1 INTRODUCTION

Underperformance in professionalism is a high stakes situation for medical learners and educators alike. Problems with professionalism, unless appropriately and effectively remediated, may portend serious problems in practice.1 Yet, remediation for unprofessional behaviour is particularly challenging—and understudied.2 Increasingly, educators are turning to reflective writing as a remediation strategy in residency, yet little is known about why educators use reflective writing, what they expect reflective writing to accomplish, or how they evaluate whether or not a learner has met expectations.

Professional competency is fundamental to meeting societal expectations of future doctors. Professionalism involves being ‘committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation and maintenance of personal health’.3 Professional identity formation—‘a representation of self’4—is an ‘active, constructive, transformative process’4 within medical education in which the ‘characteristics, values and norms of a profession are internalised, resulting in an individual thinking, acting and feeling like a physician’.5 A lack of professionalism may impede the delivery of quality patient care and compromise physician health and workplace relationships.6-8 These unintended consequences of behaviour resonate with discussions and concerns regarding physician wellness and rising rates of burnout.9-12 Research further suggests that minor professionalism breaches among trainees may be associated with more severe instances of unprofessional behaviour later in practice.1, 2, 13-16 Addressing professionalism in medical education is a formidable challenge. Educators must identify the problem, determine when to act and balance situational and contextual factors in understanding the lapse and planning remediation.17

In medical education, remediation is ‘the act of facilitating a correction for trainees who started out on the journey towards becoming a physician but have moved off course’.18 Remediation is required to help struggling learners and ensure a quality physician workforce.17 It typically involves ‘a series of prescribed and officially sanctioned episodes of additional corrective training and monitoring, ending with an assessment of whether the learner has met the predetermined set of remediation goals’.1 Despite the recognised seriousness of unprofessional behaviours in trainees, there remains a lack of scholarly and pedagogical attention to the problem of professionalism remediation in postgraduate medical education.2, 19 While a 2015 study considered how professionalism competencies are formally addressed in the undergraduate curricula of Canadian medical schools, including reporting and remediating lapses,20 less is known about the postgraduate medical education context. Assessment of professionalism continues from medical school into postgraduate training, yet ‘a formal professionalism development continuum projecting from medical school, through postgraduate training into continuous medical education is still lacking’, and ‘basic principles of dealing with unprofessionalism … still need adapting to the postgraduate, clinical context’.2 Contextual and situational differences exist between the undergraduate and postgraduate medical experience, including the volume of patients, complexity of medical cases and ever-increasing responsibilities.21 Context matters, including with respect to remediation, as Kalet, Chou and Ellaway argue: ‘… remediation is intrinsically situated, it is always in context, and that context can shape and direct remediation practices both for good and ill’.17 While the literature, in practice and scholarship, offers general direction for structuring remediation programmes, such as steps in the remediation process and potential techniques to address students' unprofessional behaviour,1, 18, 22 strategies for its remediation are not standardised,1 and medical educators have little guidance on how to deal with problems of professionalism in residency.2

Reflection is among the modalities for teaching professionalism in postgraduate medical education.23 Reflection may be understood as a “metacognitive process that creates a greater understanding of both the self and the situation so that future actions can be informed by this understanding.”24 Reflection is thus essential to both “self-regulated and lifelong learning, and it is also required to develop both a therapeutic relationship and professional expertise.”24 More broadly, Charon and Hermann conceptualize reflection as a “cognitive, affective, imaginative, and creative means to perceive, represent in language, and thereby undergo one's lived experiences.”25 In this view, individuals make meaning of and experience their lives through reflection and, in doing so, move toward “presence, identity, self-awareness, intersubjectivity, and ethical discernment.”25 Within medical education, reflective practice aims to raise awareness about professionalism and the development of residents' professional identity,23, 26, 27 which may in turn lead to improvements in empathy, communication, and collaboration.27, 28

Reflective writing is leveraged as a tool to nurture reflective practice among medical learners. Writing, then, becomes a process that enables reflection to occur:

