Reflective Learning, Mindful Practice, and Professional Competence

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Reflective Learning, Mindful Practice, and
Professional Competence

• Ronald M. Epstein, MD
• Professor of Family Medicine and Psychiatry
• University of Rochester
• January 2003

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This being human is a guest house.Every morning
a new arrival.A joy, a depression, a
meanness,some momentary awareness comesas an
unexpected visitorWelcome and entertain them
all!Even if they are a crowd of sorrows, who
violently sweep your houseempty of its
furniture,still, treat each guest honorably.He
may be clearing you out for some new
delight.The dark thought, the shame, the
malice,meet them at the door laughing,and
invite them in.Be grateful for whoever
comes,because each has been sentas a guide from
beyond. Jelalludin Rumi (1207-1273)
The Guest House
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Uninvited Guests in Medicine

• Ambiguity and uncertainty (Schon)
• Conflict between the needs of patients and
  clinicians
• Strong emotions the patients and ones own
• Technical errors

• Contradictory evidence
• Unanticipated serious illness
• Impermanence of knowledge
• Illusion of competence
• Lack of control

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Mindfulness

• Paying attention, on purpose, to ones own mental
  and physical processes during everyday tasks to
  act with clarity and insight.
• leads the mind back from theories, attitudes
  and abstractions to the experience itself

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Mindfulness

• the study of subjective experience from the
  inside out
• a state of mind that permits insight
• can apply to emotions, thinking, ethics,
  technique, actions
• refers to actions in the moment, not just
  philosofizing or monday morning quarterbacking

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Delusion

• The tendency of the mind to seek premature
  closure...that quality of mind that imposes a
  definition on things and then mistakes the
  definition for the actual experience
• M Epstein

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Practice-based LearningandSystems-Based Care

• Problem Case 1Pseudo-Dehydration Cured by
  Foley Catheter

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Issues in Competence

• Individual issues
• poor info gathering
• poor judgment
• inattentiveness
• lack of presence
• lack of compassion
• fatigue
• ignoring the obvious

• Systems issues
• undue deference to authority
• protection of colleagues
• poor communication between staff (or inadequate
  means to do so)
• no mechanism for f/b
• diffusion of responsibility

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Cognitive Science and Mindfulness

• Tacit and explicit knowledge
• Personal and public knowledge
• Competent ? Proficient ? Expert ? Master
• The neurobiology of multi-tasking

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Other Consequences of Delusion

• Knowing in action vs. espoused knowledge
• Over-concreteness
• Addisons?
• Multi-tasking
• The sexual history

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Is there an underlying construct that describes
good medical practice?

• Knowing ones limits
• Setting boundaries
• Tolerance of Ambiguity
• Biopsychosocial approach
• Compassion

• Skills
• Knowledge
• Attitudes
• Caring
• Self-awareness
• Patient-centeredness

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Habits of Mindful Practitioners

• Attentive observation
• observing the observer while observing the
  observed
• peripheral vision
• pre-attentive processing
• Critical curiosity
• asking reflective questions that tend not toward
  edification
• Tolerating (and enjoying) being wrong

• Beginners mind
• informed flexibility
• willingness to set aside categories and examine
  bias
• Presence
• diminished reactivity
• control of anxiety
• ego-lessness, singlemindedness
• focus on the task and the other
• tolerating contradictory ideas
• personal involvement and investment
• compassion based on insight

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Goals of Mindfulness in Medicine

• Attentive observation
• Critical curiosity
• Beginners mind
• Presence

• Clinical reasoning / EBM
• Technical skills
• Relationship-ctrd. care
• Ethics

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Problem Case 2 PE WNL
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What Could Have Gone Wrong

• Inattentiveness
• Ignoring that there was something different
• Lack of curiosity
• Fulfilling rather than challenging expectations
• Lack of flexibility
• Rigid categorization as somatizer
• Lack of presence
• Inability to respond appropriately

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What Can One be Mindful Of?

• Mindfulness of the body
• breath, contact, movements (technical skills)
• Mindfulness of feelings
• unpleasant and pleasant sensations (the sinking
  feeling)
• cognitive processes (decision-making,
  reflection)
• Mindfulness of emotions
• countertransference sadness, anxiety,
  heaviness, acceptance (diagnosis of mental
  disorders)
• Mindfulness of mind
• self-awareness state of alertness/attentiveness,
  holding on/letting go

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Professional Competence and Mindfulness
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Defining Professional Competence

• The habitual and judicious use of communication,
  knowledge, technical skills, evidence-based
  decision-making, emotions, values and reflection
  to improve the health of the individual patient
  and the community.

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Facets of Competence

• Cognitive
• acquisition and use of knowledge (e.g. EBM)
• Integrative
• synthesis of data, clinical reasoning, judgment
• Relational
• communication with patients and colleagues
• Affective / moral
• patience, willingness, self-awareness

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Facets of Competence

• Habits of mind (Epstein)
• attentiveness, curiosity, flexibility, presence
• Context (la Duca, Klass)
• Competence is the relationship between an
  ability in the professional and a task in the
  world
• Developmental (Dreyfus)
• student ? novice ? advanced beginner ? competent
  ? proficient ? expert ? master

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Mindfulness and Micro-Ethics

• Self-knowledge to distinguish ones own values
  from those of the patient
• Greeting the uninvited (or unwanted) guest with
  hospitality
• Ethical response to delusion and suffering
• Purposeful presence in small actions

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From Competence to Capability (Frazer BMJ
2001323799-803)

• Competence what individuals know or are able to
  do in terms of knowledge, skills, attitude
• Capability extent to which individuals can
  adapt to change, generate new knowledge, and
  continue to improve their performance

