Correlates of Reflective Practice in Medicine

Personality

Correlates of Reflective Practice in Medicine

SILVIA MAMEDE* and HENK G. SCHMIDT1

Innovare Institute, Centre of Educational Development, Medical School, Federal University of

Ceara, Fortaleza, Brazil; 1Department of Psychology, Erasmus University, Rotterdam, The

Netherlands (*Corresponding author: Phone: +55-85-30886444; Fax: +55-85-2651949; E-mail:

[email protected])

Received: 14 May 2004; Accepted: 7 April 2005

Abstract. Background: The ability of physicians to critically reflect on their professional practice

has been increasingly valued. Previous research brought to light the multidimensional structure

of reflective practice in medicine. It comprises at least five sets of behaviours in response to

complex medical problems encountered in professional practice. Factors associated to reflective

practice among physicians have, as far as we know, not yet been explored by empirical study.

Purpose: To study factors correlated to reflective practice among physicians. Methods: A ques-

tionnaire exploring characteristics of professional practice and educational experiences was

administered to primary health care physicians. Measurements were related to scores on a

reflective practice measuring instrument developed previously. Associations between variables

were examined by statistical analysis with tests of correlation and analysis of variance. Results:

Reflective practice is negatively correlated to physician’s age and number of years of clinical

practice. Working mainly in hospitals and attendance to medical residency programmes in some

specialties apparently have a positive effect on reflective practice. Conclusion: Reflective practice

tends to decrease with experience. Findings are consistent with the literature on medical expertise

that shows a decline of analytical reasoning in proportion to the increase in experience. Some

specialty programmes seems to enhance concerns with the scientific basis to professional practice,

thereby favouring reflective approaches. Local features of primary health care settings probably

explain their negative effect on reflective practice. Strategies to develop reflective practice among

physicians should be explored by further research.

Key words: medical expertise, reflective practice, critical thinking, clinical reasoning, medical

education

Introduction

This article reports on a study of factors associated to reflective practiceamong physicians. Reflective practice occurs when physicians engage them-selves in critically thinking about their own professional activities, therebyanalysing own decisions and reasoning. The notions of learning from

Advances in Health Sciences Education (2005) 10:327–337 � Springer 2005

DOI 10.1007/s10459-005-5066-2

reflection on experience and reflective practice have their roots on the work ofDewey (1933) and Schon (1983). The themes frequently come up in teachersand nursing education fields (Hatton and Smith, 1995; Wanda, 1998). Themedical literature has explored characteristics of reflective physicians’ work(Epstein, 1999; Maudsley and Strivens, 2000a). Recent studies providedempirical evidence to the structure of reflective practice in medicine. Startingfrom a theoretical model conceived on the basis of pertinent literature,Mamede and Schmidt (2004) examined behaviours and reasoning processesof primary health care physicians when dealing with complex, non-routinecases. A multidimensional structure of reflective practice was brought to lightby the studies. Reflective practice comprises at least five sets of reasoningprocesses and attitudes in response to difficult problems encountered inprofessional practice: (I) A tendency to respond to difficult or unexpectedproblems with deliberately seeking alternative explanations. This tendencycould be called Deliberate Induction. (II) A tendency to deduce from thesealternative explanations new predictions that might be tested against newdata, called Deliberate Deduction. (III) A willingness to Test these predictionsextensively against the problem at hand and Synthesize new understandings.(IV) An attitude of Openness towards Reflection as a means of solving patientproblems, and (V) the ability to reflect about one’s own thinking processes,called Meta-reasoning.

Reflection on practice and learning from experience are considered keyrequirements to acquire and maintain expertise in medicine (Guest et al.,2001). Physicians are not expected to engage in reflection when dealing withcommon, familiar problems. Research demonstrated that, in these situations,doctors’ reasoning is highly automatic, based on activation of instances ofsimilar patients previously seen (Norman and Brooks, 1997; Schmidt andBoshuizen, 1993). However, there is also some evidence of the use ofreflective approaches by physicians when dealing with complex problems. Inrecent studies, physicians showed to differ in the extent to which they engagein reflective practice. While some practitioners do this quite often whenencounter difficult cases, others almost never engage in reflective practice(Mamede and Schmidt, 2004). Nevertheless, it is not clear why some physi-cians apparently do not engage in reflective practice when faced with acomplex problem, whereas others frequently do this. What are the factorsassociated to reflective practice among physicians, if any?

