongoing vertical and diagonal integration of pathology within the matrix of the undergraduate curriculum [7]. Further, in keeping with the CASEcurriculum, students were introduced to the new pathological concepts through active learning strategies including in-class jigsaw learning, pre-assigned reading assignments with presentations, specially designed pathology games, poster creations, impromptu quizzes, Turning Point questions with clicker responses, and case explorations with in-class debates that complemented the traditional formal lecture sessions. All first-year students are aware of the concepts of multiple intelligences with preferred learning styles that serve as the underlying structural framework for the CASEcurriculum model.

Following an in-class discussion of the proposed self reflective assignment, in the context of their learning experiences, students were provided with a reflective questionnaire template as a practice assignment (Appendix 1). Students were requested to submit a one-page (500 word) reflective document of their learning experiences as an ungraded (pass/fail course) but compulsory component of the midterm and final examinations. These documents were collected over two academic years amongst two cohorts of students (2007-2008; 2008-2009). The documents were randomly analyzed through a blind evaluation process by two investigators that each read and evaluated the entire set.

Reflections were categorized on a "5 levels of reflection-awareness" scale using a specially designed rubric based on the accepted major theories of reflection, with level 1 representing the poorest understanding of reflection and level 5 representing greater understanding (Table 1). Documents were categorized based on the reflection-awareness of: 1) personal abilities, such as strengths and weaknesses 2) personal learning styles 3) relationships between course material and the students' personal histories 4) emotional responses and relations to personal values, beliefs, and sense of self and 5) future applications of the material/experience being discussed at both a personal and professional level. The levels of reflection-awareness (1-5) analyzed in these documents were also vertically categorized in the following dominant themes consistent with existing literature on reflection:

Category A: Significant events from course that led to reflection

Category B: Information/Skills acquired from the course

Category C: Personal abilities

Category D: Personal learning style

Category E: Connections between the course and past life experiences

Category F: Oneself in relation to the situation (emotions, values, beliefs, etc.)

Category G: Future applications in a broadened spectrum

It is important to recognize that the 'levels of reflective-awareness' does not represent a strictly linear scale but rather attempts to classify five different levels of students awareness and understanding of the self- reflective process within the context of their learning environment in this early stage of their education.

Following independent analysis by each investigator the results in agreement were pooled. The disagreed results were discussed and reappraised to reach a mutually acceptable consensus opinion. As assessment of reflection is difficult to be linked to explicit educational goals of learning and understanding [5], a combination of such qualitative analysis with quantitative numerical categorization was specifically used in this study based on past experiences [7].

This study was conducted with ethics approval from the University of Saskatchewan Behavioral Research Ethics Review Committee.

Over the course of two academic years a total of 410 self-reflection documents were collected and analyzed from the two student cohorts. A sample of 'student comments' from each category (A-G) and level (1-5) is provided in Appendix 2. Students demonstrated a strong ability to outline their personal learning style (Category D: 17.3% level 5- "I learn best through multiple modalities where I can make interconnections", 44.3% level 4-"I am an extreme multiple-modality learner", 11.2% level 3-" I find that I am a visual learner"). This may be attributed to the template that specifically prompted students to include this in their discussion. The majority of the students included some detailed mention of the course content (Category B: 13.4% level 5 -" I need this general pathology to understand the mechanisms causing systemic oral diseases and the body's reactions to them such as inflammation encountered in gingivitis ", 17.5% level 4 -"I enjoyed the sessions on neoplasia and atherosclerosis because of the value of this information. These illnesses are the two leading causes of death worldwide making learning how they develop more interesting", 23.1% level 3 - "In the second portion of this course we focused on neoplasia, atherosclerosis, infectious disease, and environmental pathology"). In this context, many (> 85%) submitted a 'log-book', or an account of some of the major topics covered, without providing any evidence of deeper understanding with critical thinking. As seen in Figure 1, Categories E ("Connections between the course and past life experiences") and F ("Students identified oneself in relation to the situation"), the majority of students were at a level 1-2, indicating that they struggled to connect information from the course to 'the self' and thereby failed to personalize their learning. Reflections at level 1 awareness included a) the identification of specific teaching strategies utilized to enhance learning (Category A: 58.4% - "I think that I have learned many things throughout this course"), b) identification of personal abilities (Category C: 53% Did not mention any strengths and weaknesses:), and c) the relation of emotional responses, values, and beliefs to the material being covered (Category F: 71.5% - "I enjoy topics more as I collect more knowledge about them"). Students' abilities to connect information to future events (Category G) were more evenly distributed across all 5 levels of awareness (Figure 1).

