REFLECTIVE MEDICAL PRACTICE FOR CAP STUDENTS MONICA DEMASI MD HARVARD MEDICAL SCHOOL THE CENTER FOR PRIMARY CARE Stop Memorizing and Think for a Minute

Amusing Question #1 The best analogy for learning in the health care professions: A. Drinking from a fire hose B. Jumping into the deep end of the pool C. Walking on eggshells D. None of the above

Learning is a Change Process  Not simply transmission of facts, ideas, behavior, attitudes  Requires recognizing limitations of one’s own knowledge and abilities  Requires making an action plan to move past those limitations  So this reflection  transformative change  learning Mezirow J. Transformative dimensions of adult learning. San Francisco: Jossey-Bass, 1991

How Adults Learn…

How Dr. Goodell Learned that Studying is a Good Idea CONCRETE EXPERIENCE Dr. Goodell shows up at college, wonders what everyone is doing at the library. Figures it’s too bad those kids aren’t as smart as she is. Dr. Goodell promptly flunks first chemistry exam. REFLECTIVE OBSERVATION “How could this have happened?!?!? I don’t fail things!! I am so smart!!! Unless I suppose smart people also have to study occasionally. Perhaps I should try that next time.” ABSTRACT CONCEPTUALISATION Dr. Goodell decides to go talk to the chemistry professor, who suggests doing the homework. Dr. Goodell decides to even do the “suggested” problems, and to study before the next exam. ACTIVE EXPERIMENTATION More time in the library, many more homework problems. Pays attention in lab. Next exam – Success!! A 93!

What is Reflection? “An important human activity in which people re-capture their experience, think about it, mull it over, and evaluate it.”  (Boud 1985) “... A process where individuals think about and evaluate their experience in order to come to new understandings and appreciations.”  (Williams 2002) “A conscious and deliberate reinvestment of mental energy aimed at exploring and elaborating one’s understanding of the problem one has faced (or is facing) rather than aimed simply at trying to solve it.”  (Eva 2008) Sorting through the information received during a clinical encounter and selecting the pertinent details for further study.  (Kjaer 2008) “A mental process of trying to structure or restructure an experience, problem, or existing knowledge.”  (Driessen 2007) Thinking through an experience to make sense of it.

Amusing Question #2 Why is Dr. DeMasi torturing you in this way?!? A. To placate those members of your class who were English majors B. To help you get in touch with your deepest emotions C. To help you learn better now, and show you a way to learn more in the future

Why is Reflection Important? Promotes deep learning and understanding (v. memorizing) Experience alone doesn’t necessarily lead to learning  62 studies measured physician knowledge/quality of care (performance) vs. years of experience,  Physician performance declines in > 50% of studies  Only 1 study showed improved performance for all outcomes measured. A tool for integrating new experiences with previously held assumptions/understanding (schema building) An option for continuing professional development by identifying and addressing learning needs

How do you do reflection? PUNS/DENS  Patient Unmet needs/Providers’ Educational Needs  Clinically focused, problem oriented What? So What? Now what?  Describe an event that stands out in your day. Why does it stand out to you? In what way will this alter your practice in the future? Critical Incident Analysis What happened? When did it happen? What have you learned? What changed? VignettePUNsPENsPlan

IFP Option 1 In one paragraph, describe a compelling patient encounter. In a second paragraph, explain why this encounter was meaningful to you, and how it will change your practice of medicine in the future. List 2- 3 concrete steps you can take to ensure that your plans for change become reality.

Excellent Example #1 During the third week of CAP I had an encounter with an 8 year boy and his mother. The boy was the patient and had an inflamed nose with internal itching and yellow crusting around the external areas. I have worked with children in a pediatrics setting before and while I felt comfortable interacting with the child, there was an obvious communication gap between the child’s mother and I. During my interview of the child, the mother interrupted frequently, answered my questions to her child and continuously told me what condition she thought her child had. While I believe her input to be extremely important and vital to a full interview, I was taken aback by her interruptions and impatience. I knew that I was conducting the interview at a reasonable pace and that I also had certain goals to reach in terms of composing an adequate patient history. My frustration following the interview led me to appreciate my deficit in working with parents in a pediatric setting and inability to balance the interests and opinions of parents against my own goals. I plan to talk to my preceptors about how they handle similar situations, especially in situations where there is little familiarity with the patient. I will also observe my preceptors with their patients. If this is unsuccessful, I will also refer to pediatrics textbooks. Once I have the information, I will develop my own short protocol for dealing with similar situations, both pediatrics and possibly geriatrics. I then plan to practice the protocol with patients. If the protocol is unsuccessful then I will re-examine it to see what pieces fell short and what should be changed.

IFP Option 2 In one paragraph, describe an encounter within your team that left you feeling that there was something you needed to learn. In a second paragraph, explain what your perceived knowledge deficit is, how you will learn what you need to learn, and what you will do with the information once you have it.

Example #2 My team is working on a group visit model based on motivational interviewing. I realize that though I understand the concept, I don’t really know what it means in practice. I felt embarrassed to say this in front of the group. I am going to ask my mentor for some MI resources and then practice on my roommates. Next time a phrase comes up in a team meeting that I don’t understand I will be brave and ask during the meeting, or maybe just after.