Reflective Inquiry in the Medical Profession

Abstract

This chapter begins by examining the challenges and problems of preparing physicians for modern health care and the practical implications for the doctor who is unprepared or unwilling to learn from thinking and experience, the core intention of reflective inquiry.

The components of reflective inquiry as proposed by Schon, reflection before action (RbA), knowingin action (KiA) reflection in action (RiA) and reflection on action (RoA), are defined as fundamental tenets in the education and practice of the reflective professional. Although these concepts may be inseparable in the personal and professional life of a doctor, I will approach the topic of this chapter, reflection in medical education and practice, as if they were separate entities.

In medicine, RbA is the way a doctor prepares psychologically for an imminent patient encounter. KiA is the way a skilful and experienced doctor thinks on his feet and reacts to variations in practice, almost unconsciously. Thus, KiA is mainly intuition or pattern recognition with rapid metacognition oversight. Intuition, although useful in urgent situations, can lead to cognitive errors such as diagnosis fixation or search satisfaction, if the doctor’s intuitive assumptions are not tested. In this chapter I will draw upon new cognitive understandings as to why well focused, dedicated and conscientious doctors can make serious, often life threatening cognitive errors.

Reflection in action explores the cognitive processes behind how doctors think during a patient encounter. Decision-making, clinical judgement, teamwork, scene analysis and communication are all components of RIA. RiA requires intuition but it is mainly a metacognitive process, i.e. being able to see about how one and other people think and feel. It includes the capabilities of emotional intelligence such as self-awareness, self-regulation, zeal, persistence and motivation, founded on a firm knowledge base. An examination of the elements of medical consultation can help identify cognitive biases and errors, challenge false assumptions and demonstrate how RIA can improve patient safety, clinical practice and ultimately health outcomes.

Reflection on action implies a delay between the original action and the reflection. Thus, RoA occurs after the action when details are recalled through rich description and analysed through careful unpicking and reconstructing of all aspects of practice, in order to gain fresh insights and make amendments if necessary. Critical literacy is an important skill set that enables the student and the expert practitioner to question and understand the motivations, perspectives, inequities and the socio–political power that affect health care in the modern era. RoA can also be viewed as a process of aesthetic enquiry or professional artistry, where curricula, curriculum materials and clinical practice are viewed as akin to works of art and analysed in terms appropriate to works of art, through observation, experiential learning and research. My goal therefore is to explore the role of RbA, KiA, RIA and RoA in the cognitive, professional and moral education in undergraduate, postgraduate and life-long learning environments. I will integrate these components of RI through a paediatrician’s reflective narrative on a clinical case. The pedagogical strategies, curricular needs, learning contexts and the role of Art as a product and generator of reflection in medicine are also addressed.