Navigating the continuum between competent and reflective practice in residency


Dr. Susan O'Leary
Ms. Diana Deacon
Dr. Andrew Major
Dr. Chris Jenkins


Portfolios and ePortfolios




Memorial University of Newfoundland



Anesthesiology residents felt that having a short, specific learning experience helped prepare them for their first narrative reflection assignment. The workshop activity contextualised the background information on the portfolio and reflective practice within the residents’ everyday practice.



A workshop and video exercise was created to prepare residents in an Anesthesia program for the reflective learning section of their Professionalism portfolio. The reflective piece included a written narrative based on a personal experience followed by discussion of the narrative with a delegated faculty Anesthesiologist.  The focus of the workshop was on teaching the verbal reflective process.



Take-home Messages



Short, focussed interactive learning experiences can be incorporated into existing academic sessions to help residents develop and contextualize skills navigating the continuum of medical education and practice.


Summary of Work


All Postgraduate Year 1-4 Anesthesia residents attended an academic half-day session to learn the process of reflection. An education specialist guided the learning process.  A group discussion utilizing questions specifically developed to facilitate reflective learning followed a video of an emotionally charged scene in the Emergency Room.  This teaching session was to prepare residents for reflection on their own and/or others professional behavior.  Students were surveyed at the end of the session to determine the effectiveness of the learning activity. The survey used both a 10-point Likert-type scale to rate a list of items and several open-ended questions.




ER video link:

Summary of Results



table results



The authors would like to express their gratitude to the residents of the  Memorial University Anesthesia Residency Program for their assistance in the development of the portfolios, for their participation in the workshop and subsequent reflective narrative activity of the professionalism portfolio.


References are listed in the details section.




Although residents participated in the development of the portfolio, significant reluctance remained surrounding the relevance and utility of the entire project particularly with regard to the reflective exercise. The workshop developers felt that learning this skill in a non-threatening environment would ease the resident into the individual reflective discussion. This method of critical review of one’s own behaviour often needs to be taught to residents to become an effective lifelong learning activity.  The Professional role was the first portfolio.  In future, each CanMED role will be developed into a specific portfolio with a reflective exercise as one of the components.


The MUN Anesthesia Residency Program Portfolio Project was created in the 2011-12 academic year. The first portfolio focuses on the CanMED role of Professionalism.  The Royal College of Physicians and Surgeons of Canada identified seven CanMEDS as the key areas of residency training. It is generally acknowledged that the non-Medical Expert CanMEDS roles: Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional are more challenging for programs to teach and assess.  A sign of a successful consultant is one who continually reflects upon their practice to determine how they may improve in all CanMEDS domains.  This will allow a recent graduate of the residency program to move from being “competent” to “expert” over the first few years upon completion of residency.  Ideally, this reflective process should continue for the rest of his/her professional career.  


The following are the guidelines for the narrative reflection section of the portfolio. The narrative report is to be completed by the delegated attending anesthesiologist who reviews the narrative with the resident to document the resident had the reflective discussion.  There is no formal "evaluation" of the narrative and reflection.


Narrative Reflection Section Guidelines



The Portfolio project was initiated at ACUDA by all 17 Canadian Anesthesia program directors as a way to document learning activities in all 7 CanMEDS roles.  It is generally acknowledged that the non-Medical Expert CanMEDS roles (Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional) are more challenging for programs to assess, and yet the RCPSC requires this for accreditation purposes, and also for the Final In-Training Evaluation Report (FITER) for final year residents.   

It is acknowledged that a sign of a successful consultant is one who continually reflects upon their practice to assess how they improve their practice in all 7 CanMEDS domains.  This will allow a recent graduate of the residency program to move from being “competent” to “expert” over the first few years upon completion of residency.  Ideally, this reflective process should continue for the rest of his/her professional career.  The residency program should encourage residents to learn how to reflect upon their performance (in all 7 CanMEDS domains) during residency, such that this can continues post-residency (concept of life-long learning).

It is also acknowledged that not infrequently, it the non-medical expert roles that cause difficulties for consultants in their practice, and can create problems for hospital department heads. 

Portfolios are really an “instrument of instruments,” or a collection of assessment tools. Their components may include logbooks, multi-source feedback instruments, continuous quality improvement projects, and learning diaries, encounter cards, essays, rating scales, etc. When designing a portfolio for assessment, it is important to be clear not only on its purpose, but also on the role of the learner in collecting the material, the degree of reflection desired, the medium (e.g., paper or online), and on how expectations and standards will be set. 


Narrative Proposal

The resident is expected to prepare the CanMED role of professionalism for his/her portfolio for this academic year of 2011/12. For the resident, the portfolio project involves 3 steps for each CanMEDs role:

1.  The resident is expected to do the background reading on the CanMED role.  This reading is provided to the resident. 

2.  The resident is then expected to provide a narrative summary of a clinical or non-clinical (e.g. teaching, research) experience, which had some sort of impact on the resident.  This narrative should highlight the CanMED role.   Situations which residents find stressful are often fruitful situations for inclusion in their portfolio. 

3.  The most important aspect of the portfolio should be the reflective component: the resident should reflect upon this experience and demonstrate what aspects were handled well, and what aspects the resident would do differently should a similar experience occur in the future. 

