• It is a self-regulatory process that monitors and evaluates your own cognitive processes.
• Metacognitive practices help you identify your own strengths, weakness and limitations so that you can identify strategies to expand your knowledge or skill level.

• We do not learn from our experiences by simply having them.
• Reflection on action allows us to gain understanding and learning from the experiences we have had.
• The Adult Learning Cycle by Kolb (1984) is one way to conceptualize the steps we take to learn from our experiences. Reflection on action is a key piece.

Figure 1. The adult learning cycle by Kolb. Courtesy of www.infed.org/biblio/b-explrn.htm.

Steps in Adult Learning Cycle:

1. You have an experience.
2. You reflect back on that experience. You may identify actions you took or reactions you had and the consequences or outcomes.
3. You analyze and try to understand why you took those actions and/or where the reactions came. You hypothesize about  how they led to the consequences.  You think about how you may apply these concepts to other situations and identify any learning needs you may have to close a gap in your knowledge or skills.
4. You plan how what you will do next time you are in a similar situation based on your conclusions from Stage 3.

Example 1:

1. You take an exam assessing your knowledge of cardiovascular drugs and receive a score below what you expected.
2. You reflect on your study strategy which included making flash cards to test yourself on the mechanism of action, half-life and side effects of each medication. The test, however, required you to select appropriate drugs based on clinical scenarios.
3. While you are confident with the pharmacokinetics and the mechanism of action of the medications you think you might not have gained a deeper understanding of the down stream effects on the patient’s physiology. You think that understanding drugs at this level will likely be applicable to other systems, as well.
4. You make a plan that next time you lean about a drug you will consider how the medication will affect physiology and what the down stream effects may be. You will also identify clinical problems that would be treated or managed by these effects.

Example 2:

1. You are taking a history from a teenage girl. During the social history portion, you ask her if she has a boyfriend. She crosses her arms, becomes quiet and participates minimally in the rest of the interview.
2. You reflect on the conversation and identify that her behavior and engagement changed when you asked her about the boyfriend. You also recalled that you did not inquire whether she had romantic or sexual relationships with females and wonder if she felt isolated or judged after asking only about male “boyfriend-type” relationships.
3. You hypothesize that some people may feel uncomfortable answering closed ended questions with limited presented options. You consider that you may be applying your own or other societal norms to your questions that may feel alienating to the patient.
4. You make a plan that next time you are taking a social history, you ask open-ended questions when inquiring about sexual orientation, gender identity, relationships and family structure.

Supplemental Reading:

Sandars J. The use of reflection in medical education: AMEE Guide No. 44.  Medical Teacher. 2009;31:685-695.

Other references:

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.