Reflecting on insight and insights into reflection: a systematic review of insight and reflection in post graduate medical education

Clinicians recognize insight as important for safe independent medical practice. Clinical education literature focuses on self‐reflection. The aim of this review is to describe how clinical educators conceptualize reflection and ask is it analogous to how clinicians conceptualize insight?


Introduction
As a newly qualified fellow of the Royal Australasian College of Surgeons I (NP) was party to a conversation with a respected senior clinician who was detailing the saga of a former colleague's fall from grace.This covered multiple professional difficulties, dismissals, and eventually loss of licence to practice.So significant was this final event, he illustrated his point with a carefully folded newspaper clipping, produced from the pocket of his jacket.The respected Professor's final pronouncement was 'the problem is, he lacks insight'.
Prior to this, and subsequently, I have heard this assertion uttered with an air of finality.Seemingly it is the most damming judgement that can be made of a fellow clinician.In my role as a surgical educator, I have also heard supervisors making this observation of some trainees in difficulty.This raises the question of what does insight mean?How is insight assessed and can it be remediated?Could insight be part of the selection process, or learnt early in training?
The Merriam-Webster dictionary definition of insight is: '(1) the power or act of seeing into a situation (penetration) or (2) the act or result of apprehending the inner nature of things or of seeing intuitively'. 1This definition appears to be aligned with the common use of the term amongst clinicians.However, a preliminary search for insight in the medical education literature failed to identify the term 'insight' used in the way described above.][8][9] For example, in the development and validation of the Self-Reflection and Insight scale Grant et al. define self-reflection as 'inspection and evaluation of one's thoughts' and insight as 'the clarity of understanding of one's thoughts…'. 8In the scale they list factors under 'insight' that are related to self-awareness or self-consciousness.For example; 'I am usually aware of my thoughts' or 'I usually know why I feel the way I do'. 81][12][13][14][15] However, some theorists raise concerns about reflexive exercises in medical training.Ng et al. describe a concerning divergence between theory and practice with the risk of reflective practice becoming 'trendy' in education, distracting from the richer potential of reflection as a way of managing diagnostic uncertainty and of challenging dogma. 7Leigh and Baily describe reflective practice as 'success words' or 'terms that elicit positive and supportive responses, but ultimately conceal considerable conceptual contestation and confusion'. 16here appears to be a tension between everyday use of the term insight by clinicians, theoretical frameworks of insight and reflection, and educational initiatives that focus on the act of reflection without clear links to an outcome.We sought to understand how the medical education literature conceptualizes insight and reflection, to inform initiatives to nurture insightful, reflective and self-regulated clinicians.We also see this as a first step towards unpacking the problem of the doctor who is said to lack insight.
The aim of this review is to identify how the current literature conceptualizes insight and reflection and how it characterizes the relationship between them in the context of postgraduate medical education and clinical practice.Our ultimate aim is to create a framework for clinical education that will promote development of clinicians with the skills that enable them to practice with what their supervisors and future colleagues describe as insight.

Methods
This study followed three procedural steps: comprehensive search strategy; evaluation of the included reports; and thematic analysis of the concepts described in the reports.

Search strategy
A systematic search strategy following PRISMA guidelines 17 was designed with assistance from a research librarian.Five electronic databases (Medline, Embase, PsychINFO, ERIC and Scopus) were searched in August 2019 and February 2023 and included articles published between 1970 and 2022 inclusive.
The search terms (and derivatives) are detailed in Table 1, using a combination of thesaurus terms and broad category (keyword) terms as described by Shaw et al. 18 Category A terms were used to identify reports on the topic of insight, reflection and key synonyms from database thesauri.Category B terms achieved a focus on medical postgraduate training or specialist practice.The whole search was then limited to 'Medical'.Reference lists of selected reports were scrutinized.
Inclusion criteria were reports concerned primarily with insight, reflection or a Category A term and included a range of study designs.Reports that focused on the introduction of a reflection exercise were included if they discussed the link between the exercise and the development of insight or a similar defined endpoint.Reports were included if they were set in postgraduate medical training or specialist practice.Only reports written in English were included for analysis.
Reports were excluded if they were non-medical, analytical or theoretical discussions that did not focus on an element of insight or reflection (Category A terms).Reports or descriptions of reflection exercises were excluded if they did not involve description of a theoretical framework or conceptual link to one of the Category A terms.

