The role of reflection in medical practice: Continuing professional development in medicine

This chapter starts by discussing the theoretical roots of the idea that reflection on experience is the basic mechanism for learning and improvement of professional practice. Moving to the medical domain, the chapter presents recent studies on reflective practice in medicine and synthesizes what is known about the nature of reflective practice in medicine. The multidimensional structure of reflective practice in medicine is discussed, with a description of behaviors and reasoning processes that have been shown to characterize reflective physicians. The next section starts by addressing the origins and adverse effects of diagnostic errors. The importance of cognitive diagnostic errors - mistakes originating from flawed clinical reasoning or faulty data gathering or interpretation - is discussed, as well as the role of heuristics and bias in diagnostic failures. Efforts to minimize diagnostic mistakes and improve performance depend on better understanding of how doctors reason while diagnosing patients’ problems. The section then summarizes the available empirical evidence on how knowledge is acquired and restructured in memory in the course of the years of medical education, including early clinical experiences. Particular attention is given to the constructs of knowledge encapsulation and illness scripts and to the role of an increasing store of patient examples. This chapter discusses how they provide the basis for the nonanalytic way of processing clinical cases that characterizes expert physicians’ reasoning. Subsequently, the chapter explores how this automatic way of dealing with daily problems affects professional performance and lifelong learning. Existing evidence on the benefits and pitfalls of nonanalytic reasoning is discussed with particular attention to their relationships with medical errors. The role of reflective reasoning in avoiding diagnostic mistakes is discussed, and studies showing effects of reflection on the accuracy of medical diagnoses are synthesized. The similarities between the concept of reflective practice and the construct of deliberate practice, which has been shown to be the primary mechanism in acquiring expertise, are discussed, together with the potential role of reflection in lifelong learning and improvement of performance throughout life. Finally, the chapter concludes with the implications for medical education that can be drawn from research on reflective practice in medicine and suggestions of future research.