In this article, findings of an attempt to explore factors related to reflectivepractice among physicians will be reported. To address this issue, a ques-tionnaire was developed to verify the influence of two major categories ofbackground factors: characteristics of professional practice and the nature ofphysicians’ educational experiences.

Instance-based theories of medical expertise already pointed out theincreasing use of non-analytic reasoning that comes together with

SILVIA MAMEDE AND HENK G. SCHMIDT328

professional experience (Norman and Brooks, 1997; Schmidt and Boshuizen,1993). A recent study on aging and physician’s performance reinforced thisconstruct. Experienced physicians’ failures seem to be correlated with pre-mature closure of clinical cases, apparently due to difficulties to explorealternative explanations (Eva, 2002). This seems to reveal gaps in behaviourssuch as Deliberate Induction, Deliberate Deduction, and other dimensions ofreflective practice. This literature suggests, therefore, that reflective practicecan be expected to decrease with years of practice.

Despite this tendency, it is acknowledged that even experienced physiciansmay adopt analytical reasoning to reduce uncertainty when facing a complex,unusual problem (Allen et al., 1998; Maudsley and Strivens, 2000a). Experi-ence can, therefore, lead to reflection provided that it somehow disruptsroutine expectations (Boud et al., 2000; Kolb, 1984). Therefore, to the extentthat the professional practice comprises intriguing problems it would morelikely favour reflection. The particular context of a physician’s work isprobably a key aspect here. Such context stimulating reflective practice maybe primary health care. Primary care physicians deal with a broad range ofproblems, usually characterized by their complexity and ill-defined nature(Starfied, 1992). Social and emotional dimensions are frequently embedded inpatients’ problems and doctors often have to thoroughly exam complaintsand interventions for management of cases (Barry et al., 2000; Bodenheimeret al., 2002; Stanley et al., 1993). This context stimulates exploration ofalternative explanations or solutions for a problem. Such behaviours areassociated to Deliberate Induction or Deliberate Deduction. It would thus bereasonable to expect that practice in primary care settings provides physicianswith more opportunities to face challenging problems. This would favourreflection. However, this potentially stimulating environment could be re-stricted by factors such as the number of patients to be seen and the availabletime. Poorly developed primary care services may refer high proportion ofpatients, including exactly those cases requiring particular attention. Thesewould set limits to physicians’ engagement in reflection. When only very re-stricted time is available for each consultation, chances to stop and think onown reasoning are likely to decrease. Routine, immediate reference of difficultcases may deprive physicians of intriguing episodes that trigger reflection.Whether and how far characteristics of primary health care settings areassociated with reflection is, therefore, an issue that merits investigation.

The second category of factors of potential interest is the nature of phy-sician’s educational experiences. It is assumed here that some dimensions ofreflective practice could be influenced by postgraduate courses or continuingeducation. Programmes that address critical reasoning and evidence-basedmedicine have been widely emphasized (Fraser and Greenhalgh, 2001; Freyet al., 2003; Hatala, 1999; Tonelli, 1998). They might enhance capability tocritically examine grounds for one’s own hypotheses and management of

REFLECTIVE PRACTICE IN MEDICINE 329

problems, key components of Deliberate Deduction and Testing and Syn-thesizing. It is unknown how far local programmes incorporated thesethemes. Nevertheless, it would be worthwhile to explore whether physician’seducational experiences have influenced reflective practice.

The study to be reported below was carried out by administering aquestionnaire addressing characteristics of professional practice and educa-tional experiences to a group of primary care physicians. Statistical analysiswas carried out to explore relations with measurements of reflective practiceobtained among the same physicians in a previous study (Mamede andSchmidt, 2004).

Methods

Participants

Participants were 202 physicians working in primary care in major cities ofthe Brazilian state of Ceara. At the time of the study, around 1100 doctorsworked in family health centres at the state. A research assistant visited theparticipants in their offices or during meetings. The questionnaire was self-administered and returned to the assistant.

