By Patricia Stubenberg, MPH, Ph.D., CHCPDirector of CME and Preceptor Development, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Alliance National Learning Competencies
Competency Area 1: Use of Adult and Organizational Learning Principles
Competency Area 2: Designing Educational Interventions
Points for Practice
- Reflective practice has the potential to impact physician behavior change and patient care.
- Reflective practice can be meaningful to busy practitioners, even in surgical specialties.
- The impact of reflective practice in CE is yet to be fully explored
Let’s begin by defining what “reflective practice’ is before we examine how it fits into continuing education (CE). Louise Aronson describes reflective practice as the process of analyzing, questioning and reframing in order to make an assessment of it for the purposes of improving practice1. Recent literature on the role of reflective practice in clinical teaching is proving promising for CE in the health professions. For example:
- Ramani and Leinster present self-reflection as being essential to educating physicians and crucial for clinical teachers in adopting a professional approach of reflective practice to their teaching.3
- Plack and Greenberg reference a conceivable CE application by stating, “Although much has been written about reflection and its importance in the learning process, what is yet to be fully explored is the impact of reflective practice on clinical practice.”4
- Paget explored how reflective practice influenced long-term changes to nursing clinical practice. In his retrospective, multimethod study, data highlighted positive responses, including “I am now more analytical of experiences in the clinical environment” and “We have since re-evaluated pain control regimes in my unit.” This suggests that once the skill of reflecting is learned, it can be a medium for continuous review of professional practice.5
This research suggests fertile ground for exploring the role of reflection in clinical practice and structuring today’s educational activities to meet lifelong learning competencies and practice improvement.
At its most basic, the theoretical context of reflective practice (e.g., Knowles adult learning principles, Dewey’s experiential education/reflection, The Dreyfus Model of Skill Acquisition) details a way to inject interactive components into continuing education, establishing importance to the provider and helping them to synthesize learnings into their existing practice.
Reflecting Upon Reflections
My interest in reflective practice began when I was exploring and analyzing dissertation interviews (qualitative inquiry) on clinical teaching excellence with physicians. The dissertation in question was a grounded theory study aimed at:
- describing and explaining descriptions of teaching excellence among academic and community-based preceptors; and
- generating theory related to the explanation of the phenomenon of clinical teaching excellence.2 What surfaced from the interview process, in addition to supporting historical data including pedagogical practices and intrinsic commitment, was a pathway to address continuing education activities through reflective practice and its impact on changing physician behavior and patient care.
For example, several interviews with physicians captured insightful, reflective practice messages. Dr. “Adelane,” an academic-based surgical oncologist, was extremely devoted to the surgical care of her patients. Her interview was inviting and thought-provoking and highlighted a rich reflective process that strongly influenced her personal and professional qualities. Adelane embodied the qualities of an excellent clinical teacher by creating an environment of active learning as well as a commitment to compassion in her role as a surgeon. As she reflected on her past experiences in medical school, her current teaching role and profession, it became apparent that her humanistic approach and experiences of allowing patients to die with dignity highlighted her competence and patient-centered care. Adelane was articulate and thoughtful in her responses, providing time for me to reflect on her role as a surgeon and teacher. She appeared humbled by the interview process, allowing her to embrace her own self-awareness in professional and personal growth. Interviewing a surgical oncologist, I suspected, would have been the most challenging and unpleasant specialty to interview. In fact, this was my most memorable interview and promoted my interest in the benefits of reflective practice.
Dr. “Trevor” embraced the teaching of clinical problem solving in the care of his pediatric patients and their families with students. As a physician and mentor to first and second-year medical students, he reflected upon his clinical teaching ability, highlighting the importance of both communicating at the students’ level and of regarding the patient as learner. As a pediatric intensivist, he was frequently unable to communicate with his patients (e.g., patients on life support). He highlighted the importance of being self-aware during emotional situations that occur frequently when communicating with student learners and patients’ families. He reminisced of a memorable moment when a first-year medical student shared in the emotional pain of a young patient who had her hair burned in a fire. The student wanted to cut his own hair and give it to that young patient. Reflection was key to Trevor recognizing the student’s role in taking responsibility for the child and Trevor’s own ability, as a mentor, in influencing the student’s development.
Reflective practice concepts can help healthcare professionals improve on performance and patient health, achieving desired professional development outcomes. When operationalized, or approached systematically (e.g., through educational interventions, self-assessment inventories, personal interviews), reflective practice can be effective in continuous improvement, meeting CE educational requirements (practice gaps, active learning/skill-building exercises) and the needs of the CE community.
Leung et al., discuss the Reflective Learning Framework (RLF) as a learning strategy in assisting physicians’ recognition of cognitive tasks performed in the context of their self-directed learning and assessment, and stimulates their reflection on action. The RLF offers a guide for reflective learning curricula and the effects of CE on practice.7 As a learning strategy in CE, reflective practice should be incorporated within the context of theoretical foundations such as Knowles Adult Learning Principles and the integration of new learning with existing knowledge.
In the interviews, physicians were asked to think about their own medical school experiences. New learning (clinical teaching excellence) was integrated in their existing knowledge of medical school and their perceptions of what makes a good clinical teacher. Reflective practice has potential implications for educational interventions and their impact on performance improvement, clinical outcomes and improved patient care, and should be explored further by the CE community (Figure 1 above).
- Aronson L. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher. 2011;33(3):200-5.
- Stubenberg, Patricia A. (2013). “Descriptions of Clinical Teaching Excellence in the First Two Years of Medical School: The Views of Academic and Community-Based Preceptors”. Graduate Theses and Dissertations.
- Ramani, S., & Leinster, S. (2008). AMEE guide no. 34: Teaching in the clinical environment. Medical Teacher, 30(4), 347-364.
- Plack, M. M., & Greenberg, L. (2005). The reflective practitioner: Reaching for excellence in practice. Pediatrics, 116(6), 1546-1552.
- Paget T. Reflective practice and clinical outcomes: practitioners’ views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing. 2001;10(2):204-14.
- Accreditation Council for Continuing Medical Education. Effectiveness of continuing medical education: updated synthesis of systematic reviews. http://www.accme.org/ Accessed February 3, 2017.
- Leung KH, Pluye P, Grad R, Weston C. A reflective learning framework to evaluate CME effects on practice reflection. The Journal of continuing education in the health professions. 2010;30(2):78-88.