medical reflection essay

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Reflective practice in health care and how to reflect effectively

Kiron koshy.

a Brighton and Sussex University Hospital

Christopher Limb

b Western Sussex University Hospitals, Worthing

Buket Gundogan

c UCL Medical School, University College London, London

Katharine Whitehurst

d Royal Devon and Exeter Hospital, UK

Daniyal J. Jafree

Reflective practice is a paper requirement of your career progression in health care. However, if done properly, it can greatly improve your skills as a health care provider. This article provides some structure to reflective practice to allow a health care provider to engage more with reflective practice and get more out of the experience.

Introduction

Reflective practice is something most people first formally encounter at university. This may be reflecting on a patient case, or an elective, or other experience. However, what you may not have considered is that you have been subconsciously reflecting your whole life: thinking about and learning from past experiences to avoid things that did not work and to repeat things that did. For example after tasting a food you do not like, you remember that experience, think about it, and when you next see that same food you know to avoid it. In medicine it is one of the best approaches to convert theoretical knowledge into practice.

As you progress through medical school and into foundation years as a doctor it becomes even more common. It is now expected to provide evidence of your reflections through your training on the ePortfolio and then throughout the rest of your professional life in revalidation. Hence, it is a good idea to get it right from the beginning.

First and foremost the biggest mistake you can make when reflecting is to treat it as a tick box exercise and a waste of time. With a bit of thought reflections can be a very useful tool in learning. Would you remember a generic case from a book? Would hanging all of those facts on a patient you have met make it more memorable? It allows you to recognize your own strengths and weakness, and use this to guide on-going learning. By reflection you will develop your skills in self-directed learning, improve motivation, and improve the quality of care you are able to provide.

What to reflect on

This can be anything.

Most reflections are on things that go wrong. These situations stay in one’s head and force us to begin to think about whether they could have done anything differently. For example:

• Postoperative complications
• Missed diagnosis
• A dissatisfied patient
• Failed procedure

However, reflecting on things that went well can often be more rewarding and be just as useful. It can build confidence and help you to repeat it again on another occasion. For example:

• A well-managed cardiac arrest
• An interesting seminar or conference
• A patient thank you letter
• A difficult but well performed procedure

Stages of reflecting

There are numerous models for reflections, but it is important to understand why you are asking each question and how that will help you to reflect 1 . This an integration of many concepts but the broad process is similar in all models: what happened, why does this matter and what are the next steps? 2

What, where, and who—the situation

Think about the situation in detail: What happened exactly and in what order, where were you at the time and who else was involved? What part did you have to play? What was the final outcome?

How did it make you feel—your emotional state

What was running through your head and how did you feel about it? Be honest with yourself: were you afraid, confused, angry or scared? If you can understand how you were feeling at the time it will help you put together why things happened as they did, and help you to recognize similar situations in the future.

Why did it happen—making sense of the situation

Now you have thought about the situation in greater detail, and probably recognized things that would have otherwise gone unnoticed, think about why things happened as they did. How did the situation, yourself, and others interact at the time. Did the situation go well or was there room for improvement?

Could you have done anything differently—critical review and development of insight

With the help of hindsight how would you have managed the situation differently? Think about what factors you could have influenced: is there anything you could have tried that may have improved the situation, or is there anything you did that was particularly important in the situation? It is easy to remember the things that you did not do and it is often the things that you did well that are forgotten.

What will you do differently in the future—how will this change your practice

This is arguably the most important stage in reflecting. You need to pull together everything you have thought of before to learn, change your own practice, and improve 3 . Do not only think about what you would do differently in that specific situation, but think whether you have thought of any transferable knowledge or skills you can utilize elsewhere. For example: if you reflect on a postprocedural complication do not only think of how you would manage this again but also how you would prevent it happening if you performed the procedure yourself! If you are a part of a well-led cardiac arrest do not think only of what you would do next to help, but also how you would lead an arrest in the future, or even how you would lead a team in any other situation!

Re-enforcement—what happens when you put this into practice

Test your reflections: When comparable situations happen again, do things change as you would expect them to? This is a chance to repeat the reflective cycle to refine and develop your understanding.

How to make the best use of reflective practice

As mentioned previously most people see reflective practice as a tick box exercise, but it does not have to be.

Over the next day take note of any interesting situations that arise. Later in the day try mentally reflecting, following this framework, and if you think any will be particularly useful to you write them down. If you try this for a week you will begin to see similar situations arising and how your reflective practice is positively affecting you.

Remember: you do not always have to learn only from your own experience; learn from others’ mistakes as well. Reflect on situations that you have witnessed to work out why things happened as they did, and how this can influence you.

It can be useful to take these reflections for peer or senior review: others may be able to draw light on things you have not noticed. This can allow you to recognize points for improvement and work on them. This can also be a useful learning opportunity for the other involved!

An example to put this into practice

I was involved in a patient confrontation; the patient was unhappy with her hospital stay and wanted to be discharged home. Unfortunately she required a package of care and so could not be discharged. I explained this and she returned to her bed. I was happy I had explained everything to her and continued with my other jobs.

Who, what, and why

I was involved in a patient confrontation; an elderly patient was unhappy with hospital stay and wanted to be discharged home. She was under our general surgical team for a head injury and observation after a normal CT head. She had been seen on our ward round and told that she was medically fit for discharge but still awaiting social services: her house had been reviewed and deemed unsafe so she was waiting for banisters to be installed. The issue was raised with me by chance as I was doing other things on the ward. I explained this to her and although she remained annoyed I was able to make her understand what the delay was and she returned to her bedside. She did not seek further clarification that day.

How did it make you feel

At the time I felt rushed and frustrated. I had a lot of other work to be done and this was distracting from that. She had already been told she was waiting for social services in the morning. I understood why this was difficult for her but did not think I would be able to do anything to help.

Why did it happen

The morning ward round was quite rushed and so our explanation was limited to telling her we were waiting for social services. I can understand from her point of view this may have meant very little, and so my explanation of what exactly we were doing may have relieved some frustration. Having been waiting up to this point, it is no surprise she continued to be angry but may have been accepting of this plan.

Could you have done anything differently

I think my explanation was very good, and the patient seemed happy with this, although I did not give a rough idea of how long this would take. It may have been useful to have spoken to the sister in charge to ask for what progress had been made to feed back to the patient. Also I did not ask her whether she was happy with this explanation: I may have been able to satisfy her frustration further by answering a few more questions or even recognize any other issues at home that may need addressing before discharge. Although the information given in the ward round was correct, it was not understandable to the patient. If this had all been quickly clarified in the morning, the patient would have been happy throughout the day and not caused a problem later on.

What will you do differently in the future

I think that the route problem in this situation was our explanation on the morning ward round. Furthermore, I am not sure how long such issues take to be addressed. To avoid a similar situation in the future I will speak to the other health care professionals on the ward to get a round idea of how long occupational interventions such as this and other community interventions take to start. This means when future patients are medically fit I can spend a moment in the morning informing them of what needs to be done and how long it may take. Hopefully this will allow me to address patient concerns early to avoid them becoming an issue when it is too late.

Re-enforcement

I will reflect on how future situations similar to this develop, looking for an improvement in the quality of my patient care.

Following a structure helps to focus a reflection: I am sure you will agree the learning points are much clearer from a good reflection!

Conclusions

To summarize, the benefits of reflecting are clear: it may be difficult to do initially, but through practice you will develop your own skills and become a better learner. Many structures are available so choose one what works for you. Reflective practice is an important part of your career progression on paper, but if done well, can greatly improve your skills as a health care provider.

Conflict of interest statement

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 15 June 2017

To grade or not to grade: assessing written reflection

Just over a year ago, while I was a fourth year medical student (SL), I was required to write a reflective essay entitled, “When a patient became a person.” This piece of work contrasted starkly with the “scientific,” evidence-based approach that I had grown accustomed to. I relished this opportunity to think holistically about a patient encounter. Committing my thoughts to paper allowed me to revisit clinical experiences, and to reflect on my personal and professional progress. I have found reflection particularly useful in patient encounters that are challenging or emotionally loaded. Reflecting on these situations has enabled me to learn from good practice I have observed and to be better equipped to communicate with and support patients. The Medical Schools Council and the General Medical Council recently released guidance on reflection specifically for medical students , emphasising the importance of reflective practice and suggesting ways for students to develop skills as “reflective practitioners”, both independently and through medical school assignments. [1]

At UCL Medical School (UCLMS) reflective writing forms part of the formative medical student portfolio. Students in their first clinical year submit two 1000-word reflective pieces as part of the clinical and professional practice (CPP) curriculum. This reflective work is marked and graded by trained tutors. Grading of our reflective essays has always stirred significant debate among my peers. There is also discussion about the emphasis on written work as the mainstay of reflection.  

Much has been written on reflection , including by medical students and junior doctors . [2,3] As a medical student representative, I wanted to investigate my peers’ opinions regarding our reflective writing assignments. I therefore compiled an anonymous, voluntary questionnaire, which I and other student representatives distributed to students who had completed these assignments. Students were asked to rate their views on reflective writing, its grading and to suggest possible changes.  

Through this questionnaire I learned that views on reflective writing were polarised. Many students valued reflective writing, acknowledging reflection to be a key skill in becoming a doctor. Many of my peers also appreciated grading of reflective work and found it gratifying to receive a high grade for their assignments. Bespoke feedback from tutors was largely well received and deemed to be valuable. I personally found receiving tailored support and guidance from a senior on subjects that can be sensitive or difficult to communicate to be a real strength of the curriculum.

