Troubling Muddy Waters

Problematizing Reflective Practice in Global Medical Education

Abstract

The idea of exporting the concept of reflective practice for a global medical education audience is growing. However, the uncritical export and adoption of Western concepts of reflection may be inappropriate in non-Western societies. The emphasis in Western medical education on the use of reflection for a specific end—that is, the improvement of individual clinical practice—tends to ignore the range of reflective practice, concentrating on reflection alone while overlooking critical reflection and reflexivity. This Perspective places the concept of reflective practice under a critical lens to explore a broader view for its application in medical education outside the West. The authors suggest that ideas about reflection in medicine and medical education may not be as easily transferable from Western to non-Western contexts as concepts from biomedical science are.

The authors pose the question, When “exporting” Western medical education strategies and principles, how often do Western-trained educators authentically open up to the possibility that there are alternative ways of seeing and knowing that may be valuable in educating Western physicians? One answer lies in the assertion that educators should aspire to turn exportation of educational theory into a truly bidirectional, collaborative exchange in which culturally conscious views of reflective practice contribute to humanistic, equitable patient care. This discussion engages in troubling the already-muddy waters of reflective practice by exploring the global applicability of reflective practice as it is currently applied in medical education. The globalization of medical education demands critical reflection on reflection itself.

McDonald’s wanted India to fall in love with the Big Mac. When the fast-food chain was introduced to India, a country where cows are considered sacred, McDonald’s replaced the beef-based Big Mac with burgers made of mutton or potatoes. To prepare for this introduction, the global super-brand had intensively explored the Indian market, consulted with local experts, and then modified as much as 75% of its well-known global menu.¹ However, it is not so much the love of burgers or fast food but, rather, the global branding and what it represents that have made McDonald’s popular in India.^1,2 This expansion into the Indian market was a successful endeavor because of the conscious adaptation by McDonald’s of Western methods and preferences into the local context and the company’s intensive collaboration with local food manufacturers and businesspersons. The lesson here is in the twofold strategy adopted by McDonald’s: first, consulting experts on the local market and, second, demonstrating a flexibility of thought in reenvisioning its products, including its most iconic product in mutton or potato options.

Clarifying Reflection and Reflective Practice

As a Western-trained clinical psychologist of South Asian descent practicing in an urban environment in South Africa, one of the authors (T.N.) has often wondered if attempting to apply Western principles to global medical education at the expense of local beliefs, perspectives, and practices represents the conceptual equivalent of introducing the original Big Mac into India. Out of this author’s sense of disquiet and curiosity—and out of the two authors’ collaborative reflections on the cultural moorings of reflective practice itself—arises this Perspective.

In the calls to include reflective practice as an educational requirement, there is an apparent understanding that reflective practice involves practitioners thinking about their own thinking and doing and evaluating their personal functioning in order to improve their performance.^3–5 However, the concept of reflective practice itself remains murky. There is no clear definition or consensus on what reflective practice entails and how it should be fostered and taught.^4–7 Of concern is that this lack of characterization has not suppressed the tendency to promote reflection despite admissions from medical educators about the difficulty of recommending guidelines for its practice.⁷ Moreover, it appears that the terms reflection and reflective practice are generally used interchangeably in medical education.

Conversely, disciplines such as education, psychology, and anthropology view reflective practice as encompassing reflection and critical reflection,⁸ defined in this Perspective as follows:

• reflection: thinking about one’s actions during or after the action, usually with the purpose of improving one’s performance; and
• critical reflection: thinking in ways that connect individual identity, social context, and reflexivity.

Reflexivity involves the practitioner engaging in introspection, intersubjective reflection, mutual collaboration, and social critique, as well as placing taken-for-granted beliefs and assumptions under a critical lens.^9,10

In this Perspective, we engage in troubling the already-muddy waters of reflective practice by placing the concept under a critical lens and exploring the global applicability of reflective practice as it is currently applied in medical education. This article also explores the question, When “exporting” Western medical education principles and strategies, how often do Western-trained educators authentically open up to the possibility that there are alternative ways of seeing and knowing that may be valuable in educating Western physicians?

