Developing professional judgement in surgical trainees: the role of critical reflection

Critical reflection is a disciplined process that aims to critically evaluate everyday medical practices to more fully understand and learn from them. It can lead to improved professionalism and clinical reasoning and is increasingly seen as a core component of continuing professional development in a number of disciplines. While critical reflection is a central element of expert surgical practice, its processes are often tacit and hence invisible to trainees. In this paper, we describe a pilot project aimed at introducing critical reflection techniques into a plastic surgery training program. We also discuss the use of critical reflection as a tool to allow learning surgeons to develop, observe and critique their own clinical thinking, and outline a framework for surgical supervisors and trainers to guide, monitor and assess the development of professional judgement in their trainees.


Introduction
Learning to 'be' a surgeon, and in doing so acquiring the required operative and clinical skills, has traditionally been something to be program. This is coupled with an increasing desire of trainees to shorten the time to complete specialist training as well as an expectation of hospitals to comply with safe work hours for specialist trainees.
As a result, learning in the clinical setting seems to have become less structured and opportunistic, given the increasing service requirements of both trainees and surgical teachers. 1 The contemporary professional surgeon draws on complex theoretical knowledge together with professional judgement and communication skills to tailor general clinical principles and technical skills to the practical management of a specific condition in an individual patient. Surgical activity is a complex process that involves many momentby-moment judgements that may not be apparent to the observer. Technical knowledge and skills are relatively easy to observe and teach, but the critical thinking and reflective processes that underlie expert surgical practice are invisible and tacit.
Professional judgement is an essential component of surgical practice. 2  On the basis of this literature search, a structured program of critical reflection was implemented as follows: • Each SET trainee has a structured weekly meeting with the head of department in which they reflect on their case load for that week. The emphasis is on the clinical and surgical decision-making before, during and after the cases but also allows trainees to reflect on their professional interactions with families and colleagues from other disciplines-a critical element of pediatric surgical practice. These discussions take place in a supportive environment, where the trainees feel that they can openly and frankly discuss their management of patients. It is also an opportunity for trainees to clarify clinical and operative decision making they have observed but not received adequate explanation of in the 'heat' of an operative procedure. The meeting concludes with a discussion of learning strategies to address any knowledge or skill gaps identified with a plan to review at the next meeting.
• Trainees and Fellows present a structured written reflective case discussion at weekly department meetings. This written reflection is done using a structured PowerPoint template based on the format outlined in Figure 2. The emphasis is on the decision making in preoperative, operative and postoperative phases of care and utilizing literature reviews to underline the decision making. For example, what were the reasons for this patient with a velopharyngeal incompetence, why were they booked to have a superiorly based pharyngeal flap and not a sphincter pharyngoplasty.

Evaluation
Initial evaluation of the program has been through the informal end-of-term interviews with trainees to get their feedback on the process on the impact on their clinical decision making.
Having successfully established the program, we are developing a more structured evaluation in collaboration with the Melbourne University Department of Paediatrics. Initial interviews by

Results
The initial feedback has been extremely positive at both a consultant and junior medical staff level.
There is a general feeling and commentary from the SET trainees that both forms of reflection have been extremely valuable. There are two common themes that they report. Firstly, these sessions help them to solidify their knowledge and secondly, their ability to understand the process of decision making in patient care is heightened. These

What is critical reflection?
Critical reflection is a disciplined process that aims to critically evaluate everyday medical practices to more fully understand and learn from them. 4 It is a process that contrasts with the narrative methods of case discussion often used in clinical meetings and morbidity and mortality meetings where the focus is on a description of a technical process, or on what went wrong. The purpose of reflection is to allow the clinician to consider their decisions and actions and the (sometimes unconscious) underlying cognitive processes, in order to understand these in the context in which they occurred, and to use that understanding to refine and improve future decision making and professional judgements-why did the surgeon do 'X' and not 'Y' at that point in time of the procedure.
The concept of 'reflection' is widely used in medical education to describe a range of educational processes with differing intended learning outcomes. A wider definition that is useful for the purposes of this paper is: Reflection is a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters. 5 While reflection is a familiar concept in everyday life, surgical supervisors and trainers must distinguish and define a particular skill set associated with important educational outcomes.

Effective reflection can result in transformative
learning with the potential for improved professionalism as well as better handling of complex clinical situations and professional interactions. 1,5,6 Three forms of reflection have been described. 7,8 These are time dependent in relation to the task and occur after the task, during the task or before the task.
1. Reflection-on-action-the 'typical' form of reflection after the task is completed in order to inform future behavior.
2. Reflection-in-action-the reflection on events and actions to guide decision making while carrying out a task.
3. Reflection-for-action-the use of knowledge and experience to mentally rehearse actions to optimise successful completion of the task in the future. • What is the underlying reason why the identified issue arose?
• What knowledge or skills do I need to develop in order to deal with this situation better in the future?

Reflection to develop professional judgement
Reflection allows surgeons and trainees to consolidate the complex integration of knowledge and skills required for professional practice to maximise learning and mentally prepare for future actions and decision making.

Models of reflection
There are many models of reflection in the literature.
Here we will focus on Models of Reflection-onaction as this is the 'default' form of reflection used in many areas of education. This can be a simple approach as outlined by Driscoll 9 (Figure 1) or a more structured format that encourages deeper inquiry (Figure 2).  The goal of reflection is to learn from experience.
Combining written reflection with regular formal feedback sessions allows supervisors to help trainees set training goals and monitor and track their progression through the term.

Ethical considerations
Supervisors must be mindful of the potential for deep reflection to generate emotional or ethical disquiet. While sharing reflections with peers is a powerful learning opportunity, trainee's privacy and safety needs to be protected, as does those who may be mentioned in the reflection. Creating rules around confidentiality is an important element of shared reflection, and trainees should be offered the opportunity to keep their reflections confidential if they contain emotional or personal elements.
Supervisors must also decide in advance how they will manage the depiction of unprofessional or concerning actions or statements, as allowing these to go unchallenged implies tacit assent. 5

Modelling reflection
While a large proportion of practicing plastic surgeons would already use these techniques in their clinical practice, they are often invisible to observers. Surgical educators can facilitate the development of trainee's reflective skills by making their own reflective activities 'visible' to trainees.
Some strategies that may facilitate this are: • Modelling clinical judgement by verbalising decision making before, during and after procedures.
• Articulating ethical and professional dilemmas that arise as part of this process.
• Encouraging trainees to articulate their own thoughts and decision making while performing procedures under supervision.
• Requiring trainees to adopt a reflective approach to case presentation allowing sharing of challenges and solutions amongst peers as well as allowing supervisors to assess and give feedback on their decision making.
• Requiring trainees to complete a number of formal written reflections on challenging clinical/ ethical decisions, and patient or inter-professional communication encounters.

Conclusion
There is good evidence to suggest that effective critical reflection has the potential to change practice and help develop clinical judgement and professionalism in surgical trainees. The