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 Table of Contents  
SPECIAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 625-628

Reflective practice and resident doctors


1 Renal Unit, Division of Specialty Medicine, Worcestershire Royal Hospital, Worcester, United Kingdom
2 Department of Internal Medicine, Federal Medical Center, Katsina, Nigeria
3 Departmentof Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
4 Department of Family Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
5 Department of Surgery, University College Hospital, Ibadan, Nigeria
6 Department of Surgery, Federal Medical Center, Nguru, Nigeria
7 Department of Orthopaedics and Trauma, Delta State University Teaching Hospital, Oghara, Nigeria
8 Department of Medicine, University College Hospital, Ibadan, Nigeria
9 Department of Family Medicine, University College Hospital, Ibadan, Nigeria
10 Department of Internal Medicine, Abubakar Tafawa Balewa Teaching Hospital, Bauchi, Nigeria

Date of Submission18-Jul-2021
Date of Decision07-Aug-2021
Date of Acceptance30-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Oladimeji Adebayo
Department of Medicine, University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_124_21

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  Abstract 


Reflective practice has evolved over the years from being an informal subconscious process to a deliberate and formal one. Residency training programs are avenues for preparing residents for a lifetime of specialist practice, and reflective practice is being incorporated into the curriculum of the program in many parts of the world. There is no universal template for carrying out reflective practice; however, there appear to be accruable benefits to residents who can surmount the barriers and undergo some form of reflection using any of the available models. This article seeks to appraise reflective practice and the inherent benefits to the resident doctor and his practice. Thus, it makes a case for incorporating reflection into the curriculum of residency training programs in Sub-Saharan Africa. It also demonstrates the need to ensure standardized, reproducible methods of reflection globally.

Keywords: Reflection, reflective practice, resident doctors


How to cite this article:
Omosule B, Muhammed AA, Somiari A, Agiri Jr. U, Worgu GO, Ezeme C, Obazenu LO, Uyilawa O, Adebayo O, Williams A, Ishaya DG. Reflective practice and resident doctors. Niger J Med 2021;30:625-8

How to cite this URL:
Omosule B, Muhammed AA, Somiari A, Agiri Jr. U, Worgu GO, Ezeme C, Obazenu LO, Uyilawa O, Adebayo O, Williams A, Ishaya DG. Reflective practice and resident doctors. Niger J Med [serial online] 2021 [cited 2021 Dec 8];30:625-8. Available from: http://www.njmonline.org/text.asp?2021/30/5/625/327950




  Introduction Top


Reflection is central to the development of human thought and values as it helps give meaning to our experiences.[1] There is no universal definition of reflection, but after an evaluation of previously held opinions, Nguyen proposed an all-encompassing definition as “the process of engaging the self in attentive, critical, exploratory, and iterative interactions with one's thoughts and actions, and their underlying conceptual frame, with a view to changing them and with a view on the change itself.”[2] This purposeful act provides opportunities for further learning (reflective learning) and practice (reflective practice) which ultimately lead to improved and better outcomes.[3],[4] Reflective practice is something most people first formally encounter in the university; however, it is believed that subconscious informal reflection is inextricably linked to daily events.[5] By reflective practice, we think about experiences, learn from errors, identify skills and strengths, develop options and actions for change and future advancement or success, and ultimately promote a lifelong process of learning and development.[6],[7]

Professional colleges and licensing authorities, particularly in the health professions, place priority on how professionals maintain and enhance their knowledge with self-awareness and reflective practice as major components of professionalism. The Accreditation Council for Graduate Medical Education requires all US residency programs to facilitate a form of reflective practice, and the UK General Medical Council also requires demonstration of proficiency in reflective learning in revalidation procedures for doctors.[8],[9] Reflective practice in medicine is associated with improved and greater diagnostic accuracy, and failure to reflect can lead to diagnostic mistakes and poor patient management and outcomes.[10] Inculcating the art into practice by the resident doctor is invaluable as it helps build the foundation for a lifelong reflective practice.


