I’ve been reflecting on reflection for some time now, at least since I started formally collecting my lessons from Sydney HEMS and probably even before that, because this sort of meta nonsense is something medical education enthusiasts like me enjoy doing. In the process of putting this post together I also recorded a podcast with Simon on reflection, which you can find below.
The following represents my thoughts and perspectives on the tricky task of meaningfully reflecting on practice in the current medical education climate and is intended to provoke and encourage debate. I am interested in the ways we can navigate these waters, for ourselves and for our trainees, and welcome comment here on the blogpost or discussion via twitter.
Reflection on practice is something which seems to divide medical practitioners; tweets like the one above are common and often justified, representing a wider dialogue around medical education in practice, self-development and whether prescribing a particular education activity removes its efficacy. Dave Jones, an anaesthetic consultant, expresses his frustration here in response to Dan Furmedge’s BMJ article declaring written reflection to be “dead in the water” – I don’t entirely disagree with either of them.
Certainly the response of training programmes, from the Foundation Programme to Higher Training, in necessitating evidence of compulsory “reflection” on practice has caused anxiety. As a graduate entering the first year of the new Foundation Programme back in 2005 evidence of reflective practice was necessary to progress to F2 and beyond; this stipulation followed me through higher training (being required at ARCP) and through critical incidents (when I labelled a blood sample with the wrong patient’s details, a “reflective piece for my portfolio” was something strongly suggested as part of my post-error rehabilitation) and now forms part of the requirements for revalidation.
Therein lies the problem; reflection is not particularly useful when people are forced to do it, when it does not arise organically, when structures must be adhered to and when there is latent threat of its contents being used as evidence against you in court. Compulsory reflection is rarely meaningful; reflection perceived to be a high-risk activity is infrequently useful. But the paradox – the search for insight into one’s practice for the purpose of development is key for the perpetual learner, and perpetual learner is what we must be should we wish to remain up-to-date and deliver optimum care to our patients. In fact, it is part of the modern Hippocratic oath (which many newly graduated doctors affirm).
In addition, reflection is something you can only really do yourself – no third party can force you to do it (although it is entirely possible to give the outward appearance of having engaged with reflective processes) – just like forgiving someone or falling in love.
Why does it matter?
In Louise Aronson’s Twelve Tips for Teaching Reflection at All Levels of Medical Education1, reflection is defined as:
“…the process of analyzing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice).”
I also quite like Sandars’ explanation2:
“Reflection is a metacognitive process that creates a greater understanding of both the self and the situation so that future actions can be informed by this understanding.”
From an educational perspective, reflection is one of the most powerful tools available to us. Consider elite sportswomen and sportsmen; we know that after a tennis match, the act of replaying footage shot-by-shot and analysing the elements contributing to the outcome as a whole is central to improvement and evolution. In the same way, considering the decisions we have made, the words we have used, and the physical actions we have undertaken and the how and why of their contribution to a particular situation can help us to make better choices in future, consciously at first and ultimately subconsciously.
In short, I believe reflection is hugely powerful as a developmental and educational tool and one we should be focussing on for ourselves as well as for our learners and trainees.
How can we do it effectively?
Aronson’s Twelve Tips paper outlines a reasonably sensible process but my major criticism is that it is too focussed on providing evidence of reflection for the benefit of educational programme designers and assessment panels. For true, meaningful reflection I think we should consider two scenarios.
1. Formal or planned reflection
This might occur as part of a work-place based assessment, for example. Some time has been set aside specifically for a “learning interaction”, allowing you to:
- set out specific objectives or areas for feedback (a prebrief, as you might use in simulation3)
- observation of the learning event, then
- debrief and feedback on those specific objectives in a safe learning environment
- reflection on the event itself and performance, decision-making or specific skills as agreed in advance
2. Informal or spontaneous reflection
This might occur after you have looked after a particularly sick patient (e.g. a cardiac arrest or major trauma). The difference here is that there is no pre-brief or specific objective identified, so a greater degree of flexibility is required of the teacher/supervisor, together with humility and openness on both sides. These elements combine to produce a more organic reflection which may be more meaningful but the playoff is the absence of agreed ground for discussion and thus an increased awareness of psychological safety.
But how do we do it?
This is likely to vary from person to person; the key is making it a habit such that it happens naturally. Tools such as Kolb’s learning cycle can be helpful when starting out (Simon outlines a practical embodiment of the theory in the linked post) although it is likely to feel unnatural and clunky at first. Essentially, we want to break down the:
- facts (what happened)
- underpinning reasoning (why things happened that way)
- and planning for the future (what could be done differently to generate a different outcome or what should be done again)
The key to this is honesty. To get the most from reflection we must be honest with ourselves and this can also take practice (as outlined in the “threats” section below). It can take a significant amount of humility, maturity and self-confidence to admit to the components of events that are genuinely our “fault” (in the context of error and adverse outcomes) and, at least in the early stages, the psychological safety provided by a trusted mentor/facilitator can help us and our trainees to develop this mindset. Conversely, when we are in the grip of impostor syndrome we may actually need “permission” to take credit for the things we’ve done well and a mentor/facilitator can help with this too.
What should we reflect on?
