Effect of feedback on reflection, on deep learning of undergraduate medical students in a clinical setting

Effect of feedback on reflection, on deep learning of undergraduate medical students in a clinical setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of feedback on reflection, on deep learning of undergraduate medical students in a clinical setting Zainab Maqsood, Madiha sajjad, Raheela Yasmin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4399599/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Reflection is crucial for deep learning and self-regulation. However, reflection alone may not produce the desirable effects unless coupled with feedback. This study aims to investigate the impact of ‘feedback on reflection’, on deep learning and concept building among undergraduate medical students. Objective: To determine the effect of feedback on reflection in deep learning of undergraduate medical students in clinical setting of gynaecology. Method: This was an experimental study, conducted from February 2023 to July 2023, following approval from the Ethics Review Committee. The study sample were 68 final year MBBS students divided into study and control group through simple randomization. A pre-test was done to establish baseline measurements. Both groups then received similar teaching sessions on obstetrics and gynecology topics over a period of 6 days. Written reflections based on Gibbs reflective cycle were collected from all participants, and the study group additionally received verbal feedback. A post-test concluded the study. Both the pre and post-tests comprised 30 multiple-choice questions at a higher cognitive level. Data evaluation was done through SPSS 26. Descriptive statistics and t- test was used to compare the means of both groups. P–value of < 0.05 was considered significant. Results: No significant difference in gender distribution was found between the two groups. Baseline pre-test scores showed no significant difference between control group (37%) and study group (39%). Both groups demonstrated significant improvement from pre-test to post-test (p < 0.0001). However, post-test results showed a significant increase in the scores of study group (69%) compared to the control group (51%) (p < 0.0001). Net gain of learning after addition of feedback along with reflection in intervention group was 18.6%. Student feedback supported the effectiveness of the teaching method in facilitating learning and exam preparation. Conclusion: Incorporating feedback along with reflection enhances conceptual learning among undergraduate medical students, resulting in significantly improved test scores compared to reflection alone. Reflection feedback deep learning clinical setting Figures Figure 1 Figure 2 Introduction Thinking and reflecting on what has been learned are crucial elements in the learning process, and they are considered metacognitive phenomena that can occur before, during, and after learning. Metacognition refers to the ability to monitor and regulate one's own thinking and learning processes 1 . It involves being aware of one's own knowledge, understanding, and cognitive strategies, as well as being able to plan, monitor, and evaluate one's learning experiences. Metacognitive strategies such as self-questioning, summarizing, and seeking clarification help learners to actively engage with the material, deepen their understanding, and make connections between new information and existing knowledge 1 , 2 . In addition to RP, feedback is also an essential tool that drives learning and improve clinical performance 3 . Receiving effective feedback from experienced and trained instructors is widely recognized as a crucial tool for enhancing the capacity of learners. Such feedback plays a vital role in enabling learners to self-reflect on their practice and strive towards achieving a desired level of competency. With the guidance of trained instructors, learners can critically assess their performance, identify areas for improvement, and make necessary adjustments to enhance their skills and knowledge. By engaging in this process of self-reflection and incorporating the insights gained from expert feedback, learners can progress towards reaching the acceptable level of competence and excel in their learning journey 4 , 5 . Reflection offers health profession learners the means to cultivate problem-solving skills, enhance clinical reasoning abilities, engage in self-regulated learning, and embrace lifelong learning. By actively reflecting on their experiences, learners develop a deeper understanding of their own practice, continuously improve their skills, and become competent and adaptable professionals in the dynamic field of healthcare 6 . However the use of feedback on reflection as a method of formative assessment to enhance learning in medical schools in Pakistan is unfortunately limited. Consequently, there are only a few studies that employ a quantitative approach to demonstrate the benefits of reflection in expanding medical knowledge. Most studies conducted in this context are non-comparative and rely on qualitative surveys, which do not utilize scoring or grades to evaluate the impact of feedback on reflection on medical education 7 , 8 . Aim of the study was to compare the effect of combining feedback with reflection verses reflection alone in enhancing deep learning of undergraduate medical students in gynaecology setting. We hypothesized that there would be a significant difference in the deep learning of undergraduate medical students in clinical settings between those who receive feedback alongside reflection and those who solely engage in reflection. By adopting a more robust research approach, medical schools can gain valuable insights into the benefits of integrating feedback into the reflection practices. This will facilitating the development of evidence-based approaches to optimize learning outcomes for aspiring future in medical professionals. Methodology Experimental study design was applied to understand feedback on reflection affects deep learning of students, compared to reflection alone. Ethical approval for the study was taken from ethical review committee of Riphah university and Rawalpindi medical university (app # Riphah/IRC/23/3034) (Reference no: 341/IREF/RMU/2023). Participants: Study participants included fifth-year undergraduate medical students of Rawalpindi medical university undergoing their clinical rotation (ward, operation theatre and outpatient department) in the gynecology and obstetrics for 8 weeks who consented to participate in the study. The sample size for this study was calculated to be 34 in each study and control group, using the G*Power sample size calculator, with a predetermined level of significance (α) of 0.05, statistical power (1-β) of 0.80, and an effect size of 0.7 based on previous studies 8 , 9 . To ensure fairness among participating and non-participating students, it was explicitly stated that taking part in the study would not influence their grades in the module. Grades for both participating and non-participating students would be determined using the traditional assessment criteria established by the Faculty. This approach aimed to alleviate any concerns among students regarding potential academic consequences associated with their involvement in the study. Participants were divided into control group and study group by simple randomization technique. A mcq based pre-test was conducted for both control group and study group as a baseline measure for students’ knowledge before the study and to check for any difference between the groups. Students were taught to write a written reflection in preclinical years. However a refresher training for reflective writing was done for all the participants prior to start of activity, facilitated by a set of pre designed questions based on the 6 steps of Gibbs reflective cycle which were:- What have you learned from clinical ward class? What are your thoughts and feeling about topic? What were you thinking during the topic discussion? Any previous experience of the situation/topic? How did it help you in making your differential diagnosis or diagnosis? Were there any ambiguous or difficult to understand concept What is your plan to improve your learning based on this experience? Both groups were taught by one facilitator in ward and class for 6 days. Facilitator discussed 6 cases of obstetrics and gynaecology (Antepartum haemorrhage, post-partum haemorrhage, pregnancy induced hypertension, Gestational diabetes mellitus, anemia, intrauterine growth restriction) during ward rotation followed by class in a holistic way (history, examination, investigation, differential diagnosis and management). At the end of each class, both groups submitted a written reflection based on Gibbs reflective cycle. Intervention: Feedback was given by same facilitator to study group after each reflective activity. Feedback was prepared by reading the reflection of participants of study group. This feedback was given on next day before starting ward rotation to address the learning gaps of students, identified by facilitator. This feedback was given for the purpose of guidance to address their queries. Instrument for evaluation: Pre-test and post-test: A multitude of multiple-choice questions (MCQs) were generated covering six topics within the field of obstetrics and gynecology (Antepartum haemorrhage, post-partum haemorrhage, pregnancy induced hypertension, Gestational diabetes mellitus, anemia, intrauterine growth restriction). The MCQs underwent validation by two experts specialized in obstetrics and gynecology, one of whom possessed expertise in medical education. These experts meticulously scrutinized the structure of all the MCQs, ensuring their alignment with criteria pertaining to higher-order cognitive levels— application (C3), analysis (C4), and evaluation (C5) components. While a specific standard-setting approach was not employed, they assessed the level of difficulty inherent in the MCQs, aiming to establish a balanced level of complexity between the pretest and post-test, ensuring comparability. Major flaws were checked and corrected. 30 MCQs were added in each paper (pretest and posttest), 5 MCQs from each topic of gynaecology and obstetrics) from the pool of MCQs. Data analysis: Data was entered into SPSS version 26. Descriptive statistics, including frequency, percentage, mean and standard deviation were calculated for quantitative variables. Inferential statistics were calculated which included T-test to compare the means of both the groups. P –value of < 0.05 were considered significant. Paired sample T test was used to compare the Pre-test and post-test scores of both the study and control groups. Independent sample two- tailed T test was used to compare the scores of both groups. Control of biases: Random assignment of participants to both groups ensured that each participant had an equal chance of being placed in either group, reducing the risk of bias and increasing the validity of the study's findings. We took precautions to inform all participants that the assessments conducted in this study would not be used in their final grades. By doing this, we aimed to eradicate the pressure of achieving better grades and lessen the impact of extraneous factors on the observed effects of reflection and feedback in the learning process. Results In this randomized controlled trial, a total of sixty eight (n = 68) final year medical students of either gender were enrolled. There was no statistically significant difference in gender distribution between control group and study group M:F ratio (M = 22, F = 44, P = 0.380). Comparison of pretest and posttest of both control and study group: Pretest test was conducted for both groups to know about their knowledge at baseline. This pretest was conducted before taking any class of the students. Control group mean obtained marks in pre test were 11.29 out of 30 with percentage of 37%, similarly study group mean obtained marks in pretest were 11.68 out of 30 making percentage of 39% (P value = 0.529) Table 1 . Post test was taken on 7th day, 6 topics were taught to the students in ward followed by discussion in class followed by written reflection and feedback. Feedback was given to study group only. Control Group posttest mean obtained marks were 15.29 out of 30 making their percentage 51%. While study Group post test mean obtained marks were 20.88 out of 30 making their percentage of 69% by applying independent sample t test (P value 0.0001) Table 1 . Comparison of pre test and post test score of study group showed significant results after feedback on reflection by applying paired sample t test (P = 0,0001) Table 1 . Table 1 Pre-test scores mean +/-standard deviation (%) Post-test scores mean +/-standard deviation (%) P value (Paired sample t test) Study group 11.68 +/- 2.60 (38.93%) 