  History of Reflective Practice Top


The concepts of reflection and reflective practice have come a long way and have consistently evolved. Notes were made of these in the ancient Greek and Buddhist eras as reflective practices were incorporated in teachings on meditations, and reflective methods were demonstrated in the educational systems of ancient times.[7],[11],[12] In the early 20th century, discussions about the reflective practice were traced to John Dewey, who is commonly described as the father of experiential education.[6] He opined that critically and deeply thinking about an experience or event inevitably leads to a clear purpose in making more careful judgments based on objective grounds.[13]

Another prominent figure in the history of reflective practice was the Swiss psychologist John Piaget, who postulated that the triad of experience, reflection, and action (reflective practice) defined the adult learning process.[14] Kurt Lewin, a German-American psychologist and an important figure in experiential learning and reflective practice, developed the concept of the field theory of learning and tried to establish the links between experience, learning, and social change.[15] In the late 20th century, the works of David Kolb and Donald Schon on reflective practice stood out. Kolb argued that by reflecting on past experiences and constant practice, the individual could learn more, master a skill set, and be innovative, especially in a professional setting.[1],[16] Donald Schon introduced the concept of the “reflective practitioner” as one who may reflect-in-action (thinks and acts quickly drawing from experience) or who may reflect on an action already taken (reflection-on-action).[1]


  Global Practice of Reflective Practice Top


In the context of health care, the need to constantly improve medical education at all levels is glaring in the face of emerging and re-emerging diseases, pandemics, and the challenges of health systems, especially in developing countries.[17] Reflective practice is an example of a response to this call.[12] Across the globe, the principles, concepts, and practice of reflection in medical practice have largely been developed and expanded by the developed world. Outside the Western world, the incorporation of reflection in medical practice or training has been challenging as there are concerns about the suitability of Western methods in other regions of the world.[18] Despite this, the clamor for the incorporation of reflection in continuing medical education and its adoption in undergraduate and postgraduate medical training has continued.[3]

The residency program is a supervised postgraduate specialist training, and programs in the United States and other parts of the developed world have incorporated some elements of reflective practice in their syllabus. However, this is not the case for most medical residency programs in Sub-Saharan Africa.[3],[19]

Around the world, most medical practitioners (including resident doctors) incorporate some form of reflection activities in their day-to-day work (mostly without even realizing so). Various reflective methods usually practiced in clinical care include case-based reflection exercises, use of reflective journals, personal diaries, clinical reasoning exercises, narrative writings, reports of important clinical cases or incidents, autobiographies, and peer group inquiries.[20],[21],[22] The choice of a particular method would undoubtedly depend on the user and the learning or educational outcome desired.


  Models of Reflective Practice Top


There are various models or processes of reflective practice, which are all largely expansions of the works of the founding fathers of reflective practice. Kolb's model suggests that concrete experience about action or situation is a sequence of proper observations and reflections, followed by the formation of abstract concepts and generalizations and testing of concepts in a new situation.[16] Gibbs built on Kolb's model and described a model which follows a sequence of description (the situation), feeling (emotional state), evaluation (making sense of it), analysis (critical review), conclusion (how this will change practice), and personal action plan (reinforcement).[23]

Schon's model describes reflection in action (thinking ahead, analyzing, experiencing, and critically responding) and reflection on action (thinking through a situation, discussing, and reflective journal).[1] Driscoll's model seeks to reflect by asking these three stem questions: what, so what, and what next?[12]

The choice of which model to be used depends entirely on the reflective practitioner based on individual or system preferences.


  Relevance of Reflective Practice to Resident Doctors Top


Most reflections are on things that went wrong; however, reflecting on things that went well is equally helpful as it can often be more rewarding and builds confidence.[5] The resident doctor can benefit from reflective practice by meeting patients' needs and expectations, recognizing his limitations, enhancing performance, and ultimately improving systems and standards. As espoused by Schon, reflection-on-action is likely to be performed by early-career practitioners such as resident doctors as it transforms the experience into knowledge.[1]

Winkel et al.,[24] in a systematic review of 16 studies on reflection involving 477 residents, reported that reflection has a positive impact on empathy, deepens professional values, increases comfort with learning in complex situations, and enhances engagement in the learning process. These are essential values that are at the core of medical practice as a whole, and a resident doctor who is often starting a career is expected to exhibit them.

Furthermore, studies that examined the role of reflection in enhancing residents' learning found that graduates who received instruction in reflection continued to engage in reflective practice after training.[24] This inevitably leads to better patient outcomes. Reflective practice leads to metacognition, a capacity of learners to improve their ability to meditate about their thinking, self-evaluate, judge the quality of work based on evidence, and explicit criteria for doing better work: development of critical thinking, problem-solving, and decision-making.[12] Resident doctors ultimately transit to becoming consultants who are inevitably faced with problem-solving and decision-making, and metacognition acquired through reflective practice becomes helpful in making choices.

Reflective practice by resident doctors leads to improved patient safety. A study conducted among internal medicine residents in the US found out that the quality of systems reflections was lower than personal reflections and that reflection scores are associated with the preventability of adverse patient events.[25] Thus, the preventability of adverse patient outcomes strongly influences residents' reflectiveness.

