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Three kinds of reflection
  1. John Launer
  1. Correspondence to Dr John Launer, London Department of Postgraduate Medical Education, London Deanery, Stewart House, London WC1B 5DN, UK; jlauner{at}

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A few weeks ago I was invited to run a workshop on reflective practice at a conference. I assumed the arrangements would be much as usual—a 90 min slot with maybe 10 or 12 people attending. I was mistaken. When I arrived I discovered the organisers had planned two slots for me, each lasting only three-quarters of an hour. Twenty-five people had already signed up for each of the slots. The thought of teaching reflective practice to such large numbers in such a short space of time seemed absurd, a contradiction in terms. It challenged my autonomic nervous so much that I had to go to the toilet.

While there, I managed to collect my thoughts. I remembered how often health professionals complain that it's impossible to practise reflectively because time is so short and the circumstances too pressurised, and I wondered if I could use this opportunity to demonstrate the opposite: that reflective practice is always possible if you decide it's your main priority. I worked out a way to show exactly that.

I went to the seminar room where the workshops were taking place and arranged the chairs in a circle around the wall. I pushed the projector table and flip chart into a corner, and made sure I had no notes or papers in my hands or by my chair. Once everyone had come in and settled, I allowed a minute or two for people to sit in silence, expectantly. I introduced myself and pointed out that we had already created between us the ideal circumstances for reflective practice: a group of highly experienced professionals in a quiet room with no distractions and no interruptions. I told them that I didn't intend to teach them anything, but simply to allow them 45 min of protected time for reflection with some clear structures and rules to make sure this happened.

Immediately, someone objected—in the nicest possible way. Since I was meant to be an expert on the subject, she asked, couldn't I just explain to them how to make reflective practice happen in the impossible conditions of today's health service. I replied that this was exactly what I hoped to do, but through modelling it rather than telling people what to do. I told them that I was going to introduce a simple exercise that can be used almost anywhere, and that was going demonstrate three different kinds of reflection. The first kind of reflection is inner dialogue: talking to oneself about a problem and what to do about it. The second kind consists of talking about this to another person. And the third kind involves having a further person (or persons) to witness the conversation and then offer their own thoughts about it.

Reflective exercise

Then I gave them the instructions for the exercise. First, I asked people to get into groups of three, trying if possible to get a mixture of individuals by gender, specialty or whatever. Next, I asked each group to ask one person to think for a couple of minutes about a case or professional issue that was bugging them. I told them they should then allocate 10 min for the person to talk about the problem, with one of the other two asking them questions about it—but nothing else. The role of the third person was just to listen to the conversation, keeping their own views and comments to themselves until the end. I told them that after 8 or 9 min of conversation the three people in each group could briefly share their reflections about what had been discussed, but they should then rotate their roles straight away so that during the course of half an hour every member of each group got a chance to present a problem, ask questions, or be an observer.

Even with such clear instructions, I know from experience that conversations like this can turn into requests for advice from case presenters wanting a quick fix. This calls forth a barrage of suggestions from the questioner and the observer, so that no genuine exploration of the problem takes place. That may be fine in some everyday situations but it isn't reflective practice. So I made things a bit harder for everyone by insisting that the questioners had to obey three simple rules:

  1. You can only ask open questions (eg, ‘what have you thought of doing?’ and not ‘have you thought of discharging her?’)

  2. Every question must link up with words the case presenter has already used and not with your own ideas (eg, ‘what do you mean by “bad COPD?” ’ and not ‘does the patient fit the criteria for home oxygen?’)

  3. You should withhold any suggestions or advice till the end, and avoid giving away your own thoughts by the way you ask your questions.

Satisfying outcome

I've used variations of this exercise many times before but never under such pressure of time, or with a large group of people who were unknown to each other and had no previous training in this method. The outcome was very satisfying, both with this group and with the second group who followed them. Almost everyone reported being astonished by how hard it was to follow a strict set of conversational rules like this, and yet how rewarding the results were when they did. People taking on the role of questioners and observers said they were bursting to give advice and tell the case presenters exactly what they would do in their shoes—a habitual position of certainty and expertise that most doctors take on far too readily. Yet when forced to pay attention, withhold their own opinions, and only respond when enough time had passed for them to form a considered judgement, they were amazed at the quality of the reflections they were then able to share.

The most common remark was that the case presenters' problems seemed to become resolved through the very process of talking, questioning, and listening, and this seemed more productive than direct problem solving of the kind that doctors do most of the time.

Reflection through dialogue

Despite the simplicity of this exercise, it draws on a wide range of thinking about education, psychology, and dialogue that are used in many other fields. Most people involved in medical education will know of the work of Donald Schon and his distinction between ‘reflection in action’ (what one is able to do on the hoof by way of reflective practice) and ‘reflection on action’ (what happens afterwards).1 They will also be aware how much the quantity of the latter will enhance the former, particularly if practised regularly. People may be less familiar with the ideas of thinkers like the Russian psychologist Lev Vygotsky2 and his contemporary, the linguist Mikhail Bakhtin.3 Although working in separate fields, they both came up with theories to suggest that thinking, speaking, and action are in essence not individual activities but ones that are formed through—and informed by—the social process of dialogue.

A similar approach is taken by systemic psychotherapists, who work with clients mainly through the use of carefully crafted questions and dialogue rather than through advice and interpretation.4 These ideas all point towards a close interrelationship between the quality of the conversations we have with each other, the quality of reasoning that takes place within our own minds, and the quality of what we are then capable of producing as a result.

If the brief experience of these two short workshops is anything to go by, it shouldn't be hard to improve patient care through the three simple disciplines of focusing one's mind on an issue, having a proper dialogue about it with someone else, and then conferring with an independent witness to the dialogue. For that to happen, you first need to clear away the noisy paraphernalia that usually surrounds and distracts you, and insist that reflective practice comes first and makes a real difference. It isn't difficult and it doesn't take long.



  • Competing interests None.

  • Provenance peer review Commissioned; internally peer reviewed.