Friday, 10 August 2012

'Reflections' on reflection...

In the varied topography of professional practice, there is a high, hard ground, overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation, is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner must chose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and non-rigorous inquiry?” Schon, 1987, p.3.

I make no apologies for reproducing the first paragraph of Schon’s classic text, Educating the Reflective Practitioner in full – it is a paragraph that turned my world upside down! At the time I was undertaking an MA in Higher and Professional Education and working as a Senior Lecturer (in Speech Pathology and Therapeutics). I was trained (and was training) within the technocratic, scientific tradition captured in the pre-clinical/clinical divide of professional education. Schon’s glorious imagery of the high-ground (the ivory tower of academia for me at that point) and the messy swampy lowlands (of clinical practice) immediately resonated with my lived experience of both being a clinician and of preparing future-clinicians. The invitation to adopt a critical stance to the ‘apply theory to practice’ mantra of professional education was thrilling. Donald Schon became my ‘first love’ in the world of educational theory, and although he has subsequently been supplanted by my ‘grand affair’ with socio-cultural and activity-theorists, I will always have a soft spot for him. 

Which is perhaps why I feel the need to speak out about the injustices being committed in his name, through the wholescale adoption of (compulsory), written ‘reflections’ as part of the assessment practices of medical, dental and healthcare professionals. These instrumental practices seem so very far removed from Schon’s accounts of professional artistry and the ways in which expert practitioners negotiate the swampy lowlands, generating and testing out novel solutions to complex problems that do not respond to a by-the-book approach.

Schon’s accounts of reflection-in-action relate to the types of in-the-moment analysis and problem framing that happens when we encounter a unique case or situation, that, in his words ‘falls outside the categories of existing theory and technique’ and cannot 'be solved by applying on the rules in her store of professional knowledge’ p. 5.  The practitioner adjusts her problem framing, and formulates a response, which may involve aspects of improvisation, hypothesis formulation and testing and experimentation, which in my experience at least, may involve simultaneous internal narrative (what if, shall I, it might be, I could, I wonder if, lets go with) with external action.  Evidence-based practice, clinical guidelines and protocols sit rather uncomfortably with Schon’s account of the expert’s ‘professional artistry’.  Reflection-in-action feels a long way away from the rather predictable, ‘chose something that did not go so well this week, reflect on why that was the case and rationalize what you will do differently (and therefore better) next time’.

So, how might we reclaim and revive reflection-in-action in medical training, or rather more grandly, create a curriculum to foster professional artistry?

According to Schon, we need to find ways to ‘bring past experience to bear on a unique situation’. One way to do this, might be in the use of Case Based Discussion (or chart stimulated recall). Rather than fall into the trap of using CbD to check out whether practice was by the book (ie done the way you would have done it), the case becomes a trigger for a richer discussion, that allows exploration of other ways of thinking and responding to the situation in hand and situations in the future.  

The case of the 45 year old man presenting with ‘x’ and ‘y’ on findings is extended into other scenarios. 
  • What if it had been a 23 year old man, how might that have influenced thinking or action?
  •  ‘imagine that the finding ‘y’ had in fact been finding ‘z’, what might you have done then?
  •  ‘What would you have done if he didn’t respond in the way he had?’ and so on. 

Encouraging explicit links between this and other experiences is vital. 
  • To what extent did he present / not present typically?’, 
  • ‘think of another case that has presented like this, but turned out to be something different…what was the pivotal piece of information /action that helped move things forward?'

Schon also encourages on-the-spot experimentation, clearly something that raises alarm bells in the clinical world. But how would it be if we used simulation rather more creatively here? Rather than create ‘surprise’ scenarios for ‘simulated teams’, why not provide opportunities for actual teams to come together, to re-run known situations, trying out and discussing a range of possible options for action? They might also rehearse new practices, anticipating those situations which don’t always go according to plan, using think aloud and debrief techniques so that ‘reflection’ becomes a shared endeavour, rather than a solitary pursuit in front of computer screen. Through rehearsing different approaches to a known situation, it is possible to find ways of thinking and working together that allow experimentation. This fits well with Schon’s encouragement to use virtual worlds, where ‘the pace of action can be varied at will’, allowing slow motion replays of both action and thinking.

