Mind The Gap: A Philosophical Analysis of Reflection’s Many Benefits

Abstract

Issue: Expectations of reflection run high in medical practice and medical education; it is claimed as a means to many ends. In this article, the authors do not reject the value of reflection for medical education and medical practitioners, but they still ask why reflection can (potentially) yield so many different benefits, and what that implies for the status of reflection in medical education practice. Evidence: Based on a conceptual analysis of debates about reflection in the philosophical tradition, the authors argue that there are two quintessential gaps that play a role in the proliferation of (potential) benefits. First, reflection deals with bridging the gap between theory and practice; second, it deals with bridging the gap between the individual sense and communal sense. These gaps prevent the systematization of reflection, and they are fundamental to human thinking and experience in any situated environment, which led contemporary research on reflection to list a wide variety of benefits. Implications: The authors argue that if reflection resists systematization, it cannot be learned by following rules or protocols, but only practiced. Then, reflection should no longer be taught and researched as an individual skill one learns, nor as a means to some particular, beneficial end. Rather, one should practice reflection, and experience what it means to be part of a community wherein professionals jump the theory–practice gap constantly in a myriad of situations. Based on their analysis, the authors provide three concrete recommendations for reflection in medical education. First, to give precedence to reflective activities that encompass both gaps wherein situated examples can flourish; second, to use reflective guidelines as sources of inspiration; third, to show reserve about assessing reflection.

Keywords:

• Reflection
• Benefits
• Philosophical Analysis
• Theory Practice Gap
• Communal Sense

Introduction

Expectations of reflection run high in medical practice and medical education; it is claimed as a means to many ends. Reflection can reduce burnout,^1,2 increase empathy,² decrease stress,³ develop professionalism,⁴ refine clinical skills,^5–7 help practitioners transition from theory to practice,^8–11 and many more. Albeit various researchers show some reserve about the empirical evidence concerning the benefits of reflection,^12–15 reflection seemingly blossoms with potential. Consequently, some researchers attempt to create order in reflection’s proliferated ends, for instance by categorizing reflection’s purposes in three domains,¹³ while others argue that “reflection has become a generic salve to heal all wounds,”^16(p263) or has become reductively utilized as purely a means to an end.¹⁷ While we do not reject the value of reflection for medical education and practitioners, we ask why reflection can (potentially) yield so many different benefits, and what that implies for the status of reflection in medical education practice.

We argue that it is important to critically analyze how reflection relates to its many (potential) benefits because teachers and trainees dedicate much time and many educational resources to reflective activities. In medical curricula, there is a wide variety of ways to reflect, teach, and assess reflection. Reflective activities span written portfolios, essays, journals, mentor programs, training programs, or discussing clinical experience with peers in small groups.¹⁴ Reflective activities receive justification based on the premise that they yield certain benefits.

Our analysis will consist of a philosophical investigation of the concept reflection. We will focus on debates from the philosophical tradition, specifically how philosophers connected reflection to the gap between theory and practice, and the gap between an individual sense and communal sense. We will then relate our philosophical considerations to the current research on reflection to determine how researchers conceptually used reflection to pinpoint its benefits. Finally, in the light of our analysis we will formulate three concrete recommendations for reflection in medical practice and education.

A philosophical approach to research on reflection

For this article, we conducted a philosophical, conceptual analysis of reflection.^18–20 We questioned the theoretical presuppositions surrounding reflection, and traced background premises and values that affect this educational practice and its (potential) benefits.^21,22 We drew our philosophical considerations from the continental philosophical tradition, particularly the work of Immanuel Kant, Martin Heidegger, Hannah Arendt and Jacques Derrida. We turned to these philosophers because they map the limits of human knowledge, and critically think about aporias, or how “gaps” play a vital role in human experience and reflection. For them, these aporias should not be understood as problems that are to be solved, but rather as limits that require awareness. Therefore, we started our analysis from the perspective of the gaps to help us understand reflection and its relation to the alleged benefits.

Our analysis consisted of two phases. First, we focused on key philosophical debates on reflection, particularly the gap between theory and practice, and the gap between the individual and communal sense. Second, we related our philosophical considerations to current research on reflection, and scrutinized how researchers conceptually used reflection to pinpoint the benefits. Therefore, we drew insights from literature reviews about research on reflection in medical education or medical practice since the 2000s until 2021.