Self-directed learning such as that used by lifelong learners requires "proactive rather than reactive thought" [1]. This novel thought pattern may result from a myriad of experiences culminating together and strengthened with input from personal emotions and ideals. The word 'experience', originates from Latin for 'trial' or 'experiment', indicating a part of education that must include trial-and-error learning [9]. Nearly 100 years ago, in 1933, John Dewey was the first to write about the value of reflection, suggesting there is more to learning than simply varied experiences [10]. Since Dewey, numerous researchers have attempted to outline steps to the reflective process and pinpoint the precise benefits of this action. Theories of many influential thinkers such as Dewey, Boud, Schön, Moon, Mezirow, and Kolb share commonalities that together may provide the fundamentals of understanding reflection. In 1985 Boud et al. conclude that structured reflection is a key element in learning and proposed a reflective process whereby one must: a) mentally return to the experience, b) identify/attend to feelings that arise in response to these events with recognition of self-held 'truths' barring full understanding, and c) re-evaluate the experience through association, integration, validation and appropriation [11]. Information gained from such a process can then be used to guide future decisions and choices. Varied structures of this reflective process are echoed in the theories of McCarthy [12] and Kolb [13]. Such iterative processes often begin with (i) the identification of a problem which is resolved (ii) the collection and analysis of pertinent information/emotions, and (iii) the incorporation of the same into future actions. The critical step of this process is the second (ii); the investigation of the positive/negative emotions triggered by an event tempered by the underlying beliefs and self-values that determines one's decision and choice [14]. Zull states "Even if we experience something that has happened to us before, it is hard to make meaning of it unless it engages our emotions" [15]. Only a few students in our study were able to effectively connect information to personal experiences (Category E Level 4-" I found that having a personal experience with cancer in my family increased by interest in the lectures dramatically") and self-values (Category F Level 5- "I was very interested in the atherosclerosis and obesity section. I come from a population that has a high rate of obesity, diabetes, and many other diseases so I feel that as a future health professional, it is one of my responsibilities to try and promote healthy choices. Improvements will be made with proper awareness and education as well as with positive role models in the community like health care professionals with a background in these conditions."), congruent with models of reflections by Mezirow [16], and Hatton/Smith [17] that values 'critical analysis' at the highest level of reflection. This may be attributed to lack of previous exposure to such critical thinking tasks, perhaps directly related to inexperience as approximately 45% of the students had not completed a four year undergraduate university degree prior to their acceptance into medical/dental school. Students' written language competencies could also have a significant bearing on the overall assessment of these narratives, in terms of the student's ability of effective written communication skills. However, for the purposes of this study it was assumed that all students possess the necessary written communication skills needed for this assignment as they had at least 2 years of university education and many had 3-6 years of university experience.

Schön suggests three types of reflection that may occur: 1) reflection-on-action (reflection post-event), 2) reflection-in-action (reflection during the time of action), and 3) knowing-in-action (intuitive knowing established from repetitive practice) [18]. Each of these reflective processes must include the various elements as discussed above. Through 'reflection-on-action' one may develop the ability to choose correctly as a 'knowing-in-action' reflection. In our study, the self-reflection assignment was undertaken as part of the structured course, focusing on events of the past and concurrent activities as stimuli for learning, both within the classroom and in the extended learning environment. In our specially-designed "5-levels of reflective-awareness" rubric (Table 1): 1) categories A and B evaluated students' abilities to 'reflect-on-action', which is also the first step in Schön's reflective process [18]; 2)categories C, E, and F assessed the second criteria, reflection-in-action, as students identified aspects of themselves within context of the situation as it occurred; and 3) categories D and G appraised the ability to 'know-in-action', by in-the-moment identification of one's abilities with future directions.

Reflection and reflective practice are essential attributes for competent healthcare professionals that have to function in complex, changing healthcare systems. Formal requirements for practitioners to provide evidence of reflective practice is becoming mandatory in many of the licensing and re-validation processes of the governing bodies such as the College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, and General Medical Council UK [19]. Therefore, it is imperative that early and repetitive practice to acquire competency in this skill is explicitly included in the curriculum in the early years of undergraduate medical education.

