How do residents reflect in practice? Building an evidence base for meaningful reflection education in General Practitioners'''' specialty training

BACKGROUND Competency-based medical education, such as General Practitioners’ specialty training, depends almost entirely on residents’ ability to learn from experiences. Trainees often perceive reflection as vague and difficult to do, which can lead to frustration. There is a lack of impact of reflection programs in medical curricula. Given the limited evidence regarding how reflection takes place in practice, this is not surprising. In the jungle of often-contradictory theories and recommendations in literature, some medical curricula oversimplify reflection. But a one-size-fits-all method, in which residents are expected to follow a check-list approach to reflection, is no solution. Not only is such an approach inconsistent with the context-bound and personal nature of reflection, it obviates the value of reflection as an antidote to habitual ways of thinking. APPROACH Rather than formulating ‘good reflection’ from theory and looking for it in behavior, our approach starts with what GP residents actually do when asked to reflect. Analyzing reflective talk on a micro-level allows us to systematically describe the reflection process as it develops in real-time, and relate it to both the assessment criteria of GP specialty training (educational themes and CanMEDs competencies) and the practical issues residents encounter when developing into competent reflective practitioners. The resulting taxonomy of reflection profiles will be an evidence base of how GP residents reflect during their training, on which meaningful reflection education can be built: a balance of theory, practical frames, and real-life examples. We will describe how residents at two Dutch GP training institutes reflect in three different settings: individually, in dialogue with their residency supervisor, and in peer groups at the training institute. Using video- and audio-recordings of talk in these settings, we analyze what residents reflect on, the structure of the moment-by-moment reflection process, and the linguistic strategies they draw on. Our ultimate goal is to make reflection tangible and valuable for residents, so that they are motivated to continue their journey as reflective practitioners into their professional life. With this project, we believe that we can contribute to the current paradigm shift in medical education: away from a positivistic, instrumental approach to reflection research and education, towards a focus on what works in practice. RESEARCH QUESTION How do residents reflect in practice? METHODS We will use two Discourse Analysis approaches: Directed Content Analysis (DCA) and Discursive Psychology (DP). DCA will allow us to use the frameworks presented to trainees as their educational material to determine where there is alignment and where there is contradiction between their experience and the guidance received. DP is ideal to describe reflection practice, because it avoids the question of what reflection is, and instead describes the way residents themselves construct reflection on their own terms. We will code the data in three overlapping analytic layers, resulting in a rich taxonomy of reflection content, structure, and strategies. WORKPLAN We will use video-recordings of 40 group reflection sesions at all eight GP training institutes across the Netherlands that we have recorded for another project, and recruit 40 residents from two training institutes (VUmc and Rotterdam) to self-record their individual reflections (audio diaries), and supervisory conversations. Additionally, we will collect the curriculum materials that the Dutch GP institutes use to shape reflection. All data will be collected during the first year of the project, and professionally transcribed. This 4-year project consists of four studies. See Table 1 for project overview and deliverables. STUDY 1: What is the content of residents’ reflection? We describe the topics and triggers that residents construct as objects of reflection, and the way these relate to the educational themes and competencies formulated by GP specialty training. STUDY 2: How does residents’ reflection fluctuate between different levels of abstractness and concreteness? Using DCA, we will describe the level of abstraction of the discussion at each moment, and adapted to the levels that residents themselves orient to. STUDY 3: Which discursive strategies do residents use to reflect? We describe the discursive strategies that residents use to reflect on the topics and triggers, including the context in which they apply these strategies, and the effect they have on the reflective process. STUDY 4: How does reflection in practice by residents relate to reflection models and theory as described in the medical education and institutional curriculum materials (teaching guides, manuals)? We will form an integrated interpretation of the findings using curriculum materials and theory. Fragments of (anonymized) video- and audio recordings will serve as curriculum materials for residents.