Phase one: philosophical debates on reflection

The theory–practice gap

In the tradition of philosophy, philosophers regularly contrasted reflection with knowledge acquisition, or blindly following rules and calculation. The ancient Greeks already acknowledged that true wisdom required something more than mere “bookish” knowledge. Aristotle, for instance, described reflection (sometimes also translated as deliberation) as the ability to connect acquired knowledge with professional experience, or theory with practice.²³ It was the key to “practical rationality” (“phronèsis”), which he considered as the highest intellectual virtue, and as an absolute necessity of professionalism in fields such as medicine, politics, law, and military strategy.

The fact that theory can be connected with practice (or knowledge with experience) also implies that there must be a gap between them to begin with. It is precisely this gap that has posed a continuous philosophical problem, to which reflection formed a potential solution. To get a sense of that problem, we can refer to Kant, who in many ways is considered the father of modern philosophy. Kant, too, acknowledged that there exists a gap between theory and practice. One may, within a particular professional field (he mentions law and medicine as examples), know all the rules and concepts, but may still be unable to properly apply them in practice. He aptly calls this “stupidity.”²⁴

The ability to properly apply a rule or concept in a given situation is what Kant calls the power of judgment, but with this power of judgment comes a problem. If judgment means applying a set of rules to practice, a second set of rules will always be necessary to determine how the first set of rules should be applied. However, that second set of rules would require a third set of rules to determine how they should be applied, and so forth. In this way, we end up in an infinite regression of formulating rules for applying rules, and we would never bridge the gap from theory to practice. To illustrate this point, consider Kant commentator Henry Allison’s explanation of playing chess.^25,26 Formally learning the rules of chess is necessary to play, but making a good move requires complex interpretations of the given, concrete situation. The situation cannot be remedied with devising more rules, since there are always exceptions and alternatives in any given situation. One is not relieved of the necessity “of determining for oneself what the particular situation requires.”^25(p206) Therefore, Kant argues that it must be in principle impossible to formulate, teach, or learn the rules for judgment. In Critique of Pure Reason, he concludes that judgment is “a particular talent that cannot be taught at all but can only be practiced.”^{27(p(A133/B72)14)}

Judgment that cannot be taught seems quite unsatisfactory, and so it was too for Kant, which is why he returned to this problem in his later work Critique of Judgment. Judgment, he argues, cannot merely consist in the ability to apply a set of rules to practice (a limited understanding which he now calls “determinative judgment”). As Allison writes: “an account of judgment solely in terms of determination is inherently incomplete, requiring as its complement the activity that Kant terms ‘reflection’.”^27(p18) Besides the ability to apply rules, judgment also consists of the ability to acquire, expand, and develop rules and concepts; people reflect on them on the basis of, and in dialogue with, practical experience. This he calls “reflective” judgment.

What reflective judgment does is described by Kant in the following way: “To reflect (or consider) is to hold given presentations up to, and compare them with, either other presentations or one’s cognitive power [itself], in reference to a concept that this [comparison] makes possible.”^{28(p400,FI,211)} In other words, reflective judgment involves not so much a “ruling over” the matters at hand, categorizing and determining them in abstract fashion (which would be determinative judgment), but rather “harmonizing” one’s (conceptual) thought with the object or situation one is dealing with. Reflective judgment, according to Kant, thus forms the very condition of one’s experience, since it assumes that the concepts one uses and the rules with which one applies them are principally related to the world.

The gap between an individual and communal sense

In Section 2.1, we explained that reflection for Kant involves bridging the theory–practice gap, and that it is the very condition of experience. In this section, we show that Kant identified another quintessential gap that plays a role in reflection, and it resides between one’s individual sense and a communal sense. Arendt argued that the most important aspect that sets Kant’s notion of thinking (as “reflective judgment”) apart from his predecessors’ is not only the practical, but also the social nature of it. Reflective judgment, for Kant, consists in the public use of one’s reason, and hence the negotiation of one’s considerations with others:

[Kant] believes that the very faculty of thinking depends on its public use; without ‘the test of free and open examination,’ no thinking and no opinion formation are possible. Reason is not made ‘to isolate itself but to get into community with others’. ^29(p40)

The public nature of reflection is clearly distinguished from mere calculation or rule following, for which one would not need the considerations or recognition of others. Kant illustrates this public nature of judgment by means of esthetic judgments, i.e. statements concerning the beauty of certain objects. One’s esthetic judgments, Kant argues, are based on what he calls a sensus communis, a shared sense. One considers judgments of beauty not as merely subjective feeling, but rather as a sensation that individuals imagine is shared by all. For example, if I enjoy the sight of a beautiful flower or the sound of a Mozart sonata, I cannot help but expect that others will share my feeling, precisely because there is nothing in particular about me that would distinguish my sensation from that of others. Comparing my judgment with those of others, however, does not mean that I adjust my taste to that of the majority. I only presume that my sensation of beauty cannot merely be my own; it must be based on some generally shared sense of beauty.