… writing is used to attain the state of reflection …. [W]riting unlocks reservoirs of thought or knowledge otherwise inaccessible to the writer. Representing one's experience in language is perhaps the most forceful means by which one can render it visible and, hence, comprehensible. Writing is how one reflects on one's experience.25

With respect to professionalism, reflective writing is among the educational interventions used to remediate lapses, with written reflections focused on three domains of professionalism: commitment to the profession, altruism and commitment towards patient and society and self-regulated learning on the ethics and code of conduct of the profession.17, 18 Despite the increasing use of use reflective writing as an educational approach to facilitate reflection across the medical education continuum, research on the application of reflective writing to professionalism education in postgraduate training is limited. As a learning tool to develop professional identity,4, 29, 30 reflective writing is leveraged as a process that enables reflection on ‘complex experiences for meaning-making within a safe learning climate’30 and that guides physicians in ‘the identification and discussion of ethical issues in the everyday practice of medicine’.31 As a tool to assess competency around professionalism, reflective writing offers a useful way to assess professional ethics’.32 Notwithstanding its growing use, questions—and scepticism—linger around the utility of reflective writing for learning and summative assessment. With respect to learner engagement in written reflection, scholars argue that there is no guarantee reflection will occur,32, 33 noting ‘variation in the extent to which doctors both engage in and document evidence of reflection’.33 Others have cautioned against reductionist approaches, which tend to be influenced by discourses of assessment and evidence.30, 34-36 The notion that reflective writing can be readily used for assessment has also been challenged based on issues of validity and feasibility.35 Debates about the nature and uses of reflective writing demand that we scrutinise its uptake, particularly in remediation contexts. While scholars explore and debate the use of reflective writing for developing and assessing competency around professionalism as part of routine postgraduate training, research has yet to consider what happens when a resident demonstrates a lapse in professionalism and the ensuing role that reflective writing plays in professional remediation. In this study, we sought to understand why and how medical educators use reflective to remediate professionalism lapses in postgraduate medical education.

2 METHOD

Given the limited knowledge about reflective writing as a strategy for remediating professionalism in residency, we used a constructivist grounded theory37, 38 approach to theorise about why and how medical educators use reflective writing to remediate professionalism in Canadian residency programmes. Constructivist grounded theory is a qualitative research methodology suited to exploring social processes that are poorly understood by existing theories,37 such as the process of using and interpreting reflective writing in professionalism remediation at the postgraduate level. Researchers collect and analyse data iteratively to then theorise ‘how—and sometimes why—participants construct meanings and actions in specific situations’.37 The resulting theory is grounded in the researchers' construction and interpretation of the data.37, 38 The intent is not to produce a ‘Theory’, ‘shrouded in all its grand mystique or acts of theorising’, but rather to ‘try to answer questions’ in ways that offer explanation or understanding—‘to offer accounts for what happens, how it ensues, and … why it happened’.37 Constructivist grounded theory37, 38 leads to a conceptual explanation or understanding of poorly understood concepts or processes.

2.1 Participant recruitment

We anticipated that finding individuals with significant experience in remediating professionalism with reflective writing might be challenging, given the specialised nature of our topic. Remediation is an uncommon event in postgraduate medical education generally. As a subset of this area, remediation for professionalism is even more rare. The use of reflective writing in this context is yet another subarea. For this reason, we cast a wide net with our recruitment strategy. We anticipated that postgraduate medical education offices, given their oversight role in resident remediation, would be helpful in identifying individuals suited to the study and in ensuring that the invitation reached those individuals. As such, we recruited through postgraduate medical education offices at 12 of Canada's 14 English-language medical schools. We did not include all schools, as some required a local co-investigator for research ethics clearance. We sought to interview medical educators with experience relevant to the use of reflective writing for remediation of medical learners, such as programme directors, programme or school assessment or remediation leads and associate deans. Participants may have assigned and/or interpreted writing for residents requiring professionalism remediation and/or engaged in strategizing about and/or implementing the use of reflective writing to remediate professionalism. Informants may also have used reflective writing for informal learning plans.