Evaluation of the included reports and quality appraisal
The review of the reports was focused on the theoretical constructs they described rather than summating their findings.For quality appraisal the theoretical constructs in each report were evaluated for conceptual richness using the criteria adapted from those described by Pearson. 19,20his categorizes reports as 'rich', 'thick' or 'thin' according to the degree to which they outline a cogent and complete theoretical grounding.The criteria used for evaluation are listed in Table 2.For the purposes of this study, reports identified as rich are of higher theoretical quality than those identified as thick or thin.

Thematic analysis
Our thematic analysis focussed on the theoretical constructs expressed in included reports, following the six-phase process described by Braun and Clarke. 21Braun and Clarke emphasize the role of the 'researcher's subjectivity as [an] analytic resource' 22 all authors have a background in medical education.NP is a surgeon and PhD candidate in clinical education, TJ is a medical educator with a background in qualitative research and JW is an anaesthetist Sensitizing themes were drawn from the link between insight and self-reflection defined in the Self-Reflection and Insight Scale 8 and the concept of reflection as an epistemology of practice vis-àvis reflection as critical social inquiry. 23Initial reading of the selected reports involved summary memos, including description of the theoretical framework, and identifying key passages and quotes.This data was recorded on a spreadsheet.Summary memos were then reviewed to identify common themes.The first author conducted the primary analysis with review by all authors to clarify the coding framework and agree on developing themes.

Results
We identified 7126 reports (Medline 1998; Embase 760; PsychInfo 1332; Scopus 1468; and ERIC 1568) with 5249 remaining after duplicates were excluded.Due to the broad contexts of the search terms, many reports were excluded by review of title alone.If the title was ambiguous abstracts were reviewed.The remaining 313 reports were then reviewed by abstract and, where necessary, full text.Of these there were two further duplicates, 47 'not postgraduate medical education', and 25 letters or brief editorial commentary were all excluded.A further 164 reports did not meet the inclusion criteria because they only included category A terms in the abstract but in a different context or they lacked a theoretical framework and were thus unsuitable for analysis.This left 75 reports.Hand searching of reference lists did not yield any secondary reports that satisfied the inclusion criteria.The systematic search is summarized according to PRISMA guidelines 17 (Fig. 1).
As noted in our preliminary review, variable terminology remained an issue.Within each report authors tended to select one name for the phenomenon of interest, for example, 'self-awareness' or 'mindfulness' without explicit justification.In only a few reports did authors specifically evaluate their choice of terminology or discuss multiple phenomena as either alternative, complimentary or hierarchical.
Table 3 provides a summary of the included reports with groupings based on their evaluation as rich, thick or thin.Additional details are their context (e.g., family medicine residents, internal medicine CPD), literature type, and themes from the thematic analysis.
The reports covered a broad range of study types.There were 10 literature reviews using various methods.The 27 reports labelled 'theoretical' were expert opinion pieces and proposals for, or critiques of, reflection-based curriculum initiatives.These were published under categories such as perspective, commentary or opinion and tended to focus on theory or justification for reflection without empirical support or formal literature review.Nine reports were practical descriptions of initiatives on aspects of reflection that had been launched or were under way, but without any empirical data to report outcomes.Finally, 29 reports were empirical investigations of aspects of insight or reflection that have been introduced in practice.These reports all reported on outcomes of the practice but were variable in terms of methodology and study design.
In the evaluation of conceptual richness, 35 reports were classified as thin, 30 were thick, and 10 were rich (Table 3).There was no relationship between conceptual richness and literature type.The rich and thick reports provided a more cogent argument for their theoretical position, thus making a greater contribution to the thematic analysis.

Literature synthesis
Each report was approached initially to examine the theoretical justification for the chosen model of reflection or insight.Some reports contained no theoretical justification (thin) and some examined multiple theories (rich).All reports discussed an aspect of reflection that was applicable to the postgraduate medical educational context being explored, whether or not a specific theory was employed.We identified three important facets of reflection: stimulus; process; and outcome.Further exploration of these facets showed that distinct patterns of stimulus/process/outcome groupings were described variably in different reports and contexts.Further refinement of these groupings led to the development of three major themes each a conceptualisation of reflection: episodic reflection; cyclic reflection; or reflection as a state.Additionally, our analysis explores how the authors conceptualize the relationship between these three themes.
As identified in our preliminary search the reports in this body of literature use variable terminology.The majority focus on reflection but a variety of synonyms are also found.For purposes of this analysis we will use the term reflection broadly unless additional clarity demands utilizing the specific term the authors favoured in their report.