However, many of us also feel that reflection is personal, subjective and does not lend itself to grading. Receiving a low grade can be demoralising and can imply that the student has reflected “incorrectly,” which many students find inappropriate. I can also see how fulfilling specific grading criteria may encourage contrived writing at the expense of genuine reflection.

When students were asked to comment on possible changes to reflective writing, some suggested greater standardisation of marking and feedback, while others proposed removing set titles or the grading system altogether. Some expressed anxiety about the confidentiality of written reflection in the wake of the Bawa-Garba case , in which the contents of a junior doctor’s reflective portfolio may have “fed into” court proceedings. [4] There were also comments about alternative methods for reflection, with many preferring face to face or verbal reflection. 

Some students like myself, had participated in Balint groups or Schwartz Rounds, both of which are confidential formats for group discussion and reflection around clinical experiences . [5,6] Poetry, music and art were also suggested as formats for reflection. These are all important creative outlets, but may not be practical for medical school reflective practice. In addition, they may not provide the same function or the same benefits as written reflection. Reflective writing requires deliberate, considered thought around an experience, to allow for learning and potential changes to future practice; other media for reflection may not deliver this.   

When I reported these findings to faculty (FG, JY), it resulted in a change to the reflective curriculum. A more detailed online guide to reflective writing for students has been introduced outlining the purpose of reflective practice, relevance to our future careers, different reflective opportunities available within our curriculum and useful models for reflection. In addition, welcome tips on composing the assignment have been provided. Additional essay titles, some suggested by the student body, have been included to widen the choices available. It was gratifying to see these changes implemented.

As someone who has participated in reflective practice at every opportunity during my undergraduate career, being able to co-create and contribute to the reflective curriculum has been invaluable. I appreciate the difficulties in incorporating reflective, unexamined aspects into a full medical education, and feel fortunate to be part of a medical school which can be responsive to the needs of its students. 

Jenan Younis is a Colorectal Surgeon and Clinical Teaching Fellow at UCL Medical School Competing interests: None declared

Faye Gishen is a consultant physician and the associate head of the MBBS at UCL Medical School. Competing interests: None declared

References:

• General Medical Council. The reflective practitioner – a guide for medical students. 2019. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/the-reflective-practitioner—a-guide-for-medical-students (accessed 3 September 2019)
• Macaulay CP, Winyard PJW. Reflection: tick box exercise or learning for all?. BMJ. 2012;345:e7468. 
• Furmedge D. Written Reflection is Dead in the Water. BMJ . 2016;353:i3250. 
• Dyer C, Cohen D. How should doctors use e-portfolios in the wake of the Bawa-Garba case? BMJ . 2018;360:k572. 
• Roberts M. Balint groups: A tool for personal and professional resilience. Can Fam Physician. 2012;58(3):245-7.
• Gishen F, Whitman S, Gill D, Barker R, Walker S. Schwartz Centre Rounds: a new initiative in the undergraduate curriculum—what do medical students think?. BMC Med Educ. 2016, 16:246 https://doi.org/10.1186/s12909-016-0762-6

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Reflective Practice in Medical Education

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• First Online: 23 November 2021
• Cite this living reference work entry

• Rachel Conrad Bracken 3  

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Critical reflection ; Reflection ; Reflective writing

“Practice” refers both to the repeated exercise of a skill or activity in order to achieve proficiency and the application of a method, skill, or belief. Accordingly, “reflective practice” refers to the ways in which reflection, as a skill and a habit of mind, is first acquired and then utilized by professionals. Within the fields of medicine and medical education, reflective practice encompasses both a praxis – to do the work of healing patients guided by ongoing reflective thought – and the curricular interventions through which medical trainees hone their reflective capacity. As it pertains to reflective practice, “reflection” is “the process of analyzing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice)” (Aronson, 2011 : 200–201). The capacity for reflection as “an epistemology of...

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Bracken, R.C. (2021). Reflective Practice in Medical Education. In: Crawford, P., Kadetz, P. (eds) Palgrave Encyclopedia of the Health Humanities. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-26825-1_203-1

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Reflection: how do I do it?

• Related content
• Peer review
• Rhona Knight , portfolio general practitioner and senior clinical educator 1 ,
• Jemima Henstridge-Blows , second year medical student 2 ,
• Helen Stacey , second year medical student 2 ,
• Josiah Knight , second year medical student 2
• 1 University of Leicester, Leicester, UK
• 2 St Andrews Medical School, St Andrews, UK

You will be expected to reflect on your experiences at medical school and beyond

Reflection: what is it?

Reflection is something we do every day. It is an established part of medical education and a requirement for revalidation with the General Medical Council. 1 It is a focused learning process, which facilitates the development of insight and understanding, transforming the learner and guiding future practice. Reflection can take many forms: it can be the individual quietly pondering over an event; a discussion or debrief with a colleague; a written piece of work for our own learning; or a formal piece of work for assessment purposes. It can also take more artistic approaches.

Reflection: why bother?

Reflective practice is a core skill needed in professional medical practice, which enables us to learn to cope with an ever changing work environment—hence the efforts to integrate it into the undergraduate curriculum. 2 In an article in JAMA , Ronald M Epstein wrote, “Reflection and self-awareness help physicians to examine belief systems and values, deal with strong feelings, make difficult decisions and resolve interpersonal conflict.” 3 Most doctors value opportunities to reflect on a patient’s care with colleagues and appreciate time to discuss areas of work that they are finding difficult. 4 This emphasis on reflection is not new—philosophers have long advocated reflective thought. Socrates said, “The life which is unexamined is not worth living,” 5 and George Santayana observed, “Those who cannot remember the past are condemned to repeat it.” 6

Reflection: an essential part of the curriculum

Tomorrow’s Doctors identifies the need for doctors to assess, apply, and integrate new knowledge; to adapt to changing circumstances; to develop a portfolio including reflections; and to “continually and systematically reflect on practice, and wherever necessary, translate that reflection into action.” 7 As a result, medical schools are using a variety of ways to encourage reflective practice.

At St Andrews, reflective writing is required regularly from the first year, beginning in freshers’ week. Staff encourage analysis of thoughts and feelings, from the first experience in the dissection room, to peer and self appraisal in group tasks and scenarios. Students are expected to evaluate encounters with simulated patients and volunteer patients from the community. Similarly, at Leicester medical school, formalised reflection is found throughout the course. The use of reflective templates is encouraged in personal development portfolios. Reflection on patients’ stories and team roles is a key part of inter-professional learning.

Reflection is also used in the learning and assessment of some student selected components. In the medical education component, for example, students are required to reflect on their experiences of teaching and learning before and after the course. They are also encouraged to keep a reflective learning log throughout the course and to meet once a week in collaborative reflective groups. Final reflective assignments have included the opportunity to use more artistic forms of reflection (fig 1 ⇓ ). The skills learnt can be taken on into postgraduate training, where reflection is a key part of the foundation curriculum, being mentioned 15 times in the 2012 curriculum document, 8 and where reflective learning logs are assessed as part of the e-portfolio.

Fig 1 One of a collection of reflective poems. Emma Boothby, University of Leicester

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Alternative forms of reflection using multimedia approaches, such as the use of digital storytelling, are also beginning to be encouraged. 9 10 An example of this, used for teaching students about reflection in Leicester, incorporates a digital story created by a general practitioner registrar and one of his patients, which is based on a series of photos taken by the patient to document her experiences of healthcare. These photographs and the trainee’s interactions with the patient, with the appropriate consent and due attention to confidentiality, became the basis of a reflective digital story presented with pictures, music, and narrative in PowerPoint.

The use of digital methods, such as e-portfolios, can also facilitate the sharing of experiences with a wider audience and over long distances, allowing the reflective work of others to be seen. This can help in exploring different points of view and understanding different approaches. With the increasing variety of technological platforms, reflection can be recorded in numerous formats—for example, recording oneself on a digital voice recorder or recording, with permission, a discussion with colleagues and peers. These methods encourage the development of a more informal style, which can help those who find reflective writing challenging. The use of video—for example, a consultation with a simulated patient—can also be a useful reflective device because it provides a record of an experience for analysis.

How to reflect: do, review, plan

Models of reflection are usually cyclical, 11 12 13 and most can be crystallised into three stages—do, review, and plan. 14 You can enter the cycle at any point and repeat the process as you revisit the experience in different contexts, contributing to your continuous professional development.

Stage 1: Do—the experience

Examples of this could be going to a lecture, meeting a patient, preparing for and taking an examination, having a difficult encounter with a consultant, or getting good feedback from a ward clerk.

Stage 2: Review—the reflection

During this stage, you try to make sense of your experience. This stage is best divided into three parts.

Part 1: recollect the experience in detail

What happened?

What were you thinking and feeling?

What did you notice?

What else was happening? Were you thinking about work, home, study, or health?

What might others there have noticed, thought, and felt?

What might someone looking in have seen?

Part 2: looking beneath the surface

This part of reflection encourages you to consider the experience in more depth. This includes considering possible answers to the question “why?”

Why did the experience play out the way it did?

Why did I react, think, and feel the way I did?

Why did others react, think, and feel the way they did?