What Kant says about the nature of esthetic judgment is true for judgments in general, according to Arendt. That one takes the perspective of others into account is a fundamental part of what constitutes thought and even what makes us human. It connects the way one experiences the world with a community. Again, this does not mean that I claim that everyone will actually agree with my judgments. Rather, in reflection I relate my judgments to a hypothetical community:

We compare our judgments not so much with actual as rather with the merely possible judgments of others, and [thus] put ourselves in the position of everyone else, merely by abstracting from the limitations that [may] happen to attach to our own judging. ^28(p.160)

To place oneself in the position of everyone else depends on the power of imagination, but that does not mean that the community is entirely fictitious. “By the force of imagination it makes the others present and thus moves in a space that is potentially public, open to all sides.”^29(p43)

Bridging gaps and the madness of reflection

We saw in the previous sections that reflection concerns two quintessential gaps that play a role in human experience: the theory–practice gap, and the gap between the individual and communal sense. This brings the analysis to the point how practitioners can bridge these gaps, and the pressing question becomes whether and how reflection can be taught and learned.

We return once more to Kant’s philosophical analysis of reflection, specifically to two ways reflection fundamentally resists systematization. First, as we have seen, Kant argued that the ultimate rule to connect theory with practice cannot be formulated because that would lead to an infinite regression. To recapitulate briefly, there is a difference between formally learning the rules of chess, and making a good move by interpreting the complex situation at hand, which requires reflective judgment. Therefore, Kant suggested to train reflection with examples, not by formally learning rules like a recipe.²⁶ Reflection cannot be taught but only practiced as that peculiar talent that brings general rules into dialogue with particular circumstances. From this perspective, reflection fundamentally resists systematization.

The second type of resistance to systematization concerns the gap between the individual and communal sense of reflection. As we explained in Section 1.2, individuals relate their personal judgments to those of the (imagined) community. However, this community is not fully stable but contingent; moreover, the individuals who constitute the community are also viable to change. Thus, the community alters with the passing of time and unique constitution of the community. In the case of reflection, the community’s relative instability prevents anyone from definitively formulating what the outcome of reflection should be for everyone, at all times, and everywhere.

After Kant, the resistance to systematization has been much debated in philosophy. In some cases, reflection has even been pitted directly against science, understood as calculative rationality. The philosopher Heidegger provocatively stated that “science does not think,”^30(p8) which was certainly not meant to disqualify science, but rather to emphasize that (philosophical) reflection does not proceed according to a predetermined methodology, logically inferring on the basis of evident premises. The thinker, according to Heidegger, enters a much more uncertain field: “There is no bridge here – only the leap,” and that takes us not only to the other side, but to a totally different place.^30(p8)

Heidegger’s criticism of science is exaggerated, and ignores the fact that scientists regularly tread terrain as uncertain as that of the philosopher. Still, Heidegger’s point is relevant for our analysis of reflection in the medical field: if one would know beforehand how to proceed, one would not have to “think.” There is, in other words, a fundamental difference between reflecting (or thinking) and calculating or rule following. One could therefore say that reflection resists precise formalization, and that reflection even becomes jeopardized when it is translated into uniform learning-outcomes. If reflection becomes a matter of blindly checking the right boxes, such a process risks replacing actual reflection, and with that the professional attitude.

To consider a professional attitude that encompasses reflection, we take into consideration how the philosopher Derrida argues that the practice of law is never a mere application of the law. He therefore makes the distinction between law and justice. For justice to occur, one must always decide whether the law is, in this case, applicable. In other words, a process of professional reflection is needed, which involves the interpretation both of the law and of the case at hand. Were that not so, and justice would consist in the mere following of a rule or protocol, it would be a fully calculable process and we could easily outsource it to a computer. There would, in the strict sense, be no moment of decision or judgment at all. This leads to an interesting paradox for medical professionals. Each decision involves a necessary moment of “undecidability,” that is an uncertainty whether the decision is right, or just.³¹ “The instant of decision is madness,” as Derrida quotes from Søren Kierkegaard.^32(p65) This might seem exaggerated, but Kierkegaard precisely emphasizes the impossibility of reducing reflection to rule-following or certain knowledge.