Instruments

A questionnaire consisting of 22 questions was used for data collection. Thefirst group of questions dealt with the physician’s education. Closed ques-tions inquired about attendance to specialty programmes or postgraduatecourses. Subsequent open questions requested details, in case of affirmativeresponses. Other items verified participation in continuing education pro-grammes and reading of scientific literature. The second group of questionsaddressed several aspects of professional practice: current and past work-places, time of work in each one of them, years of practice, time dedicated toclinical practice, number of patients seen each week and per hour. Thequestionnaire is appended as Appendix I.

A cover page included on the questionnaire assigned codes to participants.It was removed later on to ensure anonymity. The same procedure had beenpreviously used for administering a questionnaire that explored reflectivepractice among the same group of physicians. All measurements couldtherefore be related. The latter instrument addressed the five dimensions ofreflective practice, previously conceived on a theoretical basis and empiricallytested: Deliberate Induction, Deliberate Deduction, Openness for Reflection,Testing and Synthesizing andMeta-reasoning. This questionnaire consisted of65 items. Some of them were five-point Likert items (agree-disagree or never-always type), while others requested participants to answer with an estimate.Items such as ‘‘Exploring signs and symptoms that are not compatible with


the conjectures I made about a patient’s problem can be worthwhile forreaching a diagnosis’’ were used to assess engagement in Deliberate Induction.Deliberate Deduction was measured by items such as those requesting phy-sician to inform cases in which poor treatment outcomes had led him/her toreview literature. Attributes related to Openness for Reflection include thecapability to acknowledge difficulties, tolerance to uncertainty and dispositionto remain thinking about complex cases. The latter attribute was measured byitems such as: ‘‘Patients whose problems I had difficulties in understanding ormanaging cross my mind at a later stage.’’ Testing and Synthesizing wasassessed, for instance, by questions investigating how frequently physicianused own ‘‘experience with similar patients in the past to assess feasibility ofthe measures considered for the treatment.’’ Finally, Meta-reasoning wasmeasured by items such as those requiring physician to report cases in whichhe/she ‘‘realized that own preconceptions in relation to patients’ beliefs orbehaviours had restricted or distorted, in a first moment, reasoning aboutpatients’ problems or unexpected outcomes.’’ A reflective practice score wascomputed by adding scores obtained on each factor multiplied by the numberof items related to that factor and dividing by the total number of items.

Statistical analysis

Results of the study of the model of reflective practice in medicine arereported elsewhere (Mamede and Schmidt, 2004). It provided measurementsof reflective practice among the same group of physicians who participated inthe present study. The data collected through the questionnaire on possibledeterminants of reflective practice were analysed using SPSS for Windows.This provided descriptive statistics for the variables studied and analysis ofcorrelations between reflective practice measurements and variablesexpressed as interval data. One-way ANOVA was used to analyse associa-tions between reflective practice and variables related to characteristics ofphysicians’ work and educational background.

Results

Physicians’ mean age was 42.47 (SD = 10.27). Eighty-four participants werefemales and 118 males. The percentage of physicians who had attended to aspecialty programme corresponded to 56.9%. More than 73% of thephysicians were not engaged in continuing education. Almost 60% reportedthey did not regularly read any medical journal.

Around 80% of the physicians reported to work in two different places.The second workplace, besides the primary care centre, was mostly a publichospital. Almost 38% of the physicians cited three workplaces. Although alldoctors practiced in primary care, 48% indicated hospital as the first optionwhen inquired about their workplace.


The physicians had on average almost 17 years of practice (SD = 10.45).The mean time of work in the current primary care centre was 4.01 years(SD = 3.31). The previous workplace was also a primary care centre for28.80% of the physicians. Physicians spent on average 35.46 hours(SD = 19.06) seeing patients each week. The average number of patientsseen each week was 148.31 (SD = 91.46). Therefore, the average amount oftime spent on each patient was 14 minutes.

The statistical analysis showed a negative correlation between reflectivepractice and physician’s age (Pearson correlation = )0.150, p < 0.05). Thisfinding was confirmed by an ANOVA test using extreme groups(F(3,193) = 2.75, p = 0.04). Physicians who were bellow 33-years-oldshowed higher mean of reflective practice scores (Mean = 3.20, SD = 1.16)than physicians who were older than 53 (Mean = 2.68; SD = 0.63). Therewas also a negative effect of years of clinical practice (F(3,198) = 3.15,p = 0.03) on reflective practice. The mean of reflective practice scores for thephysicians with less than 8 years of practice was 3.13 (SD = 1.10). Itdecreased to 2.75 (SD = 0.67) for physicians who had been practicing formore than 24 years. Gender and social position of parents did not show anysignificant association with reflective practice.