2.2 Data collection and analysis

We conducted 13 semistructured interviews with educators from five medical schools. Participants received a letter of information and informed consent and subsequently provided written or oral consent prior to the interview. Among our questions, we probed into why participants used reflective writing as a window onto professionalism underperformance and a trigger for performance improvement, how they structured the reflective writing experience, how they assessed whether what a resident wrote was satisfactory and what they perceived as the greatest challenges for both the residents and for themselves as educators. One author (TM) conducted all interviews by phone, lasting 60 min on average. All were recorded, transcribed and anonymised. Participants were also identified by a code to further protect anonymity from team members during data analysis. Only the interviewing author (TM) knew the identity of participants. Data collection and analysis proceeded concurrently and iteratively through stages of initial (i.e., line-by-line) and focused (i.e., conceptual) coding and theory development (i.e., through memo-writing).37 All authors independently coded the first three transcripts line-by-line to develop initial codes. Using constant comparison, we developed and refined focused codes that reflected recurring ideas identified in the data. We evolved the interview script as needed to support achieving a robust conceptual understanding of the data. We used NVivo 12 software to code transcripts. To ensure consistent coding, two authors (TM and CG) coded each transcript. Discrepancies were resolved through discussion among the two authors, and a third author (AW and CW) resolved lingering discrepancies. TM and CG continuously compared and refined conceptual codes and the understanding of the relationships between them in theoretical exploration through continuous memo-writing and monthly discussions with the team.37, 38 The written memos provided an accounting of our developing analytical insights, and we reviewed and compared these memos periodically and then wrote further memos as part of our process to elevate codes into concepts. Through successive levels of memo-writing, we defined major and minor categories and explored the relationships between them as part of the process to shape our analysis and frame our explanation of why and how medical educators use reflective writing to remediate professionalism lapses.37 We also iteratively evolved the interview guide in response to participant interviews, following up on patterns and exploring relationships between them to understanding concepts more fully and to evolve the codes from descriptive to theoretical. Recruitment and data collection continued until we reached theoretical sufficiency, meaning that the research team collectively determined that there was enough data to explain the concept under study.37-40 Theoretical sufficiency, not data saturation, guided recruitment; however, as the interviews evolved, we noted consistent repetition of concepts, signalling consensus among those interviewed.40

Given the unique experiences of each author, we practiced reflexivity throughout the project, discussing our various observations, experiences and pre-existing and evolving perspectives. TM is an academic researcher interested in writing practice and pedagogy and uses of reflective writing in medical education. CG is a doctoral candidate interested in critical reflection in health professions education. AW and CW are clinicians, medical education researchers and current and former postgraduate deans (respectively) with oversight related to remediation of residents.

Research ethics approval was received or exempt from all universities where recruitment occurred.

3 RESULTS

Here, we present our conceptual understanding of why and how medical educators use reflective writing as an educational strategy to remediate professionalism lapses in residency. Educators reported shared purposes—and ensuing tensions—around their use of reflective writing for professionalism remediation. Specifically, they reported using reflective writing for dual purposes—that is, as a learning tool to develop insight and as an assessment tool to unearth evidence of insight. This duality, however, presented a problem: the goal of learning may compete with the goal of assessment. This conflict, in turn, created tension that led to (a) uncertainty about the sincerity, quality and effectiveness of reflective writing and (b) concerns about learner safety. Educators were uncertain about whether learners wrote to perform and pass or to reflect and transform and about how to judge the effectiveness of reflective writing as a learning tool. Educators expressed concern about creating a safe environment for learners—one that enables the genuine reflection required for insight development—while still meeting the requirements of the remediation process. We explore each of these concepts—insight, uncertainty and safety—below, illuminated by participant quotes.