The philosophical analysis applied to examples

At this stage, it is helpful to illustrate how our philosophical analysis of reflection and the two gaps could relate to two concrete examples from medical practice and medical education.

Our first example comes from 2008, when patient Elaine Bromiley tragically died after competent and expert anesthetists failed to recognize that they could not intubate and ventilate.³³ “[They] persevered with attempts to intubate and ventilate when they should have changed to another strategy.”^34(p61) Evie Fioratou and colleagues assessed this as a fixation error, or an “unhelpful reliance on past experience to the detriment of the current situation.”^34(p61) They argued that there is no easy fix to prevent this error. Generally, developing routine, following protocols and using checklists are important.^7,35 However, Bromiley’s case also showed how fixation is a “natural by-product of (…) rules of thumb.”^34(p62)

Bromiley’s case illustrates Kant’s problem of bridging the theory–practice gap. Just like Kant, medical practitioners and research experts turn to reflective judgment to pinpoint how practitioners must come to grips with applying rules and standards in particular situations. According to experts this encompasses, for instance, training to accept uncertainty and deliberately seeking out alternatives,³⁶ embedding moments to “stop and think” (and review checklists in light of the case⁷), and exposing practitioners to routine and non-routine cases to increase their awareness about potential fixations.^34,36 Ultimately, however, the gap between theory and practice will remain, and practitioners must learn to deal with jumping over it.

Elaine Bromiley’s case also illustrates the value of bridging the gap between an individual and communal sense.³⁷ Contrary to the anesthetists, the attending nurses did recognize the problem, but were unable to communicate that to the anesthetists, and failed to “override and change the clinicians’ mental model.”^35(p116) Understanding the social dimension and allowing feedback from team members is therefore advized.^36,38,39 It checks practitioners’ individual sense (and certainty) about their correct application of procedures.

Our second example comes from a study on weekly group reflection sessions in the Dutch GP specialty training.^40,41 Mario Veen and Anne de la Croix studied how participants themselves make experiences “shared” and “reflectable.” One case involves registrar Ilone, who told the group how her supervisor criticized “the way she says her name when she answers the phone, which upset her.”^40(p329) Then, Ilone asked her peers: “I wondered if with you they also observe in such detail? (…) Is this part of it or is it something that my GP trainer suddenly focusses on, very fussy details.”^40(p328) What ensued was a discussion of this experience, which involved exploring (loosely) related themes and giving advice.

Like Bromiley’s example, Ilone’s example also illustrates reflection and both gaps. Compared to the Bromiley example, however, the two gaps materialize differently. First, GP registrars explore (retrospectively) what general principles (theory) play a role while being supervised, and second, how those relate to Ilone’s experience (practice). The case involved how supervisors should supervise; balancing attention to detail with fussing over details; providing feedback; meta-communication and setting boundaries as a registrar.⁴⁰ Moreover, Ilone asked peers about their experiences with supervision. This is a form of shared meaning making,⁴² and the registrars (re)constructed their individual and communal sense of being supervised.

In sum, with these two examples we illustrate reflection’s flexibility to yield value for practitioners, if one understands it as a fundamental human capacity to cross the gaps between theory and practice, and the individual and communal sense in a particular situation. Reflection used for clinical reasoning is different from doing weekly (retrospective) group reflection sessions for the sake of professional development. The situatedness of reflection deserves our critical attention; however, each case transcends mere calculation and blind application of rules that would not require input from others. No decisions or judgments need to be made when everything is clear and certain; then, a computer could execute the tasks. Practice is riddled with minor or major moments of uncertainty. Uncertainty occurs when practitioners face the madness when general principles (captured in rules, procedures, models, theory) do not neatly fit the unique reality.