20.88 +/- 2.98 (69.32%) 0.0001 Control group 11.29 +/- 2.38 (37.15%) 15.29 +/- 2.66 (51.00%) 0.0001 P value (Independent sample t test) 0.52 0.0001 Net gain of learning after addition of feedback along with reflection in intervention group was 18.6%. Student feedback regarding the teaching method indicated that the combination of feedback on reflection helped them address their queries and better prepare for their studies in advance. Discussion This study was a randomized experimental study aiming to assess the effectiveness of reflection with feedback compared to reflection alone, in enhancing deep learning of undergraduate medical students. We found that our educational intervention increased the deep or higher order learning among final year medical student who came for ward rotation in the gynecological department. Similar results were produced by Choi et al in 2020 where practicing written clinical cases with reflection and feedback yielded additional benefits of diagnostic accuracy compared to a traditional dermatology elective 15 . According to two studies conducted in Saudi Arabia and Taiwan, the findings revealed a notable and meaningful association between reflection performance and critical thinking disposition. Furthermore, the study demonstrated that reflection performance could effectively predict the variability in critical thinking disposition. These results suggest that nursing students who actively engage in reflective practices are more likely to possess stronger critical thinking abilities 10 , 11 . Another study conducted on residents of gynaecological department in 2013 which showed that reflective exercise improves with practice and it helps in self-assessment, surgical skill development, communication and professionalism 1 , 12 . These studies collectively demonstrate the importance of incorporating reflective practice into nursing education and professional development. Engaging in reflective practice empowers medical professionals to critically evaluate their experiences, thoughts, and actions. Through this introspective process, they can gain valuable insights, identify areas for growth, and refine their critical thinking abilities. By actively engaging in reflective practice, nurses cultivate a continuous learning mindset and nurture their capacity for making informed decisions and providing optimal patient care. Our study included two groups, control and intervention group, and took written reflection. Written reflection is also a way of getting important feedback from students that how they learn and promote reflective practice. This was similar to a study done in Taiwan which included 2 groups of paramedical staff using self-reflection methodology to improve their critical thinking 10 .This was ascertained by another study conducted in 2004. While this study does not included any intervention group. In our study feedback was given by one instructor throughout this teaching strategy to reduce the biasness in results. This feedback was given by instructor to the students on their written reflection while another study had feedback by the peer and instructors both. This study proved that reflection followed by feedback helped in improving student’s history taking skill, enhance their medical knowledge and improve reflective writing 9 . Literature proved that by embracing feedback, individuals actively propel their growth and development forward, utilizing insights garnered to enact tangible enhancements. When integrated with self-reflection, positive feedback assumes the role of a potent catalyst. Through this symbiotic relationship, individuals not only refine their skill sets but also cultivate a deeper understanding of their capabilities and areas for improvement 14 . The synergy between constructive feedback and introspection empowers individuals to continuously evolve, fostering a culture of continuous improvement and personal excellence, ultimately leading to heightened levels of success and fulfillment 13 . Practical implications of recognizing and incorporating feedback on reflection in educational settings involve enhancing teaching and learning practices, developing reflective practitioners, promoting a culture of constructive feedback, improving educational design and assessment strategies, and facilitating professional competence and continuous improvement. These implications can contribute to a more engaging, effective, and learner-centered educational environment. Study limitations: Our study had few limitations. It was conducted at a single center, specifically focusing on medical students who were undergoing elective rotations in the gynecology department of Holy Family Hospital with a relatively small sample size. This may limit the generalizability of the findings. The study did not include gathering feedback from the students at the end of the learning activity to assess their satisfaction or perception of the learning experience. Which could have provided valuable insights into their preferences, engagement, and perceived effectiveness of the teaching methods used. Conclusion The findings of this study suggest that Integrating feedback along with reflection enhances conceptual or deeper learning among undergraduate medical students, resulting in significantly improved test scores compared to reflection alone. Declarations I. Ethical Approval and Consent to Participate: Ethical approval was taken from Rawalpindi medical university (Ref no:341/IREF/RMU/2023)and Riphah international university (appl: Riphah/IRC/ 23/3034). Informed consent was obtained from all individual participants included in the study. II. Consent to Publication All authors give their consent for the publication of this manuscript. III. Data Availability statement: All data, which is generated or analyzed, is included in this publication article. IV. Conflict of interest: No conflict of interest V. Funding: No funding required for this research VI. Authors contribution: Zainab Maqsood: concept of research, objective, research proposal, data collection, data analysis, article writing and proof reading Madiha sajjad: concept of research, help in data analysis, article writing and proof reading. Raheela Yasmin : concept of research and proof reading. References Al-Hashim A. Critical thinking and reflective practice in the science education practicum in Kuwait. Utopia y Praxis Latinoam. 2019;24(6):85–96. Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2011;33(3):200–5. Harasym PH, Tsai TC, Hemmati P. Current trends in developing medical students' critical thinking abilities. Kaohsiung J Med Sci. 2008;24(7):341–55. Lara R, Mogensen K, Markuns J. Effective feedback in the education of health professionals. Support Line. 2016;38(2):3–8. Qureshi NS. Giving effective feedback in medical education. Obstetrician Gynaecologist. 2017;19(3):243–8. Rahimi M, Haghani F. Reflection in medical education: A review of concepts, models, principles, and methods of teaching reflection in medical education. Res Med Educ. 2017;9(2):24–13. (in Persian). Khoshgoftar Z, Barkhordari-Sharifabad M. Medical students’ reflective capacity and its role in their critical thinking disposition. BMC Med Educ. 2023;23(1):19. Larsen DP, London DA, Emke AR. Using reflection to influence practice: student perceptions of daily reflection in clinical education. Perspect Med Educ. 2016;5(5):285–91. 10.1007/s40037-016-0293-1 . Tawanwongsri W, Phenwan T. Reflective and feedback performances on Thai medical students' patient history taking skills. BMC Med Educ. 2019;19(1):141. Chen F-F, Chen S-Y, Pai H-C. Self-reflection and critical thinking: The influence of professional qualifications on registered nurses. Contemp Nurse. 2019;55(1):59–70. Khalil AI, Abou Hashish E. Exploring how reflective practice training affects nurse interns' critical thinking disposition and communication skills. Nurs Manag. 2022;29(2). https://doi.org/10.7748/nm.2022.e2045 . Khanum Z. Effectiveness of reflective exercises for obstetrics and gynaecological residents. J Coll Physicians Surgeons–Pakistan: JCPSP. 2013;23(7):468–71. Zoe Talent Solutions. The Role of Feedback and Self-Reflection in Enhancing Productivity and Performance. [Internet]. [cited 2024 Apr 30]. https://zoetalentsolutions.com/the-role-of-feedback-and-self-reflection-in-enhancing-productivity-and-performance/ . Hardavella G, Aamli-Gaagnat A, Saad N, Rousalova I, Sreter KB. How to give and receive feedback effectively. Breathe (Sheff). 2017;13(4):327–33. Choi S, Oh S, Lee DH, et al. Effects of reflection and immediate feedback to improve clinical reasoning of medical students in the assessment of dermatologic conditions: a randomised controlled trial. BMC Med Educ. 2020;20(1):146. 10.1186/s12909-020-02063-y . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 17 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 16 Jul, 2024 First submitted to journal 10 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4399599","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":328053922,"identity":"685c2938-3f33-4216-9d9c-4d8ed6cc265b","order_by":0,"name":"Zainab Maqsood","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYFACxgYQSjAAcyoYGAxI0MIMpM4QpQWiC6KFsY0ILfLth9se/NzBkGcukX/8wc95h+XN2ZsPMPyo2Ibbgp7EdsPeMwzFljOSGRt7tx023NlzLIGx58xtnFqYGRLbJHjbGBI33EhmbODddphxw40cA2bGNtxa2Pgftkn+hWpp/DvnsD1BLTwSiW3SMFuaeRsOJxLUIiHxsE1aFugXgzOPDWfLHEtP3nDmWMJBfH6R709/JvkWGGIGxxMffHxTY2274XjzwQc/KnBrgYL/MEYzmDxASD0yqCNF8SgYBaNgFIwQAACWOl8a2jPI/QAAAABJRU5ErkJggg==","orcid":"","institution":"Rawalpindi medical university","correspondingAuthor":true,"prefix":"","firstName":"Zainab","middleName":"","lastName":"Maqsood","suffix":""},{"id":328053923,"identity":"fbc6abbe-6258-4809-b247-4e209dbb574e","order_by":1,"name":"Madiha sajjad","email":"","orcid":"","institution":"Riphah International University","correspondingAuthor":false,"prefix":"","firstName":"Madiha","middleName":"","lastName":"sajjad","suffix":""},{"id":328053924,"identity":"d8ecf89e-f88c-4ccf-9bec-c8e9ac86842a","order_by":2,"name":"Raheela Yasmin","email":"","orcid":"","institution":"Riphah International University","correspondingAuthor":false,"prefix":"","firstName":"Raheela","middleName":"","lastName":"Yasmin","suffix":""}],"badges":[],"createdAt":"2024-05-10 09:16:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4399599/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4399599/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-06648-3","type":"published","date":"2025-01-14T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61954312,"identity":"07a0726c-812a-40a8-a8f5-78174d026245","added_by":"auto","created_at":"2024-08-07 13:17:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":493021,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Methodology section.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4399599/v1/04bcab9b6179f3107db9a2a3.jpeg"},{"id":61954310,"identity":"66c3f51d-26ad-4118-86c4-26836de08179","added_by":"auto","created_at":"2024-08-07 13:17:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44068,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Results section.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4399599/v1/aab8a94269cede0eb24a165f.png"},{"id":74284509,"identity":"074a646c-36c2-45e7-a722-c0ca4c4641e5","added_by":"auto","created_at":"2025-01-20 16:08:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1098942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4399599/v1/dedf2b26-9901-457a-9bb1-473630eaf757.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of feedback on reflection, on deep learning of undergraduate medical students in a clinical setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThinking and reflecting on what has been learned are crucial elements in the learning process, and they are considered metacognitive phenomena that can occur before, during, and after learning. Metacognition refers to the ability to monitor and regulate one's own thinking and learning processes\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It involves being aware of one's own knowledge, understanding, and cognitive strategies, as well as being able to plan, monitor, and evaluate one's learning experiences. Metacognitive strategies such as self-questioning, summarizing, and seeking clarification help learners to actively engage with the material, deepen their understanding, and make connections between new information and existing knowledge\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn addition to RP, feedback is also an essential tool that drives learning and improve clinical performance\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Receiving effective feedback from experienced and trained instructors is widely recognized as a crucial tool for enhancing the capacity of learners. Such feedback plays a vital role in enabling learners to self-reflect on their practice and strive towards achieving a