‘Oh yes, that is also reflection’—Using discursive psychology to describe how GP registrars construct reflection

Learners in medical education generally perceive that reflection is important, but they also find that reflection is not always valuable or practically applicable. We address the gap between the potential benefits of reflection and its practical implementation in medical education. We examined the perspective of Dutch GP registrars who (must) reflect for their GP specialty training to understand their participant perspective on reflection. Our aim is stimulating alignment between reflective activities that occur in a medical curriculum and the ideals of reflection as a valuable educational activity.

discursive psychology to analyse the focus group data by focusing on 'assessments of reflection'.We analysed their discursive features (how something was said) and content features (what was said) and related these to each other to understand how GP registrars construct reflection.
Results: Participants constructed reflection with nuance; they combined negative and positive assessments that displayed varied orientations to reflection.First, their combined assessments showed complex orientations to norms and experiences with reflecting in practice and that these are not simply negative or positive.Second, GP registrars constructed reflection as a negotiable topic and showed how reflection and its value can be variably understood.Third, through combined assessments, they displayed an orientation to the integration of reflection with other educational tasks, which impacts its value.
Conclusions: Generally, GP registrars speak positively about reflection, but the value of reflection partly depends on its proper integration with other educational tasks.
When meaningful integration fails, activities to stimulate reflection can overshoot their own goal and hamper learner motivation to reflect.Developing a healthy 'reflection culture' could mitigate some challenges.Therein, reflection is treated as important while learners also have adequate autonomy.

| INTRODUCTION
2][13] However, the attitudes of learners in medical training towards reflection are diverse. 14me studies showed that learners found reflection valuable for their training, [14][15][16][17][18][19] for instance that group reflection 14 or reflective journal writing was helpful to stimulate reflective thinking. 16,18Other studies found that not all learners were convinced of the benefits of reflection 14 or that some preferred group reflection exercises over reflective writing. 159][20][21][22][23][24][25] In sum, practical drawbacks that learners experienced could stand in the way of the intended benefits of reflection in medical training.We address this tension to illuminate the gap between the potential of reflection and its practical implementation in medical education.
What is presently missing in research that investigates learners' experiences with reflection [14][15][16][17][18][19]25 is how learners themselves construct what reflection is, based on their own exposure to formal reflection activities during training. Ou aim to uncover such a perspective is important for stimulating alignment between reflective activities that occur in a medical curriculum and the ideals of reflection as a valuable educational activity.26 For instance, understanding the participants' perspective of reflection can offer more insight about why some reflection activities are valuable for learners 27 and why others turn learners into 'reflective zombies' who simply go through the motions to pass courses.23,28 Furthermore, the participant perspective on reflection can provide knowledge about why learners (dis) engage with reflection, and it helps to map how the 'educational environment within which reflection is expected to occur' influences learners and their motivation.29(p.689)This study focusses on the participant perspective on reflection from Dutch GP registrars.While there are studies 30 that investigated a participant perspective on reflection from physicians working in hospitals, the participant perspective from learners in a specialty training who engage intensively with reflection is still underdeveloped.
It is therefore appropriate to study the GP specialty training context, since it has had a well-established 'culture of reflection' since the 1970s that encompasses different reflection activities. 31Dutch GP registrars have extensive exposure to institutionalised reflection on a regular basis; therefore, we examine how Dutch GP registrars construct reflection.

| Setting
In the 3-year Dutch GP specialty training, each week consists of 4 days of residency learning and 1 day of training at the university. 32e weekly training day consists of education about medical subjects, patient communication and so on.At the residency and university, they also engage in various types of institutionally organised reflection activities.4][35] At the university, registrars also take part in 'supervision sessions' that emphasise reflection on one's personhood and professionalism, and registrars are taught additional group reflection techniques.Furthermore, they also share experiences with their supervisor during weekly meetings at the residency.Finally, GP registrars prepare assignments and log educational progress in a portfolio. 36In our study, we addressed how GP registrars construct reflection across these activities.