What went well? What went less well? Why?

It is at this stage that connections may emerge: with past experiences; the curriculum; other disciplines and perspectives; art, film, literature, and other humanities; professional responsibilities; and your values and beliefs, as well as those of others.

Not all people learn best through words, and it is this part of reflective practice that is particularly open to the use of art, dance, drama, creative writing, and music. Facilitated reflection often encourages learners to look more broadly and deeply than they would alone.

Part 3: identifying insights

In this part you try to crystallise those “light bulb” moments that have emerged from your reflection. Questions to help you identify these include:

What have I learnt about the situation?

What “eureka” moments have there been?

What have my emotional reactions told me about myself and how I relate to others?

What have I learnt about the way I think, learn, and act?

What have I learnt about me as a person, my values, and my beliefs?

What have I learnt about others?

What has challenged me?

What have I learnt about medicine, the role of the doctor, and me as a future doctor?

Stage 3: Plan—what next?

This part encourages you to identify how you might approach a similar situation in the future. Whereas the first two stages are often done informally as we mull over our day and talk with colleagues, this stage benefits from taking time to formally identify and write down your key learning points, what changes you need to implement, and what other actions you need to take forward.

There is something about writing things down that makes them more likely to happen, and when you review what you have written at a later stage you can see how you have fulfilled your plans and consider how they have helped. This formal process can be aided by a template. Medical schools often provide their own templates (fig 2 ⇓ ). In the template, brief notes on the experience, reflections, and future actions can be made, taking care to ensure patient confidentiality.

Fig 2 Reflective learning template

In the days of smart phones and iPads, a template can be accessible in seconds so making time in a busy schedule to reflect formally is not that difficult. Reflective notes can be made in time snatched in the coffee room, on the bus home, in the few minutes before a lecture starts, or as you wait to do something on the ward. It really doesn’t take too long, so you can get into the habit of recording the evidence of reflective learning on a daily basis and upload your findings on to electronic learning portfolios if needed. Hyperlinks to relevant documents or websites can also be added, and these can become a good revision or reference source. Evidence of further reading, reflection, and other learning resources can also be added at a later stage and, if required, the notes in the template can be used to help complete more detailed reflective assessments.

Reflection: is it worth it?

Helen, jemima, and josiah:.

Initially we approached reflection with hesitation because it was difficult to appreciate its relevance and importance amid the demands of the course. As we persisted and practised our reflective skills, we have begun to see the value of routine reflection. Having a record of past experiences and approaches enables us to develop. It is not the writing of a piece but the subsequent application of what has been learnt that is the reason for reflection. Most importantly, reflection should be constructive. Medical schools should produce medical students who have the ability and desire to reflect independently.

Reflection is part of my everyday professional life as a general practitioner and an educator. In preparing a lecture on reflection, I reflect on what happened at last year’s lecture. After the difficult consultation with the woman with dementia and her family, I reflect on what happened. In both cases, I look beneath the surface of what worked and what didn’t work, at people’s reactions, and their feedback. I consider other related areas, what I have read since, and conversations I have had. I consider and plan what to do next time. I review, plan, and do. Formal reflection gives me the opportunity to spend protected time in a structured way, learning from my experiences; this leads to increased practical and professional wisdom.

Originally published as: Student BMJ 2013;21:f6387

Competing interests: Dr Knight reports one of the co-authors is her son, and the two others are his colleagues at university. The final year students who provided two of the figures were part of a SSC she led at the University of Leicester in 2012.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ General Medical Council. The good medical practice framework for appraisal and revalidation. 2012. www.gmc-uk.org/static/documents/content/GMC_Revalidation_A4_Guidance_GMP_Framework_04.pdf .
• ↵ Lachman N, Pawlina W. Integrating professionalism in early medical education: the theory and application of reflective practice in the anatomy curriculum. Clin Anat 2006 ; 19 : 456 -60. OpenUrl CrossRef PubMed
• ↵ Epstein RM. Mindful practice. JAMA 1999 ; 282 : 833 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ 2009 ; 14 : 595 -621. OpenUrl CrossRef
• ↵ Plato. Apology. Jowett B, transl. Pennsylvania State University. http://www2.hn.psu.edu/faculty/jmanis/plato/apology.pdf .
• ↵ George Santayana (1863-1952). Internet Encyclopedia of Philosophy. 2006. www.iep.utm.edu/santayan/ .
• ↵ General Medical Council. Tomorrow’s doctors. 2009. www.gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf .
• ↵ Academy of Medical Royal Colleges. Foundation programme curriculum. 2012. www.aomrc.org.uk/publications/statements/doc_details/9468-foundation-programme-curriculum-2012.html .
• ↵ Sandars J, Homer M. Reflective learning and the net generation. Med Teach 2008 ; 30 : 877 -9. OpenUrl PubMed
• ↵ Murray C, Sanders J.Reflective learning for the net generation student.Newcastle University. www.medev.ac.uk/newsletter/article/247/ .
• ↵ Kolb DA. Experiential learning: experience as the source of learning and development. Prentice Hall, 1984.
• ↵ Schön D. The reflective practitioner: how professionals think in action. Temple Smith, 1983.
• ↵ Moon JA. A handbook of reflective and experiential learning: theory and practice. Falmer, 2004.
• ↵ Sandars J. The use of reflection in medical education: AMEE guide no 44. Med Teach 2009 ; 31 : 685 -95. OpenUrl CrossRef PubMed

Clinical Experiences: Personal Reflection Essay

Clinical experience is precious to the practice of medical professionals because it provides an opportunity to immerse myself in my future profession fully. Thus, going through this stage was especially valuable for me, as I learned a lot and increased my efficiency and effectiveness as a professional. During my clinical internship, I had to perform various tasks and assist in treating and providing care to patients. Therefore, I was involved in performing practices such as conducting diagnostic tests. This is of particular value because it enables me to understand how to analyze the patient’s medical situation and determine the correct course of treatment.

In addition, it was my responsibility to help patients with minor injuries of all kinds. Critical in this process is proper communication to give peace of mind and comfort to the individuals. Moreover, as part of my clinical practice, I interacted with and worked with people with chronic health issues and mental concerns. In the latter case, it is essential to circumvent the possibility of stigma about mental issues, as “public knowledge about physical diseases is usually seen as beneficial, knowledge about it is often disregarded” (Mannarini & Rossi, 2019, p. 1). It is also worth noting that biased opinions and personal judgments must be avoided when providing medical care.

During my clinical experience, I encountered several problems and challenges. This allowed me to improve my problem-solving skills and to work collaboratively with other professionals. For example, I often consulted with other doctors and nurses when I had problems with diagnoses in order to understand my situation better and to prescribe the most effective treatment. In addition, I worked with different age groups, which gave me an understanding of the unique characteristics and treatment of children, adolescents, and adults. I realized that each group needs to be approached differently depending on their developmental characteristics, both mental and physical.

Mannarini, S., & Rossi, A. (2019). Assessing mental illness stigma: a complex issue . Frontiers in Psychology, 9 , 2722. Web.

• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2023, December 13). Clinical Experiences: Personal Reflection. https://ivypanda.com/essays/clinical-experiences-personal-reflection/

"Clinical Experiences: Personal Reflection." IvyPanda , 13 Dec. 2023, ivypanda.com/essays/clinical-experiences-personal-reflection/.

IvyPanda . (2023) 'Clinical Experiences: Personal Reflection'. 13 December.

IvyPanda . 2023. "Clinical Experiences: Personal Reflection." December 13, 2023. https://ivypanda.com/essays/clinical-experiences-personal-reflection/.

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Non-medical prescribing reflection examples

• Non-Medical Prescribing

Why do non-medical prescribers need to learn to become reflective practitioners?

During your non-medical prescribing course and clinical practice, nurse prescribers and pharmacist prescribers will be required to regularly reflect on their clinical practice to develop reflection and reflective practice skills.

Moreover, if you’re undertaking a non-medical prescribing course, you will be expected to submit as part of your coursework many reflective essays, i.e., a reflective account – so understanding what a reflection is and how to reflect is undoubtedly worth the investment.

Do medical prescribers need to reflect on their practice?

There is no one-size-fits-all answer to this question, as the need for reflection will vary depending on the individual and their clinical practice. However, medical prescribers should generally reflect on their practise to improve patient care and ensure they use evidence-based practices. Additionally, reflection can help medical prescribers identify areas where they need further education or training.

Do independent prescribers need to reflect on their practice?

Independent prescribers need to reflect on their practice to ensure that they prescribe safely and effectively. By reviewing their own practice, independent prescribers can identify areas where they may need to improve and make the necessary changes. This is important to protect patients’ safety and ensure that they are receiving the best possible care.

The above is relevant for all non-medical prescribing students, including; (1) future nurse prescribers, ; (2) allied healthcare professionals and (3) pharmacist prescribers wanting to undertake advanced practice training.

What is reflection?

Reflection is a mental process where people examine their experiences to better understand their whole profession. It allows individuals to enhance their work habits or the care they provide to patients regularly. It is an essential, continuous, and routine element of the job of healthcare and social service providers.

Teams comprised of professionals with different backgrounds, skill sets, and working experiences should be encouraged to reflect openly and honestly on what occurs when things go wrong. These practical reflective activities help develop resilience, enhance well-being, and increase professional devotion.

