Medical students' honesty in summative reflective writing: A rapid review

Reflection is a highly individual metacognitive process of contextualising experiences in our environment. It is a core skill for medical students, as it helps future practitioners tackle complex scenarios. It is subject to assessment, which goes against the philosophical underpinnings of reflection, thus risking students only emulating reflective practice without actually engaging with it. We sought to provide an overview of the current literature on medical students' views of summative reflective writing.


| BACKGROUND
Reflection has long been one of the core skills that medical students are expected to have by the end of their university training. 1Although there is no unanimity behind the theory of reflection, 2 Sandars defines it as a highly personal metacognitive process of heightened emotional awareness before, during and after situations with the purpose of developing one's understanding of self and the environment. 3It is a form of acquiring knowledge through anticipatory preparation for future encounters based on our previous experiences. 3This type of transformative learning is well recognised within the medical field, [2][3][4] as it helps the practitioner navigate complex scenarios, including professional challenges and one's own emotions. 4It allows the healthcare practitioner to establish iterative cycles of analysing experiences and identifying professional and personal aspects for self-development.][3][4] This integration of reflection into medical education poses us with a discombobulating paradox-on one hand, we have to prove that medical students are adopting reflective practice 1 while also trying to quantify a highly-individualistic poorly-defined concept such as reflection. 2 Many different models of reflective practice have been proposed and applied in medical education in order to offer generalisable guidelines into the assessment of reflection. 2,3This technicist approach goes completely against the philosophical underpinnings of reflection, 2,5 leading us to question whether by attempting to quantify reflective practice we push students towards just emulating the skill without actually engaging with it.
There is a gap within the literature when exploring medical students' views of assessment of reflection.It is critically important to consider the medical students' perspective, specifically the level of engagement on their end, to guarantee that the doctors of tomorrow are reflective practitioners.This paper sought to provide a current review of the literature on medical students' views of reflection as an actively assessed part of the medical school curriculum and whether it affected the genuineness of their reflective assignments.

| METHODS
A rapid review was undertaken to answer this question.The process of extracting the relevant literature is presented in Figure 1.
A rapid review typology was deemed suitable for this paper because of time constraints surrounding its development, 6 with the full production taking place over November 2022.A peer reviewed the keywords to ensure wider vocabulary and relevance.Only papers after 2009 were considered, as that is when the British General Medical Council (GMC) released their 'Tomorrow's Doctors' protocol, thus officiating reflection as an essential skill for future doctors. 1 The Critical Appraisal Skills Programme (CASP) tool for appraisal of qualitative studies 7 was used to evaluate the primary studies (Appendix 2).Only opinion pieces scoring 'Yes' on all six categories of the JBI Critical Appraisal Checklist for Text and Opinion Pieces 8 were included to maximise their validity.
Only papers that addressed undergraduate medical education were included.Further inclusion criteria were that the study must address the assessment of reflection as well as students' perceptions of summative reflective practice.Studies that pertained to allied healthcare professions or researched reflection in postgraduate medical development were excluded, as they did not address this rapid review's question.Lastly, papers that grouped reflection with professionalism or other summative components of the medical curriculum were excluded, as it was deemed too difficult to isolate reflection as a singular concept in these.
All papers were screened against the aforementioned inclusion and exclusion criteria.The search results and the subsequent included papers were reviewed only by one researcher.

| RESULTS
The literature search yielded 10 results-seven primary studies and three opinion pieces.They all discussed different types of reflective exercises undertaken by medical students during their course of study.Results were tabulated and presented below (Table 1).

