Medical students’ perspectives of reflection for their professional development | BMC Medical Education

The study participants included 10 males and 10 females with the mean age of 24 years from different stages of the medical program at Shahid Sadoughi University of Medical Sciences in Yazd in 2023. All participants were Iranian and Muslim. In terms of their family status, 4 were married, 2 were engaged, and 14 were single. The content analysis technique revealed 168 primary codes which were categorized into three main themes and seven sub-themes within the concept of reflection. As can be seen in Table 1, the identified main themes included: [1] self-awareness; [2] professional competence; and [3] reflection culture.

Self-awareness; I accepted my real self as I am

Self-awareness constitutes a critical component of reflective practice, especially within the framework of medical education and professional development. It encompasses the capacity of individuals to identify and comprehend their own thoughts, emotions, and behaviors, along with the effects these have on others. In the context of medical training, self-awareness is essential for fostering empathy, refining communication skills, and ultimately improving the quality of patient care [17]. Research shows that individuals who have a clear understanding of themselves tend to exhibit higher levels of confidence and creativity. This self-awareness also leads to improved decision-making, stronger interpersonal connections, and enhanced communication skills. Additionally, individuals who possess this level of self-awareness are less likely to engage in deceitful or unethical behavior, and are more likely to excel in their professional roles and leadership positions [34].

Self-acceptance; Reflection made me accept myself as I am

Self-acceptance plays a crucial role in maintaining mental health. Failure to embrace oneself can lead to various emotional problems, such as uncontrolled anger and depression [35]. Majority of participants emphasized the significance of self-reflection in recognizing their skills and accepting themselves unconditionally.

“Through self-reflection on my learning process and the skills I possess, as well as those I lack, I gradually come to accept myself as I am. I observe that some of my peers struggle to acknowledge their deficiencies in truly understanding concepts, relying instead on rote memorization without practical application” (P.4. clinical training level).

This reflection underscores the role of self-awareness in promoting acceptance, enabling individuals to acknowledge their shortcomings rather than overlook them. Furthermore, it addresses a more pervasive concern within educational settings, wherein certain students may refrain from engaging with the material on a deeper level.

Another participant stated:

“Upon entering the university, I viewed university as an extension of high school where learning was solely based on textbooks and lectures, I gradually realized the need to reassess my study habits and learning approach. Reflecting on the discrepancy between studying anatomy and physiology, I recognized the necessity of seeking out diverse sources to properly grasp the material. This process of reevaluation allowed me to embrace my strengths and weaknesses, ultimately guiding me towards a more effective and self-aware approach to learning” (P.6. basic science level).

This assertion highlights the significant impact of reflection within academic environments, stressing that self-acceptance extends beyond mere recognition of one’s present condition; it also involves a proactive commitment to personal development and the modification of learning approaches.

Metacognitive self-exploration; I started to explore about myself

John Flavell first coined the term metacognition in the late 1970s and defined it as “cognition about cognitive phenomena” or, in simpler words, “thinking about thinking” [36]. Self-exploration is defined as the mindful, and enduring practice of identifying and challenging one’s assumptions and actions in light of new information arising from exposure to new surroundings and the passage of time [37]. Participants in this study highlighted the transformative impact of metacognitive self-exploration on their learning experiences. One student reflected on her academic journey, stating:

“After three years of studying medicine, I observed that while some students excel in exams, they may struggle to explain the material or apply it in real-world scenarios. Through exposure to reflection from a senior student, I gradually learned to assess my own learning process and identify areas for improvement over time” (P.11. physiopathology level).

This quotation illustrates the importance of peer influence and reflective practices in fostering metacognitive awareness, enabling students to critically evaluate their understanding and application of knowledge.

Another student at the clinical level stated:

“In my initial year at university, I discovered that my study techniques were inadequate during the first mid-term exams. I am now appreciative of this realization as I progress through my clinical coursework. The use of concept maps has proven to be extremely beneficial in improving my studying methods. Had I not taken the time to reflect on my learning strategies early on, I would have likely encountered numerous challenges at present” (P.8. clinical training level).

This reflection emphasizes how early metacognitive awareness can lead to the adoption of effective study strategies, significantly enhancing academic performance.