To be reflective during your prescribing practice, healthcare professionals must first be open to new ideas, explore them from various perspectives, be inquisitive – asking questions – and remain patient if the problem isn’t “simple.” (While this may suddenly leap out at you).

Your prescribing practice and reflective accounts need to make transparent to others and what you’re getting wrong or right. Therefore being honest with yourself is essential as a non-medical or independent prescriber.

Why do nurse prescribers, pharmacist prescribers and non-medical prescribing students need to reflect and write reflective accounts?

Reflection may help you learn a lot from your prescribing practice and prescribing decisions. There are several reasons to reflect. You can use it to:

• Learn from the experience of independent prescribing
• Improve your prescribing decision-making skills
• Help you make decisions in the future
• Identify continued professional development (CPD) needs

You can reflect on anything, but as a non-medical or independent prescriber, you should focus on your prescribing experiences. This will help you understand and develop your skills as a prescriber.

When thinking about your experiences, you should consider both the good and the bad. It’s important to reflect on what went well and what didn’t go so well. This will help you learn from your mistakes as well as your successes. Furthermore, it will ensure you identify gaps in your professional development needs.

There are many different ways to reflect. You can use written reflection, audio recordings, or even video. The important thing is that you’re taking the time to think about your experiences and what you can learn from them.

If you’re not sure how to get started, some helpful reflection templates and examples are below. You can also talk to us at MEDLRN for guidance on how to reflect on your independent prescribing experiences.

Remember, reflection is an integral part of being a successful non-medical prescriber. By reflecting on your experiences, you can improve your practice and make better decisions in the future.

Reflective practitioners and the benefits

The General Pharmaceutical Council, the General Chiropractic Council, the General Dental Council, the General Medical Council, the General Optical Council, the Health and Care Professions Council, the Nursing and Midwifery Council, and the Pharmaceutical Society of Northern Ireland’s top executives have signed a joint statement called Benefits of becoming a reflective practitioner.

https://www.pharmacyregulation.org/sites/default/files/document/benefits_of_becoming_a_reflective_practitioner_-_joint_statement_2019.pdf

This is what they say:

“We are committed to supporting our registrants in their professional development and we recognise the benefits of registrants engaging in reflective practice.

Reflective practitioners are more resilient, and adaptable and have a greater capacity to maintain their registration throughout their careers. They demonstrate professionalism by being able to reflect on their own values and behaviours, and how these might impact the people they care for.

Reflective practitioners are able to make well-informed decisions, using a range of strategies including critical thinking, problem-solving and lifelong learning. They can identify their own development needs and are committed to maintaining their registration by engaging in continuing professional development (CPD).

We would encourage all registrants to reflect on their practice and to use reflective tools and resources to support their professional development.

Reflective practice is a key part of being a healthcare professional. It helps us to learn from our experiences, both good and bad so that we can improve our practice and make better decisions in the future.

How to get started with reflective writing

Most people are unfamiliar with the concept of reflective writing. However, the following comments indicate a lack of clarity regarding reflective writing when it comes to courses and assessments: ‘I thought I wasn’t supposed to use “I” in my work.” ,,,,,,,,,, ‘I won’t say what I truly believe unless it is going to be evaluated.’

The following points will help you to understand what is meant by reflective writing and how it can be used to support your non-medical prescribing course:

• Reflective writing is a way of exploring and analyzing your own thoughts and experiences.
• It can help you learn from your own experiences and make better decisions in the future.
• Reflective writing is different from other types of academic writing as it allows you to share your own thoughts and feelings on a subject.
• When writing reflectively, you should use first-person pronouns (I, me, my) to share your own experiences.
• You should also be honest about your thoughts and feelings, as this will help you learn from your experiences.
• Reflective writing is usually informal in style and can be written in the first or third person.
• It is important to remember that reflective writing is about your own thoughts and experiences, so you should use “I” when sharing your reflections.
• When writing reflectively, it can be helpful to use a reflection template or guide. This will help you to structure your thoughts and ensure that you cover all the essential points.
• Reflective writing is an integral part of the non-medical prescribing course, as it helps you learn from your experiences. By reflecting on your prescribing experiences, you can improve your practice and make better decisions in the future.

What is a reflective essay?

A reflective essay is a type of writing in which you (the author) interact with an audience (readers, listeners, viewers) to describe an experience and how that experience has changed you.

Reflective essays are usually written after a milestone. For example, a student may write a reflective essay at the end of a course of study or after completing an internship or other practical work.

The purpose of a reflective essay is to describe the experience and examine the meaning of the experience and how it has affected you as an individual.

Reflective essays are personal pieces of writing, so they should use first-person pronouns (I, me, my, we, us) and express your own thoughts and feelings about the experience.

Reflective essays can take many different forms. Standard formats include journals, letters to the editor, blogs, and photographic essays.

When writing a reflective essay, it is essential to use descriptive language. This will help the reader to understand your experience and how it has affected you.

It is also important to use concrete details and examples in your writing. This will make your essay more attractive and easier to read.

Finally, remember to proofread your essay before you submit it. This will help ensure that there are no errors or typos in your writing.

Writing critically and reflectively during your non-medical prescribing course

Both critical and reflective may be used in a directive to ‘reflect critically’ on anything. The terms describe a writing trait in which the reader can discern that the text has been carefully considered.

To be critical, you must go beyond description and into the analysis. You evaluate ideas or methods (evaluate), apply them in your work (apply), and defend or refute them (defend). You also reflect on what you have read, thought, or experienced.

In both types of writing, the key features are similar: good, strong, and well-written essays. The major distinctions between critical and reflective writing are as follows:

1 You and your thoughts will be more apparent in your writings.

2 Your personal history – what you have done, thought about, read, and changed throughout your life – is a significant source of evidence in your writing.

3 You are more likely to use the present tense when writing reflectively.

The key features of critical and reflective writing:

Critical Writing 

• More formal
• Focuses on ideas and methods
• Uses evidence from other sources
• Tends to use the past tense

Reflective Writing 

• Less formal
• Focuses on you and your thoughts
• Uses your personal history as evidence
• Tends to use the present tense

Reflective writing for non-medical prescribing students and medical prescribers

Non-medical prescribing students and medical prescribers will be expected to:

• Participate in or observe an incident (such as the care of a patient)
• Discuss what went well and not so well about it
• Examine their thoughts about it by linking to relevant theory/policy/science/guidance and to the experience of others in similar circumstances
• Draw conclusions about what might be done differently next time and how this might improve patient care.

The use of frameworks to help non-medical prescribing students and medical prescribers write reflective essays or reflective accounts

A ‘framework’ is a method for structuring and analyzing an issue, scenario, or experience. It may help you extract the learning points from an event by taking a systematic approach:

• What happened?
• What was my role in it?
• What went well and not so well?
• What could I have done differently?
• What did I learn from it?
• How can I use what I learned in the future?

Reflective writing using the Gibbs Reflective Cycle

The Gibbs Reflective Cycle is a framework for reflection that helps you to think about your experiences and how they relate to your learning. The cycle is made up of six stages:

• Description
• Action Plan

These stages can be usefully applied to any reflective writing task.

An example of reflective writing using Gibbs reflective cycle

I recently observed an incident in which a patient was being discharged from the hospital. I was part of the team responsible for their care. I felt that the discharge process could have been better organized and that the patient could have been given more information about their condition and what to expect after leaving the hospital.

I evaluated the situation and identified some areas for improvement. I discussed my observations with the team, and we came up with a plan of action. I learned that it is important to be organized when discharge planning and to make sure that patients are given all the information they need to make a smooth transition from hospital to home. I will use this learning in future when discharge planning.

Example two of a reflective account using Gibbs reflective cycle

When I was first asked to do this reflective essay on weight loss, I was a little apprehensive. I wasn’t sure if I wanted to share my personal journey in this way or not. But after giving it some thought, I decided that it might be helpful for others who are either considering or currently trying to lose weight. So here goes…

I started my weight loss journey about 6 months ago. I had been feeling unhappy with my appearance for a while, and my health was also starting to suffer. I knew I needed to make a change, but I didn’t know where to start. Thankfully, a friend of mine recommended the Atkins Diet, and I decided to give it a try.

The first few weeks were tough. I had to make a lot of changes to my diet and lifestyle, and it was all very new to me. But I stuck with it, and after a few weeks, I started to see results. I felt better, both physically and mentally, and people were starting to notice the difference too.

Since then, I’ve lost a total of 30 pounds, and I’m still going strong. It hasn’t been easy, but it’s definitely been worth it. I’m now at a healthy weight, and I’m feeling the best I’ve ever felt.

The whole experience has taught me a lot about myself. I’ve learned that I’m capable of making big changes in my life, even when it’s hard. I’ve also learned that I’m stronger than I thought I was.

If you’re considering losing weight, or if you’re currently on a weight loss journey, then I encourage you to keep going. It’s not easy, but it’s so worth it. Trust me, I know from experience.

Gibbs’s Reflective Cycle (Gibbs, 1998) helps you to understand and practice your reflective skills. Use the template to reflect on a recent event in which you demonstrated a reflected ability to improve or demonstrate the need for further learning or development.

Description: what happened? 

I had undertaken a supervised consultation as part of the non-medical prescribing course in the presence of my designated medical practitioner(DMP) and university tutor. Mary (pseudonym) middle-aged woman with a previous diagnosis of hypertension, was invited to attend the OSCE, which involved taking a comprehensive medical history in order to undertake a clinical assessment of the patient. Mary was invited to attend the OSCE, and prior to the OSCE, she was informed of the particulars of the assessment, e.g. the presence of my university tutor and DMP etc.

