Lifelong Learning and Reflection

7/31/2019 Lifelong Learning and Reflection

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Lifelong Learning and Reflective Analysis

Dr Wesley Scott-Smith

Module Lead for Clinical Practice


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Learning at BSMS

During your studies at BSMS you will be exposed to a number of

environments which necessitate different approaches to learning

Delivery of healthcare across the professions relies not only upon

factual knowledge (biomedical information) but acquired knowledge

derived from experience (events and people-usually clinical)

There are a number of basic skills and competencies which you have to

learn in a standardised way (at first) then hone these skills through

clinical practice e.g. examining a patients chest or blood pressure

Many skills have several depths in expertise e.g. communication skills

in giving bad news-how do you tell someone they have cancer?


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Millers Pyramid (1990)

Does

(Professional Practice)

Shows How

(Practical competence)

Knows How

(written or simulated)

Knows(Written)

Reflective analysis


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How do you learn best?

Reading alone?

Reading alone but verbalising back to yourself?

Reading alone and posing questions for yourself?

Reading and annotating? Reading, annotating and drawing diagrams or mapping?

(visuospatial)

Touching/feeling/seeing and doing/kinasethic-

engagement in deliberate practice Discussion with peers


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Reflective Analysis

Do

Review

Plan

AMEE Guide: the use of reflection

in Medical Education, Guide No 44

John Sanders, Medical teacher, (2009) 31; 685-695

One of the key attributes that you should aimto foster is reflective analysis (critical); thisskill helps you improve subsequent actions


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Underlying principle

Let their future behaviour be guided by systematic

and critical evaluation, and analysis of actions andbeliefs and the assumptions that underlie them

Dewey quoted in Driessen E, Van Tartwijk, Dornan T. The self critical doctor;

helping students become more reflective. British Medical Journal.2008. 336,

827-830.


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Changing behaviour

Future behaviour and thought is guided by reflective

analysis of previous events? Experiential learning cyclesmerely structure this process but may be blurred by

jargon.

60% of complaints against doctors are concerned withcommunication, so how can we learn to prevent theseepisodes occurring?

By developing the ability to look at our behaviour, opinions,knowledge, skills and beliefs with a critical stance


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What prompts change in behaviour?

Often negative events influence our behaviour e.g. Critical incidents in

practice

Case Scenario: If the first time you prescribe a drug the patient hasan acute allergic reaction, then this influences how you might dealwith the same instance in the future i.e. It makes you very wary

Extraordinary events create far more significant memories thanordinary events, however your thought processes and reasoningshould not be swayed by unusual extraordinary events without some

critical analysis first


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Heuristics

Heuristics are mental short cuts which may be useful inhelping the decision making process, however it is easyto develop abnormal heuristics

It is important to be aware of your own heuristic tendenciesin making responses and decisions

Room A Room B


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Why adopt reflective practice?

Reflective learning implies an intention to improve anddevelop professional skills

..it made me feel uncomfortable observing this consultation

as the patient clearly wanted a prescription for herweight problem and the doctor didnt want to give in. I

thought they were going to have an argument........... Idont think they were on the same wavelength

What is the primary response of the student observing thiscase?


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Descriptive (superficial) analysis

What happened... The interaction between parties involved... The

emotional reaction.................?

These comments are often situated in the self, rather than looking atthe perspectives of others

Doctorsagenda

Studentperspective

PatientAgenda


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Portfolios in Medicine

How are they useful??

They can identify student learning needs

Improve integration of theory with practice

Encourage engagement with reflection and self-awareness

Sharing reflections improves confidence (mixed effect)

Driessen, Tartwijk, Van Vleuten & Wass. 2007. Portfolios in medical education: why

do they meet with mixed success? A systematic review. Medical Education, 40:

862-866.


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Primary Care context: Continuity in Practice

What was therelationship likebeforehand?

