Thinking. We do it all the time, from the most minute choices to the most momentous decisions. Part and parcel of our daily lives, thought is inextricable from how we see, feel and believe. But how often do we take the time to reflect? To ruminate on our experiences and flesh out how dynamically we are molded by them?
Reflection is at the very core of an individual who extracts richness from their life experiences and grows from them. Particularly through the grueling progression of medical training, reflection is a critical means to mark one’s initiation and progression into the ranks of medicine. The first time we call a death. The first time we deliver bad news. The first time we lead a code. The first time we feel that we have truly made a change for the better in our patients’ lives. These are all milestone moments during the journey that demand time for careful, deliberate thought — which constantly forces us to re-evaluate ourselves and our value systems.
A recent ethnographic study examined how patient experience feedback can prompt reflection in the clinical setting. Researchers interviewed nursing, medical and administrative staff on different types of patient feedback across eight acute care units in three NHS hospital trusts in the United Kingdom. As revealed by the thematic analysis of patient experience data and interview data, formalized feedback from patients often prompted learning, reflection and ultimately meaningful changes in attitudes and practice.
However, we frequently shy away from the process of reflection, simply because it is painful. As acknowledged by the researchers, reflection requires a “disorientating dilemma,” or a sense of uncertainty, that drives a deeper exploration of ourselves. Reflection compels us to confront the often concealed parts of ourselves that we do not want to face, oftentimes because they contradict our fundamental self-image. As professionals in-training, we prefer to view ourselves through rose-tinted glasses — the ever empathetic, ever benevolent, ever egalitarian individual who works for the health and well-being of all their patients. And while this idealized image may certainly underlie our actions, it might not always align with them.
This leads to the crisis of reflection in medicine. While reflection is slowly being integrated as a tool in graduate medical education, it remains to be incorporated on a wider scale in training and clinical practice. Medical students are routinely asked to engage in dialogue and reflections in formal electives. But during the formative premedical years and post-graduate years (residency), structured reflections are largely neglected. This can have profound implications on how practitioners are shaped by their experiences, as well as how the skills they learn are applied in caring for patients.
It’s important to remember that reflection is complex and nonlinear. Especially for more monumental events, reflection may not always be a neat and discrete process. It may be intermingled with other emotions and experiences, and may take much longer than expected. Therefore, it’s crucial that we refrain from putting a timeline on the process, or simply treating it like one more piece of scut work to cross off a list. A good way to start embedding reflection into daily lifestyle is by building it in before or after a task you know you routinely complete. For example, you know you will be making coffee every morning. How about taking a few minutes before or after for reflection? Making space for reflection in your life is the first step to routinizing it.
As premedical students, medical students or physicians, there is so much that occurs in the span of a single day. It can be daunting to decide what to even begin reflecting on. This is where many individuals might become overwhelmed and refrain from reflection entirely. It’s key to be mindful of the fact that reflection does not have to be particularly structured or productive. It can be about anything that captures our mind and makes us pause, such as: a well-performed procedure, a thank you from a patient or a well-managed situation. These can help affirm our existing strengths and beliefs, and drive us to our fullest potential. But we might also want to reflect on a dissatisfied patient, an error or missed diagnosis or a failed procedure. These are the reflections that might make us uncomfortable, these are the reflections that will hurt. But these are also the ones that will push us to come face to face with our emotions. Through our hindsight, we will gain insight into what we did well, but what we also could have done differently.
An emphasis on reflection may be a particularly effective inroads to dismantling the culture of perfectionism that reigns in medicine, one that is unforgiving towards errors and other failings. Care providers have often suppressed the thoughts and emotions that result from errors, instead of coming to terms with them through a healthy coping mechanism. Reflection can encourage us to dwell on the situation, to learn and to consider how we might act in a future comparable situation. In these ways, reflection can enable us to concretely move forward and implement tangible change, rather than burying away the inherent pain and discomfort that churns within us.
We can engage in reflection through a variety of methods – journaling, conversation, vlogging and mediation, among other means. Using a structure can help focus a reflection session a bit more. Regardless of the method used, reflection (if done wholeheartedly) can help heal the spiritual, mental, emotional and physical traumas that we grapple with through training and beyond. It can, and it will, hurt. But it can also help us, in turn, extend better care and support to our patients.
Image courtesy of Mili Dave.
Pulses of Connection is an attempt at delving into mind-body connections in medicine. This column will strive to emphasize how mobilizing the deep connections between our mind and physical bodies can enhance our sense of oneness, health, and well-being. Through narrative and exposition, I will explore how practicing physicians, medical students in training, and premedical students can integrate mindfulness in their lifestyles, as well as how such approaches can be crafted to bring healing to our patients.