| Data collection and participants
We conducted and video-recorded five online and two in-person focus group sessions with GP registrars in 2021 across two Dutch GP educational programmes (see Table 1).We opted for focus groups because these can provide space for varied perspectives on a topic. 37,38).We adhered to the Helsinki declaration of medical research. 43

| Data analysis
Since our aim was to analyse the participants' perspectives of reflection, we used discursive psychology (DP) 40,[44][45][46] to analyse the data. 37,45,47,48DP focuses on how psychological concepts (in our case, reflection) are used and constructed in interaction, while taking into account their social context, form and content.DP examines how participants use discursive devices (rudimentary building blocks of interaction, such as asking questions, using metaphors, providing disclaimers) to perform social actions. 40ing DP in this study had the following implications for our research design.First, we studied the participant perspective on reflection dynamically 39 in (inter)action, without adopting a theoretical framework or concept of reflection that functioned upfront as an analytical lens.For DP, this was a sound methodological choice, since adopting an analytical lens a priori would have undermined our attempt to present how participants themselves constructed reflection. 40,49Furthermore, this agnosticism was apt since there is a lack of consensus on what reflection means 11,39 and that learners can have varied experiences with reflection.The potential variation in our data was something we embraced, while striving for data saturation was not an aim from our interaction research perspective. 45,50cond, we used the word 'constructing' 51,52 (reflection) as a technical term.p.7)p.13)Therefore, we did not portray what participants said as 'participant experiences', or 'participant feelings' about reflection, unless participants themselves oriented towards reflection as, for instance, having a 'feeling' about reflection.We do not deny that participants had experiences or feelings, but we only scrutinised discourse and rhetorical constructs about reflection, which can differ from their intentions or inner states.
Following DP methodology, we analysed the focus groups in four data-driven steps. 40,46First, we familiarised ourselves with the data through open coding using Atlas.ti. 53,54In this preliminary analysis, we found that when participants spoke about reflection, they did so through evaluations, which we have called 'assessments of reflection'.
p.57)For example, 'I tasted it' [object of assessment], 'it was really horrible' [assessment], and these are common in daily and institutional talk.Second, we collected all fragments containing assessments of reflection. 40Third, we analysed the assessments' discursive features (how something was said) and their content features (what was said).Finally, we related these features to each other to describe how participants constructed reflection.
A common feature of DP is to hold 'data sessions' [60][61][62] at various stages during the research in which a variety of attendees analyse anonymized data fragments.Attendees share their primary impressions of the data; subsequently, these are collaboratively checked against the data.This process leads to explicating what the 'procedural infrastructure of interaction' in the data is, 62(p.141) which validated our findings.We conducted five data sessions, and these were attended by linguistic researchers, but also stakeholders such as GP specialty training teachers, GP registrars, and other health care professionals.GP registrars who participated in the focus groups did not attend the data sessions.

| Research team
Our team consisted of the principal researcher who has a background in philosophy, interaction research and education and who is also a licensed teacher (SS), a linguist and educationalist with much research and teaching experience in the medical education field (AC) and a philosopher and interaction researcher, who has much experience with researching medical education (MV).

| RESULTS
We found that participants constructed reflection with nuance; they combined assessments 57 that display varied orientations to reflection.We will illustrate three orientations to demonstrate the variance.In Section 3.1, we demonstrate how participants combined assessments that show complex orientations to norms and experiences with reflection in practice and that these were not simply negative or positive.In Section 3.2, we illustrate how combining assessments made reflection a negotiable topic.In Section 3.3, we present how combined assessments displayed an orientation to the integration of reflection with other educational tasks and the impact of integration on the value of reflection.

| GP registrars construct reflection with nuance by combining assessments
By combining negative and positive assessments, participants constructed reflection as potentially valuable, but also problematic in educational practice.Excerpt 1, in which participant J describes a regular day at the university, illustrates a typical combination of negative and positive assessments in our data: After an initial description (line 2), J combines a string of positive (+à) and negative (Àà) assessments, signposting them with contrastive discourse markers 'but' (lines 3, 13). 63With these combined assessments, J constructs reflection in light of a shared norm 45,58 that reflection is relevant.J's qualifications are not expressions of his personal opinion, but as qualities of the assessed object. 57Instead of the pronoun I ('I find cases relevant'), he uses a generalised 'they' (lines 8, 13) and contrasts what happens with what should happen to demonstrate a shared norm. 45p.349)With negative assessments, J displays how the day's excess and merging of reflective activities, which causes exhaustion (line 14), obstructs what should (positively) happen: fun and relevant cases should receive attention.
Assessments are not always produced by a single speaker.
Excerpt 2 illustrates how two participants combine assessments across their turns, while placing the positive and negative assessments in a different order in comparison to excerpt 1.
In line 1, B positively assesses 'as her opinion' 57 that she finds reflection 'super good'.This strongly intensified formulation, followed by a contrastive marker (line 2), can be understood as a disclaimer 40 that mitigates upcoming criticism. 64B proposes that reflection can turn into tiny extra tasks and explicitly frames this as undesirable (line 2).H shows alignment with B and upgrades the undesirable aspect of doing tiny tasks as a dreaded activity (line 3), that for B has little 'added value' (line 5).In sum, while the participants initially orient to reflection as something very positive, the combined assessments show how they use the conditions (dreaded, tiny tasks) to also say reflection can lose value in certain situations.