Simply, anything and everything. It’s natural at first to focus on the events that provoke strong emotional reactions, but developing a curiosity into our own thoughts and behaviour over time will help us to find golden nuggets of learning in everyday practice – the good, the bad, the unusual and the mundane. In discussing this post, I really liked Rick Body’s thought that it’s ok to reflect on when we’ve done well – not just for the nice warm fuzzy feeling but also to focus us and motivate us to want to practice that way all the time. Reflection helps us to work out why the case was so great and to capitalise on the key components of our successes.
And, like the elite sportsperson reviewing their game, we need to have the fullest picture to get the greatest benefit, which means knowing as much as we can about the final patient outcomes. We should also try to make a habit of following up on the patients we see and treat; again, not just the interesting ones but the bread-and-butter ones too. If following up every patient is unfeasible due to sheer volume, try sampling at random from your patient dataset. This approach (random quality testing) is employed by Toyota on car production lines and is part of the highly regarded Japanese concept of “Shippaigaku no susume” (invitation to the science of failure) approach to learning from mistakes (H/T to Kevin Mackway-Jones for bringing this one to the St Emlyn’s ED).
The continuum of reflection/debrief/feedback/coaching
For the adult learner, and particularly the expert learner, there must be some crossover between reflection, debrief, feedback and coaching. These discrete components are particularly relevant when reflection occurs in a collaborative environment (rather than by a healthcare professional independently). There is an overarching need for psychological safety, which explains why some of the most behaviour-changing reflection occurs in the context of longitudinal mentor relationships.
Other common threads include the importance of aligned purpose; understanding what both parties expect from an observed clinical interaction is key to effecting change where it is needed. At this point I want to recommend again Thanks for the Feedback! – it’s well worth reading this and thinking about its content in the context of facilitating reflection.
What are the threats?
The most pressing concern we have is that, following high-profile instances, our reflections might be used against us to end our career. When we seek to develop a no-blame culture in response to error, the idea that a healthcare professional’s attempt to learn and identify their own cognitive or diagnostic errors or other unconscious incompetence might be used as a stick to beat them, it’s no wonder that we are wary. Trainees are told repeatedly that the consultant has ultimate overall responsibility for patient care and that this should offer an element of protection, but we have seen that this is not always the case in a worrying trend of court cases.
There exists a further threat in the ongoing division between the academia of medical education and the realities of medical practice and professional development. In well-meaning pursuit of valid and valuable reflection, educational programmes create proformas and dictate the number of reflective entries to be made in a particular timeframe. In reality, this simply creates a divide between compulsory reflection and meaningful reflection, the former occurring by necessity as a tick-box exercise with little actual engagement and carefully crafted responses, the latter occurring more organically in the company of trusted colleagues and rarely recorded formally.
Lastly, we must remain aware that just as with our reflection in a mirror, what is seen (or thought, or discussed) will naturally and unavoidably have been altered in small ways, often unintentionally as a result of our inherent cognitive errors and implicit biases but occasionally intentionally when we find a narrative we prefer to believe for the purpose of self-preservation or to “save face”. I have my own example of this – during an ED intubation, I was assisted by a member of nursing staff with an anaesthetist nearby. When the video laryngoscope screen failed, I asked for the direct laryngoscope (apparently to the annoyance of the anaesthetist present who did not hesitate to point out that my VL device could be used for DL). Afterwards I reconciled this decision with myself by attributing a rather grand rationale – the nurse was task fixated on trying to resurrect the VL screen and I wanted to remove it from the equation altogether – but in all honesty I doubt I had this much speed nor depth of thought in the circumstances. While the change to DL had the desired effect it was more likely an accidental byproduct of my natural comfort with DL over VL and readiness to revert to what I know best when things became difficult. What does this mean in a wider sense? Probably nothing of great significance, but reflecting on my construction of this apparently wise narrative to readily explain a behaviour that was challenged at the time has left me with a number of other things to think about. I am sure I am not alone in having this reaction – I wonder how many others are aware that they do it too.
What should we do?
First, we must recognise that this tension exists for our trainees. We can be frank about the reflection they are required to undertake and the reflection that they will find useful, and handle these things separately.
We should support our juniors in ensuring that formally documented reflection does not incriminate them and help them to carefully consider the wording used, particularly when reflection is mandated in response to a critical incident. I think we need to see this as a separate skillset, a different form of reflective capacity (as Wald and Reis4 described it) from the deeper, evidential reflection we hope for in lifelong learners. There is good guidance from the MDU on how to do this.
Secondly, we must spend our face-to-face time with trainees encouraging organic reflection, debriefing with good judgement5 to the best of our ability in all clinical settings (not just simulation, not just when things go particularly well or badly) and helping our juniors and our peers to record anonymised learning points for their own benefit. There is a recreation of the simple spreadsheet I used to record my reflections from a year at Sydney HEMS in my Google Drive here, which you can copy and adapt for your own use.
As lifelong learners
As lifelong learners, we should ensure we engage meaningfully with reflective practice ourselves. It can take effort initially to develop reflection as a habit and to overcome the anxiety that scrutiny of our clinical skills and decision-making presents, but it is a rewarding part of our self-care practice as a mindfulness activity, with a study of social workers6 suggesting that mindfulness as part of self-care can positively affect the care we can deliver and the lives we lead.
Just like being in love 🙂
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