Semantic perception; I understood the meaning of the behavior and words of others

The concept of semantic perception is often discussed in psychology and philosophy [38, 39]. It has also been explored in educational contexts and semantic web technologies [40]. Some experts in the field of education propose that semantic perception functions as the sixth human sense, and they state that the inherent nature of semantic perception has a physiological basis. Semantic perception is unique for each person. The sixth sense of perception is explicitly used to sense and identify a variety of semantic relationships in observations and spoken language [41].

We chose to name this subtheme “semantic perception” after considering feedback from students regarding the behavior of medical teachers and other observations within the university setting.

Participants expressed their experience as follows:

“In the initial stages of my time at the hospital, I lacked an understanding of various behaviors and their impact on patients. During clinical rounds, I observed patients becoming visibly uncomfortable when surrounded by a group of students and teachers at their bedside. Despite noticing signs of distress such as changes in facial color and embarrassment, I failed to grasp the significance of these reactions. Reflecting on these experiences afterwards, I realized the stress and difficulty our presence caused for patients. This realization led me to question why some teachers did not prioritize the well-being of patients. I now take the initiative to communicate with patients beforehand, explain procedures, and offer reassurance to alleviate their anxiety. By seeking permission before conducting physical examinations, I have found a sense of fulfillment in ensuring patients’ comfort and well-being” (P.16. clinical internship level).

This reflection illustrates how developing semantic perception can enhance empathy and improve patient interactions, ultimately fostering a more compassionate healthcare environment.

Another participant expressed:

“Upon gaining insight into the concept of reflection, I came to comprehend the significance of human behavior and the qualities of an effective teacher. In our classroom, a teacher used a unique approach to address misbehavior by invoking a sense of shared fatigue, followed by reciting a poem and sharing a personal anecdote with a moral lesson. This method effectively transformed a disruptive student into a well-behaved one. While some of my peers attributed this success to the teacher’s patience, I recognized the value of reflection in uncovering the deeper meaning behind the teacher’s actions. This experience underscored the importance of reflecting on our surroundings to extract valuable educational insights” (P.7. basic science level).

This statement emphasizes the notion that semantic perception transcends isolated interactions, encompassing a comprehensive understanding of broader educational dynamics. It accentuates the significance of reflection in identifying effective pedagogical strategies.

Professional competence

Literature provides a comprehensive definition of competence as: “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served [42].”

Self-directed learning; I set a learning plan for myself

Self-directed learning, as identified in the extracted codes, encompasses intrinsic motivation, the setting of personal objectives, and self-regulation. One student shared her insights on the impact of self-reflection in her learning process:

“Initially, I doubted my ability to grasp the complex subjects within the medical field. Despite feeling anxious, I reassured myself that if I had been accepted into this field, I possessed the necessary capabilities. Through continuous introspection, I established a goal, devised a study plan, and diligently practiced. Seeking guidance from experienced individuals in the field further aided my success” (P.12. clinical training level).

This reflection accentuates the significance of self-efficacy and systematic planning in addressing initial uncertainties and improving educational results.

A fellow student who participated in an internship and completed the final clinical rotation shared his perspectives on the impact of reflection on his academic achievements. He noted that despite hearing about the importance of reflection from various sources—peers, teachers, and online platforms— it was not until he experienced it firsthand in the emergency department that he truly understood its efficacy.

“During my first experience performing a nasogastric tube insertion, I engaged in reflective practices before, during, and after the procedure, identifying areas for improvement and subsequently enhancing my skills through targeted practice. This approach yielded positive outcomes, prompting me to incorporate reflection into my learning process for other procedures with great success. I now advocate for self-reflection as a valuable tool for personal growth and emphasize the role of individual accountability in my academic journey” (P.3. clinical internship level).

This statement points out the transformative power of reflection in skill acquisition and the importance of taking ownership of one’s learning process.

Professional identity formation; reflection helps to understand professional values

Professional values and ethics are the moral principles and beliefs that individuals rely on to determine the ethical standards and conduct expected in a professional setting. They serve as a guiding framework for ethical decision-making and behavior in the workplace [43]. One student reflected on his experiences in the hospital, noting:

“I noticed overlooked situations in the hospital, but by reflecting on them, valuable lessons can be learned. In one of my rotations, a medical teacher prescribed medication for a child without considering the potential interactions with his asthma medication. Despite the lack of serious consequences, the teacher admitted fault and apologized, prompting differing reactions from students. Through deep contemplation, I gained valuable insights from this experience” (P.18. clinical internship level).