Implications of Exporting Reflective Practice

As in most scholarly fields, Western theoretical perspectives dominate the literature in the area of reflective practice in medicine and medical education. Outside the West, reflective practice may be seen as an extravagance because it requires time—an especially elusive commodity in developing countries where resources are limited and both demands for resources and disease burden are very high. In such settings, it is not unheard of for health care professionals to declare that there is too little time for reflection.¹¹

Furthermore, in Western-based medical education, reflection and related activities are generally framed in terms of outcomes-based education and competencies. Although a competency-based approach may be appropriate for learning in the biomedical and clinical sciences, it has been criticized as inappropriate when applied to learning the humanistic aspects of medicine.^12,13 Nonetheless, calls for reflection in medical education often frame the concept of reflection in terms of a cognitive, introspective, individual activity.⁵ Self-regulation, self-assessment, self-directed learning, and self-knowledge are presented as central to reflection.^6,14,15 Both the cognitive and reflective aspects of reflective practice are embodied in the calls for the development of “critical thinking” as an essential part of professional development.^6,16,17 Implicit in this worldview is an ideology of independence, self-sufficiency, and self-critique. This does not, however, imply that Western-based medical education ignores collaborative reflective practices. As Wear and colleagues¹⁸ and others^13,19–21 point out, an emphasis on transformative action in reflective practice shifts reflective practice from a solitary act to a social act in which one’s gaze shifts from inward contemplation and awareness toward others and out into the world. These views are in line with a rich tradition in the West—with writers as diverse as Mead and Morris,²² Bakhtin and Emerson,²³ Habermas,²⁴ Bourdieu,²⁵ Freire,²⁶ Vygotsky,²⁷ and Lave and Wenger²⁸—that emphasizes mutual recognition, dialogue, and social context as the basis of human interaction. Yet, framed by official calls for reflection, reflection-for-export often appears to lack the interactional, social dimension of working with collaborators outside the West to establish how Western-developed ideas should be transferred meaningfully.

This view is perhaps best supported by evidence that much of the literature in medical education makes reference to the reflective cycle of learning, which focuses on introspective learning.^3,5,6,14 There is little in the medical education literature that looks at the theoretical application of social or collaborative reflection in the contexts of clinical teaching and learning. Some writers have noted the “social turn” in reflective writing in Western medical education, which sees educators encouraging students to interrogate through reflective writing such issues as power, inequality, and social justice in medicine and in the larger culture.²⁹

The issue, however, with proposing reflective practice primarily as introspection or as self-examination is that this view is not always resonant with non-Western views of appropriate, valid, and desirable behavior. Difficulties can arise when non-Western health care practitioners trained in Western practices and theories are practicing in their local contexts. In South Africa, for example, one of the authors (T.N.) has supervised clinical psychology trainees and medical students who, when meeting patients from local cultures, will disregard contextually relevant elements of patients’ presentations to search in vain for solutions based on Western theoretical perspectives developed in Western contexts. Presenting reflective practice and medical practice in this way may lead to superficial and stereotyped assessments of patients and may foster doubt in clinicians in non-Western contexts about what they see and hear and what they know about the local context from their own cultural and life experiences.

Whereas one might argue that the individual patient is the focus of the practitioner’s attention in the West, in other societies, such as that of South Africa, the ethnic group and community are fully present in the consultation room along with the patient. Practitioners must develop another type of reflective practice in this context. A collaborative reflective practice that focuses on relationship building, tradition, and ritual must emerge in place of an individualistic, positivist, “objective” approach. It involves the creation of spaces for dialogue and the oft-explicit acknowledgment of greater forces that may influence the outcomes of concern. Addressing the challenge of accommodating this kind of reflective practice in busy clinical settings would require commitment from dedicated professionals and acknowledgment of the long-term benefits of such an approach to practice. The space in which the clinician may share power and yet continue to actively engage with the client is often lacking in Western medicine and lies at the very core of calls for patient-relationship-centered care.³⁰

The introduction of patient-centered practice in Western medicine has presented the potential for religious, cultural, spiritual, and contextual aspects of health and illness to be highlighted in patient–physician interactions. Outside Western-based practice, traditional health practitioners have routinely, actively, and consciously acknowledged the influences of these aspects of human experience in collaborating with patients in managing their health and illness. This type of collaboration, in a sense, does not merely balance power and responsibility between the patient and the physician; it also engages social, spiritual, and cultural dynamics that may be beyond the direct or immediate influence of both parties. For example, dream interpretation, meditation, and spirit communication are legitimate and widely accepted forms of communal and collaborative reflection used in traditional health practice, and people in many non-Western contexts routinely consult both Western-trained and traditional health practitioners. Yet, how receptive are Western and Western-trained practitioners to considering and applying collaborative reflective practices that may be taboo in Western contexts, such as dreams or intuitions about patients’ diagnoses or treatment?