3.1 Insight: Using reflective writing to develop and to assess learner insight Across participants, insight was identified as critical to professionalism remediation. Educators understood lapses in professionalism to often stem from a learner's lack of insight into their own problematic behaviour and its impact on patients, peers, the system and their future career. As one participant noted:

Oftentimes the concerns raised are not self-identified. It's hard for the learner to see that it is a big problem, or they do not necessarily have the insight, or nobody has made them aware of it. Without the learner being able to self-identify those big problems, they do not necessarily see them that way. So, for me, the purpose to get them to write a reflective piece is to have them see this. (P6)

For this educator and others, reflective writing was a tool to help learners gain self-awareness and acknowledge and develop insight into their unprofessional behaviour: ‘Reflective writing allows them to recognize. When they write and share it, it is through the writing and the sharing that they may affirm something that they didn't know before, something that might not have been clear to them’ (P9). Building on this process of introspection, educators used writing prompts to build empathy and encourage residents to imagine alternative approaches to similar scenarios. One educator noted:

[The resident] reviewed how they felt the issues had been looked at through their eyes versus those eyes around them, reflected on the level of disruption to the work environment that the behaviour may have caused, and finally, concluded with some concrete steps that could be taken to improve the situation. (P4)

Inherent in using reflective writing for professionalism remediation was the idea that the written product should demonstrate learner insight and could therefore be assessed as a measure of insight. One participant said: ‘We have a scoring sheet for the paper, and I actually have to do an evaluation at the end … Have they gone deeply enough into what happened …? Do they have insight’? (P11). In assessing reflective writing, educators reported that they focused on the content, not the quality of expression. They looked for evidence that learners had gained insight into their unprofessional behaviour and its effect (on the self, on others and on future practice), insight into what they had learned from the experience and insight into how they might adapt their attitude or actions going forward. As one participant said:

I think the recognition that there's a problem is part of it—showing insight—and then for there to be a meaningful discussion within the essay about the implications of the unprofessional behaviour—why it was important to address and then steps to change the unprofessional behaviour in the future. (P3)

3.2 Uncertainty: Questioning the assessment of reflective writing

While there was a general sense among medical educators that reflective writing is useful in remediating professionalism challenges, they expressed uncertainty about how to judge a ‘good’ piece of writing and about whether reflective writing translates into sustained behaviour change. While educators generally recognised that ‘good’ reflective writing should develop insight, many were uncertain about whether the written product accomplished this goal.

Educators described the value of writing prompts in both stimulating reflection and in helping them to gauge their satisfaction with the written reflection: ‘Have they satisfactorily completed what I asked them to do’? (P9). Most often, residents did—that is, they attended to the prompt with detail, description and depth in ways that addressed the impetus and impact of their behaviour and considered alternative approaches. Less frequently, educators reported that the content of residents' writings sounded more like venting or regurgitating educational readings than reflecting. Educators also emphasised the importance of grounding a prompt in the specific type of professionalism lapse. For example, one participant used this prompt to stir reflection on a resident's approach to conflict resolution: ‘Think of an example where conflict led to a breakdown in the relationship between you and another health practitioner? How did that conflict affect your relationship with that healthcare practitioner, and how then did it affect the care you were able to provide for the patient’? (P6).

Educators consistently reported that they struggled with assessing reflective writing, foremost because of challenges in assessing its sincerity, the high stakes of remediation and the subjective nature of the assessment. Many educators said they looked for a demonstration of sincerity in the writing—that learners took ‘a wholehearted and genuine approach to improving the situation and growing’ (P6). Educators expressed concern that the act of judging the writing may lead learners to perform rather than to genuinely reflect. One educator noted: ‘My biggest challenges are to believe that what is written is real. You know, these people are smart people … , so they often can figure out what they need to say or [how they need to] behave in order to get through these kinds of hoops sometimes …’ (P1). Some educators acknowledged that typical approaches to assessment tend to fail when looking for a show of sincerity. It often comes down to a ‘subjective sense of sufficiency’, as one participant explained:

On the one hand, it would be nice if there was a scale that we could use to rate it—a genuineness scale or a component scale—to see ‘is this sufficient or not?’ But on the other hand, … I think that, in many cases, we have gone way too far in that direction—looking for absolute objectivity and independent evaluation …. I think there's a large component of subjectiveness that should be considered reasonable. (P4)

Feelings of uncertainty as to whether the written piece was adequate reflected, in part, the subjective nature of assessing reflective writing. Educators thus reported that they looked for ‘evidence’ of sincerity in multiple domains, including in the reflective writing piece itself and in subsequent debriefing meetings with the resident. The reflective writing assignment acted as ‘an effective tool to open up a discussion forum’ (P13) with the learner. Educators said these debriefing meetings were a critical piece in gauging the learner's sincerity and depth of insight into the situation that led to the remediation and, again, in determining their own satisfaction with the written reflection.

Reflective writing was consistently evaluated using a pass-fail binary, and educators found it challenging to fail a learner. Furthermore, what constituted an inadequate reflection was so poorly defined that most tended to accept anything short of plagiarism or not completing the assignment at all. A participant commented:

You know, we have not ever said ‘what you have written is unacceptable ….’ If you say it is unacceptable and the resident challenges it, then what kind of recourse do you have to say ‘well, this is why it's unacceptable?’ Is it defensible with regards to post grad or even legally when you say that someone is not remediated properly because their reflective writing piece wasn't sincere enough? (P1)

Even with a pass-or-fail approach, educators questioned how much weight to give the reflective writing task in the remediation plan: ‘It's hard to put a lot of weight onto [reflective writing] where the consequences of failed remediation mean either delayed training or lack of licensure. [There are] such profound implications on their training and on their employment, on everything’ (P6).

Educators also questioned the role of reflective writing in behaviour change. Fuelling such uncertainties were educators' concerns about the inability to truly gauge the sincerity of the writing as well as their acknowledgement that behaviour change takes time to see, making it challenging for educators to determine the success of a remediation in the short term or to know how much of it to attribute to the reflective writing itself. One participant commented:

I think the resident lacked a certain … understanding of the depth of the issues [in the written reflection]. But I think that perhaps the resident … reflected on them more as they travelled through their remediation, and then afterwards when remediation was complete …. They were certainly successful moving forward. How much a part of their success had to do with their reflective writing, I'm not sure. (P7)

Regardless of these uncertainties, educators saw value in using reflective writing as a component of remediation. At minimum, it provided ‘a paper document’ (P3)—a way to document the programme's effort at remediation. It also constituted another step in the remediation process that might influence its impact: ‘A multifaceted approach is likely to be more successful than a singular approach’ (P1).

3.3 Safety: Recognising learner vulnerability Participants recognised that medical learners undergoing remediation are vulnerable, given the gravity and high stakes of remediation in residency. One participant said: ‘It is a very scary process … because there is not a lot of support for the residents through the process’ (P11). They noted that these factors may expose residents and exacerbate their anxieties, making reflective writing an inherently vulnerable task. Another participant commented:

… when you think about the vulnerability of [learners] writing a reflective piece, depending on how seriously they take it or how much they are willing to divulge in their reflections, … there can be some tensions in them going through that practice and documenting it and then having to submit it. There is an obvious power differential in medicine and medical education … A resident would not necessarily always feel comfortable sharing some of those more personal or reflective thoughts. (P6)

Educators emphasised that learner buy-in was critical to realising the value of reflective writing in professionalism remediation. Yet, they noted a disconnection between the value they ascribed to reflective writing as a tool for introspection and the value ascribed by the resident. Learner engagement was either facilitated or hindered by their attitudes towards reflective writing and their ability to be open and vulnerable in the process. One educator commented: ‘When you really, truly write in a way that is truly reflective and introspective … you open yourself up in ways that we don't usually want to do as human beings and certainly not as doctors’ (P12). But buy-in, as one participant noted, sometimes involves a process:

