CBME, by the ICBME Collaborators, Competency-based medical education
by ICE Blog Admin

Reflecting for Change: A simple model for Reflection to Strengthen Professional Identity Formation in Distributed CBME

By: Machelle Linsenmeyer, EdD, FNAOME

Why Reflection?

Reflection has long been integral to health professions education as a way to navigate the complex process of professional identity formation (PIF)—the multi-year journey of ‘thinking, acting, and feeling like a doctor.’ While many programs use reflective writing to promote metacognition and critical thinking, research shows that practices vary widely, and superficial or ‘zombie’ reflections often fail to deliver meaningful growth.1

Reflection is more than self-assessment; it is a disciplined, metacognitive habit that converts experience into durable learning and action—especially vital in distributed programs where learners rotate across sites, modalities, and supervisory cultures. Framed through dual-process cognition (Type 1 intuitive and Type 2 analytical), structured reflection can help learners and clinicians interrogate heuristics, surface hidden-curriculum influences, and align values with behaviors in real contexts. When implemented intentionally, it safeguards diagnostic reasoning, fosters adaptive expertise, and advances professional identity formation across diverse learning environments.

Effective reflection should be longitudinal, integrated throughout formal and hidden curricula, and move beyond self-assessment to critical reflection—examining how social and systemic factors shape beliefs and behaviors. When fully embedded, reflection can mitigate hidden curriculum influences and foster deeper self-awareness, enabling learners to analyze not only what they experienced but why they responded as they did and what that reveals about their evolving identity.2

Core Frameworks

There are multiple frameworks that have been mentioned in the literature to support reflection.  A few of them include:

  • Schön’s reflection-in-action/on-action which invites micro-pauses during encounters and structured post-encounter debriefs.3
  • Gibbs’ six-stage cycle—Description, Feelings, Evaluation, Analysis, Conclusion, Action Plan—which offers a clear scaffold for journaling and ePortfolio entries.4
  • PEARLS which blend learner self-assessment, focused facilitation, and directive teaching to normalize reflection and psychological safety in simulation.5

There are also opportunities for reflection in discussions using case-based discussions and entrustment-based discussions which help learners review cases and, with EBDs, move beyond case review to examine understanding, risks, and context differences.

Simple Reflection Model

However, to really embed reflection and integrate it longitudinally across the complex nature of a distributed learning environment, the reflection activities must be simplistic and endure multiple purposes.  For this reason, several institutions are using tools that provide simple questions that are easy for learners or clinicians to remember and that support dual-process thinking—Type 1 (intuitive) and Type 2 (analytical)—helping learners examine biases and improve reasoning.2 These tools promote safer diagnostic decisions and reduce hidden curriculum effects.

The most effective approach combines Driscoll’s model6 and Nguyen et al.’s framework7. Driscoll’s three questions—What? So what? Now what?—are straightforward and adaptable. Nguyen adds a critical prompt: Why do I think that? Together, the hybrid model guides learners to describe events, analyze meaning, plan changes, and uncover underlying assumptions.  Thus, an effective model (the simple hybrid model) becomes:2

  • What?
    • Describe the event/context using observations and actions.
  • So what?
    • Analyze meaning, effects, and tensions (e.g., hidden curriculum).
  • Now what?
    • Specify behavior changes, resources, and follow-up.
  • Why do I think that?
    • Move into thinking about the conscious or unconscious framework that supports their thoughts and actions to uncover values, biases, and Type 1 assumptions.

This method pairs well with Powerwriting: a 10-minute, uninterrupted write using these prompts. Such practices help avoid superficial ‘zombie reflections’ and foster habit-oriented, meaningful reflection.2

Where to Embed Reflection in Distributed CBME

The simple hybrid model is flexible enough to be used solely throughout training and in multiple contexts or situations by making it a structured expectation intertwined into CBME programming (e.g., set a weekly, monthly, or quarterly requirement but let learners decide the context of the reflection).  It could also be combined with other frameworks, if greater specificity is required for specific situations.  For example, telemedicine EPAs could include a reflection using Schon’s framework before the visit to set intentions (for-action) and then during to take micro-checks to adjust communication (in-action) with the simple hybrid model following to debrief and develop a concrete plan forward.  For simulation, you might use PEARLS for debrief flow, then the simple hybrid model for written reflection in an ePortfolio. For workplace-based assessment, you might pair mini-CEX/DOPS with the simple hybrid model, so reflections translate into specific change plans that travel across sites.

Closing

In CBME, reflection is the mechanism that converts data, debriefs, and experience into meaningful change. By using simple models for reflection or pairing simple models with established frameworks, programs can standardize depth while preserving local flexibility—cultivating metacognitive habits, safer reasoning, and a coherent professional identity that endures across sites and contexts.

Refrences:

  1. de la Croix A, Veen M. The reflective zombie: problematizing the conceptual framework of reflection in medical education. Perspect Med Educ. 2018;7(6):394–400. https:// doi. org/ 10. 1007/s40037- 018- 0479-9.
  2. Linsenmeyer, M., & Long, G. (2023). Goal‑oriented and habit‑oriented reflective models to support professional identity formation and metacognitive thinking. Medical Science Educator, 33, 569–575. https://doi.org/10.1007/s40670‑023‑01752‑9
  3. Schön, D. A. (1983). The reflective practitioner: How professionals think in action. Basic Books.
  4. Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Oxford Polytechnic.
  5. Eppich, W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS). Simulation in Healthcare, 10(2), 106–115.
  6. Nguyen, Q. D., Fernandez, N., Karsenti, T., & Charlin, B. (2014). What’s reflection? A conceptual analysis of major definitions and a proposal of a five‑component model. Medical Education, 48(12), 1176–1189.
  7. Driscoll, J. (1994). Practising clinical supervision: A reflective approach. Senior Nurse, 14(1), 47–50.

About the Author:

Dr. Machelle Linsenmeyer is Assistant Vice President for Institutional Effectiveness and Academic Resources and Professor in the Department of Clinical Education at the West Virginia School of Osteopathic Medicine in Lewisburg, West Virginia.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The University of Ottawa . For more details on our site disclaimers, please see our ‘About’ page