Western Dominance in Reflective Practice in Global Medical Education

Western writers who apprise of critical consciousness and advocate the consideration of the impact of broader power dynamics on clinical practice have encouraged a more nuanced view of ways of thinking and interacting in the clinical environment.^{18,29,31–33} There is still little room, however, for the consideration of non-Western spiritual and religious beliefs beyond those that individual physicians choose to consider. This oversight may be attributable to a dominance of Western educational theory that is founded on a causality-based, biomedical, “value-neutral” paradigm. This approach has tended to obfuscate other perspectives in reflective practice and, perhaps worse, has aborted the emergence of extended views on how reflective practice should be applied.

There is a tendency among Western observers to assume that non-Western medical schools do not encourage reflective practice.³² It is also a common misconception that non-Western students are not encouraged to question their teachers. Rather, they are generally expected to learn the theory first and then question. The emergence of reflective practice is part of a major shift in Western medical education that acknowledges the need for students to act and think independently as an integral part of learning throughout the course of professional study, rather than insisting that students must learn the theory before they can engage in practice.³⁴ It may be argued, though, that this emphasis on independence in learners is contextually dependent. Do practitioners in the West ever question the value of constantly questioning, sometimes for the sake of questioning or merely to learn how to question? Can this approach of appearing critical for form’s sake result in the flexing of “critical muscle” without a foundation of knowledge or without action oriented toward actual change? In non-Western contexts, such as Asia and Africa, the apparent acquiescence of students may reflect a belief that the right to question is earned through time and work in the profession, an alternate view recognizing that teachers have an existing base of knowledge and experience. A culture of respect, humility, and observation may direct the learner’s performance of actions without the learner’s initial understanding of their exact meaning.

If reflective practice in medical education is to be exported, it is essential to adopt an open-minded approach to understanding how reflective practice happens in non-Western contexts. For example, practitioners in many collectivist cultures make extensive use of tacit, nonverbal, and contextual information in addition to patients’ verbal communication to make decisions on patient care and management.^8,35 Kim and colleagues³⁶ observed that, in Hong Kong and Beijing, interdependence within groups positively predicted preferences for doctor decision making and for family and joint decision making as opposed to personal decision making. This appears to stem from a cultural emphasis on humility and respect that is based on a hierarchical social system.³⁶

In some societies, the healer is expected not only to include perceptions of nonverbal cues and family background in patient assessments but also to possess extensive knowledge about new patients without prior questioning. In African traditional health practice, the healer tells the patient about the problem, conveying it as a message from the ancestors for a putative transgression or the neglect of responsibilities. The patient listens and nods, accepting the message the healer conveys from the ancestral spirits. The healer has essentially collaborated reflectively with the relevant ancestral spirits, a practice which the patient knows will occur and explicitly seeks when consulting a traditional healer. For Western-trained practitioners to consider this a possible illustration of collaborative reflection, they must consider spirit communication not just as a possibility but as a reality. Yet Western-trained doctors from non-Western countries are compelled to suspend or renounce their traditional beliefs about the possibilities for reflection or face a constant tension within themselves—an intellectual splitting of sorts—in attempting to balance non-Western cultural practices with imported approaches.

Indeed, it is ironic that the influence of culture in reflective practice has not often been explored in Western medical education, considering that one purpose of reflective practice is to understand the impact of contextual factors on the practice of medicine. A possible explanation for this oversight is that medical educators do not habitually look outside the medical education literature to examine how culture is conceived and taught.²⁹ The same is true for reflective practice, the practices and forms of which have not been explored outside the West in the medical literature. This is partly attributable to issues of power. The emphasis on introspection or simple reflection (i.e., evaluating one’s own performance instead of consulting or collaborating) in reflective practice in medical education in the West corresponds with doctors’ professional self-identity and power in Western medicine, which Bleakley and colleagues,³² following Foucault, describe in terms of sovereign power designed to maintain the status quo. Medical training anchored in basic and clinical sciences promotes the identity of physicians as scientists and fosters power rooted in scientific knowledge.³⁷ Encouraging simple reflection suggests that physicians can address mistakes or problems independently. The implication of this view is that medical training provides practitioners with the knowledge, skills, and insight to improve their practice relatively autonomously.