Episodic reflection
In this theme reflection is considered in a relatively narrow sense, occurring as single discrete episodes.This was more prevalent in reports classified as thin.Reflection as an episode treats each reflective event as a conscious and isolated exercise.This theme includes reflective exercises introduced into educational programmes, as they are discrete, definable, and assessable.5][26] There were three sub themes within episodic reflection: episodes that were spontaneous; episodes that occurred as a mandated activity; and episodes that were tied to a specific activity (Table 3).Some descriptions of episodic reflection are of spontaneous episodes.These episodes may be triggered by cognitive dissonance 27 or a disorientating dilemma. 25Using reflection only to process errors or stress however risks being superficial, with limited meaningful outcomes. 28Episodic reflection as a mandated exercise is most often related to reflective writing exercises.9][30] The rationale for mandating reflective writing is the central role reflection plays in Kolb's learning cycle 31 where 'purposeful critical analysis' is required for deep learning. 14Proponents of reflective writing argue that the individual episodes may lend new insights to specific incidents, and the skills developed lead to a changed way of experiencing incidents in the future. 32Reflective writing has been claimed to be a 'learning tool to develop insight and as an assessment tool to unearth evidence of insight'. 33hen mandated reflective episodes are to be based on sentinel events trust can be an issue.If participants are unclear about the audience and ramifications of their reflections the requirement to record the reflection may undermine the reflective process itself. 34When reflections are tied to high stakes assessments there is a concern learners may write 'to pass more so than to reflect'. 33A related but distinct use of episodic reflection is in the context of a specific educational activity to maximize outcome, such a debrief following a simulation. 35,36[43][44]

Cyclic reflection
This theme describes reflection when it occurs as part of a broader process or cycle.Many of the rich/thick descriptions of cyclic reflection 10,25,45,46 draw on traditional educational descriptions of learning cycles such as Kolb 31 and Mezirow. 47These descriptions reference the inherent role of reflection in the learning cycle or   draw parallels with the clinical audit cycle.Cyclic models represent an advance on episodic models due to the expectation that they will involve change. 15Cyclic reflection is considered integral to lifelong, self-directed learning. 48Describing reflection as a process restores a richness that some authors feel is lost when reflection is reduced to single episodes. 30Alternately some authors conclude that mandated reflective episodes may lead to the development of habitual cyclic reflection. 10Within the theme of cyclic reflection there are two sub-themes: cycles that are reactive in nature and those that are proactive (Table 3).
Reflective cycles may be reactive in response to problems or negative feedback, or proactive as quality improvement processes.In some included reports, there are examples of both, where the initial stimulus may have been reactive in response to feedback, but leads to a proactive follow up (Table 3).Reactive reflection requires cognitive and emotional space for the individual to process the event, and in busy and stressful clinical contexts may not occur effectively. 49roactive cyclic reflection is a growth and quality improvement model and considered an essential part of many CME and recertification processes. 25,50The cycle of reflection may be sparked by recognition of knowledge or performance deficits, 45 and thus relies on recognition of these deficits.However, there is concern that self-assessment is unreliable 51 and thus capacity for truly selfregulated learning through cyclic reflection may be limited. 9,52,53eflection alone may not provide accurate assessment of one's own performance.Accordingly, a more reactive model is suggested by many, where reflection is guided 10,20 or informed by feedback. 11ndeed it is this responsiveness to feedback that forms the basis of Murphy et al.'s proposal for 'Insightful Practice', in one of only two reports that used the term insight as the primary phenomenon of interest. 54

Reflection as a state
This third theme views reflection as a state.Rather than reflection being an occasional illuminating experience, in this theme reflection is constantly occurring, or seen as an inherent quality.
In this theme, we found the greatest variation in terminology.Insight, self-monitoring, self-awareness, and mindfulness are used by different authors.This theme encompasses the concept of metacognition, or awareness of one's own thought processes, rather than the more formulaic approaches in episodic and cyclic reflection.Two of our included reports proposed that reflection as a state could be considered the ideal form of reflection, to which episodic or cyclic reflection aspire. 28,34When reflection as a state is described, it is considered an inherent quality of the practitioner.The reflection is constant, as a way of self-monitoring. 10Reflection as a state could potentially evolve if episodic or cyclic reflection became internalized and unconscious. 10hile reflection is seen as an internal process, 55 there are two distinct subthemes related to its expression.A reflective state can be seen as predominantly informed by intrinsic processes 10,56 or it can be informed more by sensitivity to extrinsic cues 26,57 (Table 3).

