'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.