The initial writings were about venting and recognizing that they are now physicians, held at the highest behaviour and decorum …. So, I think that, in the beginning, they wrote that they were basically ticked off that anybody dare say anything about them anyways, but then, in the end, they realized that there was some room for them to change their behaviour. (P8)

Participants acknowledged that many factors may hinder learners from buying into and participating openly in the process of writing reflectively. These factors included time constraints, not accepting the reason for being on a remediation plan, a lack of formal training in and comfort with reflective writing and concerns about being evaluated on their writing. Educators perceived that learners may be more concerned with producing a piece of reflective writing that will pass than engaging in introspection through writing. Learner vulnerability was therefore heightened by the evaluative component of the task. One participant said: ‘The hardest part for them is allowing themselves to be vulnerable and the fear of judgement’ (P6). Because reflective writing has been used for dual yet competing purposes—to develop insight and to assess insight—educators questioned whether learners can reflect openly and sincerely when they know the written product will be used as evidence in determining the success of their remediation. A participant commented: ‘The people who are evaluating you are also the ones who potentially could end your career’ (P12).

Participants emphasised the need to create and ensure safety for learners around the writing assignment because, without it, learners cannot be sincere in their reflection. Participants described tension—and the need for balance—between supervising and evaluating the resident under remediation. One participant described: ‘… I was trying to support her, and was responsible for enforcing the timeline around the remediation plan and reporting back to Department-X. I think there's a conflict in there. I think you have to separate those roles’ (P2). Another echoed: ‘Can you use a method of ‘support’ simultaneously as a method of punishment’? (P10). Participants also recognised that part of supporting a learner through professionalism remediation involves ensuring confidentiality. For this reason, participants explained that remediation using reflective writing must come with a guarantee that the written product will be kept private and only shared with the designated individual(s) outlined in the remediation plan. This designate varied across medical schools—from the programme director to a faculty member supporting the learner, to a professionalism coach. Without this guarantee of confidentiality, participants urged that there could be no expectation of honest and meaningful reflection because learners would not feel safe to engage.

4 DISCUSSION

Our findings have led to a conceptual understanding of reflective writing as a process to remediate professionalism in residency that illuminates both its potential and its pitfalls. Reflective writing is used for dual and duelling purposes—that is, for learning and for assessment. The former is developmental, and the latter is judgemental. From these different purposes, tensions emerge. The goal of using reflective writing as a learning tool (i.e., to develop insight) may compete with the goal of using it for assessment (i.e., to measure insight). This tension leads to uncertainty for educators about the effectiveness of reflective writing as a strategy to remediate professionalism, and it also highlights the challenge of ensuring psychological safety for learners engaging in this high-stakes process. Feelings of uncertainty and concern for learner safety lead educators to structure their use of reflective writing in ways that aim to mitigate these concerns and the tensions they create. Overall, educators view reflective writing as a useful, though limited, means for remediation—one that has potential to stimulate learner insight and guide educators in setting goals for continued learner development but that cannot be used as a meaningful assessment strategy in the context of remediating professionalism lapses.

Medical educators use reflective writing to develop learner insight—‘an awareness of one's performance in the spectrum of medical practice’.41 The very act of writing is viewed as a process that enables the learner to reflect on the situation where the unprofessional behaviour occurred—to introspect, to empathise and to plan for change. They simultaneously use the written reflection to assess learner insight into their professionalism lapse. While scholars Charon and Hermann advocate the use of writing as an educational tool to nurture reflective capacity, they argue that, in extending the use of reflective writing from learning to assessment, medical educators have come to use reflective writing in a reductive manner—one that may reduce its potential utility for learning altogether.25 Learners write to ‘perform’, rather than write to ‘reflect’, and ‘this impulse perhaps distorts and squanders the potential deep dividends of the work of reflective writing’.25 Countering the emerging trend towards reflective writing as assessment, they advocate a view of writing as ‘discovery’—a process through which learners can grasp and make meaning of their experiences.25 While reflective writing may have value for remediation, we concur that it should not be used to assess learners but, rather, as a tool to develop their reflective skills and insight. In fact, the potential of reflective writing may only be realised if we studiously avoid its use as part of the assessment strategy for remediation.

