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The Value of Reflection in Internal Medicine Residency Training

By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.”                 –  Confucius

I’m on the internal medicine residency training committee as third year residents’ coordinator. I try to meet them as a batch (of usually 20-22 residents) a few times each year just to see how they are getting on and if they’re having any problems. Some are reticent and some are quite vocal at these meetings. Some meetings are not as productive as the residents just tell me there are absolutely no problems, which i sometimes doubt.



I decided to do something different this year. I am meeting the residents in groups of 5 or 6, two Fridays in a month. With this schedule, I can meet all the third year residents in two months, that’s 6 times within a one year period.

Here’s the format I am using. I play a short video and then go round the table asking each resident in turn to speak up about what they thought about the video. I ask follow-up questions. I give my own comments. I also summarize the discussion at the end. I would call this facilitated reflection?

After the meeting, I ask them to make three tweets (sentences of 140 characters each) as a form of reflection. Not all the residents have Twitter accounts and I haven’t made up my mind yet if I should require them all to get one. Being on Twitter, I know how difficult it can get to condense one’s ideas in 140 characters but doing so often gives more clarity to my thoughts. I learned that at #HCLDR tweet chat! I also know how busy these residents are that writing a 500-word essay may be too much. I’d also have to read them. 🙂

It was @ClinicalArts on Twitter who introduced me to the Kolb Cycle of Experiential Learning. I’d like to think that this is what I’m doing with the residents. Granted, the video I ask them to see is not really a clinical experience in itself but it does trigger a recollection of their own experiences. The brief one hour I have with them is an opportunity for reflective observation or at least of talking aloud one’s thoughts. Hopefully, the short Tweet-like sentences I ask them to write covers abstract conceptualization. Active experimentation will be up to them!



I’ve done two meetings so far and I am indebted to Lisa Fields (@Practical Wisdom) for introducing me on Twitter to Dr. Brian Goldman (@NightShiftMD) and Dr. Leana Wen (@DrLeanaWen) whose talks on Ted I have chosen.

Meeting 1 (Jan 10) – Brian Goldman: Doctors Make Mistakes. Can We Talk About That?


Meeting 2 (Jan 24) – The low-tech healthcare revolution: Leana Wen at TEDxCortland


The residents’ reflection tweets are starting to come in. I’d have to ask if they would agree that I document their responses in another blog post.  I’d like to think this activity is helping them, but it has definitely helped me reflect as well on my own values.





6 thoughts on “The Value of Reflection in Internal Medicine Residency Training”

  1. Some years ago I was adjunct faculty at a college teaching a course on gender, race, and ethnicity in counseling — love your solution. Think it would be fine to require the tweeting — they can have private, locked accounts so only you and their group have access to their private learning efforts. The discipline of 140 characters I think is excellent! Always interested in your perspective, Iris.

  2. Might I suggest that you get the group of 5 to 6 members to do their own synthesis and produce three core tweets on the subject? And perhaps do a presentation on it? You have four groups in total so they could present to each other as a class.

    In a way, you are acting as a perfect modern coordinator of group work (traditionally called leader). They would benefit from that experience, taking it in turns to coordinate. It is an experience that becomes clinically important when the doctor becomes the key worker in a multidisciplinary team.

    I half remember a quote from the origins of independent learning – Whenever a teacher does something for a student that they could have done for themselves, a golden opportunity for independent learning has been lost.

    (I really must get round to the next in the MedEd series on the use of group work and formal structuring when I get time…. ;P)

    Clinical thinking really is just like coordinating group work. Coordinating group work is external, visible practice for this that can be observed and reflected upon.

    Clinical thought is like managing a disparate multidisciplinary team inside your own mind. In the complexities of the clinical situation, there is often an argument between various uncertain possibilities based on risk and benefit. One part of the mind argues for the strictly clinical, another for the individual psychosocial situation, Somehow the mind must argue and synthesise this into a single management plan that considers all of these internal team members opinions and reconciles their conflicting interests.

    Group work should be an ideal democratic process. Unlike in society, it is an educated and informed democratic process of listening, discussion and debate leading to a consensus decision based on prioritisation. The presentation must be time limited to force the group into identifying the most important, core themes.

    So it is a part of the culture of getting all of the basics right instead of doing everything that could be done according to the small print whether it can be argued as appropriate or not. The culture of group work focuses the mind on all of the basics without overcomplicating everything.

  3. Thanks, what a wonderful idea! I could still meet them as a batch of 20 plus residents. There might even be an opportunity for this batch of third year residents to present in a conference that includes all the residents (first year to third year).

  4. I have finally got round to writing something on flat structured teamwork for #meded but it is such a wondrous and wide subject that I really need to write a whole book on the matter. Hence it is a bit bitty and not fully explained…. It is only a very brief introductory guide but I hope that it is interesting or even helps in your coordinator role…..

    In practice, it does work miracles and transforms culture.

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