 Mary was called to the consultation room, and verbal consent was gained. The consultation involved the following; undertaking a comprehensive history taking using the Cambridge and Calgary model, taking blood pressure, and an explanation of the pathology of hypertension and its management.

Upon completion of the consultation, I was informed by the DMP I had passed my assessment and feedback was given.

Feelings: what were you thinking and feeling?

As a pharmacist, this was the first time I had undertaken a structured consultation using the Cambridge and Calgary model. However, having been qualified for over 5 years, I was confident with my consultation skills, in particular, my communication skills and my knowledge of the pathophysiology and management of hypertension. In addition, I was comfortable and relaxed when taking Mary’s blood pressure as I have had considerable practice during my placement with taking blood pressure and felt confident when explaining the relevance of the readings as well as offering health advice. After the OSCE, I felt satisfied with the outcome and in agreement with the feedback of my DMP.

Evaluation: what was good and bad about the experience?

On evaluation, the event was good for a number of reasons. Firstly, Mary said she was satisfied with the advice and the explanation she was given regarding hypertension and the relevance of her blood pressure readings. In addition, feedback from my DMP included my good use of communication skills, especially eye contact and body language(NICE,2010). Furthermore, another positive of the consultation was that I was able to follow the Cambridge and Calgary model and address all the relevant assessment requirements. However, a negative of the consultation was that Mary had asked me to quantify how much of various fruits count towards your ‘5-a-day fruits requirements; however, I was a bit unsure and had to double-check the advice with my DMP even though it was correct. As such, I would have liked to have been more confident in providing that advice.

Analysis: what sense can you make of the situation?

Mary had asked me to explain to her what amount of different fruits count toward the ‘5-a-day’ requirement (NHS,2015), and I was unable to provide the answer confidently as mentioned above; this was the ‘part’ of the OSCE that did not go too well. A reason for this was that I had assumed certain health advice is ‘common knowledge and would not require much explanation. As such, It had never occurred that this was a gap in my knowledge. This negative aspect could have been avoided had I thought more deeply about the advice I offered and affirmed the understanding of patients. Conversely, a part of the consultation that did go well was that I was able to utilize the Cambridge and Calgary model to structure my consultations.

This was because I had undertaken considerable learning regarding structuring a consultation and practised the Cambridge and Calgary model on multiple occasions with my DMP and modified it slightly to address my needs. Furthermore, with regards to taking blood pressure, during my training with my DMP, I had reviewed best practice guidelines when undertaken taking blood pressure and asked for regular feedback, which ensured I was constantly improving my technique and skills.

Conclusion: what else could you have done?

As a result of the consultation, I have learned that I must confirm the understanding of the patient with regard to the health advice that is being given (Nursing Times, 2017) and ensure there is no confusion or misunderstandings. In addition, this experience (of undertaking a consultation) has highlighted the importance of ensuring there is structure to consultation and how I can use a model of consultation to suit the needs of the situation (Royal College Of General Practitioners Curriculum, 2010). Furthermore, I would have liked to have undertaken a level 3 clinical medication review (Brent CCG,2014) to determine adherence to the medication, as many hypertensives have poorly controlled blood pressure (heart Foundation,2016) with a lack of adherence to treatment cited as a major reason (Izzat,2009).

Action plan: if the situation arose again, what would you do?

In order to be better prepared to face a similar experience, I have decided I will continually practice using the Cambridge and Calgary model of consultation wherever possible and undertake self-appraisal (Royal College of General Practitioners,2013); in addition, in order to ensure I have adequate knowledge in health education, I will continue to undertake CPD and have decided to attend a training course within the next 4-8 weeks. Also, currently, I am trained to take blood pressure using an electronic machine but am not confident in measuring blood pressure manually, which would be useful if a patient had atrial fibrillation (NICE,2016). As such, I have decided to take further training under the supervision of my DMP to develop this clinical skill.

• Brent CCG ,2014. Medicines Optimisation:Clinical Medication Review [pdf]. Available at:<https://www.sps.nhs.uk/wp-content/uploads/2016/08/Brent-CCG-Medication-Review-Practice-Guide-2014.pdf> [Accessed 2nd April 2018].
• Heart Foundation,2016.  Guideline for the diagnosis and management of hypertension in adults [pdf]. Available at:<https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf> [Accessed 2 April 2018].
• Izzat, L.,2009.  Antihypertensive concordance in elderly patients  [Online] Available at <https://www.gmjournal.co.uk/media/21571/gm2april2009p28.pdf> [Accessed on 28 February 2018]
• National Institution for Health and Clinical Excellence, 2010.  Principles of Good Communication [pdf].Available at:<file:///C:/Users/ProScript%20Link/Downloads/supportsheet2_1.pdf> [Accessed 1 April 2018].
• National health service, 2015.  Nhs Choices 5 A Day portion sizes . [Online] Available at:<https://www.nhs.uk/Livewell/5ADAY/Pages/Portionsizes.aspx> [Accessed 1st April 2018].
• National Institute for Health and Care Excellence (2016).  The clinical management of primary hypertension in adults (NICE Guideline 127). [Online] Available at: https://www.nice.org.uk/guidance/cg127 [Accessed 25 February 2018]
• Nursing Times, 2017.  Communication Skills 1: benefits of effective communication for patients [online]. Available at:<https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-1-benefits-of-effective-communication-for-patients/7022148.article> [Accessed 1 April 2018].
• Royal College Of General Practitioners Curriculum, 2010.  The GP Consultation in Practice [pdf]. Available at:<https://www.gmc-
• uk.org/2_01_The_GP_consultation_in_practice_May_2014.pdf_56884483.pdf> [Accessed 1st April 2018].
• Royal College Of General Practitioners, 2013.  What are consultation models for? [pdf]/ Available at:<http://journals.sagepub.com/doi/pdf/10.1177/1755738013475436> [Accessed 2nd April 2018].

Author:  Faheem Ahmed

Pharmacist Prescriber, 2x Award-Winning Pharmacist, Pharmacy and Clinic Owner, Founder of MEDLRN and loves sharing his experience with pharmacists.

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• Open access
• Published: 15 May 2024

Reflect to interact – fostering medical students’ communication through reflection-focused e-learning

• Laura Janssen 1 ,
• Kristina Schick 1 ,
• Tiziana Neurohr 1 ,
• Sylvia Irene Donata Pittroff 1 ,
• Sabine Reiser 2 ,
• Johannes Bauer 2 ,
• Pascal O. Berberat 1 &
• Martin Gartmeier 1  

BMC Medical Education volume  24 , Article number:  541 ( 2024 ) Cite this article

125 Accesses

Metrics details

Previous research indicates that reflection can foster medical communication competence. However, best practices for embedding reflection in online medical education are missing. This study examined how reflection processes can be promoted and embedded in an e-learning course on physician–patient communication to foster learning.

We investigated three differently designed e-learning conditions featuring different proportions of reflection triggers and compared their effects on students’ reflections. We had 114 medical students in their first clinical year complete one of the variants: video modelling (VM, n  = 39), video reflection (VR, n  = 39), or a variant merging both approaches (VMR, n  = 36). Each student wrote a total of nine reflections based on the same guiding questions at three time points embedded in the course. The students’ levels of reflection were measured using an adapted version of the REFLECT rubric (scale 0–18).

Students of all course variants achieved good levels of reflection beyond the descriptive level at all three time points, with no significant differences between the variants. The mean reflection scores at the end of the course were M  = 14.22 for VM ( SD  = 2.23), M  = 13.56 for VR ( SD  = 2.48), and M  = 13.24 for VMR ( SD  = 2.21). Students who completed VM showed significantly improved levels of reflection over the course, whereas we found no statistically significant development for those in VR or VMR. The reflection scores correlated significantly positively with each other, as did the text lengths of the written reflections. Reflection scores also correlated significantly positively with text length.

Conclusions

Our study offers a teaching strategy that can foster good levels of reflection, as demonstrated in the three e-learning variants. The developed reflection prompts can be easily embedded in various e-learning environments and enable reflections of good quality, even in settings with limited available teaching time.

Peer Review reports

Interaction with patients is fundamental to medical practice [ 1 , 2 , 3 , 4 ] and providing quality care [ 5 , 6 ]. Physician–patient interactions have an impact on patients, physicians, and the relationship between them [ 7 ]. It affects patients’ health [ 8 , 9 ] as well as physicians’ health (stress level and burnout risk) [ 4 , 10 ]. Problems during physician–patient interactions also cause a major part of patients’ complaints [ 2 ]. Hence, medical students must develop clinical communication competence [ 6 ], which must go beyond familiarity with basic theoretical concepts or being able to reiterate phrases commonly used in interactions. Prospective physicians have to adapt their communication [ 11 ] in a context- and situation-specific way to the individual patient [ 6 ]. They must also develop sensitivity to their verbal and non-verbal expressions, integrate the patient into the conversation, and be able to cope with emotions [ 12 ].