Phase two: how the philosophical considerations relate to research on reflection

In phase two, we related our philosophical considerations to research that discussed reflection’s (potential) benefits. We found that literature reviews about research on reflection since the 2000s listed a wide range of benefits. Meanwhile, many reviews also admonished the lack of a unified theoretical understanding and the paucity of empirical evidence.^12–15 We did not assess theoretical consensus nor empirical evidence in these reports, but used our philosophical considerations to scrutinize the conceptual use of reflection and how that allows researchers to pinpoint various benefits.

The theory–practice gap in research on reflection

In the literature reviews, we saw the following conceptual inclination occur. The research field embraced reflection as a fundamental way to bridge the theory–practice gap. This is, however, the very condition for human experience, and the field ended up listing benefits of reflection that are ubiquitous and multi-applicable. This strategy became especially salient when one kept in mind that practitioners must cross the theory–practice gap on a daily basis, on many different occasions, and for many different reasons.

The literature reviews reported that “reflection helps narrow the gap between theory and practice, ultimately enhancing practice.”^10(p495) Additionally, reviews also used different wordings to describe the transition between theory and practice. For instance, reflection helped practitioners relate experiences from practice to theory,⁸ linked or integrated theory with practice,^43,44 handled ambiguity,⁴⁵ through contextualization,¹³ or exposed how theory is embedded in practice.⁹ Reviews also demarcated specific domains wherein reflection helped traverse the theory–practice gap, for instance, clinical reasoning.⁴⁶ Take note that within the latter domain different conceptions of reflection exist, which led to variation in its beneficial effects.⁷

The focus on the theory–practice gap led reviewers to report that reflection instigated a variety of changes. For example, reflection transformed behavior and adapted knowledge.^46,47 Another review linked reflection to empowerment and implied various transformations, like more consistently

using research evidence in practice; taking time to link theory with practice; critically evaluating, questioning, dialoguing about, and problem solving clinical situations and practices; enacting changes in their practice and thinking; debating implications of their actions in practice; taking risks to challenge previously held values, beliefs, and assumptions; and integrating new learning with prior knowledge. ^44(p643)

This quote illustrates the conceptual inclination clearly: contemporary research posited reflection as a central means to address a fundamental problem, which in Kantian terms is bridging the theory–practice gap. Consequently, researchers found how reflection became a beneficial driver for many different but fundamental (behavioral, cognitive, identity) changes that help cross that divide, resulting in many (potential) benefits in a wide range of situations.

The gap between the individual and communal sense in research on reflection

In the literature reviews, we encountered the following conceptual inclination that occurred within the domain of the individual and communal sense. Literature reviews connected the benefits of reflection to self-awareness, which led to a wide array of things one can become self-aware of, with diverse beneficial effects for oneself and the community. This strategy co-occurred often with references to professional development or growth.

The reviews generally reported that reflection impacted professional development,⁴⁸ by learning more about oneself.⁶ Overall, “established models of reflection propose that personal growth occurs over time, as experiences are examined to produce new understanding that informs future practice.”^49(p437) In particular, reflection helped identify personal beliefs,^13,49–53 gain insight into one’s professional strengths and weaknesses,^3,6 recognize personal bias,^4,5,54 and attitudes,^5,52 decrease stress and anxiety,^3,6 and prevent burnout.^1,2 Other beneficial effects for practitioners, by doing for instance reflective writing exercises, include:

an ameliorated attitude towards work; a development path for [their] job potential; an enhancement of their introspective knowledge; an enrichment of their expressive capability; an improvement of their interpersonal relationships with patients and colleagues and [it] develop[s] their use of critical and reflective thinking. ^6(p8)

Literature reviews not only listed benefits of reflection for the individual practitioner, but also benefits for the community. It “generate[d] a climate of trust which promoted a sense of community,”^9(p1642) or supported building a community of practice and better interprofessional relations.^55,56 Reflection helped practitioners understand “other perspectives, medical culture, and the importance of diversity.”^49(p.432) Patients were no longer mere objects of care but practitioners also empathized with them,^2,49,52 and understood “the importance of why they were caring for patients.”^4(p10) Reflection kindled altruism,⁵⁷ while it also helped practitioners “challenge dominant discourses and oppressive power and social structures.”^55(p221)

The conceptual inclination that underlies the various individual and communal benefits pivots around self-awareness. “Self-awareness may lead to [the] perception that environmental manipulation is needed in one situation and knowledge improvement in another.”^46(p387) Or as some researchers concluded: “‘Higher quality’ papers identify (…) increased self-awareness and engagement in reflection (…) and continuous professional development.”^53(p312) When researchers turned to reflection that instigates self-awareness, it became a linchpin for many benefits.

