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The importance of critical reflection

Jonathon Tomlinson (@MelloJonny) is an NHS GP working in Hackney, London. He writes about the importance of reflection being critical and the intellectual challenges this creates for doctors.

There are strong currents of suspicion, scepticism and downright cynicism about reflection in medical practice and medical education. In part this is because we are pressured for time and also evidence/ outcomes oriented and so naturally ask – ‘what difference is this going to make?’ Without a clear and compelling answer, many people conclude that it is not worth the time and effort.

There is another common reason for resistance to reflective practices, whether they take the form of Schwartz rounds, Balint groups, supervision sessions or reflective writing.

Emotions

When people enthuse about reflective practices, they typically recall a case that was really emotional. People involved were moved to tears, the story was really powerful, shocking and so on. Stories about being distressed by the death of a child or a terrible mistake, a vexatious complaint or some other traumatic experience are shared – often to great empathic effect with others responding, ‘yes, I too know how you feel’.

There are risks with this. One of competitive trauma, where people bring increasingly distressing cases, which exclude or alienate people whose experiences are, by comparison mundane. Another risk is that people who are less emotionally bruised by their work, feel excluded because they have so little in common or because their issues are not emotionally charged.

More likely though is that quite simply, even for healthcare professionals, talking about or admitting that our work affects us, or even hearing about how it affects our colleagues, makes us feel very uncomfortable. We feel safer in the belief that we are clinically engaged, but emotionally detached.

People who feel like this need to be reassured that reflective practices do not have to involve emotions.

Steven Brookfield – who has written a great deal about reflection in education thinks that most importantly, reflection should be critical.

Reflection is not, by definition critical. And if it happens that it is not critical, it doesn’t mean that it’s not important. Put briefly, reflection becomes critical when it has two distinctive purposes. The first is to understand how considerations of power undergird, frame and distort so many educational processes and interactions. The second is to question assumptions and practices that seem to make our teaching lives easier but that actually end up working against our own best long term interests – in other words, those that are hegemonic.

Power

In my experience of Schwartz rounds, for example, hierarchies are replicated as more senior and more confident people speak out in large groups. Brookfield would have us reflect critically on whether the physical structure (large room with a panel and an audience) reinforces hierarchies. Power is ever present and a force for good as well as harm as I have tried to illustrate in two previous blogs –Medical Power and Power in the Consultation. Critical reflection should pay attention to the way power is used by clinicians, managers, politicians, patients, organisations etc.

We should reflect on statements like:

We are empowering our patients

Giving patients more responsibility is empowering

Patients should take more responsibility

Doctors are powerless these days

Managers have too much power

Nurses have too little power

I feel powerless/ afraid/ intimidated/ bullied

Questioning assumptions

Brookfield says we should question different types of assumptions, first and foremost, ‘paradigmatic assumption’. These are the facts that we take for granted about what we do. Examples include:

We practice evidence-based medicine

Medicine is a science

Medicine is a vocation

Doctors should be objective

Empathy cannot be taught

It is better to be clinically excellent than a good communicator

Patients’ needs are what matters, not what they want

I know what my patients want and need

Patient-centered care means giving them what they want

Surgeons don’t do compassion/shared-decision making

Palliative care doctors are lovely

Patient-feedback improves the quality of care

Brookfield concludes with six reasons why critical reflection is important:

  1. It helps us take informed actions
  2. It helps us develop a rationale for practice
  3. It helps us avoid self-laceration
  4. It grounds us emotionally
  5. It enlivens our classrooms
  6. It increases democratic trust

It may not be obvious that these follow from analyses of power and assumptions, but when I read his work the conclusions make a lot of sense.

Reflective practice must be founded on trust which is supported by confidentiality, respect, curiosity and non-judgement. It is a skill that like playing an instrument, improves with practice and fades with neglect and sounds better with company.

Brookfield concludes:

Critical reflection is inherently ideological. It is also morally grounded. It springs from a concern to create the conditions under which people can learn to love one another, and it alerts them to the forces that prevent this. Being anchored in values of justice, fairness and compassion, critical reflection finds its political representation in the democratic process. Since it is difficult to show love to others when we are divided, suspicious and scrambling for advantage, critical reflection urges us to create conditions under which each person is respected, valued and heard. In pedagogic terms this means the creation of democratic classrooms. In terms of professional development it means an engagement in critical conversation.

By highlighting that reflective practice need not be all about emotions, but is also an intellectual challenge that has potential to improve professional relationships and patient care, I hope that some sceptical colleagues may be tempted back.

This was originally posted on Jonathon’s own blog.

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