| Understanding reflective practice
There was a great heterogeneity within the types of reflective practice assessed by the primary research articles, including written reflections in the form of short essays, 11,14,15 group reflective exercises, 12,13 reflective portfolios, 9 a mix of methods 14 or unspecified. 10The articles represent the voices of medical students from all stages of university training.
A consistent finding among the studies, as highlighted by Birden and Usherwood, 11 is that students valued reflection as a key part of their professional growth.Ross et al. 9 noted that medical students, • Students need a clear explanation of the purpose of portfolios.
• Students felt that reflection should not be assessed as that encouraged them to only provide the 'socially acceptable' answer.
• Students had limited insight into reflective portfolios with none of them understanding the benefit of it.• Students often felt 'forced' to write reflection.
• Students viewed grading as pushing them away from truly reflecting as they write to pass the assessments.
• Students noted that those who avoid engaging with reflection are the ones who would benefit the most.• Assessment of reflections was seen as 'arbitrary, useless and trivial'.
• Students confessed to 'gaming the system' and writing their reflection around the assessment criteria in order to achieve the desired result, but did not see themselves as dishonest in doing so.
• Views were consistent throughout all focus groups and there were no dissenting voices.
8/1/1 (Continues) • Authors emphasised the need for genuine reflection rather than linking reflection to overformalised requirements.
Cusimano et al. 12 2018 Group-peer-led 56 medical students in either firstor fourth-year of study • Authors recognise that prior professionalism and reflection curriculum, interventions did not consider students' perceptions.
• Students describe freedom to be honest with peers, specifically feeling 'more comfortable to say something that might not be considered mainstream'.
• Nearly all students preferred the peer-led reflection group to a university tutor-led one.would only describe events that are true to themselves but also that are acceptable within the culture and expectations of medicine.
• Authors recognised that students would formulate their essays to fit the acceptable construct of the examiner.
• Overall coding suggests that essays are effective in making students reflect and actively push them towards suitable professional principles.
• Essay assessment was effective at picking out students who only reflected superficially.
• Authors recognise that essays cannot tell us what students actually do in practice.(Continues) irrespective of their year of study, were cognizant of the importance of developing their reflective skills but had limited insight into the benefit of portfolios.Vivekananda-Schmidt et al. 10 reiterated these views but recognised that students often felt 'forced' to partake in written reflection.
Cusimano et al. 12 and Lack et al. 13 both describe a noticeable preference among students for group reflection.The social context was highly valued, as it led to a more genuine and enriching experience, especially when reflection was a non-summative task. 13In a peer-led setting, medical students emphasised the comfort and freedom they felt being candid with their peers. 12

| Challenges of assessing reflection
There was a recurring view that assessment can have an adverse impact on genuine reflection.When tasked with summative reflective exercises, students felt pressured to provide 'socially acceptable' answers 9 or they 'had to invent problems' to address the assignment.
This strategic tailoring of reflections to fit within the assessment criteria, termed 'gaming the system', 16 was not seen as a dishonest practice. 11This concern was echoed by Pinto-Powell and Lahey 16 and De la Croix and Veen, 5 who see summative assessment of reflection as a risk to students becoming 'reflective zombies'.
Students felt pressured to provide 'socially acceptable' answers or they 'had to invent problems' to address the assignment.
Hays and Gay 17 define a critical need for more clarity as to what is cultivated and gauged in the reflective curriculum, echoed by Désilets et al. 14 pinpointing ambiguities regarding the intended and unintended consequences of assessing reflective practice.This view is further accentuated by Birden and Usherwood, 11 who call for promoting genuine reflection rather than meeting over-formalised academic requirements.
Cusimano et al. 12 suggest that curricula on reflection historically underrepresent students' perceptions, which Désilets et al. 14 aim to explore in their future research.
The prevailing narrative throughout the literature is that medical students may emulate reflective practice when it is presented as a summative task.There is a unified call to find a balance between the demands of assessments and the intrinsic value of reflective practice.Medical students may emulate reflective practice when it is presented as a summative task.

| DISCUSSION
This rapid review sought to provide a current account of medical students' views of summative reflective writing and whether the summative process impacts their reflections.

| Problematising summative reflection
None of the papers' main objectives were to explore medical students' honesty in assessed reflection.1][12][13][14] Only one paper concluded that students provide truthful lived experiences in their written reflection, but that was more or less postulated by the authors. 15It would be cynical to discredit the idea that students provide honest reflections; however, Howe et al.'s 15 presumption solely highlights the educators' uncertainty of the students' appreciation and understanding of reflective practice.'Gaming the system' 10,11,14 is a real problem that should be considered when designing reflection curricula, as it embodies the medical students' hesitance of engaging with poorly understood content.
Three of the primary studies reported a sense of agitation in the assessed cohort because of the summative nature of the reflective task. 10,11,14[18] Using it as a tool simply does not recognise the nuances of this skill, simplifies it into discrete components 2,18 and fosters agitation in the student body. 10,11,14,17