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Complexity and Uncertainty (S Frazer. BMJ
2001323799-803)
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Mindful Practice

• Attentive observation
• Critical curiosity
• Beginners mind
• Presence

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Cultivating Mindfulness
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Levels of Mindfulness

• Level 0 denial, externalization
• Level 1 imitation
• Level 2 critical curiosity (cognitive)
• Level 3 critical curiosity (socio-emotional)
• Level 4 insight
• Level 5 generalization, incorporation, presence

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Fostering Mindful Practice

• Priming
• setting expectation of self-awareness
• Identifying surprises
• Creating a setting and context
• Reflection groups, Balint groups, difficult
  case conferences, individual precepting,
  journals, hallway discussions, between patients
  in the office
• Asking reflective questions
• questions that tend not toward edification
• opening up questions
• questions to which you do not know the answer
• out of the box thinking deconstructing
  categories

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Reflective Questions

• How might your prior clinical experience affect
  your decision-making in this case?
• What are you assuming about this patient that
  might not be true?
• What did you observe?
• What surprised you about this patient? How did
  you respond?
• What interfered with your ability to observe?
• What latent errors might be present in this
  situation?
• If there were relevant data that you ignored,
  what might they be?

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Thought Exercise 1Labeling

• Participants enter a building with several
  thousand self-sticking labels, and label every
  single thing (and person) in the whole building.
  Multiple labeling may occur a window, for
  example, might be labeled window and pane of
  glass a person might be labeled diabetic and
  retired auto salesman.
• Imagine conducting this exercise in the hospital
  in which you work.

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Categories, Naming and Labeling

• What diagnoses were you entertaining when you
  first saw the patient?
• What might you be missing?
• What data about this patient doesnt fit the
  diagnosis?
• Is there a reason why this treatment might not
  apply to this particular patient?
• Are there any diagnoses that the patient carries
  that are not really applicable?

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Fostering Mindful Practice

• Active engagement
• helping to make conscious what is taken for
  granted
• Being conspicuously mindful
• transparency, thinking out loud
• Practice in discipline is freedom

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Practicing Attentive ObservationThree Days of
Red

• For three days and nights, record in written word
  the names of all the red things you see.
• K Maue, 1972

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Practicing CuriosityA Hundred Questions

• Make a list of 100 questions that are important
  to you. You can include in your list any sort of
  question, as long as it is something that you
  deem significant to your professional life as a
  physician.
• Write quickly, without worrying about spelling or
  repeating yourself.
• Gelb, MJ. How to Think Like Leonardo da Vinci,
  1998.

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Next,

• Review the 100 questions and highlight the themes
  that emerge.
• Review your list of 100 questions and choose the
  ten that seem most significant.
• Be prepared to share one of your questions with
  the group, and also to talk about what the
  process was like for you.

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Practicing Presence

• Pair off with a person whom you do not know
  particularly well.
• Choose an important question about practice or
  teaching, such as What is one way that you have
  learned to become a more effective practitioner
  (or teacher)?
• Ask the question of your partner, listen to the
  answer, say Thank you, and then ask the
  question again. Repeat several times. Do not
  engage in discussion, just reply Thank you.
• Then switch.

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Fostering Mindful Practice

• Praxis knowledge is action in the world
• The Biopsychosocial Interview
• False positive medical records
• Confirmation

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When you figure out how to assess something, it
becomes easier to teach and learn.
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Problems with Assessment

• Fragmentation
• Context-dependence
• Penalizing shortcuts
• Stifling creativity
• Testing test-taking
• Lack of reliability in small-scale assessments

• Time
• Cost
• Conflict of interest
• Reliance on experts to judge expertise

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Millers Pyramid
Does
Shows How
Knows How
Knows
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Assessment in the Real World
What we tend not to assess -- causes of common
errors -- habits of mind -- systems, teamwork
Does
Shows how
What we typically assess -- descriptions of
events rather than observed performance --
individuals rather than groups
Knows how
What we know how to assess reliably --
decontextualized factual knowledge -- performance
of specific maneuvers (Hx, PE) -- some
interpersonal skills
Knows
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Why Some Physicians Get into Big Trouble

• Personality issues
• Poor judgement
• Boundary violations
• Substance abuse

• Lack of motivation
• Poor communication
• Usually NOT lack of knowledge or skill

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Malpractice Litigation
Actual or Perceived Error
Potential for Gain or Justice
Poor Outcome


Poor Communi-cation
Litigation


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Making Assessments Useful

• Acquiring and using knowledge
• Variety of contexts
• Complexity, ambiguity and uncertainty
• Addressing public expectations
• Seamless incorporation of the art of medicine

• The right developmental level
• Using experts wisely
• Habits of mind
• Driving learning
• Driving values (tests as moral interventions)
• Feedback reinforces competence

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What is a competent system?
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Problem Case 3The Case of the Blue Kidney
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What Went Wrong?

• The personnel
• The attending surgeon
• The resident
• The 3rd year medical student
• The nurse
• The anesthesiologist

• The system
• The team in the OR
• Students and residents are often in the best
  position to recognize and prevent errors
• Punitive systems mitigate against disclosure
• Disempowerment mitigates against action

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High-Reliability SystemsCreating Mindful
Organizations

• Vigilance
• focus on safety
• assumption that systems tend to fail
• Tolerance of complexity and ambiguity
• reluctance to simplify
• patient-centeredness
• Critical curiosity
• mentoring reflection ? learning

• Sensitivity to operations
• being in touch with reality
• let them not eat cake
• Open communication
• transparency of intent
• non-punitive reporting
• Informed flexibility
• commitment to resilience
• Deference to expertise
• wherever it may reside
• after Weick, 2001

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