All of this is not to say that one approach—that is, collaborative reflective practice or individual reflective practice—is superior to the other. Rather, the two approaches are different and have relative significance and value in different cultural contexts. Further, the roles of culture, power, and difference are overlooked—or perhaps sublimated—in Western approaches that emphasize solitary reflection and individual autonomy. This lapse relates to another well-known and documented oversight in medical education, the teaching of cultural competency. Many authors have critiqued cultural competency as focusing on the idiosyncrasies of marginalized cultural groups without consideration of issues of context, such as poverty, prejudice, disempowerment, and oppression.^{15,29,31,38,39} A more effective perspective would not limit itself to “communicative competence” or the “celebration of tolerance” but, rather, would shift the discussion to privilege, power, and the foundations of inequalities.^18,29

Perhaps the solution lies not in aiming to teach cultural competence but in aiming to develop reflective skills in medical students at the levels of reflection, critical reflection, and reflective practice, thus creating the potential for medical practitioners to understand culture along with many other aspects of medical practice more thoroughly and with deeper personal engagement and insight. In a globalized world, reflective practice requires an acknowledgment of what Jencks,⁴⁰ quoted in Bleakley et al,⁴¹ refers to as “glocalism.” Whereas a current perspective tends to favor a Western-dominated view of reflective practice—which, if imposed on medical education in developing countries, may be perceived as essentially neoimperialist—a “glocal” approach may represent a fusion which transcends an oppositional relationship between neocolonial global efforts and the local environment.⁴² To return to the McDonald’s example, the adage “think global, act local” that was effectively applied to McDonald’s entry into India¹ illustrates the effective merging of the local and the global. The idea of “translating” or reconceptualizing ideas or approaches, such reflective practice, is critical to actualizing those ideas and practices in a locally sustainable manner. As Henderson⁴³ asserts:

To date, in many of our initiatives in international medical education, we have taken a simplistic, fatal leap of faith from acceptance of the universality of science to presumption of the universality of medical education.

In other words, medical education strategies should not be created in Western universities and exported worldwide under the assumption that there are specific, universally valid competencies and truths. These strategies must be context specific and fit the purposes identified in the heat and dust of local practices.

In Conclusion: Critical Reflections on Reflection

In a landmark paper, Bleakley and colleagues³² applied postcolonialist theory to argue that in the zeal to export medical education strategies and innovations to a global audience, educators often fail to turn a critical lens on the assumptions, values, and perspectives that accompany this exportation. This lack of criticality results in a type of educational neoimperialism which replicates past practices of colonization. This Perspective may be seen as an extension of their argument. Building on Bleakley and colleagues’³² view, we propose that in the area of reflective practice, the assumption there is a circumscribed orientation to reflection in medical education that tends toward an individual, noncollaborative, instrumentalist orientation and is scientific in outlook threatens to replicate neoimperialistic practices. If Western approaches and theories are accepted as the convention, clinicians practicing in postcolonial societies may often live with troubled professional identities and goals. As one of the authors (T.N.) expressed when considering her choice to use collaborative reflection with patients and interns in group therapy training and practice at a psychiatric hospital in South Africa:

Perhaps coming from the still postcolonial context of South Africa and working within a (personal and local) collectivist frame of reference, I am biased toward collaborative reflective practice—because it seems easier in the context. Nevertheless, I feel a barely suppressed guilt or anxiety at the possibility that I may be “cutting corners” in the sense that this is not doing reflective practice as it should be done. Only as my confidence in my identity as a clinician and a researcher grows can I lay claim and accept the legitimacy of my point of view.

In other words, the colonial legacy lives on. The Brazilian educational theorist Paulo Freire²⁶ has written that teaching is the expression of freedom. However, the road to liberation often passes not through clarity but by way of its opposite. The concept of reflective practice has complex dimensions and nuances that often escape attention in the drive to implement simple reflection within a framework of competencies. Instead of confining efforts to nail down definitions, it may be productive to disturb preconceived assumptions to fully explore the relevance and actual practice of reflection in global contexts.^5,13,42 Globalization of medical education demands critical reflection on reflection itself. Such questioning will serve to further trouble muddy waters; however, problematizing reflective practice in global medical education may provoke a reimagining that shifts it toward global health, equity, and justice.

Acknowledgments: T.N. thanks the University of Michigan Department of Medical Education for hosting her on a visiting scholarship during which this article was drafted.