As medical education shifts from a transmissive (teacher-centred) to a reflective learning model [ 13 ] inspired by constructivist learning theory [ 14 ], reflection is increasingly incorporated into curricula [ 15 ]. To develop individual communication strategies, students should reflect on (observed or their own) experiences with patients [ 16 ]. Reflection as a “metacognitive process creates a deeper understanding of the self and the situation to inform future actions” [ 17 ]. By critically analysing a situation and their cognitive and behavioural responses to the situation [ 16 ], students can develop self-awareness and awareness of the other and the situation itself [ 12 ]. They might identify new perspectives and lessons learned that they can apply in future interactions [ 18 , 19 ]. Implementing reflection in clinical communication training may increase students’ communicative competency [ 5 ], as reflection might correlate with communication skills [ 20 ]. Furthermore, reflection in general can improve skills in health care [ 21 ], particularly the quality of patient care [ 22 ], and may enhance empathy among practicing physicians [ 23 , 24 ]. Therefore, good medical communication training should encourage students to reflect [ 6 ].

Extending digitalisation is another shift in medical education, creating the momentum to design new teaching approaches [ 4 ] and offering new learning opportunities for medical students [ 13 ]. Studies have indicated the effectiveness of online learning in fostering the communication skills of health care providers. Learning with online modules was shown to increase the ability to break bad news [ 25 ] and enhance physiotherapy students’ ability to handle distressing communication within a single e-learning training [ 26 ], and it was more effective than role-play [ 27 ]. Further, e-learning offers the possibility of individualised learning pathways, for example, learning pathways adapted to the needs of advanced learners by providing additional content [ 28 ]. However, as a promising teaching approach within medical education [ 29 ], e-learning bears unique characteristics, opportunities, and challenges. In self-study, students can flexibly adjust the time they spend with the teaching materials. However, students often cannot ask direct questions, and individual feedback is usually delayed. Additionally, lecturers do not get an impression of their students during delivery. Therefore, it is essential to ensure that while learning autonomously, students deal with course content in a way that leads to effective learning and improved competence. Collecting evidence on promising learning environment designs and teaching approaches of online courses is essential to inform clinical teachers about how to foster the effective learning and competence development of their students.

In this respect, we consider initiated reflections embedded in e-learning formats to be particularly promising. During reflection, students actively deal with the course content. As medical education is moving towards more reflection-orientated learning, e-learning should also include methods that promote critical thinking skills and reflective practice [ 13 ]. However, there is limited research on encouraging learning environments or pedagogical strategies to enhance medical students’ reflection [ 30 ], and despite the known benefits of reflection in various health care professions, it is still not a thriving practice in medical education [ 31 ]. Various authors have described how to measure reflection, but only a few have addressed how to embed reflection into online teaching [ 32 ]. Although reflection prompts have been described in recent literature, evidence of the suspected effects remains limited [ 33 ]. Best practices are rarely known, and acceptable approaches to teaching reflection or consistent guiding principles do not yet exist [ 34 , 35 , 36 , 37 ].

The aim of this study was to examine how reflection processes can be embedded and promoted in an e-learning course on medical communication competence. Therefore, our study explores how differently designed e-learning conditions foster reflection, as well as how reflection can be embedded in courses in which little time is available for reflection. Hence, we also aimed to gain initial insights into whether short written reflections can promote reflective capacity. Understanding how reflection could be facilitated to foster medical students’ communication, considering the specific characteristics of online learning, might offer new teaching strategies and improve student learning.

We designed three e-learning variants of a course on medical communication competence with different proportions of reflection triggers and analysed students’ written reflections, as they have been proven to encourage deep reflective thinking [ 38 , 39 ]. Based on an exploratory approach without formulating hypotheses, we aimed to answer the following research questions:

Which e-learning course variant is most effective in reflecting on the course content: a teaching approach that focuses on independently deducing the course content (VR), an explanatory teaching approach based on video modelling using good practice examples and exemplifications (VM), or a variant merging both approaches (VMR)?

Which levels of reflection are reached in the course variants?

Does the quality of reflection correlate with students’ written text length?

We redesigned a face-to-face introductory course on medical communication for medical students in their first clinical year into three e-learning variants, using the course management system Moodle. All variants comprised the same theoretical content, including videos of simulated physician–patient interactions. The variants differed in their proportion of learning elements fostering reflections (reflection triggers) on course content and own learning process. The number of reflection triggers increased in the variants (0, 1, and 2 triggers). In the variant with two triggers, two different triggers were used to promote reflection (Table  1 ). All three course modules followed the same structure.

We designed the variant without reflection triggers based on video modelling (VM) [ 27 , 40 ] using an illustrative example (rule-example approach) [ 41 ], which has been proven in previous research to promote factual knowledge [ 42 , 43 ]. This variant focused on explaining good and bad practice videos. For example, students watched an entire physician–patient consultation in the correct order complemented by explanations. The level of complexity to which learners were exposed was limited, and close guidance was offered [ 41 , 43 ].

In contrast to this teaching approach, we designed another variant with two reflection triggers, which we called video reflection (VR) [ 41 ]. This variant included one interactive video exercise in each module (m), as videos—particularly interactive video exercises—have been described as a promising approach to stimulating written reflection in previous research [ 18 , 44 ]. VM focuses on interactive engagement with the same videos as in the variant VM but without offering explanations. For example, the above-mentioned physician–patient consultation was segmented, and students had to select the optimal structure by themselves. Interaction is described as a critical factor in terms of how the material is presented to capture learners’ attention and effectively facilitate student learning transfer [ 45 ]. Thus, interaction can encourage engagement with the learning material and has become one of the most important strategies in e-learning to teach critical thinking [ 46 ], which is associated with reflective capacity [ 47 ]. In addition to the interactive video exercise, we used an open-ended question at the beginning of each module as a second reflection trigger, asking the students how the exercise was associated with the course topic of this module. Students had to compose a short text before they could proceed in the course module.

The third variant (VMR) combined elements from both approaches. It contained one reflection trigger—the open-ended question about the association of the exercise with the module topic.

Each course variant contained three 45-minute modules on the basics of communication (Module 1), structuring consultations (Module 2), and empathy and emotions (Module 3). The e-learning course was moderated by two physicians (female and male) with specialisations in gynaecology and psychosomatic medicine, who conveyed the same theoretical content to all students, while different teaching approaches were used in the e-learning variants. Learning was asynchronous in all variants. The physician–patient interactions shown in the videos focused on the topics “basics of communication” and “beginning a physician–patient interaction” (Module 1); “conducting and structuring an entire physician–patient conversation with a new patient (in the medical field of internal medicine)” (Module 2); and “reacting appropriately to the emotions of stressed patients” (Module 3). At the end of each module, the same written reflections were prompted in every variant (Table  1 ). By employing guiding questions, the students reflected on the course content and their learning processes. Based on their reflections, we examined how actively students dealt with the learning material and how deeply they reflected, as well as which course variant increased the quality of the reflections.

Reflection prompts

The reflection prompts chosen to initiate the written reflections were based on Koole et al. [ 18 ] and focused on the three core elements of reflection: awareness , understanding , and future actions/transfer [ 48 , 49 , 50 ]. Koole et al. used six guiding questions to assess the quality of medical students’ reflections. These questions made the three core elements of reflection visible and distinctly measurable, although they are usually merged within a reflection process. In contrast to Koole et al., we did not pose questions explicitly asking about emotions, as we aimed to explore whether students reflected on emotions on their own initiative. We adapted the questions in the following way:

Reflection prompt: Awareness

Describe some aspects that you noticed during the physician?patient interactions shown in the videos

Reflection prompt: Understanding

What did you learn? How? Why is that useful?

Reflection prompt: Impact on your future physician–patient interactions

Which learnings might be helpful for your future work? What do you plan for your physician?patient interactions?

We embedded these questions in all variants at the end of a course module (three time points). Therefore, students answered each question three times, as recent literature indicates that a single sample is insufficient for an accurate assessment of reflectivity [ 51 ]. The students had to answer the questions to proceed in the course. A minimum of 500 characters per prompt was specified to promote the reflection process. There was no time limit. Furthermore, the written reflections were not graded to minimise extrinsic motivations [ 52 ].

Participants

Data were collected in the winter semester 2020/21 at the Technical University of Munich. The study participants were medical students in their first clinical year enrolled in a curricular, obligatory course on medical communication. Thereby, effects due to possibly above-average motivated, voluntarily participating students were reduced [ 53 ]. A total of 121 students were randomly assigned to one of the three course variants, with 114 completing all modules and reflection prompts (VM: n  = 39, VR: n  = 39, VMR: n  = 36, 80 female, 33 male, 1 other). The average age was 22.02 years ( SD  = 2.48). How students processed the e-learning environment was flexible regarding location and time. The students had not previously received lessons about reflective thinking.

Data analysis

We applied the REFLECT (Reflection Evaluation for Learners’ Enhanced Competencies) rubric, as it is an established tool for assessing reflective capacity [ 16 , 37 ] widely used in medical education [ 16 , 19 , 54 ]. The rubric developed by Wald et al. measures the depth of reflection. It comprises five criteria that assess five core processes of reflection [ 55 ]: the spectrum of written exploration , the writer’s presence in the written work, the quality of description of conflict or disorienting dilemma , the writer’s attention to their own and others’ emotions , and the meaning-making derived from the explored experience [ 55 , 56 ]. Since we wanted to prepare students for their future patient interactions with our communication course, we added a sixth criterion to the rubric: link to action , according to Hung et al. [ 54 ] This criterion evaluates whether writers mentioned actions they would or would take to apply their learnings.

