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