desired level of competency. With the guidance of trained instructors, learners can critically assess their performance, identify areas for improvement, and make necessary adjustments to enhance their skills and knowledge. By engaging in this process of self-reflection and incorporating the insights gained from expert feedback, learners can progress towards reaching the acceptable level of competence and excel in their learning journey\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eReflection offers health profession learners the means to cultivate problem-solving skills, enhance clinical reasoning abilities, engage in self-regulated learning, and embrace lifelong learning. By actively reflecting on their experiences, learners develop a deeper understanding of their own practice, continuously improve their skills, and become competent and adaptable professionals in the dynamic field of healthcare\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However the use of feedback on reflection as a method of formative assessment to enhance learning in medical schools in Pakistan is unfortunately limited. Consequently, there are only a few studies that employ a quantitative approach to demonstrate the benefits of reflection in expanding medical knowledge. Most studies conducted in this context are non-comparative and rely on qualitative surveys, which do not utilize scoring or grades to evaluate the impact of feedback on reflection on medical education\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAim of the study was to compare the effect of combining feedback with reflection verses reflection alone in enhancing deep learning of undergraduate medical students in gynaecology setting. We hypothesized that there would be a significant difference in the deep learning of undergraduate medical students in clinical settings between those who receive feedback alongside reflection and those who solely engage in reflection. By adopting a more robust research approach, medical schools can gain valuable insights into the benefits of integrating feedback into the reflection practices. This will facilitating the development of evidence-based approaches to optimize learning outcomes for aspiring future in medical professionals.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eExperimental study design was applied to understand feedback on reflection affects deep learning of students, compared to reflection alone. Ethical approval for the study was taken from ethical review committee of Riphah university and Rawalpindi medical university (app # Riphah/IRC/23/3034) (Reference no: 341/IREF/RMU/2023).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants:\u003c/h2\u003e \u003cp\u003e Study participants included fifth-year undergraduate medical students of Rawalpindi medical university undergoing their clinical rotation (ward, operation theatre and outpatient department) in the gynecology and obstetrics for 8 weeks who consented to participate in the study. The sample size for this study was calculated to be 34 in each study and control group, using the G*Power sample size calculator, with a predetermined level of significance (α) of 0.05, statistical power (1-β) of 0.80, and an effect size of 0.7 based on previous studies\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo ensure fairness among participating and non-participating students, it was explicitly stated that taking part in the study would not influence their grades in the module. Grades for both participating and non-participating students would be determined using the traditional assessment criteria established by the Faculty. This approach aimed to alleviate any concerns among students regarding potential academic consequences associated with their involvement in the study.\u003c/p\u003e \u003cp\u003eParticipants were divided into control group and study group by simple randomization technique. A mcq based pre-test was conducted for both control group and study group as a baseline measure for students\u0026rsquo; knowledge before the study and to check for any difference between the groups.\u003c/p\u003e \u003cp\u003eStudents were taught to write a written reflection in preclinical years. However a refresher training for reflective writing was done for all the participants prior to start of activity, facilitated by a set of pre designed questions based on the 6 steps of Gibbs reflective cycle which were:-\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat have you learned from clinical ward class?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are your thoughts and feeling about topic?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat were you thinking during the topic discussion? Any previous experience of the situation/topic?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow did it help you in making your differential diagnosis or diagnosis?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWere there any ambiguous or difficult to understand concept\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat is your plan to improve your learning based on this experience?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eBoth groups were taught by one facilitator in ward and class for 6 days. Facilitator discussed 6 cases of obstetrics and gynaecology (Antepartum haemorrhage, post-partum haemorrhage, pregnancy induced hypertension, Gestational diabetes mellitus, anemia, intrauterine growth restriction) during ward rotation followed by class in a holistic way (history, examination, investigation, differential diagnosis and management). At the end of each class, both groups submitted a written reflection based on Gibbs reflective cycle.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIntervention:\u003c/h2\u003e \u003cp\u003eFeedback was given by same facilitator to study group after each reflective activity. Feedback was prepared by reading the reflection of participants of study group. This feedback was given on next day before starting ward rotation to address the learning gaps of students, identified by facilitator. This feedback was given for the purpose of guidance to address their queries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInstrument for evaluation: Pre-test and post-test:\u003c/h2\u003e \u003cp\u003eA multitude of multiple-choice questions (MCQs) were generated covering six topics within the field of obstetrics and gynecology (Antepartum haemorrhage, post-partum haemorrhage, pregnancy induced hypertension, Gestational diabetes mellitus, anemia, intrauterine growth restriction). The MCQs underwent validation by two experts specialized in obstetrics and gynecology, one of whom possessed expertise in medical education. These experts meticulously scrutinized the structure of all the MCQs, ensuring their alignment with criteria pertaining to higher-order cognitive levels\u0026mdash; application (C3), analysis (C4), and evaluation (C5) components.