reflection

A comparison of two methods of teaching reflective

ability in Year 3 medical students
Louise Aronson,1 Brian Niehaus,2 Laura Hill-Sakurai,3 Cindy Lai4 & Patricia S. O’Sullivan5

CONTEXT Little is known about best practices
for teaching and learning reflection. We hypoth-
esised that reflective ability scores on written
reflections would be higher in students using
critical reflection guidelines, or receiving feed-
back on reflective skill in addition to reflection
content, or both, compared with those in students
who received only a definition of reflection or
feedback on reflection content alone.
METHODS Using a 2 (guidelines) · 2 (feed-
back) · 2 (time) design, we randomly assigned
half of our sample of 149 Year 3 medical students
to receive critical reflection guidelines and the
other half to receive only a definition of critical
reflection. We then randomly divided both
groups in half again so that one half of each
group received feedback on both the content and
reflective ability in their reflections, and the other
received content feedback alone. The learners’
performance was measured on the first and third
written reflections of the academic year using a
previously validated scoring rubric. We calculated
descriptive statistics for the reflection scores and
conducted a repeated-measures analysis of
variance with two between-groups factors, guide-
lines and feedback, and one within-group factor,
occasion, using the measure of reflective ability as
the dependent variable.
RESULTS We failed to find a significant inter-
action between guidelines and feedback
(F = 0.51, d.f. = 1, 145, p = 0.48). However, the
provision of critical reflection guidelines
improved reflective ability compared with the
provision of a definition of critical reflection only
(F = 147.1, d.f. = 1, 145, p < 0.001). Feedback
also improved reflective ability, but only when it
covered reflective skill in addition to content
(F = 6.5, d.f. = 1, 145, p = 0.012).
CONCLUSIONS We found that the provision of
critical reflection guidelines improved perfor-
mance and that feedback on both content and
reflective ability also improved performance. Our
study demonstrates that teaching learners the
characteristics of deeper, more effective reflection
and helping them to acquire the skills they need
to reflect well improves their reflective ability as
measured by performance on reflective exercises.

Medical Education 2012: 46: 807–814

doi:10.1111/j.1365-2923.2012.04299.x

Discuss ideas arising from this article at

www.mededuc.com ‘discuss’

1 5
Division of Geriatrics, School of Medicine, University of California Office of Medical Education, School of Medicine, UCSF, San
San Francisco (UCSF), San Francisco, California, USA Francisco, California, USA
2
Department of Psychiatry, School of Medicine, UCSF, San
Correspondence: Louise Aronson, Division of Geriatrics, School of
Francisco, California, USA
3 Medicine, University of California San Francisco, 3333 California
Department of Family Medicine, School of Medicine, UCSF, San
Street, Suite 380, San Francisco, California 94118, USA.
Francisco, California, USA
4 Tel: 00 1 415 514 3154; Fax: 00 1 415 514 0702;
Department of Medicine, School of Medicine, UCSF, San
E-mail: louise.aronson@ucsf.edu
Francisco, California, USA

ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814 807
L Aronson et al
INTRODUCTION
Since the late 1990s, accrediting bodies have recog-
nised the importance of reflection in medical
education to improve medical practice in a wide array
of areas from acceptance and use of feedback to
minimizing diagnostic errors.1–4 In response,
educators have added reflective activities into
courses, clerkships, residencies, recertification and
continuing education.5–8 Review of the literature on
reflection in medical education, as well as our own
experience with learner reflections at the University
of California San Francisco (UCSF), revealed an
inconsistent and often poor display of the compo-
nents of reflection as they are described in the
literature. We hypothesised that one of the reasons
why learners do not reflect in this way is that we fail to
train them to do so.
Despite a significant literature on reflection in
education generally, dating from the 1980s,9,10 as well
as consistently increasing numbers of reflection-
related health professions education publications,5,11
there remain a diversity of terminologies and defini-
tions of reflection. Similar processes are variably
described as reflective learning,12 reflective prac-
tice,13 critical reflection,14 mindfulness15 and critical
incident review,16 among others. Theorists agree,
however, that reflection is principally a cognitive or
metacognitive process, that it requires engaged
examination of both self and situation, and that its
goals are learning and improved future personal and
professional effectiveness.12–14,17,18 For health
professionals, reflection is considered a key skill
because it is thought to facilitate learning from
experience, self-assessment and self-monitoring, and
the maintenance of competence over decades in
practice.
Given the assorted terminologies for reflection,
perhaps it is not surprising that there exists no widely
accepted approach to teaching reflection. Indeed,
notwithstanding the substantial work on reflection
carried out to date, relatively little attention has been
devoted to the study of best practices for building
reflective capacity. The majority of studies on teach-
ing and learning reflection in medical education fall
into one of three types: (i) qualitative analyses of
learner reflections to identify themes in the curricu-
lum and the learners’ experience;19–21 (ii) develop-
ment and testing of scales to measure learners’
reflective skills,22–24 and (iii) assessment of the impact
of learner reflection on learning and perfor-
mance.4,25,26 Such studies describe many different
808 ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814
types of reflective exercises, including journal entries,
personal illness narratives, portfolio entries, blogs,
critical incident reports, narratives, video essays and
prompted reasoning, which suggest various peda-
gogical approaches, but they do not evaluate the
teaching method per se.
Numerous articles describe the development and
evaluation of reflection exercises, but relatively few
address the larger issue of how reflection should be
taught. Recent contributions include a description of
the qualitatively rigorous development of a frame-
work to guide faculty feedback on reflection, with
high face validity but no evaluation of efficacy,27 and
a study of student focus groups which showed that
formative rather than summative feedback, privacy
protections, and faculty champions support reflec-
tion.28 A randomised trial by Baernstein and Frye-
Edwards29 found that a one-to-one faculty interview
promoted reflection on professionalism more effec-
tively than did critical incident reports alone or such
reports followed by a faculty interview. This study was
challenged, however, by its use of a single prompt for
the critical incident report and a semi-structured
format including reflection-promoting questions for
the interview. A quasi-randomised trial by Fischer
et al.30 found no difference in level of reflection
between traditional written reflection with small-
group discussion and blogged reflections with posted
commentary. Each intervention had implementation
issues and students reported preferring the approach
to which they had been randomly assigned. These
are among the few studies that have compared
teaching methods. In the face of mounting data
showing low levels of reflective ability in medical
trainees,23,31,32 but improvements with structured
approaches to teaching reflective skill,33,34 the
paucity of data on best teaching practices needs to
be addressed.
The purpose of this study was to assess the impact of
critical reflection guidelines, feedback about reflective
ability, and the interaction between the two on the
reflective ability demonstrated by medical students in
written reflections. This allowed us to investigate the
following hypotheses: (i) there will be a difference in
reflection scores between students who do and do not
receive guidelines; (ii) there will be a difference in
reflection scores between students who do and do not
receive feedback on reflective ability in addition to
feedback on reflection content; (iii) there will be a
difference in reflection scores between two reflections
completed early and late in Year 3 of medical school,
and (iv) there will be significant interactions among
the factors in this design.
 Comparison of teaching methods for reflection