The issue at hand is that individuals compare their own judgments with those of others, or confronting their individual sense with the communal one. In effect, they (could) gain awareness of their own position on any given subject. As a result, the literature reviews listed a wide variety of things that one could become (self-)aware of, ranging from one’s values, biases, to communication and so forth. The list of things that one could become self-aware of seems potentially endless.

Discussion

With our analysis, we aim to show how two gaps play a role in the benefits of reflection, why there might be so many benefits to reflection, and what that implies for medical education. First, reflection helps practitioners cross the theory–practice gap. Second, reflection helps practitioners cross the gap between the individual and communal sense. Yet, crossing these gaps is so fundamental for human understanding that reflection runs the danger of becoming ubiquitous and generic, indiscriminately relied on for many specific benefits in a wide range of situations. Reflection almost starts behaving like a panacea.¹⁶ In our view, the list to precisely define reflection’s benefits for crossing these gaps is potentially endless, also when one takes into consideration that reflection resists systematization. Thus, we advise restraint in pursuing and empirically validating potentially endless specific benefits of reflection.¹⁸

As Stella Ng and colleagues argued, the pursuit to pinpoint all benefits of reflection plays heavily into a reductive understanding of reflection as a means to utilitarian ends.^12,14 Practitioners “may eventually perceive [reflection] as falling short of its goals because it is difficult to ‘prove’ reflection ‘works’.”^17(p468) We suggest that the moment of undecidability, or even madness, is difficult to swallow in medical education. Those who cannot accept it, attempt to fill the gaps. These critical observations still leave us with the question how reflection can be practiced if we refuse to “fill the gaps.” In the next section, we provide three concrete recommendations for reflection in medical education and medical practice.

Three recommendations

Based on our conceptual analysis of reflection in the tradition of philosophy, and how these relate to contemporary research on reflection, we think that reflection occurs in its situated use.¹⁸ We support that there is no “one-size-fits-all” to reflection.⁵⁸ Nonetheless, this does not relieve us from critically approaching reflection, and our philosophical considerations led us to certain preferred recommendations for medical education.

First, we recommend giving precedence to communal reflective activities over solitary ones, wherein situated examples can flourish and come to life. We do not deny that written reflections in the form of reflective essays, written assignments, or portfolios have some merit. For instance, they could train introspection, or “getting a second opinion from your own conscious mind.”^36(p550) Nonetheless, based on our philosophical considerations, we prefer reflective activities that include active and immediate representation of the communal sense that contrasts with one’s individual sense when practitioners wrestle with the theory–practice gap. Such exchanges curb practitioners from being “stuck”⁵⁹ in their individual sense through solitary reflective activities. Group reflection activities provide more interactive means for calibrating the communal sense of the medical profession based on concrete examples.^42,60 Practically, we take (reflective) discussion groups as a positive example, for instance the Exchange of Experience (EoE) rounds in the Dutch GP specialty training.^40–42 Once a week, a small group of GP registrars under supervision of two teachers come together to discuss their clinical experiences in an open, dialogic environment. Group discussions entice immediate exchanges of diverse perspectives between the individual and communal sense (as represented by other individuals) about concrete experiences.^40–42 Such shared meaning making “promotes the formation of professional identities.”^42(p876)

Second, when it comes to using reflection for one’s professional identity, we recommend using formal guidelines and models for reflection as sources of inspiration to reflect, and not as normative models that dictate how practitioners should reflect.^18,61 We ground our recommendation in the Kantian argument that reflection resists systematization and that formally learning rules is something other than reflection.^26,62 Thus, for Kant, reflection is trained by practice and by being confronted with (situated) examples. Concretely, we take the aforementioned Dutch EoE discussion groups as a case in point once more. In EoE, the experiences take center stage. Registrars tell stories about situated examples that allow them to sharpen their judgments during discussions in a safe environment.⁶⁰ These discussions are not dictated, but take shape as “structured spontaneity.”^40,42 The discussions become messy,⁴⁰ but registrars find that having (guided) freedom to discuss experiences is valuable for professional development.⁴²

Third, when we take formal guidelines for reflection as inspiration, then we also must reconsider assessing reflection.⁶³ Assessment of reflection often comes down to checking if certain rules are followed, and although we understand that clear assessment guidelines for reflection intend to counter problems of arbitrariness and bias, such assessment instigates behavior to correctly follow the recipe and pass the assessment.^62,64 Conversely, reflection in the Kantian sense moves beyond following rules, so assessing whether or not reflection sufficiently took place will necessarily involve moments of “madness” (leaping over the theory–practice gap). Guidelines cannot fill the gap and should be used with caution. Moreover, one is not alone in leaping, and therefore must check one’s individual sense against the communal sense of fellow professionals. In sum, the theory–practice gap and the individual–communal sense gap remain in place for assessors too, particularly when it comes to reflection.