\u003c/p\u003e \u003cp\u003eWhile a specific standard-setting approach was not employed, they assessed the level of difficulty inherent in the MCQs, aiming to establish a balanced level of complexity between the pretest and post-test, ensuring comparability. Major flaws were checked and corrected. 30 MCQs were added in each paper (pretest and posttest), 5 MCQs from each topic of gynaecology and obstetrics) from the pool of MCQs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eData was entered into SPSS version 26. Descriptive statistics, including frequency, percentage, mean and standard deviation were calculated for quantitative variables. Inferential statistics were calculated which included T-test to compare the means of both the groups. P \u0026ndash;value of \u0026lt;\u0026thinsp;0.05 were considered significant. Paired sample T test was used to compare the Pre-test and post-test scores of both the study and control groups. Independent sample two- tailed T test was used to compare the scores of both groups.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eControl of biases:\u003c/h2\u003e \u003cp\u003eRandom assignment of participants to both groups ensured that each participant had an equal chance of being placed in either group, reducing the risk of bias and increasing the validity of the study's findings. We took precautions to inform all participants that the assessments conducted in this study would not be used in their final grades. By doing this, we aimed to eradicate the pressure of achieving better grades and lessen the impact of extraneous factors on the observed effects of reflection and feedback in the learning process.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this randomized controlled trial, a total of sixty eight (n\u0026thinsp;=\u0026thinsp;68) final year medical students of either gender were enrolled. There was no statistically significant difference in gender distribution between control group and study group M:F ratio (M\u0026thinsp;=\u0026thinsp;22, F\u0026thinsp;=\u0026thinsp;44, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.380).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComparison of pretest and posttest of both control and study group:\u003c/h2\u003e \u003cp\u003ePretest test was conducted for both groups to know about their knowledge at baseline. This pretest was conducted before taking any class of the students. Control group mean obtained marks in pre test were 11.29 out of 30 with percentage of 37%, similarly study group mean obtained marks in pretest were 11.68 out of 30 making percentage of 39% (P value\u0026thinsp;=\u0026thinsp;0.529) Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003ePost test was taken on 7th day, 6 topics were taught to the students in ward followed by discussion in class followed by written reflection and feedback. Feedback was given to study group only. Control Group posttest mean obtained marks were 15.29 out of 30 making their percentage 51%. While study Group post test mean obtained marks were 20.88 out of 30 making their percentage of 69% by applying independent sample t test (P value 0.0001) Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eComparison of pre test and post test score of study group showed significant results after feedback on reflection by applying paired sample t test (P\u0026thinsp;=\u0026thinsp;0,0001) Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test scores mean +/-standard deviation (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-test scores\u003c/p\u003e \u003cp\u003emean +/-standard deviation (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003cp\u003e(Paired sample t test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudy group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.68 +/- 2.60\u003c/p\u003e \u003cp\u003e(38.93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.88 +/- 2.98\u003c/p\u003e \u003cp\u003e(69.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eControl group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.29 +/- 2.38\u003c/p\u003e \u003cp\u003e(37.15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.29 +/- 2.66\u003c/p\u003e \u003cp\u003e(51.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP value (Independent sample t test)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNet gain of learning after addition of feedback along with reflection in intervention group was 18.6%. Student feedback regarding the teaching method indicated that the combination of feedback on reflection helped them address their queries and better prepare for their studies in advance.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was a randomized experimental study aiming to assess the effectiveness of reflection with feedback compared to reflection alone, in enhancing deep learning of undergraduate medical students. We found that our educational intervention increased the deep or higher order learning among final year medical student who came for ward rotation in the gynecological department. Similar results were produced by Choi et al in 2020 where practicing written clinical cases with reflection and feedback yielded additional benefits of diagnostic accuracy compared to a traditional dermatology elective\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccording to two studies conducted in Saudi Arabia and Taiwan, the findings revealed a notable and meaningful association between reflection performance and critical thinking disposition. Furthermore, the study demonstrated that reflection performance could effectively predict the variability in critical thinking disposition. These results suggest that nursing students who actively engage in reflective practices are more likely to possess stronger critical thinking abilities\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Another study conducted on residents of gynaecological department in 2013 which showed that reflective exercise improves with practice and it helps in self-assessment, surgical skill development, communication and professionalism\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. These studies collectively demonstrate the importance of incorporating reflective practice into nursing education and professional development. Engaging in reflective practice empowers medical professionals to critically evaluate their experiences, thoughts, and actions. Through this introspective process, they can gain valuable insights, identify areas for growth, and refine their critical thinking abilities. By actively engaging in reflective practice, nurses cultivate a continuous learning mindset and nurture their capacity for making informed decisions and providing optimal patient care.