(final) clerkships in months 2, 6 and 12, respectively,

METHODS
Study design
This study follows the framework of a randomised
controlled trial (Fig. 1). After receiving definitions of
reflection and critical reflection, third year medical
students were sorted into small groups for delivery of
their standard curriculum and exposed to one, both
or neither of two methods of teaching reflection,
guidelines and feedback. Using simple random sam-
pling, half of the small groups were randomly
assigned to receive guidelines for reflection or to
simply receive a definition of reflection. All students
received feedback on the content of their reflections,
but within each experimental condition (guidelines
versus definition only), half of the small groups again
were randomly assigned to receive feedback about
their reflective skill (i.e. the process used to demon-
strate reflection). Unfortunately, this random assign-
ment of groups led to varying numbers of students in
the study arms as students who took time off prior to
Year 3 were placed together into groups that were
larger than the others and which were randomised to
the control (i.e. definition only) study arm. Learners’
performance was measured on the first and third
(final) written reflections of the academic year using
a previously validated scoring rubric. This study was
approved by the UCSF Institutional Review Board.
Participants and setting
The study population consisted of the entire third
year class at UCSF during the 2009–2010 academic
year, a total of 163 students. At our institution,
third year students participate in three mandatory
‘intersessions’, which are week-long units of class-
room time that occur after the first, third and sixth
of the third year. During each intersession, which
includes coursework on health policy, medical ethics,
basic sciences, clinical decision making and profes-
sional development, students are required to write a
critical reflection on professionalism in response to a
prompt related to that week’s curricular focus (tran-
sition to clerkships, good and bad professionalism,
medical mistakes). In prior years, students received
only a prompt for the reflection exercise. The critical
reflections were de-identified for the purposes of this
study, and all learners received feedback on at least
the content of their reflections.
Procedures
All students were given definitions of reflection and
critical reflection (reflection – looking back at some-
thing, considering it; critical reflection – the process of
analysing, reconsidering and questioning experiences
and of making an assessment of what is being
reflected upon for the purposes of learning) and a
specific prompt for each critical reflection assign-
ment. Students who were assigned to also receive
guidelines were given structured reflective learning
guidelines called LEaP (Learning from your Experi-
ences as a Professional).33,35 These three-page, liter-
ature-derived guidelines first provide guidance on
strategies for more effective critical reflection, next
take learners through a four-step process of struc-
tured questions modelled on the clinical SOAP
(Subjective, Objective, Assessment, Plan) note, and
finally provide answers to a set of frequently asked
questions about the purpose and methods of critical
reflection.
Students submitted their reflections electronically to
a research assistant who had assigned a randomly

Students
DefiniƟon of criƟcal
reflecƟon
n = 149

LEaP: Non-LEaP:
ReflecƟon No reflecƟon
guidelines guidelines
n = 68 n = 81

Feedback: Feedback:
Feedback: Feedback:
Figure 1 Study design: 2 · 2 · 2 study content and content and
content only content only
of reflection in Year 3 medical process n = 34 process n = 52
n = 34 n = 29
students at a US medical school

ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814 809
L Aronson et al
selected five-digit number to each learner.
The research assistant de-identified each reflection
and labelled it with the appropriate five-digit number
to allow individual learners to be tracked anonymously
over the study period. Two faculty members previously
trained as raters,36 with an inter-rater reliability (in-
traclass correlation coefficient [ICC]) of 0.91, between
them scored all reflections using a previously validated
rubric31 for scoring reflective ability. According to this
rubric,37 scores were given in increments of 0.5 on a
scale of 0–6, where 0 = ‘failure to address assignment’
and 6 = ‘analyses experience and feedback, identifies
lessons learned, crafts a plan for the future, and cites a
means of determining the plan’s success’.
The blinded reflections were read and each student
was given feedback on the content of each reflection by
one of four study faculty (the two raters and two others)
using an agreed-upon protocol that acknowledged the
learner’s experience and feelings, listed the learner’s
major concerns or themes, and provided comments or
questions to challenge assumptions and beliefs and
provoke further learning. Half of the students in each
arm (i.e. those using and not using the reflection
guidelines [the LEaP and non-LEaP groups]) also
received feedback on their reflective skills from two
study faculty. The consensus protocol for the reflective
skill feedback began with the phrase: ‘Reflection is not
intuitive; it requires training and practice.’ Next,
faculty noted which of the components of critical
reflection had been performed well, suggested how the
reflection might have been improved, and tried to
offer a specific example of how the next component of
the LEaP guidelines might have been applied. In the
course of training in the provision of both content and
reflective ability feedback, faculty members practised
giving feedback on reflections outwith the study until
all gave similar feedback. We also gave feedback on the
same study reflection periodically to check for drift.
Because we had few faculty and many reflections, the
feedback on the reflections was returned to learners
with a copy of the reflection at the same time as they
were given the subsequent reflection assignment at the
next intersession, either 3 or 6 months after the initial
writing. We included only the first and third reflections
in the analysis because they were similar types of
assignment.
Data analysis
We calculated descriptive statistics of means and
standard deviations for the reflection scores. We
conducted a repeated-measures analysis of variance
with two between-groups factors (LEaP versus non-
LEaP, and Feedback group–Content versus Feedback
810 ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814
group–Content + Process) and one within-subjects
factor (Time). The dependent variable measured on
each of the two occasions was a reflective ability score
obtained from two written reflections. All analyses were
conducted in SPSS Version 17.0 using a general linear
model analysis (SPSS, Inc., Chicago, IL, USA). The
level of significance was set at 0.05 for the main effect
and interaction hypotheses. We reported each F
statistic and the associated effect size as measured by
partial eta square. We reported the estimated marginal
means, which predict the reflection scores if the cell
sizes are equal, and the 95% confidence intervals for
these means.
RESULTS
A total of 149 of 167 students completed both the first
and third reflections. This represented 100% of the
students enrolled in the course throughout the year.
Although 167 students participated in the interses-
sion curriculum at some point during the 2009–2010
academic year, 18 students took only part of the
curriculum because they were returning from or
entering research years, took time off, or participated
in a single intersession to make up for a session
missed in the previous year. As these students, who
came disproportionately from the LEaP study arm,
did not complete the entire curriculum, their data
were not included in the analysis.
Table 1 shows the descriptive statistics for the
reflection scores by each level of the reflection group
(with and without LEaP), according to whether or not
the feedback included comments on students’ reflec-
tive ability, and for the two reflection exercises, as well
as the estimated marginal means and the associated
confidence intervals. Regardless of study arm, reflec-
tive ability did not change across the two occasions.
Similarly, the three-way interaction (guideline · feed-
back · occasion) and the two-way interactions (guide-
line · occasion, feedback · occasion, guideline ·
feedback) were non-significant (Table 2). Our
hypothesis that the use of guidelines would affect
performance was significant; reflection scores were
better for learners who used the guidelines than for
learners who received only the definitions of reflec-
tion. Our hypothesis that the receipt of feedback would
have an effect on both content and reflective ability was
supported; students who received feedback on content
and reflective ability achieved higher scores than those
who received feedback only on content (Table 2).
We conducted a secondary analysis. The first score
reflects only the effect of guidelines because the
 Comparison of teaching methods for reflection

Table 1 Mean reflection scores (and 95% confidence intervals) of Year 3 medical students as a function of guideline receipt, feedback on
reflection process, and occasion of measurement (time)

Score*, mean (95% confidence interval)

First reflection  Second reflection Mean of both reflections

LEaP group (definition plus guidelines) (n = 68) 3.76 (3.52–4.00) 3.86 (3.60–4.12) 3.81 (3.63–3.98)
With process feedback (n = 34) 3.86 (3.52–4.20) 3.98 (3.59–4.37) 3.92 (3.62–4.22)
Without process feedback (n = 34) 3.65 (3.30–4.00) 3.74 (3.40–4.08) 3.69 (3.45–3.94)
Non-LEaP group (definition only) (n = 81) 2.32 (2.09–2.55) 2.22 (2.03–2.41) 2.33 (2.16–2.49)
With process feedback (n = 29) 2.43 (2.09–2.77) 2.62 (2.3–2.90) 2.52 (2.33–2.72)
Without process feedback (n = 52) 2.25 (1.94–2.56) 2.00 (1.76–2.24) 2.13 (1.92–2.34)
All process feedback participants (n = 63) 3.20 (2.90–3.50) 3.35 (3.05–3.65) 3.22 (3.04–3.40)
All no process feedback participant (n = 86) 2.81 (2.54–3.08) 2.69 (2.4–2.96) 2.91 (2.75–3.07)