These six criteria were rated considering four levels of reflective capacity. The levels used in the REFLECT rubric were developed by Wald et al. [ 55 ], building on established frameworks for mapping reflection, such as the work of Mezirow [ 57 ] and Kember et al. [ 58 ]. The written reflections were scored on a scale ranging from 0 to 3 on four levels: habitual action or nonreflective  = 0, thoughtful action or introspection  = 1, reflection  = 2, and critical reflection  = 3 [ 16 ]. The sum of the six criteria of the rubric is the overall reflection score, the highest possible value of which is 18 (6 criteria × highest score 3) (cf. Additional Information for exemplified scorings). Two medical student assistants and the first author with a background in communication science were trained as raters, discussing the rubric’s criteria until reaching a shared understanding, as advised by previous research on the application of the REFLECT rubric [ 55 , 56 ]. Subsequently, they analysed 50 written reflections collected in a pilot study (summer term 2020) under identical conditions until they reached a high level of interrater reliability (the intraclass coefficient [ICC] for a one-way random model with measures of absolute agreement was 0.95). The internal consistency of the ratings (6 items) was satisfactory, with Cronbach’s alpha of a positive effect of 0.74.

We received written reflections from 117 students from the three variants. Three students did not answer all nine reflection prompts; thus, their texts were excluded from the analysis. Each of the remaining 114 students wrote 9 reflections (3 prompts per module in 3 modules at different time points). All 1026 reflection prompts were analysed. Each module’s three reflection prompts were analysed jointly to ensure that the reflection process was pictured in its entirety while leaving the three core elements of the reflection ( awareness, understanding, and transfer ) recognisable. For each student, three overall scores were identified. For quality assurance, we repeated the interrater reliability measurement after 18.90% and 54.37% of the ratings, with the ICCs remaining high (0.94 and 0.87, respectively). SPSS (version 28) was used for statistical analysis. We used a mixed ANOVA to assess the effects of course variants on reflective capacity (as measured by reflection scores [RS]). RS were normally distributed for all groups, as assessed by the Shapiro-Wilk test ( p  >.05). We conducted post hoc analysis using Tukey’s corrected p-values to test for differences between the variants. Furthermore, we used the scoring scheme of the rubric to verify the levels of reflection and conducted a mixed ANOVA with a Creenhouse-Geisser correction to analyse whether the levels of reflection changed during the course in the three variants. Lastly, after analysing the scatterplots, a Kendall’s tau-b correlation coefficient was calculated to assess the linear relationship between RS and text lengths.

Our first research objective was to analyse which teaching approach is most effective in reflecting on the course content, comparing an e-learning course variant that focuses on independently deducing the course content (VR) with an explanatory course variant based on video modelling using good practice examples and exemplifications (VM) and a course variant merging both approaches (VMR).

Comparison of the three e-learning variants

The comparison of the three e-learning variants showed a statistically significant interaction between time (module) and group (VM, VR, and VMR), Greenhouse–Geisser F(3.649, 202.51) = 5.98 , p  < .001, partial η² = 0.097, as well as a significant difference between the groups for Module 1, but none within the groups. Tukey post hoc analysis revealed a significant difference ( p  =.008) between RS of variants VM and VR in Module 1 (-1.90, 95% CI [-3.39, -0.41]). The mean RS in Module 3 was M  = 14.22 ( SD  = 2.23) for VM, M  = 13.56 ( SD  = 2.48) for VR, and M  = 13.24 ( SD  = 2.21) for VMR. Regarding students’ RS at the end of the course, we could not determine significant differences between the variants at the end of the course in Module 3. Therefore, regarding our first research question about which variant was best in reflecting on the course content, we could not determine a variant that fostered reflection significantly better.

Levels of reflection in each variant

Our second research objective was to determine which levels of reflection students achieved in the three e-learning variants. With means of RS between 11.44 and 14.22 (scale 0–18; Table  2 ), students reached the second highest level of four levels, the levels of reflection , in all variants and modules (m). Students in VM improved significantly during the course, with Greenhouse–Geisser of F (1.58, 60.00) = 23.96, p  < .001, partial η² = 0.387 , and Cohen’s d  = 0.79, indicating a large effect [ 59 ]. This significant improvement occurred from Module 1 ( M  = 11.44 [ SD  = 3.11]) to Module 2 ( M  = 14.00 [ SD  = 1.99] t (38) = 6.57, p  < .001, Cohen’s d  = 1.05), with no significant differences between Modules 2 and 3 ( M  = 14.22 [ SD  = 2.23]). The ANOVA with a Greenhouse–Geisser correction showed no significant differences between the modules in VR (Module 1: M  = 13.33 [ SD  = 3.02], Module 3: M  = 13.56 [ SD  = 2.48]), F (1.65, 62.69)  = 0.13, p = .836). Neither was there a significant difference in VMR during the course (Module 1: M  = 12.56 [ SD  = 1.93); Module 3: M  = 13.24 [ SD  = 2.21]), F (1.78, 62.55) = 1.40, p  =.253). In summary, the only significant improvement during the course occurred in VM. Students of all course variants achieved the second-highest level of reflection .

Correlation of text lengths with reflection scores

Our third research question explored whether length was related to quality. The most extended text was written in VM in Module 1 (578 words). Similarly, the variant VM of Module 1 showed the longest texts on average ( M  = 311 words, SD  = 94.73). The shortest texts, on average, were composed in VR in Module 3 ( M  = 246 words, SD  = 42.22). Variant VR also included the shortest text overall, written in Module 2 (160 words). The text length decreased from Module 1 to Module 3 (Table  3 ).

We also analysed the linear relationship between RS and text lengths (Table 4 ). The RS correlated significantly positively with each other across the modules. There were moderate effects between RS of Module 1 and RS of Module 2 ( r  =.369, p  < .001) and small effects between RS of Module 2 and RS of Module 3 ( r  =.219, p  =.001) and between RS of Module 1 and RS of Module 3 ( r  =.142, p  =.039). Similarly, there were significant positive correlations within the text lengths across all modules, all with moderate effects: between Module 2 and Module 3 ( r  =.443, p  < .001), between Module 1 and Module 2 ( r = .414, p  < .001), and between Module 1 and Module 3 ( r  =.304, p  < .001). We also found significant positive correlations between RS and text lengths in all modules, with moderate effects between RS of Module 3 and text lengths of Module 3 ( r  =.404, p  < .001) and RS of Module 2 and text length of Module 2 ( r  =.345, p  < .001) and small effects between RS of Module 1 and text lengths of Module 1 ( r  =.235, p  < .001).

Discussion and conclusions

Previous research has indicated that reflection can promote clinical communicative skills [ 5 ]. However, there are no clear best practices for embedding reflection into (online) medical education [ 31 , 34 , 35 , 37 ]. Against this background, we analysed how reflection processes can be fostered in an e-learning course on medical communication competence. We examined how deeply students reflected on the course content, as well as on their personal learning process, by measuring students’ reflective capacity in three e-learning variants of the course with different proportions of reflection triggers.

With our first research question we analysed which e-learning course variant is most effective in reflecting on the course content. According to our data, at the end of the course, the quality of the students’ reflections did not differ significantly among the variants. In VM, students showed the lowest reflection score at the beginning but improved their reflective capacity significantly from Module 1 to Modules 2 and 3. By contrast, in VR and VMR, students started with higher RS and maintained a reflection level beyond description across all modules. Therefore, in VR and VMR, no significant developments were measured. This is consistent with previous research results showing that students exhibit limited and varied development of reflective skills through reflective writing [ 35 ].

In Module 1, there was a significant difference between the course variants. The design of the beginning of the course seems to have an effect. This significant difference between variant VM (without a reflection trigger) and VR (with two reflection triggers), considered in connection with the higher reflection values in Module 1 of VR compared to VM, indicates that the placement of reflection triggers at the beginning of the course creates the setting and awareness for reflection. Accordingly, a reason for the lack of improvement in VR and VMR could be that the course designs of these variants were more focused on reflection than the design of VM, and the students had to interpret some content themselves before they wrote their first reflection at the end of Module 1, which might have fostered their self-reflective attitude. Previous research on reflection has emphasized the importance of promoting a self-reflective attitude by encouraging students to reflect on and to evaluate their own learning [ 60 ]. In our variants VR and VMR, the open question at the beginning, in which students had to write about their previous knowledge or their personal thoughts on a topic in the field of medical communication, could have promoted a self-reflective attitude. This could have improved students’ reflective capacity before the first written reflection prompt.

Since our analysis examined how deeply the students reflected on the learning content and their learning process, their reflections could only be initiated at the end of a module. In VM, the first reflection prompt was written reflection at the end of Module (1) The RS of VM demonstrated that students particularly increased their level of reflection after this first written reflection from Module 1 to Module (2) Thus, the first reflection prompts might have already trained students’ reflective capacity, which would be consistent with the interpretation that the reflection-oriented learning environments of VR and VMR (with the open question at the beginning of the modules and, in VR, additionally with the interactive exercise as reflection triggers) could have already promoted students’ reflective capacity before the first measurement. This interpretation would indicate the effectiveness of the reflection triggers in VR and VMR, especially after their first use (Module 1), after which no more effects are recognisable. The latter would again be in line with previous research that considers the development of reflective skills through written reflection to be limited [ 35 ]. Further, the higher initial scores in VR and VMR might have limited the possible increase in RS.