Context from PMH,Family and socialhistory

Before

Context of currentproblem

Risk Behaviour Influence of third person

in room (reflexivity)

Now Long term

impact againstshort term gain

Impact on familyand othermedicalproblems

The Future


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The weight problem scenario

Several discussionsbefore about weightand Diabetes

Tendency to relyupon therapeuticfix rather thanholistic approach

Prior knowledge

(Pre-encounter data)

Reinforce holisticmethods-exercise,diet, etc

Teaching context Maintaining doctor-

patient relationship

Now Long term

habits related toDiabetes

Childrenoverweight-impact on family

Future Care


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Comparison in comments/analysis

it made me feel uncomfortable

observing this consultation asthe patient clearly wanted aprescription for her weight

problem and the doctor didntwant to give in. I thought theywere going to have anargument........... I dont think

they were on the same

wavelength

Looking back on theconsultation I could see thedisparity between the patients

agenda and the way the doctor

was trying to approach a longterm issue; he was trying toopen up other areas of dealingwith the weight issue withoutupsetting the patient who

clearly wanted a dieting tablet


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Further analysis??

it made me think of another consultation that I witnessed

(uncomfortable also) about taking anti-depressants and

counselling. I couldnt help but feel that the patient wasnt

listening to the doctor.

He wasnt angry afterwards because the patient didnt take his

advice but merely remarked that the patient needed more

time to make a decision. I realise that things arent always so

black and white in practice.

I am finding this more difficult to understand than learning

about anatomy and physiology.

Contrast andcompare


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How a learning cycle might help

Action

Looking back

on the action

Awareness ofessentialaspects

Creatingalternativemethods of

action

TrialThe ALACT model

of Reflection

(see Driessen etal, BMJ 2008; 336;827-830)


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Ask yourself............

What went well?

What went wrong?

How did you solve this?

What effect did this have?

What do you think the patient/your colleague wanted?

What did you think and what did others think?

What did you or others do?

What emotional impact did this have on you and others?

AMEE Guide 45; Portfolios for Assessment and learning. Medical Teacher 2009; 31: 790-801


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What to look out for to help with the portfolio

Clinical and educational experiences that challenge your views andopinions

Issues in consultations that make you broaden your views and/or

knowledge

Discussions in lectures/seminar groups that stimulate thought/argument

Any clinical activity that illustrates learning from the course (with your

analysis)

Prescribing and ethical issues that you come across in discussion

An clinical case where the history was particularly interesting and

relevant (the narrative) What impact has your patient study made upon you over the last few

months? (this is not the same as the patient study assignment)

Perspective is professional development


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Portfolio Assignments

Year One

Mandatory Subjects

Experience of cadaveric dissection

Patient from Primary Care

Patient from Secondary Care

Experience from Science based modules e.g.

symposiumHow I have changed in the first year

Experience of the attachment with a familywith newborn child

Optional

(choose any two from list)

Professionalism in educational or clinical

practiceA patient from primary care (different case)

Therapeutics (generic issues)

A case where the narrative was important

Year Two

(provisional)

Mandatory Subjects

Consultation Skills-Self Appraisal

Learning from the simulated interview

Teamwork in the practice setting

Ethical issues using Case scenarios on-line

Experience from visiting the Patient with aChronic Condition

Experience from Science based modules

Optional

(choose any two from list)

Case base Discussion

Professionalism in educational or clinical

practice e.g. educational incidentLearning from Feedback

Therapeutics


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Run through portfolio at BSMS

Phase 1

Implant the benefits of learning from practice (reflective practice)targeted to modular activities within Phase One Introduce concept of self appraisal and PDP

Phase 2

Introduce aspects of Multi-Source Feedback (MSF) including case

based discussion, mini CEX, DOPS Develop self appraisal skills

Phase 3

Consolidate assessment activities linked to Foundation portfolio e.g.decision making with a management focus

Complete the GMC competency checklist via clinical skills logbook


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Progressive feedback

MentorSupport for

developing'learning frompractice'

Feedbackcycle 1 withsummativeassessmentat end of term

TermOne

Formative

support Summative

assessmentof fourpieces ofwork

TermTwo

Feedbackcycle on

development during theyear

SummativeAssessmentof threepieces ofwork

TermThree


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Work is clearly presented with good, descriptive useof English, adequately constructed and appearscomprehensive in nature.Detailed description with reflection, but lacking a

critical element on the experience or learning.Adequate questioning, but limited in breadth anddepth. Limited reference to relevant literature.

Minimum level for portfolio entries

Lifelong Learning and Reflection

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