Learners must authentically reflect to realise the benefits of reflective writing for discovery. This process requires a willingness to be open and vulnerable. If learners perceive being on remediation as failure—a possibility given medical culture's uneasiness with failure and vulnerability17, 42, 43—they may not recognise the opportunity for growth. In their systems-level analysis of remediation, Kalet, Chou and Ellaway note failure as a dimension of institutional cultures that impacts remediation processes, one that ‘arises from assumptions and beliefs regarding whether, when, and why individuals fail’.17 They advocate approaching remediation in the same way as medical error—that is, as an inevitability in complex medical training rather than as an individual's failure.17

That reflective writing is assessed can further inhibit learners from viewing it as a growth opportunity. Creating the conditions for authentic reflection may involve accepting that people reflect in diverse ways and abandoning checklists and moulds of what reflection is expected to look like.36 To this end, de la Croix, Chou and Veen posit that learning objectives pertaining to reflection either not be assessed or then assessed summatively in terms of a learner's progress relative to earlier writings and their individual needs and goals so as to create an encouraging environment for reflection.36 Learner buy-in is required to thoughtfully reflect on the scenario that spurred the professional lapse and on areas for improvement. Supports are needed to ensure a safe environment that encourages buy-in and, therefore, sincerity in writing reflectively. But, as our findings suggest, structuring a process to allow for sincere reflection is multifaceted and complex. Moreover, we contend that it may not be possible if using reflective writing for dual purposes that inherently conflict—that is, for learning and for assessment. De la Croix, Chou and Veen contend that reflection has been ‘operationalised: medical education has translated the age-old concept into a teachable and measureable construct’.36 Much like the educators interviewed for this study who expressed concern that residents wrote to pass more so than to reflect, so too do De la Croix, Chou and Veen argue that assessing reflective writing adds an element of performance, making it impossible to distinguish between whether a learner is reflecting authentically or merely acting, reflectively.36 They lament these implications on the development of professional identity formation, noting that ‘reflection may be the deciding factor if we want students to truly become medical professionals rather than merely acting professionally’.36 Ng et al contend that instrumental applications of reflection in medical education stray from the theoretical underpinnings that theorists of reflection have advanced, in particular resisting reductionism and promoting a space for artistry.34

Educators in this study emphasised the need for multiple approaches to maximise the potential success of a remediation—a view supported by literature on professionalism remediation in health professions education.44-46 Common among these multiple approaches is dialogue between a learner and a medical educator (sometimes referred to as a trainer, coach, or supervisor) who supports the development of professionalism through reflective practice.44, 45 For participants in our study, an important part of engendering residents' sincerity involved creating the conditions for writing, sharing and discussion. These conversations afford learners the opportunity to share their understandings of the professional lapse and identify potential strategies to avoid similar scenarios in future. These conversations afford educators the opportunity to probe into the meaning of what is written. Reserving time for these discussions in the remediation process allows for trusting and meaningful relationships to develop, which may allow learners to become more open to sharing and to receiving feedback as well as more self-aware of their strengths and lapses in areas such as professionalism.