 Proposed program expectations for each role:

  1. Does the resident understand the concepts of this particular CanMEDS role?
  2. Does the resident demonstrate an ability to reflect on their performance in this particular CanMEDS role (what they did well and what areas could be improved?

The resident will meet with a faculty member, Dr. Major during the Winter/spring of  2012. The resident will bring their documented portfolio for the role and show this to the faculty member and be prepared to discuss the scenario and reflections on the specific CanMED role.   It should be noted that the actual portfolio belongs to the resident.   The faculty member will provide feedback on the resident’s portfolio and complete an assessment form.  It should be noted that this evaluation is qualitative rather than quantitative.  The program director, Dr. O’Leary, will ask to see the portfolio at one of the biannual resident meetings to document participation in the project. 


Narrative Report


Resident’s name and PGY level:

Name of faculty:

Canmeds role discussed:

This resident demonstrates an understanding of this particular role (i.e. has read the background information and demonstrates an understanding):  exceeds expectations, meets expectations, or needs improvement (specify)

This resident is able to reflect upon the narrative clinical or non-clinical experience provided and demonstrate an ability to assess what areas were done well and what areas could be improved upon in the future:  exceeds expectations, meets expectations, or needs improvement (specify) 

Comments by faculty member:  __________________________

Documentation that narrative review was done should be submitted to the program office and program director for inclusion into the resident’s file, and a copy given to the resident.  The actual portfolio would remain with the resident, and would not go into the resident’s file.


Resident Resource

The resident resource, Dr. Jenkins, is not involved in the review of the portfolio, narrative and reflection but is available to residents who have questions or need some help to initiate portfolio writing.  It is thought that a peer may be easily approachable. Having a resident resource person may lead to desired discussion of the portfolio project among the resident group.


Narrative Reflection Section Review

This project will be reviewed and feedback used to revise the plan as appropriate for continuation the following year.  A technique for evaluation and review will be developed.  The eventual plan is the addition of a CanMED role each year for development of a resident portfolio during the years PGY1-5.

December  2011

Take-home Messages
Summary of Work

The Professionalism Portfolio includes various methods for the learning and practice of professionalism in anesthesia residency.  A narrative piece based on a personal experience is reviewed and discussed with a delegated faculty member. The following questions provide guidance.


1.    What and when was the event that simulated learning?

2.   What was learned. i.e. what will you change in your practice in the future?

3.   An example of how the learning has been applied (what did you actually change?)

4.   What needs to be learned next (did the change lead to new questions? If so, what?)

5.    How will I answer the new questions?


Various readings, didactic sessions, simulation, evidence of lifelong learning and personal wellbeing encompass the remainder of the portfolio.  The Royal College of Physicians and Surgeons of Canada Objectives of Training in CanMEDS Professsional Role form the framework for resident training in professionalism.

For this workshop, a YouTube video of a vignette from the program ER was used. This dramatic clip places the resident in a difficult situation. Utilizing this video to teach the method of reflection allowed the resident to practice in an objective non-threatening environment.  


The survey of the workshop comprised the following questions answered on a 10 point Likert scale

      1.  Did you find this workshop helpful?

2.    Are you more prepared to use the portfolio?

3.    Have you gained insight into challenges and strategies for reflection?

4.    Are you more confident in understanding the role of the portfolio?

5.    Are you more confident in completing the portfolio as a whole?

6.    Are you more confident in reflecting on your practice?

7.   Are you more confident in completing the reflective exercise in your portfolio?


Summary of Results

The following are comments provided by residents on the workshop feedback survey:


    “Reflection is terrific…as long as it’s not self-flagellation!”


    “Reflection can help with ongoing improvement to maintaining a high level of professionalism”


    “Others feel the same way! Proactive way to think about planning towards completion.”


    “I hope to be more aware of my reflections; to be able to move from thinking and reflecting towards learning and changing my behaviour and attitudes where necessary.”


    “Reflection is a path to excellence.”


    “Reflection is part of a natural process of learning.”




This portfolio and reflective exercise is based on a portfolio used by the University of British Columbia Anesthesia Residency Program.  The original portfolio format was developed by Association of Canadian Universities of Anesthesia.  The video used in the workshop was found on YouTube and is from the program ER.  The link to the video is in the summary of work section of this poster. 





•Brookfield, S. (1995). Becoming a critically reflective teacher (1st ed.). San Francisco: Jossey-Bass.

•Kember, D., Jones, A., Loke, A. Y., McKay, J., Sinclair, K., Tse, H., et al. (2001). Reflective teaching and learning in the health professions: Action research in professional education. Oxford, UK: Blackwell Science Ltd.

•Mezirow, J. (2000). Learning as transformation: Critical perspectives on a theory in progress (1st ed.). San Francisco: Jossey-Bass.

•Schön, D. A. (1987). Educating the reflective practitioner (1 -- ed.). San Francisco: Jossey-Bass.

•Tochel, C., Haig, A., Hesketh, A., Cadzow, A., Beggs, K., & Colthart, I. (2009). The effectiveness of portfolios for post-graduate assessment and education: BEME guide no 12. Medical Teacher, 31(4), 299-318.

•Wear, D. , Zarconi, J., Garden, R., Jones, T. (2012). Reflection in/and writing: Pedagogy and practice in medical education. Academic Medicine - Publish Ahead of Print March 28, 2012

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