Ultimately, reflection-in-action has to involve action – opportunities to engage in a rich and varied ‘practicum’ of the workplace. Recent calls to consider whether trainees have sufficient time to reflect are admirable, but only relevant if they have meaningful experiences to reflection in and upon.


  1. Thanks claire for once again mixing up common convention in medical education. The despair over forced reflection that trainees feel has done great damage to the whole principle of assessment in post graduate medical education. And thats the problem - for some reason reflection and assessment have become linked. The poorest doctors often fail to reflect on their practice but this shouldn't have resulted in the rest of the medical community having 'reflection' forced on them. This in turn resulted in mis-use of the concept of reflection and poor old Schon becomes black-listed by an entire generation of clinicians for creating a ardous task he never intended.

    I do believe though we can get too theoretical about things. Rather than reflect can we not simply just dwell on an interesting event and perhaps mull it over enough to chat with friends/colleagues about it at a later stage. I am sure thats how 99.9% of 'reflection' takes place in the NHS...

  2. It's an interesting point re under performance. Kevin Eva gave a great key note at ASME a few years ago where he was looking at links between insight and performance. What I took from it is that we see poor performance as the RESULT of poor insight - rather, we should see poor insight as a result of poor performance - because in order to have a mental model of good enough (to critique performance against) you need to be good enough. His arguement being that under peformers need more experience (the ironic point here being if you underperform, people delegate less work, of reduced complexity, limiting opportunities to improve). I think there is something in this about reflection - if someone is struggling in their practice, forcing a very public, written self-analysis is not necessarily going to help develop practice. I have not seen any literature showing that 'reflection' of the type going on in assessment practices has an impact and trainees tell me that they are very instrumental in what they chose to reflect upon for assessment purposes.

    The other key point you make is that reflection, meaningful reflection-on-action in this case, often involves dialogue with a group of peers - or a more knowledgable other- where you can review (debrief) and test out various angles of looking at what happened. In Schon's accounts (and in the current reflection based assessments) this is a solitory pursuit - an opinion piece perhaps. IN my view, this limits capacity to developing thinking and practice - learning for me is always a social act.

  3. Having spent 3 years writing very public reflective pieces, many about the doctor-patient relationship on my blog at abetternhs, I have recently submitted work for a Teaching the Teachers course in postgraduate medical education. These pieces, not in the public domain, -though versions of them will be published on my blog- examine much less 'what might have been done differently next time' than my own motives.

    Specifically I've been examining my 'need for power', 'tendency to dominate','co-dependency', 'sexual tension', 'insecurity', 'competitiveness', 'the impact of a SOME identity' and much more. In other words I'll be using cases to examine how my own psyche affects what happens.

    It seems that the case is the event that ought to trigger a critical self-examination, in which a wide range of possible, conflicting motivations -some of which are very personal, bring up personal and sometimes suurprising insights.

  4. Thanks Jonathon,
    Your commentary provides further stimulus about the ways in which the terms 'reflection', 'reflective practice' and 'reflective writing' are used, often very loosely, and in different ways by different people. What you offer here, for me at least, is a prompt to consider the types of 'resources' practitioners bring to bear on their work (and reflective) activity. It is interesting to consider the extent to which in our reflective writings, we make explicit the theoretical tools and concepts we draw upon (as you have done above), and the extent to which our in and after the moment re-thinking is shaped by our biographies, folk wisdom, 'evidence' and so forth.
    Real food for (reflective?) thought here! Thank you

  5. One of the myths of science (and medicine) is its objectivity. What we bring of ourselves and our past experienecs, our values and beliefs to our practice of medicine and relationships with patients is a vital part of the theraputic (or not-so-theraputic) relationship. Medicine, as it is practiced is clearly highly subjective & I think its important to recognise this. I find this fascinating and really appreciate the value that reflecting (thinking deeply) adds.

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