Discussion
This review found the term reflection is used in postgraduate medical education in a variety of ways.These range from simple practical initiatives to introduce reflective episodes, through to complex discussions of an idealized reflective state.When authors propose initiatives to introduce reflection this can be in reference to theoretical models of insight, mindfulness or reflective states but without empirical support for a link between them.9][60] More commonly the 'reflective state' was presented as if that concept was simply an accepted ideal.There is no doubt that clinicians value insight and self-awareness as an important facet of their professionalism.This was evident in every one of these reports.However, this review shows that there is a poor definition of the phenomenon itself.We have found three distinct conceptualisations of reflection.We defined episodic reflection as single occurrences that may be spontaneous or performed in response to educational requirements.We identified that reflection can also occur as part of a cycle with some form of follow up or review.We identified that the most aspirational models describe a reflective state.
When reports presented more than one of the themes described here, or argued for the inclusion of reflection in training, the authors described 'reflection as a state' as superior to episodic or cyclic models.This reflective state is the closest approximation to the quality of insight as expressed in the opening example of a surgeon who lacked insight.When a reflective state is described in relation to other manifestations of reflection there is a suggestion of a hierarchy, with the implication that growth towards a reflective state may be possible (Fig. 2).
The hierarchical relationship (Fig. 2) follows from a reflective state being described as superior to the other models.Although the reflective state is not uniformly described, when it features in the reports reviewed it is consistently held as a desirable goal.][63] However, there is no conceptual or empirical evidence that the hierarchy can be ascended, and authors who promote the primacy of the reflective state appear sceptical or even dismissive of the ability to teach it. 10,26,56,57rennan et al. describe reflection as 'the connection between experience and the generation of ideas [that leads to] developing insight'. 20Many of the reports reviewed described reflection as a process that leads to insight, although insight is not always the term used.Authors instead use a variety of synonyms such as wisdom, 64 self-awareness, 65 or even hansei 66 (a Japanese concept that incorporates acknowledging failings and pledging improvement).Reflection alone however may not be enough.In describing the link between self-reflection and insight Grant et al. 8 caution 'one may spend considerable time in self-reflection without gaining insight'.Hays et al. describe insight as an awareness of the gap between self and external assessment of capability or performance. 57They describe reflection as necessary but, without insight, insufficient in inducing change in performance.In this context, insight is seen as a higher-level function that is contingent on the practice of reflection but modelling insight as the superior quality.While reflection without insight may fail, there are further limitations to the use of reflection alone as an end-point.In order for reflection to be productive we propose that reflection needs to be accurate, meaningful and promotes improvement.

Accurate
An important component of reflection is appraising whether performance has been satisfactory or not.There is a considerable concern in the literature about the inaccuracy of physician selfassessment. 39,51,53,67,68Though Gordon 53 suggests physician self-assessment can improve with training other authors suggest that to improve accuracy, reflection must incorporate external data, highlighting the role of feedback. 38,39

Meaningful
Reflection must be meaningful for it to be productive.Whether a reflection is meaningful is difficult to judge. 3When reflection is introduced as a curriculum component, formally assessing it signals that reflection is important and a valued part of the course. 26here are validated measures for assessing reflective writing. 10here are concerns however that the culture of assessment in the high-pressure, often competitive, environment of medical education might undermine the educational aims of the required reflection, 69,70 or that the reflection is subverted by the educators as a means of surveillance of learners. 30This issue has been identified as making it impossible to distinguish if the learner is 'reflecting authentically or merely acting'. 33The implication is that these external factors may lead to shallow or formulaic reflections on the part of the learner, which undermine the rationale for introducing the reflective exercise.