Significant effects of both present (F(2,199) = 3.77, p = 0.03) and pre-vious workplace (F(6,195) = 2.46, p = 0.03) on reflective practice were alsofound. The mean of reflective practice scores among physicians who workmainly in primary care centres (Mean = 2.88; SD = 0.67) showed to belower than among doctors who mainly work in hospitals (Mean = 3.22;SD = 1.27). The other variables related to professional practice did notshow to be associated with reflective practice.

Regarding educational variables, a relationship was only found betweenreflective practice scores and the specialty programme the physician hadattended to (F(5,196) = 2.53, p = 0.03). Table I presents mean reflectivepractice scores for groups of physicians with different specialties. When

Table I. Means, minimax, and standard deviations on reflective practice questionnaire for dif-

ferent medical residency programmes attended to by physicians

Specialty of vocational training No of subjects Minimum Maximum Means Standard

deviation

None 89 1.76 5.16 2.86 0.64

Internal Medicine 27 1.80 5.79 3.01 0.89

Gynaecology-obstetric 29 1.74 4.40 2.77 0.66

Paediatrics 36 1.96 5.30 3.02 0.78

Public Health 1 – – 4.99 –

Others 20 1.64 9.03 3.32 1.58


dimensions of reflective practice were separately analysed, significant F-ratioswere found between vocational training and Deliberate Deduction(F(5,196) = 2.63, p = 0.03) and vocational training and Testing and Syn-thesizing. (F(5,196) = 2.79, p = 0.02).

Discussion

Reflective practice takes place when physicians engage themselves in criticallythinking about own reasoning and decisions during professional activities.The theoretical basis for conceiving the nature of reflective practice inmedicine comes from multiple sources. Crucial contributions were providedby Dewey’s works (1933), Schon’s studies on professional practice (1983) andother authors’ conceptualisation of critical thinking (Boyd and Fales, 1983;Brookfield, 1987). Medical literature has expressed the concern with thedevelopment of reflective physicians (Brigley et al., 1997; Maudsley andStrivens, 2000b) and explored features of reflective practice in medicine(Epstein, 1999). Its five dimensions, with their sets of attributes and behav-iours, were brought to light by previous research (Mamede and Schmidt,2004). In this article, possible correlates of reflective practice were discussedand result of an empirical study relating these factors with a measure ofreflective practice was presented. In particular, we explored whether char-acteristics of physicians’ professional experience, current work, and educa-tional background could be related to reflective practice. Items addressingthese elements were part of a questionnaire administered to a large group ofphysicians working in primary care in the Brazilian state of Ceara. Thefindings can be summarized as follows: Reflective practice is negatively re-lated to physician’s age and number of years of practice. The place wherephysicians work apparently also plays a role. Physicians who cited hospitalsas their first workplace showed higher measurements of reflective practicethan those who work mainly in primary care settings. Specialty obtainedfrom a residency programme was significantly associated with reflectivepractice. Those who received their training in public health, Paediatrics andInternal Medicine reported to engage in reflective practice more extensivelythan those who had not attended to a specialty programme or had theirtraining in Gynaecology–Obstetrics.

How can these findings be interpreted? Research showed that in routinesituations expert physicians tend to use an automatic reasoning approachbased on recognition and retrieval of instances of patients they have inmemory (Charlin et al., 2000; Norman and Brooks, 1997; Schmidt andBoshuizen, 1993). Analytical reasoning declines in proportion to the increasein experience (Eva, 2002). Physicians in our study had a mean age around 42,with almost 17 years of practice. The several dimensions of reflective practiceencompass analytical reasoning when facing complex cases. Consistent with


the literature on medical expertise, reflective practice could be expected todecrease with experience, and thereby, with age and years of practice. Thisprediction was confirmed by our findings. Reflective practice was negativelyrelated to physician’s age. Physicians who were below 33-years-old showedhigher scores of reflective practice than those who were above 53. There wasalso a decline of reflective practice scores in proportion to the increase innumber of years of practice.