In its entirety, reflection as a cognitive and affective process or activity is aimed at broadening and deepening one's understanding of the choices available through active engagement by the individual that may be triggered by an unusual experience and involves examining one's responses, beliefs, and premises to this situation resulting in an integration of the new understanding into one's personal experience. Thus, this reflection may be influenced by the situation itself, or by factors related to the individual and/or the larger environment. The process of reflection begins with the identification of a problem and a deliberate decision to seek a mindful solution; yet, the process of reflection does not always have a defined beginning and end, leading to further reflection with continued deeper understanding [14]. In our study, this assignment embodied an example of reflective practice that required students to act and think professionally as an integral component of in-course learning, facilitating knowledge transfer from in-class to professional practice [19]. Sobral demonstrated that an increased effort at reflection is associated with a more positive/meaningful learning experience with greater enjoyment of studies, and higher scores in diagnostic thinking and problem-solving. Increased reflection was also associated with greater perceived learner autonomy. Such 'reflection-in-learning' facilitated by educational interventions such as self-reflective assignments could induce readiness for stronger self-regulation of learning with enhanced diagnostic thinking ability [20]. The changing, intricate healthcare system requires clinicians to continually refresh and update their knowledge and skills to solve complex patient problems [19]. These traits, if specifically targeted by repetitive exposure to reflective practice assignments commencing in the early years of undergraduate medical/dental students' career, may result in an enhanced education with personal/professional effectiveness of critical thinking skills [14]. Through an increased awareness, understanding and recognition of their own personal learning styles, abilities, responses, and beliefs, medical/dental students may develop a readiness for application with new perspectives and a commitment to action through effective and enhanced critical thinking skills [20].

Though the broad concept of self-reflection has been thoroughly outlined in the literature, specific references to the stage of life at which such reflection should begin are sparse. The beginning of one's professional training is crucial for the development of a future professional identity [21]. To fully develop capabilities needed to succeed in any profession, exposure and ongoing reflection are necessary [22]. Students often enter medicine/dentistry with certain expectations; self-regulation enables the development of more accurate perceptions with greater flexibility and creativity [14]. Encouraging students to begin their reflective practices during the early years of medical/dental school establishes both a foundation for personal and professional development with a set of rudimentary critical thinking skills which may be expanded and perfected through the remainder of their professional career.

In their reflective documents, several of the students commented on the perceived usefulness of this activity and the importance that they believed reflective practice would have in their future. The majority of students (> 75%) who reflected on the learning process responded favorably to this activity, commenting "This assignment has made me more self-aware of the best way that I learn. This makes me want to try harder to find the learning methods that work best for me so that I can maximize how much I am able to learn". Students felt this 'reflection-on-action' contributed to their learning, commenting "There is a unique component in this course- this document. After finishing a course there is usually no time to look back at what I learned - not only at the material, but why I learned it and how I can use the knowledge. Because I will care for real patients someday, I know that I need to retain the knowledge and learn the most effective way to gain new insight; this effective learning activity teaches me to do just that". A few students (< 10%) however, did state they felt the assignment was a "waste of time" and that this was an 'assessment' that was 'highly prone to subjectivity'. This latter cohort of students had decreased awareness in many of the levels of understanding in comparison to students that valued this particular assignment as an educational growth activity. This suggests that increased awareness with enhanced reflective abilities may provide a deeper understanding of the importance of reflection and reflective practice in the educational development of healthcare professionals. These findings, however, are limited as they are an educational intervention snapshot of the students' reflections in a single course of their undergraduate education. Additionally, these findings are dependent entirely on the individual perception of the given cohort of students.

In summary, we recommend that such reflective processes be incorporated as part of a continuum in the overall curriculum design of the undergraduate education of healthcare professionals. It is well-known that in the student world, assessment drives learning. However, prioritizing self-reflection as an assessment tool is a daunting task, as one's depth of reflection is a) difficult to evaluate objectively, b) time-consuming to assess, and c) challenging to standardize. Nevertheless, with effective feedback of such educational interventions as part of formative assessment, learners can be provided with information to enhance their learning/practice with critical thinking skills, to result in affecting positive change [23].

Though reflection has existed for many millennia and continues in the current digital era as "social reflection" practices, its value in enhancing higher education is only beginning to be explored in the current literature. The process of reflecting and its benefits in enhancing learning and personal growth are emerging in the research domain as an effective teaching/learning tool that may be implemented at any level of education. The introduction of self-reflection early in undergraduate medical/dental education promotes the creation of personal meaning of one's reactions, values, and premises in the context of student learning environments. Early introduction to such cognitive processes with repetition serve as practice tools to develop and become proficient in mastering this competency resulting in the creation of future reflective health professionals.