\u003c/p\u003e \u003cp\u003e Our study included two groups, control and intervention group, and took written reflection. Written reflection is also a way of getting important feedback from students that how they learn and promote reflective practice. This was similar to a study done in Taiwan which included 2 groups of paramedical staff using self-reflection methodology to improve their critical thinking\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.This was ascertained by another study conducted in 2004. While this study does not included any intervention group.\u003c/p\u003e \u003cp\u003eIn our study feedback was given by one instructor throughout this teaching strategy to reduce the biasness in results. This feedback was given by instructor to the students on their written reflection while another study had feedback by the peer and instructors both. This study proved that reflection followed by feedback helped in improving student\u0026rsquo;s history taking skill, enhance their medical knowledge and improve reflective writing\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLiterature proved that by embracing feedback, individuals actively propel their growth and development forward, utilizing insights garnered to enact tangible enhancements. When integrated with self-reflection, positive feedback assumes the role of a potent catalyst. Through this symbiotic relationship, individuals not only refine their skill sets but also cultivate a deeper understanding of their capabilities and areas for improvement\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The synergy between constructive feedback and introspection empowers individuals to continuously evolve, fostering a culture of continuous improvement and personal excellence, ultimately leading to heightened levels of success and fulfillment\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePractical implications\u003c/b\u003e of recognizing and incorporating feedback on reflection in educational settings involve enhancing teaching and learning practices, developing reflective practitioners, promoting a culture of constructive feedback, improving educational design and assessment strategies, and facilitating professional competence and continuous improvement. These implications can contribute to a more engaging, effective, and learner-centered educational environment.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations:\u003c/h2\u003e \u003cp\u003eOur study had few limitations. It was conducted at a single center, specifically focusing on medical students who were undergoing elective rotations in the gynecology department of Holy Family Hospital with a relatively small sample size. This may limit the generalizability of the findings. The study did not include gathering feedback from the students at the end of the learning activity to assess their satisfaction or perception of the learning experience. Which could have provided valuable insights into their preferences, engagement, and perceived effectiveness of the teaching methods used.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study suggest that Integrating feedback along with reflection enhances conceptual or deeper learning among undergraduate medical students, resulting in significantly improved test scores compared to reflection alone.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eI. Ethical Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was taken from Rawalpindi medical university (Ref no:341/IREF/RMU/2023)and Riphah international university (appl: Riphah/IRC/ 23/3034). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII. Consent to Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors give their consent for the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIII. Data Availability statement: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data, which is generated or analyzed, is included in this publication article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIV.\u0026nbsp;Conflict of interest: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eV. Funding: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding required for this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVI. Authors contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eZainab Maqsood: concept of research, objective, research proposal, data collection, data analysis, article writing and proof reading\u003c/li\u003e\n\u003cli\u003eMadiha sajjad: concept of research, help in data analysis, article writing and proof reading.\u003c/li\u003e\n\u003cli\u003eRaheela Yasmin\u003csup\u003e:\u003c/sup\u003e concept of research and proof reading.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Hashim A. Critical thinking and reflective practice in the science education practicum in Kuwait. Utopia y Praxis Latinoam. 2019;24(6):85\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2011;33(3):200\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarasym PH, Tsai TC, Hemmati P. Current trends in developing medical students' critical thinking abilities. Kaohsiung J Med Sci. 2008;24(7):341\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLara R, Mogensen K, Markuns J. Effective feedback in the education of health professionals. Support Line. 2016;38(2):3\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi NS. Giving effective feedback in medical education. Obstetrician Gynaecologist. 2017;19(3):243\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahimi M, Haghani F. Reflection in medical education: A review of concepts, models, principles, and methods of teaching reflection in medical education. Res Med Educ. 2017;9(2):24\u0026ndash;13. (in Persian).