| Curricular shift
All three opinion pieces called for a fundamental revision of the current curricula on reflective practice. 5,16,17Hays and Gay 17 see current methods of assessing the outcomes of reflective curricula as inadequate and unclear, echoed by the students, which describe it as 'arbitrary, useless, and trivial'. 11De la Croix and Veen 5 note that modern curricula conceptualise reflection into a step-wise behaviourist process that confines the medical students to 'acting reflectively' like a 'reflective zombie', which is demonstrated by the students reporting fabricating experiences to reflect upon and feeling confined to reflective models. 11,14This reductionist view of reflection grossly disregards the holistic aspect of the constructivist curriculum, as it isolates the student and their experiences as a singular factor 5 and see reflection as unimodal. 16dern curricula conceptualise reflection into a step-wise behaviourist process that confines the medical students to 'acting reflectively'.
On the contrary, when embracing the diversity of opinions during reflection and removing the summative aspect of the practice, students seemed to engage highly with the programme. 12,13All 10 included studies concluded that students understand the importance of reflecting 5,[10][11][12][13][14][15][16][17] ; however, for it to be an actual learning experience, the students' diversity in this skill must be met. 2,5,16,17By recognising the different states of personal experience and allowing for freedom of reflection, we can deepen medical students' imaginative criticality. 18This goes along with the conceptual approach of reflection as a dynamic practice, which sees it as a socially and locally contingent theory. 2 It must be recognised that reflection is conceptually undetermined when pertaining to education practice and research 2 : meaning, a balance between dynamic and technicist approach must be found.
By allowing for freedom of reflection, we can deepen medical students' imaginative criticality.

| Limitations
The main limitations of this paper were the personal barriers and the scarcity of the literature.The search findings were screened by only one person, thus potentially missing out suitable articles.Furthermore, making decision regarding inclusion of results is inevitably a judgement, and these judgements are particularly challenging as a lone researcher.Although there was an active effort to follow the methodology of this review in an unbiased manner, that could be achieved confidently only through a larger research team.Because of the scarcity of the literature, no conclusive results could be extrapolated, but rather, only suggestions for further research.It must be noted that opinion pieces might not be deemed best evidence, 6 but in this context, they bring experts' views to an under-explored subject, which was seen as a valuable input in the face of the paucity of research.

| CONCLUSION
This rapid review found a moderate body of evidence that suggests that using reflection as a tool for assessment in medical school can lead to students only emulating reflective practice while not actively engaging with deeper learning.However, there is an evident gap in the literature addressing students' viewpoints of learning about reflection and its subsequent assessment.It is suggested that medical curricula should allow for diversity in reflective practice while also encouraging students to express their honest views.This subject should be expanded further by conducting primary qualitative studies that address medical students' opinions and outcomes of the use of reflection assessment tasks.

ACKNOWLEDGEMENT
I would like to thank Prof Karen Mattick at the University of Exeter who led the module this paper was originally written for.Prof Mattick provided valuable feedback, which was incorporated in this final submission.

CONFLICT OF INTEREST
There are no conflicting interests in connection to this article.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

ETHICAL APPROVAL
Ethical approval was sought from the University of Exeter Medical School and Health and Care Professions Research Ethics Committee.
This article was reviewed, and ethical approval was deemed not required because of its low-risk nature.There are no competing interests in connection to this article.

ORCID
Lyuben Truykov https://orcid.org/0000-0002-0948-2005 Methodology of the literature review.T A B L E 1 Results of the literature review, including key findings of each paper.The columns 'Cohort' and 'CASP Score' were greyed out for the Opinion Pieces as they were not applicable.ranging from first to fourth year.

•
Students understand the relevance of reflective practice.
in their final 2 years, from three medical schools • Students saw reflection as an important factor in their professional development.
-led 303 medical students in their fifth-/sixth-year of study • Students valued the group reflection activity with highly positive results because of it being a non-summative task.•Students were appreciative of their colleagues' honesty and emotional maturity, which allowed for the 'humanisation of medicine'.9/0/1 Primary mixed methodsquestionnaires Désilets et al. 14 2022 Workshops, written and oneto-one meetings with mentors 164 responses from first-and second year-medical students • Students reported that they 'have to invent problems' if they have not encountered a specific situation they could reflect on.• It is not clear what the intended and unintended positive and negative consequences of assessing reflection are.• Authors are conducting a follow-up qualitative descriptive study to discuss students' summative essays from first-fifth-year of study (10 per year group) • Authors assumed that students

••
Summative assessment of reflection and professionalism is flawed by bias and leads to students 'gaming the system', An outcome focus in measurement and assessment distracts us from true reflection.•Students know how to emulate reflection turning them into 'reflective zombies', as reflection has been conceptualised into checklists, guidelines and models.