Reflection in and on practice

Reflection in practice and on practice is essential for self-advancement and mastery of professional skills

During medical training, students need to monitor and assess their own performance if they are to master their professional development. This is a skill they must learn in medical school and residency because it has implications in terms of ongoing maintenance of competency. Reflective practice means self-assessment and self-directed learning. Reflection causes the student to examine an experience or action and subsequently integrate the newly acquired knowledge, skills or values into a new context. In his book The Reflective Practitioner: How Professionals Think In Action, Donald Schön outlines the need for professionals to “reflect in action.” He uses the term “technical rationality” to describe the solid professional knowledge base that each profession teaches, expecting the student to draw on it to solve well-constructed problems.

However, problems are not always discrete, solvable entities and factual knowledge might not cover all situations, especially complex ones. Professionals are required to be able to identify a situation that is unique, reflect upon it, problem solve, and create new solutions. This should be done continuously as part of professional development. Graduating physicians are well aware that their knowledge cannot remain static and that their ability to practice according to current standards will require constant update. There are many years of practice ahead where the student is completely responsible for the upkeep of competency. With our focus on short-term goals such as licensing examinations, we might not be steering our medical students and residents to the tools they need for lifelong learning.

A recent article in Academic Medicine reviews the attitudes of family medicine residents towards lifelong learning. It is a qualitative study of interviews on the topic. While all of the residents valued the concept of self-directed learning, they felt they lacked the skills to do it and did not think that they were taught how to engage in this type of learning in their previous training. They found self-directed learning to be especially difficult in the clinical setting, though patient care was a powerful stimulus to utilize it. Although they spent a good deal of time in the clinical setting, a lot of their work was perceived as a service obligation. Duty hours decreased the number of hours each individual resident worked but placed an increased burden on those actually at work in the hospital. They felt they had little time for the “reflection in action” that Schön felt necessary for professional development. In the clinical setting, guidance from faculty regarding how to develop skills in self-directed learning would be welcome.

There are many barriers to developing reflective practice. The work environment in many medical settings is not conducive to quiet moments of reflection. This is not a classroom with the opportunity to stop the action. Reflection also implies change. What often happens to novice students is that they find a system that works well enough most of the time. It takes encouragement to take the risk to try another approach, especially when the first tries don`t go as smoothly as their previous method. The residents who do best are those who reflect and change because they practice the concept of self-directed learning while still having the safety net of supervision. Having enough time to practice and perfect skills over time is also a benefit and might be more important than innate talent. Students in medical education at every level need directed attention to self-assessment and reflection. Medical educators should be skilled at encouraging and aiding the student as the student develops these skills while still under supervision. Reflection in practice and on practice is essential for self-advancement and mastery of professional skills.