Reflective Practice and Leadership in Medicine and Medical Education Methods for Medical Educators: Background

Physicians and other health care professionals routinely lead individuals and groups through complex challenges — medical, psychological, social, and institutional. As part of the leadership dimension of their role, physicians must be prepared to guide others through these situations with knowledge, experience, and skill. Here is our working definition:

Leadership is the process of influencing others to understand and agree about what needs to be done and how it can be done effectively, and the process of facilitating individual and collective efforts to accomplish the shared objectives (Yukl G. Leadership in Organizations. Fifth ed., 2002.)

Traditionally, technical knowledge and expertise were considered sufficient to produce effective leaders in medicine. The public, practitioners, and leaders in academic medicine, however, have increasingly expressed concern that physicians are not being adequately prepared for the bio-psycho-social competencies their profession requires and that institutions responsible for medical education must be held accountable.

Self-reflection is embedded in educational position statements by various key groups and accrediting bodies. For example, the capacity for self-reflection is central to the “Core Competency” domains of Interpersonal and Communication Skills, Professionalism and Patient Care identified by the Accreditation Council for Graduate Medical Education Outcomes Project.¹ In addition, three of the four “primary attributes” identified in the Association of American Medical Colleges Medical School Objectives Project — altruism, knowledge, and skill — refer in some way to self-reflection.² Britain’s General Medical Council also issued a report, “Tomorrow’s Doctors: Recommendations for Undergraduate Education” that explicitly links reflective practice to clinical judgment, critical thinking, and evidence based medicine.³

We think that the capacity for refection — as events are unfolding (in-action) and on review of events and actions that have been taken (on-action) — is essential to skillful leadership when complex situations require more than standardized guidelines or protocols for conduct.

Reflective practice requires taking a step back to think about why complex situations unfold as they do, articulating a model of the situation, and “testing” the model. In clinical practice, this has been traditionally referred to as the “art of medicine.” As Schön points out, the art of a professional entails the ability to comprehend and adjust to complex situations as they occur.⁴ This capability is what distinguishes a professional’s approach from that of a technician.

The Problem

The artistry of seasoned and expert physicians is clearly visible as they manage complex situations, but the skills required for such artistry are not. Successful physicians usually acquire their skills through role modeling in a professional apprenticeship, or by trial and error. This does not have to be the case. We think the requisite skills to manage complex situations artfully are essentially cognitive skills that hinge on the same method of scientific thinking that underpins expert clinical reasoning and decision making, and can be learned.

The Question

What educational methods can help improve these crucial skills?

Our Premise

Physicians are well-schooled in a scientific approach to biomedical situations, but they often lack the formal training to reason through factors that impinge on their own understanding and decision making (e.g., issues of culture, socioeconomics or personal bias) when addressing medical and professional problems.

Our Hypothesis

With suitable educational opportunities and guidance, physicians can learn to apply methods used in analyzing complex biomedical problems to difficult social situations. Physicians can translate their biomedical reasoning skills to social and institutional challenges.