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhoshgoftar Z, Barkhordari-Sharifabad M. Medical students\u0026rsquo; reflective capacity and its role in their critical thinking disposition. BMC Med Educ. 2023;23(1):19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsen DP, London DA, Emke AR. Using reflection to influence practice: student perceptions of daily reflection in clinical education. Perspect Med Educ. 2016;5(5):285\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40037-016-0293-1\u003c/span\u003e\u003cspan address=\"10.1007/s40037-016-0293-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTawanwongsri W, Phenwan T. Reflective and feedback performances on Thai medical students' patient history taking skills. BMC Med Educ. 2019;19(1):141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen F-F, Chen S-Y, Pai H-C. Self-reflection and critical thinking: The influence of professional qualifications on registered nurses. Contemp Nurse. 2019;55(1):59\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalil AI, Abou Hashish E. Exploring how reflective practice training affects nurse interns' critical thinking disposition and communication skills. Nurs Manag. 2022;29(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7748/nm.2022.e2045\u003c/span\u003e\u003cspan address=\"10.7748/nm.2022.e2045\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanum Z. Effectiveness of reflective exercises for obstetrics and gynaecological residents. J Coll Physicians Surgeons\u0026ndash;Pakistan: JCPSP. 2013;23(7):468\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZoe Talent Solutions. The Role of Feedback and Self-Reflection in Enhancing Productivity and Performance. [Internet]. [cited 2024 Apr 30]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://zoetalentsolutions.com/the-role-of-feedback-and-self-reflection-in-enhancing-productivity-and-performance/\u003c/span\u003e\u003cspan address=\"https://zoetalentsolutions.com/the-role-of-feedback-and-self-reflection-in-enhancing-productivity-and-performance/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardavella G, Aamli-Gaagnat A, Saad N, Rousalova I, Sreter KB. How to give and receive feedback effectively. Breathe (Sheff). 2017;13(4):327\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi S, Oh S, Lee DH, et al. Effects of reflection and immediate feedback to improve clinical reasoning of medical students in the assessment of dermatologic conditions: a randomised controlled trial. BMC Med Educ. 2020;20(1):146. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-020-02063-y\u003c/span\u003e\u003cspan address=\"10.1186/s12909-020-02063-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Reflection, feedback, deep learning, clinical setting","lastPublishedDoi":"10.21203/rs.3.rs-4399599/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4399599/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReflection is crucial for deep learning and self-regulation. However, reflection alone may not produce the desirable effects unless coupled with feedback. This study aims to investigate the impact of ‘feedback on reflection’, on deep learning and concept building among undergraduate medical students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the effect of feedback on reflection in deep learning of undergraduate medical students in clinical setting of gynaecology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was an experimental study, conducted from February 2023 to July 2023, following approval from the Ethics Review Committee. The study sample were 68 final year MBBS students divided into study and control group through simple randomization. A pre-test was done to establish baseline measurements.\u003c/p\u003e\n\u003cp\u003eBoth groups then received similar teaching sessions on obstetrics and gynecology topics over a period of 6 days. Written reflections based on Gibbs reflective cycle were collected from all participants, and the study group additionally received verbal feedback. A post-test concluded the study. Both the pre and post-tests comprised 30 multiple-choice questions at a higher cognitive level. Data evaluation was done through SPSS 26. Descriptive statistics and t- test was used to compare the means of both groups. P–value of \u0026lt; 0.05 was considered significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo significant difference in gender distribution was found between the two groups. Baseline pre-test scores showed no significant difference between control group (37%) and study group (39%). Both groups demonstrated significant improvement from pre-test to post-test (p \u0026lt; 0.0001). However, post-test results showed a significant increase in the scores of study group (69%) compared to the control group (51%) (p \u0026lt; 0.0001). Net gain of learning after addition of feedback along with reflection in intervention group was 18.6%. Student feedback supported the effectiveness of the teaching method in facilitating learning and exam preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIncorporating feedback along with reflection enhances conceptual learning among undergraduate medical students, resulting in significantly improved test scores compared to reflection alone.\u003c/p\u003e","manuscriptTitle":"Effect of feedback on reflection, on deep learning of undergraduate medical students in a clinical setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-07 13:17:02","doi":"10.21203/rs.3.rs-4399599/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-17T07:16:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T11:31:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-16T11:25:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-05-10T09:14:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10811b14-cebf-4bbf-b285-e412ec8cb257","owner":[],"postedDate":"August 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T15:59:49+00:00","versionOfRecord":{"articleIdentity":"rs-4399599","link":"https://doi.org/10.1186/s12909-025-06648-3","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-01-14 15:57:06","publishedOnDateReadable":"January 14th, 2025"},"versionCreatedAt":"2024-08-07 13:17:02","video":"","vorDoi":"10.1186/s12909-025-06648-3","vorDoiUrl":"https://doi.org/10.1186/s12909-025-06648-3","workflowStages":[]},"version":"v1","identity":"rs-4399599","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4399599","identity":"rs-4399599","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}