Reflection without foundations

ABSTRACT:

Reflective practice is mandated across medical education globally, yet the capacity for genuine reflection appears to diminish during training. This perspective argues that the dominant reflective frameworks (Gibbs, Schön, Boud, AMEE Guide 44) require cognitive, emotional, and embodied engagement that they do not teach. Drawing on contemporary neuroscience, this paper identifies three foundational capacities that reflective practice presupposes but curricula do not develop: default mode network engagement (the neural substrate of self-referential processing), interoceptive awareness (the perception of internal physiological signals that generates the “feelings” stage of reflection), and emotion regulation (the capacity to remain present with difficult experience rather than defensively withdrawing). A further structural problem compounds the gap: the hidden curriculum of medical training actively promotes what Shapiro has termed “professional alexithymia,” degrading the very interoceptive and emotional capacities that the formal curriculum demands. The paper proposes three curricular additions: structured interoceptive training before reflective exercises, explicit teaching of emotion regulation as a reflective prerequisite, and deliberate integration of embodied awareness practices into existing reflection frameworks. These are not replacements for current approaches but prerequisites for making them work as intended.