* Score range: 0 = no reflection, 6 = critical reflection

 
At first reflection learners had been assigned to receive LEaP guidelines or not but had not received any feedback

Table 2 Analysis of variance results of the 2 (guidelines) · 2 (feedback) · 2 (time) design

Source Sum of squares d.f. Mean square F -value p-value Partial eta squared

LEaP 152.40 1 152.41 129.80 < 0.001 0.474

Feedback 7.40 1 7.44 6.40 0.010 0.042
Time 0.14 1 0.14 0.10 0.700 0.001
LEaP · Feedback 1.20 1 1.16 1.00 0.320 0.007
LEaP · Time 0.50 1 0.50 0.50 0.490 0.003
Time · Feedback 0.80 1 0.80 0.90 0.350 0.006
LEaP · Feedback · Time 2.00 1 2.00 2.10 0.150 0.014
Error 169.10 144 1.17

students had not received feedback at the time they
wrote the reflections. The second score reflects
guidelines plus feedback. Treating the first score as a
covariate to the second score, we found the same
results as in the primary analysis: guidelines
(F = 59.09, d.f. = 1, 144, p < 0.001) and feedback
(F = 6.81, d.f. = 1, 144, p = 0.01) had significant
effects on both reflective ability and content scores,
and there was no interaction between the two
(F = 1.36, d.f. = 1, 144, p = 0.24).
DISCUSSION
We hypothesised that two teaching methods involving
the provision of, respectively, guidelines and feed-
back, would improve reflection scores on medical
students’ written reflections compared with those on
reflections written without any teaching of reflection,
and that guidelines and feedback together would be
more helpful than either alone. We found that
critical reflection guidelines and feedback on the
reflective process in addition to feedback on content
each improved performance, but there was no inter-
action between guidelines and feedback.
Our results suggest that in reflection, as in clinical
practice, guidelines improve performance. The effect
size was moderate. Although others have proposed
guidelines or structured questions to provoke more
effective reflection,22,38,39 this is the first study to
show their efficacy using a control group. Moreover,
the literature assessing learner reflective ability with-
out such structured interventions argues that

ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814 811
L Aronson et al
reflective activities which do not include guidance do
little to develop reflective capacity in learners.
Although many models of reflection have been
developed, all, including ours, present a continuum
from less to more reflective and most continua share
certain characteristics. It stands to reason that teach-
ing learners the characteristics of deeper, more
effective or ‘critical’ reflection and helping them
acquire the skills to reflect well should occur in
conjunction with evaluations of their ability to do so.
Schön18 and Mezirow14 make theoretical arguments
for the importance of mentorship and feedback in
reflective learning. Although their arguments are
sound, this paper attempts to demonstrate the
positive outcomes for which they argue. Based on the
literature showing the benefits of feedback in learn-
ing generally and in reflection specifically,3,40,41 we
expected that feedback would be at least as effective
as guidelines in improving learners’ reflective skill.
Although the effects of both guidelines and feedback
were statistically significant, their effect sizes were
quite different. Feedback had a very small effect size.
Further, we found that the impact of content feed-
back, which challenged learners’ assumptions as
recommended by Schön18 and Mezirow,14 did not
reach significance, whereas the use of guidelines did.
These findings reinforce the notion that structure
helps improve reflective ability, but raise questions
about best practices for providing feedback when
teaching reflection.
Although we had anticipated an interaction between
guidelines and feedback, we found none. It may be
that the ability to demonstrate reflection depends not
only on teaching and reflective skill, but also on the
relationships between the learner and those request-
ing the reflection and providing feedback. Alterna-
tively, and perhaps most likely, this study’s failure to
support our hypothesis may be a consequence of the
timing, amount and source of feedback in our
intervention. Ideally, all trainees would achieve near
perfect reflection scores by the time they enter
practice. Although students in the LEaP groups more
often achieved deeper and more effective levels of
reflection, their average scores still fell short of those
indicating optimal reflection (3.81 out of 6). Thus,
although we can improve skill with these exercises
using feedback and guidelines, it would appear that
more work is required to determine how to develop
and sustain in our learners skills that could be
meaningful to their professional lives.
This study had notable limitations. Firstly, because we
randomised by group and a subset of groups varied in
812 ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 807–814
size, our study arms contained unequal numbers and
learners who ended up in the non-LEaP–content
feedback only group may have differed from those in
other groups as they were more likely to have taken
time out from medical school. Secondly, two of the
faculty who provided the feedback also scored the
reflections and, although this would not result in
systematic bias, we cannot exclude the possibility that
the ratings influenced the feedback. Thirdly, we
conducted the study in a less than optimal educa-
tional context according to both the multi-source
feedback and self-assessment literatures.42,43 The
assignments took place in the sole non-clinical and
ungraded course in the third year, the reflections
were required but not graded and not necessarily
addressed by the small-group leaders, and the faculty
members who provided feedback were not associated
in a meaningful way with the course. Fourthly,
students received feedback just twice and months
after turning in their reflections, which raises con-
cerns about dose and timeliness. Fifthly, because this
was but a small part of a larger course, we were unable
to collect data on the learner experience of the
process. Finally, although the reflective ability score
and guidelines were developed independently, both
were derived from the reflection literature and thus
there is likely to be some degree of overlap between
them, despite the absence of explicit, intentional
teaching to the test.
This study helps to inform the research agenda on
reflection in medical education. Further comparison
studies of educational approaches that examine
format (journal, essay, vlog [video log], blog, etc.),
methods of instruction, most effective types and
timing of feedback, and strategies for maximising
learning while minimising faculty burden, are re-
quired. We also need to determine the dose of
education needed not just to improve reflections as
we showed in this study, but to move learners to the
point at which they can consistently demonstrate the
ability to effectively reflect.
Based on our experience, we feel comfortable rec-
ommending the following to educators: (i) reflection
should be taught from the start of medical school as it
is a complex skill that takes time and practice to
master; (ii) feedback should be provided not only on
content and to improve reflective skills, but to
establish a culture of reflection, signal its importance
to learners, and enable recipients to learn from it;
(iii) given the already full curriculum, it might be best
to build reflective skill while accomplishing another
curricular goal, such as the assessment of competency
milestones, but explicit attention should be given to

building reflective skill in whatever context it is
taught, and (iv) as teaching reflection poses chal-
lenges, figuring out how to do it in an effective, cost-
effective way is essential if indeed it is one important
skill underlying self-monitoring and lifelong learning.
Contributors: LA contributed to the conception and design
of the study and to the acquisition and analysis of data, and
drafted the article. BN and LH-S contributed to the study
design and the acquisition of data. CL contributed to the
study design and data interpretation. PSO’S contributed to
the study conception and design, and the analysis of data.
All authors contributed to the drafting and critical revision
of the article and approved the final manuscript for
publication.
Acknowledgements: the authors would like to thank the
University of California San Francisco (UCSF) School of
Medicine class of 2012.
Funding: Association of American Medical Colleges
Western Group on Educational Affairs Education Research
Award; UCSF Medical Education Research Fellowship.
Conflicts of interest: none
Ethical approval: this study was approved by the UCSF
Institutional Review Board after expedited review.
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Received 22 October 2011; editorial comments to authors
16 December 2011, 7 March 2012, 28 March 2012; accepted
for publication 2 April 2012