Promotes improvement
The rationale for promoting reflection is to improve professional performance. 43The cyclic models of reflection that lead to change and growth are amongst the richer models described, and form the basis for inclusion of reflection in medical curricula. 10,13,26,45As described above reflection performed solely to fulfil assessment requirements may remain divorced from day to day clinical performance. 34Even when reflection leads to alteration in performance concerns remain about whether the change is meaningful or enduring. 25,43,57

Hierarchy of reflection
The hierarchy of reflection we propose suggests that a reflective state may be what clinicians commonly conceive of as insight in practice but episodic and cyclic reflection are used as a surrogate in medical education.Experts are divided as to whether this reflective state can be taught or learnt, suggesting alternatively that insight may be an inherent quality that allows one to successfully climb this hierarchy.Because clear guidance surrounding how to enter this reflective state is lacking, there is a greater focus on the conceptions of episodic or cyclic reflection.These are more straight forward to teach and assess so are therefore favoured as additions to medical curricula.Educators depend on external prompts or feedback to nudge the trainee towards reflection with the hope that this will become habitual over time. 37,62,63,71he aim of this review was to describe how clinical education research conceptualizes insight and reflection and to create a framework for clinical education that will promote development of clinicians with insight.The literature on insight is lean but much has been written on aspects of reflection and links between insight and reflection exist. 6There has been wide adoption of reflection into healthcare curricula even though the literature cautions there is a lack of evidence that reflection translates into improved professional performance. 7,16,23Indeed Mann et al. 26 in their literature review concluded, 'None of the empirical studies that we reviewed addressed outcomes of reflective practice and their effect on professionals, and none addressed the effect upon professional practice beyond self-report'.What our review adds is a model of how the literature conceptualizes the role of reflection within postgraduate medical education.We found a stepwise hierarchy from simple acts of reflection, through reflective cycles to a reflective state.The reports reviewed use theoretical constructs that model a reflective state to encourage the use of reflection as an educative tool.When insight is mentioned it is held to be an important value but not clearly defined.From this literature review it remains unclear whether insight is the apex of this hierarchy of reflection or a necessary quality for the ascent.
Despite this comprehensive review of literature our questions remain largely unanswered.The literature does not clearly evidence that either insight or a reflective state can be taught.It implies that insight is an essential quality, but before there is further entrenchment of reflection into post graduate medical education more work is needed to elucidate how insight is manifested and whether it can be developed.

Limitations of this review
Limiting the search to English language meant the literature draws predominantly from western philosophical and academic traditions.There is a rich potential for learning from other cultures and their traditions of reflection and insight.This review was limited to postgraduate or continuing medical education contexts.This specifically excluded undergraduate medical education, broader health professional contexts and theoretical reports.We identified a wide variation in terminology in the early stages of this review.Producing a search strategy broad enough to capture all synonyms was challenging.As our preliminary review identified links between insight and reflection, our search strategy focused on these two concepts.Despite extensive use of search engine thesaurus terms, we may still have excluded reports that approached the concept of insight using different terminology.

Future research
Concepts of insight, mindfulness, metacognition and reflection are intertwined in the literature.Whatever terminology is used these are fundamental professional attributes required of a self-regulated professional who seeks to achieve and maintain expertise.There is broad consensus that a reflective practitioner is a desired quality.The question remains as to what is meant when clinicians reference insight.Is insight the quality required to become reflective?To date educational research has focussed on narrow and practical aspects of reflection and there remains a gap in knowledge of how this leads to improved practice.For programmes that seek to introduce reflective initiatives there is a need to better understand how the desired qualities are conceptualized and realized by clinicians in their professional life.This knowledge would allow robust evaluation of the utility of teaching or assessing reflection in postgraduate training.Future research should focus on defining clear objectives with measurable outcomes of interventions promoting insight.

Conclusion
While medical professionals refer to a professional quality of insight as integral to development and safety as an independent practitioner there is little in the medical education literature to guide curriculum design to promote this quality.The literature uses many terms to describe similar phenomena.In terms of curriculum, reflection seems to be the educational tool most commonly used to promote activities associated with the intent to improve professional performance.It is not clear whether this develops or is contingent on the quality clinicians refer to as insight.
Here we have presented a novel description of a hierarchy from discrete episodes of reflection, to cyclic process that involve reflection, through to a state in which the practitioner is reflective.There is no unified understanding of how reflection exercises move the individual up this hierarchy, and this literature offers no cohesive description of what insight is for an individual independent medical practitioner.This review highlights the need for research into how practicing clinicians conceptualize and characterize this quality in their training, practice, and CPD.

*
Reports are grouped by Richness then listed alphabetically (author, date).

Table 1
Search terms

Table 2
Evaluation criteria

Table 3
Reports reviewed and themes