Participants identified a lack of insight as a primary cause of unprofessional behaviour. Indeed, physicians with low levels of insight are more likely to perform inadequately and not be aware of their underperformance.41 Hays et al41 contend that professionals with low levels of insight may not have received enough direct, immediate feedback on their ability to self-reflect so as to strengthen their intuitive capacities. Thus, critical to a remediation strategy is the opportunity for the learner to introspect (i.e., through reflective writing) and receive feedback on that process (i.e., by using the written reflection as a catalyst for in-depth exploration between learner and educator44). Kaslow et al propose that ‘coaching and deliberate practice with feedback and monitoring are likely to be more effective strategies for addressing lapses in professionalism than are technical solutions that involve enforcement and reminders’.44, 47 Coaching builds reflective practice among learners and is key to sustained behaviour change and continued professional growth.43, 44 In assigning reflective writing, notably multiple writings such as weekly logs or journals, educators in our study hoped to instil a process of reflection-in-action by nurturing reflective skills that learners could later leverage to cope in situations that might trigger unprofessional behaviour. We contend that learners engaged in multiple reflective writings may become more adept, comfortable and insightful with time and practice. For these reasons, we suggest that longitudinal writing tasks, rather than single pieces, should be used to develop introspective capacity, and these writings should be blended with feedback and coaching.

The high stakes of remediation in residency further heighten questions and tensions around using reflective writing to simultaneously develop and assess insight around professionalism. Participants acknowledged the vulnerability of residents undergoing remediation and identified learner safety as an indispensable catalyst for sincerity in reflection. To promote learner safety, educators advocate separating the support role (the individual who supports the resident through the reflective writing process) from the supervisory role (the individual who oversees and assesses the remediation, including the reflective writing component). Based on our findings, we suggest the need to do more than separate these roles. We should also separate the tasks—that is, use reflective writing only for learning and growth around professional identity, rather than for both development and assessment. Educators struggled with simultaneously supporting and assessing a learner under remediation. The ensuing tension between these roles—and, we contend, between the learning and assessment roles that reflective writing is expected to play—becomes a barrier to genuine reflection by residents. Indeed, as participants noted, residents may be more likely to write to pass than to gain insight, especially if they are concerned about criticism of their values or fear of judgement and failure. These tensions have been highlighted elsewhere in medical education scholarship, where it has been suggested that these roles of coach and assessor should be disentangled.48 Although disentangling these roles is not simple,40 it may help create a safe space where learners feel supported and where they can be vulnerable in their writing. It may also counter conflicting roles and responsibilities within a hidden curriculum arising from resource limitations and educator commitment.17 Further separating the tasks of learning and assessment makes the distinction between coach and assessor easier. If reflective writing is used only for growth, then it can be the exclusive purview of the coach and need not also concern the individual(s) assessing the remediation.

This study advances our understanding of how medical educators are currently using—and how they may consider using—reflective writing to remediate professionalism lapses in Canadian residency programmes as well as of the ensuing potential and limitations of current approaches. We offer two key takeaways for educators: (1) use reflective writing only for learning and growth around professional identity, rather than for both learning and assessment, and (2) engage residents in multiple writings over time to develop introspective capacity and then combine these writings with feedback and coaching.

This study is limited by its inclusion of only English-language medical schools in Canada. We recognise that excluding the three Francophone schools limits our understanding of cultural differences that may influence the use of reflective writing to remediate professionalism within these schools. Another limitation is the exclusion of resident learners in this study. We recognise that interviewing residents who have undergone remediation for professionalism or conducting a systemic analysis of their completed writings would add depth to understanding issues raised by interviewing educators, such as questions about learner sincerity and safety; however, there are ethical questions associated with interviewing such residents or analysing their writings, including the challenges of identifying and ensuring anonymity for such residents as well as seeking informed consent to analyse their writings.

Future research may continue to explore practices around reflective writing and professional remediation in residency programmes. We concur with de la Croix, Chou and Veen who suggest that future research aims to describe how reflection takes place in practice to strengthen understanding of workplace learning.36 Future research may also look beyond reflective writing to consider how other reflective forms, including other arts- and humanities-based ways of reflecting, may offer potential in remediation contexts. Researchers may also look to develop a sound argument for why and how to treat reflective writings themselves as primary data, or alternatively, to create a set of representative writings that reflect our emerging patterns to support a scenario-based inquiry around how educators interpret and evaluate such writings as evidence of remediation. Such future work can explore, for instance, how reliably medical educators sort examples of resident writing as authentic and reflective versus performative and superficial.