Reflection rubric development: evaluating medical students’ reflective writing


  • Hedy S Wald,

  • Shmuel P Reis,

  • Jeffrey M Borkan

Hedy S Wald, Box GB-232, Biomedical Building, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02912, USA. Tel: 00 1 781 424 2711; Fax: 00 1 866 372 7918; E-mail:

Context and setting

Reflective capacity (RC) is deemed an essential component of professionally competent practice. Medical educators continue to strive to implement innovative pedagogy aimed at promoting RC development, often within a humanities and medicine context. The use of reflective writing exercises within undergraduate and graduate medical education is expanding; however, tools to assist with evaluation and feedback are lacking.

A reflective writing curriculum innovation was introduced into the Doctoring course in the 2 years of pre-clinical education at the Warren Alpert Medical School of Brown University during the 2005–2006 academic year. The Doctoring course teaches clinical skills and professionalism through integrating instruction in medical interviewing, physical diagnosis, cultural competence and medical ethics. The course structure includes large-group didactic sessions, small-group processing and skill instruction, one-to-one, community-based doctor mentoring for skills practice, and reflective writing assignments. Within this course, 19 structured reflective writing exercises (‘field notes’ and reflections on case write-ups) are required of medical students and guided individualised written feedback from an interdisciplinary faculty team is provided. The interactive reflective writing paradigm of guided faculty feedback on students’ reflective writing to promote reflection has recently been described.

Why the idea was necessary

Curriculum initiatives that include reflective writing have created the need for a valid, reliable evaluative tool that can be effectively applied to assess the student’s reflective level and its development. Various frameworks for assessing RC have been described, although definitions of reflection levels abound and existing measures can be challenging in their application. Publications on the utility of reflective writing in medical education have been largely anecdotal or based on student self-report.

What was done

We devised a reflection rubric for determining student reflection levels within reflective writing exercises. Our reflection rubric emerged from both a comprehensive analysis of the literature evaluating the reflection construct and the synthesis of existing reflection measure instruments, and resulted in a more concise, user-friendly format. The rubric consists of five levels of reflection, for each of which clear and thorough criteria are provided (based on the integration of literature definitions). The criteria include such features as writing from the ‘I’ or ‘we’ perspective, moving from description to reflection and introspection, attending to emotions, and displaying transformative learning. Levels are as follows (bracketed descriptors adhere to Doctoring course evaluation guidelines):

  • 1non-reflective: habitual action (unsatisfactory);
  • 2non-reflective: thoughtful action (needs improvement);
  • 3reflective (competent);
  • 4critically reflective (exceeds competence), and
  • 5transformative learning (exceptional).

Evaluation of results and impact

A 2009 reflection rubric pilot study provided encouraging results in ease of application and inter-rater reliability. The rubric was applied to a dataset of all Year 2 students’ self-selected ‘best’ reflective writing notes (= 93) and reflection levels were found to be distributed as follows (numbers of students in parentheses): level 1 (0); level 2 (17); level 3 (38); level 4 (28), and level 5 (10). Pilot inter-rater reliability on 10 random notes was at 0.7 for full agreement and 1.0 for one level of difference.

We propose that this reflection rubric represents an incremental step forward for the discipline. Longitudinal investigations of reflective writing exercises using this rubric will, we hope, assist educators as they reflect on the efficacy of such curriculum initiatives