Encouraging Reflection to Deepen Learning and Combat Burnout-Rebecca Hutchinson, MD

Kolb describes 4 stages of experiential learning, the type of adult learning that forms the cornerstone of medical education.1,2

Although all of these steps are important, reflection is believed to be particularly important to create deep or lasting learning.3  Reflection is a metacognitive process, or thinking about thinking; this process allows the learner to make connections between new information and prior experiences and knowledge.4  Effective reflection results in connections that increase accessibility of the learning, allowing application to relevant subsequent scenarios.  Reflection can be written or oral, there is no evidence to suggest superiority of one method over the other; this MITE tip will discuss methods of facilitating both.5

There are many ways that we can incorporate reflection into our education of medical trainees of all levels.  Prior to encounters, we can encourage reflection by explicitly discussing our objectives for the visit using questions such as: “What physical exam maneuvers might be most helpful to determine our management for the day?”  or “What questions should we ask the patient in order to further refine our differential diagnosis?”  This type of reflection will help the learner know what to focus on during the encounter, increasing the yield of the learning experience.  This type of ‘pre-visit’ exercise can help all members of the treatment team maximize their learning from a shared patient encounter even if they are not participating in an active way.  We can also encourage reflection after encounters.  Some examples of questions that could be used to reflect are:  “how did the physical exam compare to what we expected to find in this patient with advanced heart failure?” or “what emotion do you think the patient was having when you explained the plan for the day?”1

In addition to facilitating deep and lasting learning, reflection has also been shown to be an effective way to improve resiliency and well-being of the clinician as well as increase empathy for patients.6,7  It is particularly important to help learners take the time to reflect after challenging emotional experiences.  We can do this by having formal or informal debriefing sessions where all members of the care team have the opportunity to share how they are feeling or how the experience is impacting them personally.  We can also encourage reflection through writing, such as through the use of journaling.  Additionally, you could consider having medical students and/or residents do a writing exercise at the end of a month long rotation to encourage reflection.5  Some examples of prompts are: writing gratitude letters to patients, writing about a patient who surprised them and explaining why, reflecting on a time when they felt they communicated something difficult in a way that was effective (or not!).  One fun exercise to consider doing as a group to aid in reflection and team bonding is having everyone write a six-word story.  A famous example of this is “For sale: baby shoes, never worn,” attributed to Hemingway.  These writing exercises help our learners, but they can also help us.


  1. Maudsley G, Strivens J: Promoting professional knowledge, experiential learning and critical thinking for medical students. Medical education 34:535-544, 2000
  2. Kolb DA, Boyatzis RE, Mainemelis C: Experiential learning theory: Previous research and new directions. Perspectives on thinking, learning, and cognitive styles 1:227-247, 2001
  3. Mann K, Gordon J, MacLeod A: Reflection and reflective practice in health professions education: a systematic review. Advances in health sciences education 14:595, 2009
  4. Sandars J: The use of reflection in medical education: AMEE Guide No. 44. Medical teacher 31:685-695, 2009
  5. Aronson L: Twelve tips for teaching reflection at all levels of medical education. Medical teacher 33:200-205, 2011
  6. Chen I, Forbes C: Reflective writing and its impact on empathy in medical education: systematic review. Journal of educational evaluation for health professions 11, 2014
  7. Zwack J, Schweitzer J: If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine 88:382-389, 2013