| Treating reflection as negotiable
Participants treated reflection as being negotiable, 65   15).Overall, the combined assessments illustrate how G positively related reflection to 'awareness' (in alignment with C and F) but that reflection is not simply settled as a positive activity for G. 37,45 In excerpt 4, E displays a change-of-state 66

GP registrars construct reflection as valuable, but at odds with other tasks
By combining positive assessments with negative assessments of reflection, participants showed their orientation to reflection as either well-integrated with, or disconnected from, other education.
Integration created educational value, whereas disconnection created tensions between reflection and other tasks.One example comes from H, who states that filling out a ComBeL (an evaluation format for mapping GP CanMEDS progress) is a helpful reflection tool for her personally (Participant H, group 3).However, she is also required to write additional reflection reports, and hand in recordings of consultations for assessment and feedback, 'all of which needs to be done for the university' (Participant H, group 3).H then states: In line 1, H displays an understanding that reflection is important, framed as an institutional norm coming from the university to stimulate registrars to reflect.These expressions, however, clash with her negative assessments of practically doing reflection.She reformulates the tasks she must do for the university as a 'straightjacket', which she negatively assesses as 'so tight' (line 2).The straightjacket is detrimental to her own reflection, which she must do in her own time, although she positively assesses this as 'fine' (line 6).With this selfassessment, H is heard as not averse to doing reflective work, since she does that on top of all her other tasks.Nonetheless, she concludes that the training 'overshoots its own goal' (line 7); reflection exercises can stand in the way of valuable reflection itself.
The orientation to reflection's integration with other educational tasks occurred throughout our collection of assessments of reflection.
For instance, participant P says that reflection can 'just feel so perfunctory, that one so to say must show that one can do it, although I think we all already reflect a lot, and this is not so useful' (Participant P, group 5).P constructs reflection as a performative task that contrasts with doing (personal) reflection that already occurs.
Such a view aligns with statements from excerpt 2 by B and H: reflection as 'tiny tasks' lacks 'value' and with G's descriptions from excerpt 3.For G, reflection is something 'she must do' and initiated by her supervisor as a task.Finally, E's description of writing reports 'that you really need to sit down for' (Excerpt 4) is equally telling.Writing reflection reports as such is not bad, but E does not do this often.The formulation 'that you really need to sit down' for writing them constructs reflection as something happening separate from other tasks.
The negative assessments stand in stark contrast with C's and F's more integrated and positive descriptions of how they and their supervisors 'just try some things' and have 'fun' and are 'actively learning' (Participants C and F, group 6).Additionally, H mentions that doing the ComBeL for herself is personally very valuable (Participant H, group 3) and that participants S (group 1) and E (Excerpt 4) say that reflection happens often, for instance, when participants watch recordings of their consultations with supervisors.
These participants positively assess reflective activities when these integrate well with their training and own learning needs.Nevertheless, with combined assessments, we see how GP participants orient themselves to the manner of integration and how they construct it as a factor that impacts the value of reflection.