During reflective practice, the resident also identifies knowledge gaps, seeks out colleagues who are well-studied, and develops partnerships that will assist him in closing such gaps. Well-organized study groups can easily address such gaps, as well as discussing such gaps with the seniors or consultants in the unit. A review of reflective practice among obstetrics residents in Pakistan revealed that reflection leads to improvement in surgical skills, communication, and critical appraisal skills and helps in boosting professionalism.[26]

Reflective practice often leads the resident doctor to return to the books for answers, ruminates on how to provide better services to the patient, and learns from colleagues' experiences. It also leads to seeking the best scientific evidence on the specific questions relevant to the patient's health requirements, thus promoting evidence-based medicine.[27] Without such reflections, the practice would stagnate, and novel ways to improve the path of caring for and addressing the requirements of patients would be few.


  Challenges of Reflective Practice Top


Reflective practice has many advantages for residents, but it is not always a straightforward process. In most circumstances, taking time to contemplate after or during an event may not be possible. When some of the barriers to reflection are identified, it is possible to plan ahead to overcome them and accelerate the reflective practice process. Sewel identified six key barriers to reflective practice: time, a lack of reflective skills, corporate culture, motivation, the environment, and the self.[28] Activities in the life of a resident doctor are frequently fast-paced, either from one procedure to the next or from seeing a large number of patients in quick succession to demanding academic activities and deadlines, leaving no time to reflect on events that are currently taking place or have already taken place.

Al-Mutawa.[29] reported that 27% of family medicine residents in Qatar thought that they did not have enough time for experiential activities. It is necessary to be conscious of this and actively organize time for reflective practice, so that it becomes spontaneous or automatic to pause at predetermined periods for the exercise. Setting electronic reminders, using mobile devices, and making notes in diaries about points that resonate with us during daily activities may help prompt the residents to think and reflect.

Reflective practice is also confronted with the challenge related to the existing culture of the training facility where the resident practices. Not all management and cultures recognize the need for reflective practice and as a result, supporting the practice becomes challenging.[30]

Until institutional management recognizes, the enormous potentials of reflective practice and taps into the vast innovations, improvements, and gains accruable to the system, resident doctors are tasked with doing their best to incorporate the practice themselves into their routine. Reflective practice needs to be incorporated into the curriculum of residency training programs in countries where such does not exist. The presence of an institutional framework and support for reflective practice helps promote it.

Sanders believes that the best strategy for reflective practice should be guided by the user because everyone has a preferred style.[3] There are no easy or proper methods to accomplish it, so the individual needs to figure out what works best for him and continuously improve.

Finding the perfect setting for reflection may be an obstacle to the habit, as simple as it may sound. The atmosphere that satisfies the needs of the residents should be improved regularly until it becomes stimulating for thought. This could be done by ensuring regular training on reflection for residents and trainers and allocating dedicated times to reflect and discuss reflections.

Motivation to reflect on a completed or continuing experience can be a significant issue for the resident doctor's reflective practice. If the resident does not perceive the significance of the reflective practice, he will find it difficult to put in sufficient effort.[31] Furthermore, in an atmosphere where the resident is overburdened with work, lack of time becomes a demotivating force for reflective practice. Institutions that have not fostered a reflective practice culture also play a significant role in diminishing resident doctors' motivation to engage in reflective practice.

Given the above, it is evident that the “self” is the most significant impediment to reflective practice. By recognizing the benefits of reflective practice to oneself as a doctor in meeting the patient's needs and improving practice, the resident doctor can decide on undertaking the reflective practice. To enhance reflective practice, the resident doctor must look beyond all these challenging factors.


  Conclusion Top


Reflective practice has long been thought to have a significant impact on teaching and learning, and it has become increasingly more crucial in the practice and growth of the resident doctor. Although measures of reflective practice exist in postgraduate medical education across the globe, they may not be related to strategies aimed at improving clinical practice, may lack a standard format or curriculum for practice transfer, and are, at best, poorly supported by the training institutions where the resident doctor works. Lack of reflection may result in poor insight, poor performance, failure to innovate, and poor patient outcomes. Adopting the culture of reflective practice in one's work is difficult, especially when faced with obstacles such as a lack of time, a weak corporate culture, a lack of understanding of its importance, a lack of reflective skills, and an unconducive environment.

We propose that reflective practice be integrated into the postgraduate training programs and trainers be trained to teach the reflective practice. This will help prepare resident doctors for their roles of meeting patients' needs, understand their limitations, and improve their performance. Ultimately, the resident doctor, the patient, the system, and the profession will be better off for it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Introduction
History of Refle...
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Models of Reflec...
Relevance of Ref...
Challenges of Re...
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