PURPOSE: Medical schools are increasingly incorporating opportunities for reflection into their curricula. However, little is known about the cognitive and/or emotional processes that occur when learners participate in activities designed to promote reflection. The purpose of this study was to identify and elucidate those processes. METHOD: In 2008, the authors analyzed qualitative data from focus groups that were originally conducted to evaluate an educational activity designed to promote reflection. These data afforded the opportunity to explore the processes of reflection in detail. Transcripts (94 pages, single-spaced) from four focus groups were analyzed using a narrative framework. The authors spent approximately 40 hours in group and 240 hours in individual coding activities. RESULTS: The authors developed a conceptual model of five major elements in students reflective processes: the educational activity, the presence or absence of cognitive or emotional dissonance, and two methods of processing dissonance (preservation or reconciliation). The model also incorporates the relationship between the students internal ideal of what a doctor is or does and the students perception of the teachers ideal of what a doctor is or does. The model further identifies points at which educators may be able to influence the processes of reflection and the development of professional ideals. CONCLUSIONS: Students cognitive and emotional processes have important effects on the success of educational activities intended to stimulate reflection. Although additional research is needed, this model-which incorporates ideals, activities, dissonance, and processing-can guide educators as they plan and implement such activities.
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