Background

Reflective practice is “the ability to reflect on one’s actions so as to engage in a process of continuous learning,” (1) — that means thinking about and learning from our clinical experiences to enhance our personal professional development. 

“A person who reflects throughout his or her practice is not just looking back on past actions and events, but is taking a conscious look at emotions, experiences, actions, and responses, and using that information to add to his or her existing knowledge base and reach a higher level of understanding.(2)^“

Critical reflection is an extension of critical thinking. It asks us to think about our practice and ideas and then it challenges us to step-back and examine our thinking by asking probing questions. It asks us to not only delve into the past and look at the present but importantly it asks us to speculate about the future and act.

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But how do we build this as a skill?

The first task is to bring awareness to the thoughts and feelings we have every time we interact with a patient, with a team, with the health care system. We have both cognitive and affective reactions to our experiences. Sometimes, these are strong reactions which can make them easy to identify. Other times, our reactions may be more subtle, and more difficult to identify, but not necessarily any less significant. The ability to identify these reactions is of particular importance in our role as providers, as our reactions often impact the way we communicate with others and the way we think when caring for patients.

It has been part of the “hidden curriculum“ of medicine that physicians learn to compartmentalize their emotions, to deal with their reactions at a time and place away from patient care. In reality, the thoughts and feelings are influencing our behavior (not the other way around!) despite our attempt to separate the two.

In a mindful practice of medicine, we must flex the muscle of self-awareness.  When we practice mindfulness and reflection with our patient care, we can start to see people as they are, not as we are. Part of this mindfulness is learning to identify our reactions, understand the sources of our reactions (our personal context), and thinking about how to enhance their positive and mitigate their negative implications. Personal context can be thought of as: “the interwoven fabric of one’s unique and diverse life experiences”.  Our context shapes the lens through which we view our interactions and see the world around us.  An individual’s personal context is dynamic and formulated throughout one’s life as a result of one’s experiences, values, and culture, among other factors. Like one’s reactions, one’s personal context is neither “right” nor “wrong”, it simply is.

As we move through this course, we will also consider how recognizing your reactions and the source of those reactions influences your conversations in ethics, leadership, health systems discussions, etc. Developing an understanding for the sources of our reactions requires examination of one’s experiences throughout life – starting with those when living in our families of origin and continuing until today.

Once we are able to do this, we can do a critical analysis  and consider the implications of our reactions. We can also develop strategies and plans to help us cope in a way that enhances the positive and mitigates the negative implications of our reactions in future experiences.

This first session of Reflective Practice 101 is focused on the first two steps of the skill that is Reflective Practice – (1) identifying our reactions and (2) identifying the sources of those reactions.

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^{1 – Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books.} 

^{2 – Paterson, Colin; Chapman, Judith (August 2013). “Enhancing skills of critical reflection to evidence learning in professional practice” (PDF). Physical Therapy in Sport. 14 (3): 133–138.}

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Objectives: By the end of the RP 101 session: Foundations of Reflective Practice – students will:

1. Become familiar with the goals, objectives, and schedule for Reflective Practice in their 4 year curriculum.
2. Identify reactions they have had to clinical encounters in the past.
3. Demonstrate the ability to examine the sources of those reactions and understand that these sources (to include one’s culture, background, experiences, etc.) make up one’s personal context – something unique to each individual.
4. Demonstrate an understanding that the same scenario can evoke a range of reactions from different people.
5. Demonstrate an understanding  that the same scenario can evoke a range of reactions from the same person when considered at different times in their life.
6. Demonstrate an understanding that one’s reactions are neither right nor wrong, they simply are.

Assignment

1. Prior to the small group session, think about a patient encounter in which you had a reaction to the patient or the situation. This may be a patient encounter you had prior to starting school at USU, or a patient encounter you had or observed as part of your interviewing class. Come to the small group prepared to: set the stage, identify your reactions, and examine the sources of your reactions (your personal context).
2. Review one or more of the resources on the page and come prepared to share your thoughts on them as they relate to the concepts of reactions and personal context.

Below are examples of notes to bring with you to the small group session.  While the examples below are in paragraph format, you should feel free to write your notes in whatever way will best help you to participate in the discussion.

• Set the stage. Jot down a few lines to set the stage for the encounter you are discussing so that others will understand the situation.  As an example: 
  • Ms. M. is a 22 year old patient who was admitted to the ward with complaints of paresthesias and diplopia for the past 3 weeks. She was very anxious and worried about what this might mean. Her MRI, done on admission, showed changes consistent with Multiple Sclerosis and when I met her, she had heard this being discussed, but hadn’t had the chance to talk to anyone about it, so I was the first one to start explaining what this meant.
• Describe your reactions to the patient and the situation.  This may include your reaction to the way the patient looked, how they spoke, their physical characteristics, the chief complaint, their healthcare problems, etc. You will likely have a number of reactions, and I encourage you to note at least 2 for this assignment. You may find it helpful to note your reactions in bullet format and then describe the reaction more fully. As an example:
  • Frustrated – I found myself becoming very angry when I learned that our 22 year old patient had Multiple sclerosis. The situation seemed very unfair to me and I was unable to reconcile her reality with the world as I view it. 
  • Overwhelmed – When I realized that she had Multiple Sclerosis and that this is a lifelong illness, I felt completely overwhelmed and didn’t know what to do or say.
• Examine the sources of your reactions (i.e. your personal context). As an example: 
  • Growing in Iowa with my mom, dad and the 5 of us boys meant a lot of rough housing and wrestling matches. Being the youngest of the bunch, you might assume that I was the rag doll who would get pummeled on a regular basis. As it turns out, that did happen from time to time but not as often as you might think. I was saved by our parents’ belief in a “level playing field” which they frequently referred to as “fair play”. In terms of the basement wrestling matches, this meant that when one brother was more than 2 years older than another and we wrestled the older one could only use one arm. I don’t recall my parents putting this rule into place – we just made it up on our own, something I attribute to the five of us understanding and accepting fairness as an important value. The importance of the value of “fairness” impacted my experiences in our community as well. An example is when I was in a playoff game for 7 vs. 7 pop-warner football. While warming up, we realized the other team only had 6 players, a clear advantage for us, not only because they would have to play one person short but because they would be exhausted by the end of the game without subs. We were all grins and smiles, until our coach called the 13 of us over to the bench and had us put out one or two fingers on the count of three. We were bewildered, but he was the coach and this was farm country in Iowa – we did what he asked. Seven of us put out 1 finger and six of us put out 2. I remember sitting there with my one finger out, as he explained that the 6 boys with 2 fingers held out would play and the rest of us would sit on the bench and not play at all. As he explained it, it was the only way to make the game truly fair. I remember having mixed emotions that day – frustrated that I couldn’t play (which ironically didn’t seem fair to me even if it was fair to the other team) and also proud that I had a coach whose actions demonstrated the principles he preached. I think it was also easier to understand coming from the family in which I was raised. I think this is why I was so upset when we saw Ms. M. My belief in a sense of fair play was demolished. Here she was, a healthy, physically fit 22 year old, who had taken care of herself, and we were handing her a diagnosis of Multiple Sclerosis. Where’s the fairness in that?