Results also pointed to a correlation between reflective practice andworkplace, both in present and previous positions. All participants of thestudy were currently working in primary care, but a high proportion of themalso practiced in other services, mainly hospitals. Many doctors indicatedthese services as their first workplace. This probably reflects the time and/orattention these doctors dedicate to practice out of primary care. As we pre-viously suggested, it seems reasonable to expect primary care settings toprovide more opportunities for encountering intriguing problems, therefore,enhancing reflective approaches. Results, however, pointed in anotherdirection. Physicians who cited hospitals as their first workplace showedhigher scores of reflective practice. How can these findings be explained?Characteristics of primary health care in Brazil may be underlying them.Effectiveness and quality of primary care have been widely questioned, due toseveral factors (Mendes, 2002a, b). Primary care facilities are generallyinappropriate, with poor diagnostic and treatment support. Certification,audit and evaluation systems are absent. Low recognition of the specialty andpoor educational programmes prevent physicians’ adoption of FamilyMedicine as a career (Mendes, 2002a). Doctors view primary care centres as atransitory stage in their professional lives. This state of affairs may contributeto generate a hurtful atmosphere. Instead of stimulus for commitment toappropriate standards and search for excellence, there is an environmentwhere poor performance and carelessness are not seen as unacceptable. Thisatmosphere may contribute to decrease physicians’ commitment to rigorouspatterns of practice in primary care settings and the attention they give to it.As a consequence, engagement in questioning reasoning and decisions whileseeing patients in primary care centres could be restricted, hence reducingreflective practice.

The findings also highlight an effect of physician’s specialty on reflectivepractice. Some residency programmes, such as Paediatrics and InternalMedicine, seem to be associated with higher levels of reflective practice thanothers. In Brazil, regulations for residency programmes do not expressconcerns with reflective practice or evidence-based medicine (Ministerio daEducacao, 2003). Specialties do not differ on this and, therefore, explanationsfor the results are difficult. Specialists in Internal Medicine and Paediatricstend to deal with a broader spectrum of problems, among them unusual andcomplex cases. This could probably enhance reflective practice, thereby


explaining their higher scores. However, this is only a conjecture. What isreasonable is that better educated doctors should be more concerned with ascientific approach to their practice. This would be expressed, for instance, insearching for grounds for decisions in management of cases. Indeed, resultsindicated a relationship between specialty and two components of thestructure of reflective practice – Deliberate Deduction and Testing andSynthesizing – in which those behaviours play a crucial role.

A word of caution is required in interpreting the findings. Investigatingdetermining factors of reflective practice is a complex endeavour and the useof questionnaires therefore may not be a sufficient strategy. Reflectivepractice in medicine seems to have a five-dimensional structure, withassociated sets of behaviours and attributes. In-depth exploring factorsunderlying reflective practice may require additional study focusing on eachof them separately. The present study indicates where to look further.

Implications of the results and potential developments might be empha-sized. There seems to be a crucial role to be played by strategies to enhancereflective practice among physicians. Continuing education should considerthe need to prevent trends to restrict analytical reasoning, and therefore,reflection, that come with experience. A dilemma is possibly embedded here.If non-analytical reasoning comes together with expertise development, howthen could reflective practice be inserted into expert’s reasoning and decision-making? It certainly does not refer to replace or restrict non-analytical,automatic reasoning. Indeed, reflective practice is expected only when facingcomplex, unusual cases. Further research should explore strategies forpromoting reflective practice among physicians.

Appendix I. Inventory of professional and educational experiences

1. What is your age?

2. What is your sex?

(encircle the right alternative)

Male (1) Female (2)

3. Estimate the social position

of your parents

Lower class (1)

Middle class (2)

Higher class (3)

4. In which year did you

graduate as a physician?

———

5. How many years of professional

practice as a clinician do you have?

———

6. Did you attend to an accredited

medical residency program in

any specialty?

Yes (1) No (0)

7. If so, please indicate which one ———

8. Did you attend to diploma courses

or long-duration courses in the last

two years?

Yes (1) No (0)


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Appendix I. Continued.

9. If so, please indicate the courses most

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———

———

———

10. Please, indicate if you have any other

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11. Are you engaged in any continuing education

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———

22. On average, how many patients do you

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———


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Correlates of Reflective Practice in Medicine