Regarding our second research question and the overall level of reflection, the RS achieved in all nine measurements and variants showed that students consistently accomplished a medium level of reflection (the second-highest level of the rubric). This level goes beyond descriptive texts, indicating active engagement with the learning material and good reflection (cf. Additional Information for two examples of written reflections and their scoring). Lower levels of reflection are purely descriptive and reproductive, the medium level indicates personal insights beyond theory, and high level reflection involves critical reflection, including change of perspective and transformative learning [ 35 , 55 , 57 , 61 ]. Our finding is contrary to pertinent literature stating that students mainly reflect on a descriptive level [ 15 , 35 , 61 , 62 ] but is consistent with previous studies indicating that the highest level of reflection, critical reflection , is unlikely to occur frequently [ 57 ]. That students commonly do not reach the level of critical reflection was described in previous studies that analysed reflection exercises in health professions [ 63 , 64 , 65 ] as well as in other disciplines [ 61 , 66 , 67 , 68 ].

There is no general agreement in the literature regarding which factors hinder students from developing high quality reflections and critical reflection. A possible cause could be that accomplishing critical reflection, the highest level of reflection, requires time [ 66 , 69 ], as it involves perspective transformation, which might include a significant period from initial observations to final conclusions [ 57 , 66 ]. To improve reflective capacity and to support critical reflection, recent literature has recommended teaching students the benefits of reflection. Students should understand that reflective practice can support them in their development [ 31 ] and should be provided with evidence of the potential educational and practice-related benefits of reflection [ 70 ]. High-quality reflection may also be fostered by outlining the components of critical reflection to students, such as linking past, present, and future experiences, integrating cognitive and emotional experiences, considering experiences from multiple perspectives, stating lessons learned, and planning future behaviour [ 70 ].

With our third research question, we aimed to clarify whether longer written reflections were more qualitative and should be encouraged, for example, through a specific number of characters or more guiding questions. A higher number of words could indicate that more aspects and arguments were mentioned, which is evaluated as a higher quality of reflection. However, long texts could be formulated repetitively without offering more content, and deep reflections could also be formulated concisely. Our findings show significant positive correlations between RS and text length, indicating that higher reflective quality could possibly be measured in longer texts. This is consistent with previous research results indicating that when students engage in higher levels of reflection, they tend to write longer reflections [ 71 ]. Prior studies have described that word count correlates with reflection scores [ 67 ]. Important questions about possible reasons for this remain unanswered in current literature. Ottenberg et al. have noted that longer reflections might be assumed to show profound reflection, but that this may not always be the case. They therefore suggest that the contents of reflections could be examined as reliable evidence of depth of reflection [ 67 ].

Limitations and future research

Although our study provides new insights and evidence, we acknowledge some limitations. Based on these results, we could not derive whether the good reflective capacity levels demonstrated by the students’ written reflections led to better communicative competence and skills in patient care. We also noticed three factors that might have limited the increase in RS. First, a feedback questionnaire provided to all students at the end of the course showed that students perceived the module themes communicative basics (Module 1) and structure of the conversation (Module 2) as less challenging than emotion and empathy (Module 3). Increasing difficulty may have distorted the findings. RS, which remained constant as difficulty increased, might have been higher with steady difficulty.

Second, habituation effects must be considered: The reflection prompts were provided with the same wording across all course modules to ensure comparability and because previous research has proven single samples to be less suitable for accurate reflectivity assessments [ 51 ]. Nevertheless, students might have been less motivated to compose qualitative answers towards the end of the course, as they had to answer the same questions three times. To analyse this potential effect, time logs could verify whether students spent less time on the reflection texts over the course and whether this influenced RS.

Third, teaching students the basics and importance of reflection before the reflection exercises seems to improve their reflection [ 31 , 70 ]. In most studies, participants were trained in advance [ 72 ]. We did not pre-train students in this study, nor did we teach them the importance of reflection, as this might have distorted the results of our research questions. We also did not provide feedback to our students, as it could have influenced their motivation and the results of the study. However, there is broad evidence that ongoing feedback can improve reflection [ 70 , 73 , 74 ], and we plan to incorporate it into our subsequent courses. Since feedback given by lecturers requires resources, additional future possibilities could be the complementary use of automated feedback and more advanced artificial intelligence technologies to analyse and assess reflective writing, as well as to provide personalised feedback to students [ 68 ].

Lastly, future research will have to clarify the development of reflective skills over time and to prove whether and how increased reflective capacity leads to better physician–patient interactions in medical practice. There is limited research on the relationship between the quality of reflections and academic achievements of medical students [ 67 ], and previous studies have shown mixed results [ 75 ] or reported little evidence on how reflection correlates with other measures or performances in medical school [ 67 , 76 ].

Practice implications

Our study contributes to the understanding of how reflection can be embedded and promoted in online learning environments, offering a teaching strategy leading to levels of reflection beyond the descriptive level with the aim of improving physician–patient interactions. The developed reflection prompts can be embedded easily into e-learning and enable qualitative reflections even in short time frames if little teaching time is available. The teaching approach of starting the course with an open-ended question promoting reflection led to good reflection levels right from the beginning, presumably because these questions sharpened the awareness of reflection.

Since students achieved a good level of reflective capacity in all three course variants, and no variant promoted reflection significantly better, we recommend choosing the variant adapted to the needs of the course. If there is a demand for a more interactive learning environment from faculty or students, VR can be used as a suitable variant. If students need more exemplifications, VM can be used, as video modelling has proven to be effective for the training of communicative competence in previous research results [ 4 , 40 ].

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

intraclass correlation coefficient

module 1/module2/module3

reflection score

standard deviation

standard error mean

video modelling

video reflection

video modelling and reflection

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Acknowledgements

We thank Bernhard Haller, data scientist at the Institute of AI and Informatics in Medicine, Technical University of Munich, for his advice and support in the statistical data analysis.

Open Access funding enabled and organized by Projekt DEAL. This work was part of the research projects voLeA (11/2018–10/2021) and voLeA-TraIn (11/2021–04/2024), supported by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF) [VoLea: grant number 16DHB2133; voLeA-TraIn: grant number 16DHB2201].

Open Access funding enabled and organized by Projekt DEAL.

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LJ and MG designed the study. LJ and TN performed the formal analysis, supported by MG and KS. LJ wrote the initial draft. JB, MG, and PB supervised the entire research process. All authors contributed substantially to the conception and design, acquisition of data, analysis, and interpretation of data. Furthermore, all authors revised the draft, made essential contributions to this paper, and critically reviewed and approved the final manuscript.

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Janssen, L., Schick, K., Neurohr, T. et al. Reflect to interact – fostering medical students’ communication through reflection-focused e-learning. BMC Med Educ 24 , 541 (2024). https://doi.org/10.1186/s12909-024-05368-4

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DOI : https://doi.org/10.1186/s12909-024-05368-4

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The Unique Burial of a Child of Early Scythian Time at the Cemetery of Saryg-Bulun (Tuva)

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In 1988, the Tuvan Archaeological Expedition (led by M. E. Kilunovskaya and V. A. Semenov) discovered a unique burial of the early Iron Age at Saryg-Bulun in Central Tuva. There are two burial mounds of the Aldy-Bel culture dated by 7th century BC. Within the barrows, which adjoined one another, forming a figure-of-eight, there were discovered 7 burials, from which a representative collection of artifacts was recovered. Burial 5 was the most unique, it was found in a coffin made of a larch trunk, with a tightly closed lid. Due to the preservative properties of larch and lack of air access, the coffin contained a well-preserved mummy of a child with an accompanying set of grave goods. The interred individual retained the skin on his face and had a leather headdress painted with red pigment and a coat, sewn from jerboa fur. The coat was belted with a leather belt with bronze ornaments and buckles. Besides that, a leather quiver with arrows with the shafts decorated with painted ornaments, fully preserved battle pick and a bow were buried in the coffin. Unexpectedly, the full-genomic analysis, showed that the individual was female. This fact opens a new aspect in the study of the social history of the Scythian society and perhaps brings us back to the myth of the Amazons, discussed by Herodotus. Of course, this discovery is unique in its preservation for the Scythian culture of Tuva and requires careful study and conservation.

Keywords: Tuva, Early Iron Age, early Scythian period, Aldy-Bel culture, barrow, burial in the coffin, mummy, full genome sequencing, aDNA

Information about authors: Marina Kilunovskaya (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Vladimir Semenov (Saint Petersburg, Russian Federation). Candidate of Historical Sciences. Institute for the History of Material Culture of the Russian Academy of Sciences. Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail: [email protected] Varvara Busova  (Moscow, Russian Federation).  (Saint Petersburg, Russian Federation). Institute for the History of Material Culture of the Russian Academy of Sciences.  Dvortsovaya Emb., 18, Saint Petersburg, 191186, Russian Federation E-mail:  [email protected] Kharis Mustafin  (Moscow, Russian Federation). Candidate of Technical Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Irina Alborova  (Moscow, Russian Federation). Candidate of Biological Sciences. Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected] Alina Matzvai  (Moscow, Russian Federation). Moscow Institute of Physics and Technology.  Institutsky Lane, 9, Dolgoprudny, 141701, Moscow Oblast, Russian Federation E-mail:  [email protected]

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