“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.
