Finding Resonance: The Value of Indirection in a Reflective Exercise

By reflection… I would be understood to mean, that notice which the mind takes of its own operations… not barely the actions of the mind about its ideas, but some sort of passions arising sometimes from them, such as is the satisfaction or uneasiness arising from any thought.

John Locke, Essay on Human Understanding (1690)1

What role should the humanities play in medical education? There are 2 major streams of thought on this.2–4 One is that the humanities should offer learners a restorative refuge from the stresses of assimilating scientific data and clinical demands and that this contemplative retreat into art and stories can be therapeutic by helping to sustain resilience and imagination. The second view is that the humanities are rigorous academic disciplines centered on skills training to interpret and evaluate cultural texts (not only poems or paintings but also drug advertisements or chart notes). As such, the humanities should be used to train physicians to take a critical and analytical perspective on their work and its contexts.

The educational modality of reflection may be one area that has potential to reconcile the 2 approaches. When used in medical education, reflection usually requires a student-participant to step back and contemplate the workings of his or her identity as a professional being. The process is facilitated by having participants articulate, to others, what their reflecting minds have observed of what John Locke called their “own operations.”1 This articulation usually takes the form of narrative writing. Through this process—a retreat into contemplation, coupled with the risks of outward self-expression—some of the analytical tools of the humanities disciplines are brought to bear on the developing professional self as text. (What story does the resident tell about his or her relationship with this patient? How does he or she tell it? What does close reading of his or her telling reveal?) Reflective exercises, thus, have the potential to approach questions the humanities and arts expect of their practitioners: the introspective “How do I feel?” and the analytical “How does this work?”5–6

There are, however, real dangers in the use of reflection exercises by educators who have not fully examined the implications of the process or articulated precisely the nature of the intervention and what it can unearth. Reflection, unlike didactic education, expects signs of authentic personal responsiveness. Thus, there is a risk that the very act of requiring reflection, let alone assessing it, will shut down the open and self-revelatory process that can enable a reflective practitioner to make new sense of rote practices.

Part of the problem may lie in the educational concept of “professionalism,” which used to mean relinquishing personal concerns in favor of a mature and unemotional professional persona. Yet, the development of professionalism has increasingly come to mean efforts to reintegrate the personal into that persona. Although it is profoundly valuable to acknowledge that an absolute separation of private and work identities is impossible, there is also a danger that reflective professionalism training, if insufficiently considered, can harmfully expose the personal, which is also inherently private.

Aware of their vulnerability, participants in educational reflection exercises may avoid risk by self-defensively producing superficial performances of the appearance of reflection, while keeping the “real” safely hidden. This defeats the purpose of the exercise. Moreover, participants may suffer anxiety and regret after involuntary exposure or confession of deep, genuine feelings within an untrustworthy context. Either of these outcomes—or even the possibility of them—threatens the intent of reflective practice and can solidify the kind of defensive or cynical self-division that these interventions are meant to address.7–8

My reasons for identifying the potential downside to reflection exercises is not to discourage their use but to point out the very elegant way in which the exercise described in “Reflections in a Museum Setting” by Gaufberg et al9 circumvents some of these risks. The authors turned the overt focus of the exercise away from the participants' own minds through the use of external objects made by others—works of visual art—to offer both a catalyst for reflection and a refuge from the risks of insecure self-exposure.

As the authors point out, many medical educators have seen the value of visual art for developing the clinical skills of visual attention and observation. In contrast, their exercise asks the participants to spend solitary time choosing a work of art that resonates for them in relation to a randomly selected prompt. This is followed by communal time when they act as museum docents, presenting the chosen object—a kind of miniature curated exhibit—to the other participants. This process of indirection, where the focus is primarily on the art object rather than the participant, might facilitate the kind of contemplation and articulation of professional experience and identity that more forthright approaches to reflection might stifle.

Sympathetic Resonance

Tell all the Truth but tell it slant—Success in Circuit lies…

Emily Dickinson, The Poems of Emily Dickinson10

Some musical instruments, like the Indian sitar and the Baroque viola d'amore, have strings that are seldom if ever touched directly by the player, but instead, produce their music by resonating with vibrations from the strings that are played. They are called the sympathetic strings. “Reflection in a Museum Setting”9 reminds me of this reverberation effect. The article's authors call the other object, in their case a work of visual art, the “third thing.” Like the string actually touched by the musician, this object is carefully chosen for its ability to set up vibrations. The real depth of music, or meaning, however, emerges from the periphery, those sympathetic strings in the participant's psyche that produce imaginative echoes when shielded from direct attention.

Use of the “third thing” allows for control of self-disclosure. There is room for voluntary narration of personal experience, but a presenter may also focus on the object itself: describe its formal characteristics or meditate on its meaning. The other tremendous value of this exercise lies in participants choosing their own objects, a freedom also reassuringly managed with prompts that are narrow enough to prevent anxious and aimless searching. Because the prompts are randomly selected, the choices escape being overloaded with personal significance.

This selection by the participant is where resonances are established, recognized, compared, and where the real process of reflection and of alertness to one's own imaginative responsiveness develops. This demonstrates the value of the art gallery or museum, with its environment of physical movement among object texts that can be grasped and their resonance felt at a glance.

Most important, this exercise in “resonant indirection” allows participants to observe the cognitive and emotional operations of their minds while escaping a pedagogical context that risks feeling uncomfortably like a group therapy session, the confessional, or an interrogation. Instead, the reflective practice participant here is a curator and interpreter of resonant objects. This may be the best route to authentic self-exploration. Is this not, after all, what art is for?