Conclusion

The benefits of reflection are (potentially) abundant. While literature reviews about research on reflection attempt to list and validate these benefits, we philosophically analyzed why reflection can have so many benefits. Based on the philosophical tradition, we argued that there are two gaps that play an inherent role in reflection. On the one hand, there is the theory–practice gap that practitioners bridge; on the other hand, practitioners bridge an individual sense opposed to a communal sense of their profession in particular situations.

Philosophers like Kant, Arendt, Heidegger, and Derrida show that reflection can help cross these gaps, which one can practice. However, they also warn us that reflection, by its very condition, resists systematization. There is no definitive set of rules or protocols that form the final keystone to bridge both sides of these divides. Then, reflection also ceases to be merely an individual, learnable skill or an empirically validated means to some particular end. Consequently, if reflection cannot be caught in learnable rules, one should show reserve about assessing it. There only remains the jump from one side to the other. Practitioners can practice jumping, particularly when they are within a community of professionals and exchange their experience while they “mind the gap.”

Previous philosophy in medical education installments

Mario Veen & Anna T. Cianciolo (2020) Problems No One Looked For: Philosophical Expeditions into Medical Education, Teaching and Learning in Medicine, 32:3, 337–344, DOI: 10.1080/10401334.2020.1748634

Gert J. J. Biesta & Marije van Braak (2020) Beyond the Medical Model: Thinking Differently about Medical Education and Medical Education Research, Teaching and Learning in Medicine, 32:4, 449–456, DOI: 10.1080/10401334.2020.1798240

Mark R. Tonelli & Robyn Bluhm (2021) Teaching Medical Epistemology within an Evidence-Based Medicine Curriculum, Teaching and Learning in Medicine, 33:1, 98–105, DOI: 10.1080/10401334.2020.1835666

John R. Skelton (2021) Language, Philosophy, and Medical Education, Teaching and Learning in Medicine, 33:2, 210–216, DOI: 10.1080/10401334.2021.1877712

Zareen Zaidi, Ian M. Partman, Cynthia R.Whitehead, Ayelet Kuper & Tasha R. Wyatt (2021) Contending with Our Racial Past in Medical Education: A Foucauldian Perspective, Teaching and Learning in Medicine, DOI: 10.1080/10401334.2021.1945929

Chris Rietmeijer & Mario Veen (2021) Phenomenological Research in Health Professions Education: Tunneling from Both Ends, Teaching and Learning in Medicine, DOI: 10.1080/10401334. 2021.1971989

Madeleine Noelle Olding, Freya Rhodes, John Humm, Phoebe Ross & Catherine McGarry (2022) Black, White and Gray: Student Perspectives on Medical Humanities and Medical Education, Teaching and Learning in Medicine, 34:2, 223–233, DOI: 10.1080/10401334.2021.1982717

Camillo Coccia & Mario Veen (2022) Because We Care: A Philosophical Investigation into the Spirit of Medical Education, Teaching and Learning in Medicine, 34:3, 341–349, DOI: 10.1080/10401334.2022.2056744

John Humm (2022) Being-Opposite-Illness: Phenomenological Ontology in Medical Education and Clinical Practice, Teaching and Learning in Medicine, DOI: 10.1080/10401334.2022.2108814

Anna MacLeod, Victoria Luong, Paula Cameron, George Kovacs, Molly Fredeen, Lucy Patrick, Olga Kits & Jonathan Tummons (2022) The Lifecycle of a Clinical Cadaver: A Practice-Based Ethnography, Teaching and Learning in Medicine, DOI: 10.1080/10401334.2022.2092111

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Acknowledgements

We wish to thank Mario Veen for the invitation to write this article.

Disclosure statement

The authors declare no competing interests.

Funding

The author(s) reported there is no funding associated with the work featured in this article.