| Main findings
Our analysis provided the following findings on how GP registrars construct reflection.Their combined assessments show orientations to reflection that are not one-sidedly negative or positive.With positive assessments, GP registrars construct the norm that reflection is important, 45 while they nuance that positivity with negative assessments based on their practical experiences with reflection.The positive assessments function discursively as mitigations and precursory disclaimers for criticism.These nuanced orientations imply that GP registrars construct reflection as a complex educational phenomenon and as something that comes with tension between the willingness to reflect and the practicalities of how they (must) reflect.
In our data, the registrars' combined assessments show variations in their construction of reflection.Whereas all registrars speak in similarly positive terms about reflection, their negative appraisals vary (e.g.Excerpts 3 and 4).Such variation indicates that registrars reasonably orient themselves to (the norms about) reflection differently and that they may not share the same views about how to valuably engage with reflection. 68We do not perceive such variance negatively, but as something that researchers, teachers and curriculum designers should acknowledge. 68Furthermore, our analysis shows how registrars add important nuance and detail to their combined assessments by referencing practical reflection activities (Excerpt 4). 39[71] Our results show an overarching orientation of GP registrars to the integration of reflection with other educational tasks; these findings echo observations from previous research on reflection.From a self-regulated learning perspective, Sandars 27,29 warned that when reflection activities are merely 'bolt on', they negatively impact learner motivation to engage with reflection.According to Sandars, motivation benefits from clear goals, but a challenge with reflection is that its goals are not always (made) clear, or worse, that some registrars in our data see minimal to no value in the institutional goals.
Additionally, our data adds weight to insights about motivation and 'activity-specific' incentives (finding enjoyment in doing the task itself), as opposed to 'outcome' incentives. 27,72Whereas some registrars in our data share positive examples about reflection that align with activity-specific incentives (Participant C, group 6, and Excerpt 3), GP registrars question the value of the outcomes.When reflection activities must be done on top of other (reflective) activities as (tiny) tasks that hold little value beyond showing the teacher that one can reflect, it impacts motivation.We suggest that ('bolt on') tasks with little activity-specific incentives can incite negative, outcome-oriented motivation and tick-the-box reflection behaviour.This can turn learners into reflective zombies. 73Our findings further corroborate the assumption that mere outcome-oriented behaviour can drain energy (Excerpt 1) and that learners are forced to use self-regulatory strategies instead of being in the flow (Excerpt 3). 72e positive, activity-specific incentive is related to how much guidance and assessment is required and how much autonomy should be given to the learner in the educational environment. 74Guidance and assessment can be helpful 'to provide learners insight into their performance', 74(p.4) but it can also stand in the way of learner autonomy and the leeway to make choices that suit personal needs (Excerpts 3-5). 72Our data resonates with this tension, especially when GP registrars construct reflection as something they often do for themselves in-action, 75 versus constructing reflection as a straightjacket (Excerpt 5). 36

| Educational implications
A key question for teachers and curriculum designers should be 'why' medical students and registrars must reflect 29,76 ; is it to perform and show to teachers that one can reflect, or is it intrinsically valuable? 77 suggest critically considering how often reflection should occur in a curriculum 16,17 and how reflective activities can be meaningfully integrated with other educational activities. 14,15Teachers and curriculum designers should be vigilant about a reflective overload that incites outcome-oriented behaviour, and it would be good to minimise consecutive reflective activities in quick succession. 16,17,78p.877)Our findings indicate that not all GP registrars recognise the same activities as reflection or perceive them as valuable. 14This finding adds weight to Chan and colleagues' work, 24 who argue that learners require reflection literacy for reflection to become valuable.Furthermore, our results corroborate the argument that reflection is not a one-size-fits-all activity. 14,68We suggest that reflection is predominantly something that can be practiced valuably in various ways. 11e educational approach could be to create a healthy 'reflection culture'.While the teaching institution safeguards the shared norm that reflection is important (for instance, by organising regular, diverse reflection activities), the institution could also give learners autonomy 74 by letting them practice and experiment with different reflection activities that suit their needs.This can offer leeway to students who, for instance, prefer group reflection over written reflection, 15,36 while addressing the challenge of instituting mandatory, but meaningful, reflection. 14,16

| Limitations
Ideally, DP examines interaction in natural settings to understand how people use psychological categories in everyday practice.We prompted GP registrars in focus group settings to speak about their experiences; this is a contrived way of generating data. 79,80netheless, this allowed us to capture how GP registrars themselves construct reflection in interactionally rich ways that was otherwise impossible, though their constructions are not exhaustive. 45,50rthermore, we drafted participants from two GP specialty training institutes during the COVID pandemic under severe containment measures.While some focus groups occurred on a digital platform and others were in-person, the digital environment influenced the interactional dynamic. 81Finally, the focus group conversations may also have been affected by the institutional culture, since they took place in a setting wherein reflection activities were firmly established as educationally important.Consequently, speaking critically about one's institute can be challenging; this might encourage showing oneself as a willing, reflective learner, who also mitigates criticism to show that one is 'being constructive'.

| CONCLUSION
We applied DP to recorded and transcribed focus group data to show how GP registrars construct reflection.Their construction is not simply negative or positive; instead, GP registrars display balancing between positive and negative assessments of reflection.They align positively with the general norm that reflection is important, but these positive assessments also act as mitigations for further criticism through negative assessments.Most criticism is constructed in reference to doing reflection activities in practice that illustrate how reflection lacks value.Furthermore, the combined assessments show how registrars have a varied understanding of what reflection entails, which constructs the meaning (and value) of reflection as negotiable.
Finally, while reflection is generally constructed as important, activities that aim to stimulate reflection but lack meaningful integration with other educational tasks can overshoot their own goal to instigate reflection.Developing a healthy 'reflection culture' could mitigate some challenges.Therein, reflection is treated as important, while learners also have adequate autonomy.writing-review and editing (equal).