反思在醫學教育的應用

The Roles of Reflection in Medical Education

二十世紀末的醫學改革浪潮強調在醫療專業人員的教育中，培育專業素養與採用體驗學習方式的重要性；而反思正是上述教育目標與方式的主要元素，亦成為維持專業證照的評估內容。反思是認知行為也是情緒活動，個體自發的去審視自身的經驗，了解觀念、想法、評價、行動與情緒的背景原因與目的，從而建構知識、價值觀、新的思維、假說，產生新的行動與促進自我成長。
體驗學習是臨床教育的主要學習方式，其理論來源有杜威的經驗理論及羅吉斯的自我學習觀點。庫伯的經驗學習模式認為反思是把經驗轉化為個人知識體系的重要階段。吉布斯根據經驗學習模式提出一個6個階段的過程，把反思進一步具體化為感受、評估、分析與總結讓初學者更容易掌握。
反思實踐是以反思作為專業人員維持專業能力及追求進步的終身學習態度與方式。尚恩認為「行動後反思」與「行動中反思」是專業人員必須具備的能力與行為，而從知識的普遍性到在職場中針對服務對象的個別性應用，正是專業素養的表現。芬利以五個階段來分析反思的深度，把反思從個人層次推廣到社會與哲學層次，抱持懷疑的態度，探求在組織與社會情境下事物的不明確性與多重性意義。莫羅討論影響反思的各種因素，認為反思並非一成不變，而是會隨著時間與所面對的環境改變。
如何引導學習者反思是教育的重要議題。芬利建議的四原則及布雷特的5“R”模式是教育者可以參考的方向。而敘事醫學是透過對文學作品的反思與反思寫作，讓學習者以病人的角度感受其經驗，訓練人文關懷、溝通與同理心等達成專業素養所不可或缺的能力。

Ever since the late twentieth century, medical education reform has emphasized the nurturing of professionalism and the application of experiential learning methods in medical education. Reflection, an intellectual as well as emotional activity, prompts individuals to actively explore their experiences to better understand their underlying theories, concepts, judgment, practice, affection, and purposes so as to help develop new knowledge, values, concepts, and assumptions and facilitate new actions and self-improvement.
Experiential learning as a major learning approach in clinical education is based on Dewey’s theory of experience and Rogers̓ concept of self learning. In Kolb’s experiential learning theory, reflection is a major step of transforming experiences into knowledge. Based on Kolb’s experiential learning theory, Gibbs proposed a six-stage cycle to structure reflection on learning experiences.
Reflective practice is defined as a way of life-long learning for professionals to reinforce professional competencies and pursue continuous advancement. The ability to reflect "in action" and "on action" as defined by Schön is an integral part of professionalism that adopts general knowledge to accommodate the individual needs of different clients. Finlay identified five levels of reflection and expanded reflection from individual to social and philosophical levels. For Finlay, reflection embodies a questioning attitude for examining the uncertainty and multiplicity of meanings in organizations and social situations. Morrow discussed factors affecting reflection and found reflection changeable with time and environment.
How to teach reflection is an important issue in education. Finlay’s four guiding principles and Brain’s 5Rs framework for reflection are fine sources for educators seeking for insights. Narrative medicine, a training of reflective reading of literature and reflective writing, allows learners to experience patients’ feelings by placing themselves in patients’ positions and to foster humanistic care, responsive communication and empathy, all of which are vital elements of professionalism.