This reflection highlights how recognizing and analyzing mistakes can lead to important learning opportunities, reinforcing the significance of ethical considerations in clinical practice.

The perspectives of specific students suggest that contemplating unprofessional conduct can strengthen dedication to one’s field.

“A sixth-year medical student described an encounter with a teacher who had a financial interest in a laboratory kit manufacturing company and would order unnecessary tests for numerous patients. Despite many patients facing financial struggles, they placed trust in the doctor and proceeded with the tests. Observing this behavior prompted me to reflect on how certain individuals compromise the reputation of the profession and prioritize personal gain. This experience solidified my resolve to avoid replicating such behavior in my future career” (P.5. clinical internship level).

This reflection emphasizes the significance of integrity and accountability within the field of medicine, illustrating how the observation of unethical conduct can reinforce an individual’s dedication to professional values.

Reflection culture; conditions should be favorable for reflection

Reflection culture denotes an environment that actively encourages and values reflective practices, prompting individuals to engage in critical analysis of their experiences and decision-making processes. This culture facilitates ongoing learning and enhancement, prioritizing open communication and providing support for the exchange of insights [44]. The student’s behavior is significantly affected by the educational environment, and the educational environment is related to the success, satisfaction, motivation, and fulfillment of the student’s goals, as well as his knowledge, skills, and attitude [45].

Learning climate

The concept of learning climate encompasses the comprehensive environment in which educational activities occur. It comprises various elements, including faculty support, open lines of communication, psychological safety, and collaborative interactions among students. A favorable learning climate fosters increased engagement and enables students to feel secure in articulating their thoughts and reflecting on their experiences [46]. The educational environment plays a crucial role in shaping students’ readiness to participate in open discussions regarding their understanding and reflections. One student articulated:

“When asked by teachers or older students whether I understand a procedure or topic, I pretend that I know to avoid judgment. Instead, I actively seek to improve my understanding by utilizing online resources and collaborating with peers” (P.13. clinical internship level).

This statement highlights the pressure students feel to appear knowledgeable, which can hinder honest communication and learning.

Another student studying physiopathology shared his experience:

“When I first learned about metacognition in high school and understood the benefits of reflection in learning and error correction, I later learned in university to keep my reflections to myself and not discuss them with others. This shift in perspective towards sharing personal reflections was found to be unpleasant, leading me to believe that it was best to refrain from sharing the results of my reflections with others” (P.2. physiopathology level).

This reflection highlights the ways in which the academic setting may inhibit vulnerability and openness, both of which are crucial for facilitating effective learning.

Educational program structure

The structure of an educational program encompasses the systematic arrangement of a curriculum, which includes its content, sequencing, instructional methodologies, and evaluation techniques. Within the context of medical education, this structure is designed to enhance the acquisition of critical knowledge and competencies, thereby fostering student engagement and optimizing learning outcomes [47]. To foster effective reflective practices, managers and educational planners must create conducive environments for students. The overwhelming volume of course materials, intense and repetitive programs, and high academic demands can significantly hinder medical students’ ability to engage in meaningful reflection.

One student expressed her discontent with the circumstances, stating:

“The demanding nature of the internship stage requires students to manage various responsibilities in both clinical settings and academic environments. I question whether the rigorous curriculum and practical experiences permit sufficient time for reflection” (P.9. clinical internship level).

This highlights the concern that a packed schedule may leave little room for introspection, an essential component of learning.

Another student echoed this sentiment, noting:

“Although teachers stress the significance of reflection, there is often a lack of time for it, especially since there typically isn’t much time beforehand. Nonetheless, there are brief moments during the procedure where self-reflection on one’s performance is possible, provided that the circumstances are conducive and there is no added pressure from being monitored by a teacher or resident” (P.14. clinical internship level).

This observation underscores the need for a supportive environment that allows for reflection, particularly in high-pressure situations.