Reflective Practice and Leadership in Medicine and Medical Education Example Facilitative Responses Facilitating Component 2 & 3: Reflection/Systematic Analysis & Hypothesis Formation/Working Diagnosis

It is our experience that the second and third components of reflective practice — Reflection/Systematic Analysis and Formation of Hypothesis/Diagnosis — go hand-in-hand. It is important to start by helping participants clarify the characteristics of the case, their thinking, and the generalizable aspects of the case.

The following techniques will help participants explore their thinking:

  • Ask questions about details of the situation (e.g., who is involved, what has been tried, why), and possible interpretations or hypothetical strategies (e.g., “Do you think it is …” or “What if you tried…”)
  • Invite other participants to share their thinking (e.g., “Has anybody else been in a similar situation?”)
  • Describe analogous case experiences, emphasizing shared aspects of cases. Facilitators guide this process to illuminate less obvious factors, showing the limits of prevailing explanations or suggestions (e.g., “I was in a similar circumstance and I tried that, but …”; “…Yes, and it makes it harder if your research mentor has little or no experience working with physicians”)
  • Describe resources or constraints that may not be known to the learner – particularly if they are new to the institution (e.g., the local processes for contacting a hospital’s risk management group). Faculty, however, should be careful not to frame statements of fact as recommendations in such a way that pre-empts the learner’s efforts to reason through the situation, especially during these phases of the discussion.

To illustrate these components, we will start with a question from the research domain.

The context: A three-year research fellowship. Half-way through the first year, fellows must choose a research pathway and mentor for the next two years.

Example of an initial framing of a research question by a fellow:

What should we realistically expect from two years of research and what should we be looking for? (This question immediately prompted a number of specific suggestions and points of fact, including stipulation of the minimum requirements for board certification. That pattern led a faculty member to make the following inquiry for clarification of the actual question.)

Faculty inquiry for the purpose of clarifying the question:

Are you asking about the minimum criteria for the research requirements for board eligibility? Or, are you saying that when you began the program you had hopes of contributing to the field in a substantive way and something has now made you doubt that . If so, are you asking what are reasonable expectations of what you can and should acquire or achieve in the research arena in the next two years?

The fellow who framed the initial question agreed that this clarification revealed the actual question.

In this instance, the group initially focused all questions and suggestions on the fellow who raised the question. A faculty member used an invitation to distribute the discussion to other participants by stating, “I am sure that other people here have asked themselves the very same question.”

The invitation generated several reports of analogous experiences. The more experienced participants (upper level fellows and faculty) described how they had encountered the same doubts and anxieties about their choice of research subject and mentor. The discussion led to the hypothesis that fellows may develop the false expectation that their chosen research topic was a “make or break” decision that could be disastrous to their entire career. The group then “tested” the hypothesis by looking for evidence of its validity.

The group discussed numerous analogous cases that invalidated this hypothesis. The experienced faculty and visiting scholars noted that researchers seldom follow a straight, unvarying thread of research across the course of a career. More often, researchers follow their interest, and apply their experience and learning to emerging questions and opportunities that were often unavailable earlier in their careers. The group thus refuted the hypothesis, and focused instead on how to maintain intellectual excitement and adaptability. Participants then described how they individually determined what was a personally suitable and satisfactory set of expectations for their fellowship experience and their research pathway in general.