In the modern-day NHS, where pressure on doctors is growing, the importance of both resilience and reflection is increasing. This essay will discuss how these two factors are relevant to the lives of medical students and doctors.
Reflection is ‘ serious and careful thought. ’ (Cambridge dictionary, no date ) Defining reflection is quite difficult because there are many different models of reflection, such as Shön 1983, which is based on ‘reflection in action’ and ‘reflection on action’ (Mann, Gordon and MacLeod, 2007). Shön’s model suggests that individual starts to reflect when something seems to deviate from normal and then they later reflect in more depth once the event has occurred. Boud et al. is another model which defines reflection as the process of revisiting a personal experience and critically evaluating it (Jayatilleke and Mackie,2012).
I learned about the concept of reflective practice from a GP registrar at my CBM placement, who spoke about her experience reflecting on a prescribing error that had resulted in a patient being given too much morphine. Although the patient suffered no long term harm, the GP registrar had to have a meeting with colleagues. The discussion in the meeting involved ‘root cause analysis ’, which constitutes of identification of the causes of the error ( i.e stress ), examining the root of those causes (i.e. fatigue from working extended hours) and using this information to prevent reoccurrence of the mistake(ACT Academy, 2018). This reflective approach is relevant to me as a future doctor because if I make medical errors I will need to fill in an incident report and reflect constructively on feedback from senior colleagues. Incident reporting is used throughout the NHS for events regarding patient safety and aims to promote reflective practice amongst staff (NHS, 2017). However, a problem with this approach is that it can lead to the ‘second victim phenomenon’ (Kelly, Blake and Plunkett, 2015), where the individual involved may feel guilty and consequently experience problems such as depression. The risk of this occurring can be minimised by support from colleagues and through the emphasis on positive reflection in addition to reflection on errors. A positive reflection of events that went well can boost confidence and build resilience.
A study attempting to examine the structure of reflective practice in medicine, using multiple-choice questionnaires to survey 202 doctors in Brazil, established that reflective practice encompasses five main factors which are interlinked in a ‘multidimensional’ manner: deliberate induction of the reflective process, deliberately making deductions, synthesizing and testing new solutions, meta- reasoning ( the individual examining the reasons for their actions ) and an openness to reflect (Mamede and Schmidt, 2004). Although the sample size was quite small and limited to one country, the study depicts a more evidence-based approach to defining reflective practice. The factors the study found to be important in reflective practice can be identified in the aforementioned example of the GP registrar and in my own experiences of reflection.
As a medical student, I constantly reflect on how I communicate with patients at my CBM placement. For example, after conducting a patient interview to elicit a social history from a patient, I reflected on my questioning style. I noticed that just asking the question ‘How are things at home?’ to find out about the patient’s family circumstances was insufficient as the patient answered about her financial circumstances. Upon reflection, I realized that the patient had misinterpreted the question and I decided that in the future I would follow up the open question with more closed questions such as ‘Do you live alone ?’ in order to be more specific. In this situation, I deliberately analysed the problem, considered what I could improve and synthesized a new solution. This example depicts how reflection can lead to long term improvements in clinical communication and it exemplifies the Boud et al model of reflection as I revisited the interview and reflected in depth.
Throughout my medical education and beyond, the reflection will play an integral role in developing my communication skills, practical skills and also consolidating knowledge because reflection is a key element of Kolb’s cycle of learning (Sanders, 2009). I am also required to show evidence of reflective practice in order to be revalidated (GMC, no date ). As I progress into my career and gain more experience of consultations, Shön’s model of ‘reflection in action’ will become more relevant to me as I will be able to recognise when a consultation isn’t normal and start to reflect immediately. This model of reflection allows one to have more control of the event when it is occurring.
Resilience is a person’s ability to ‘bounce back’ from emotional or physical challenges (Southwick et al., 2014). Several models also exist that aim to define resilience. According to the compensatory model, resilience is a ‘factor that neutralizes risk ’ directly( Ledesma, 2014 ). The challenge model proposes the idea that overcoming a ‘moderate’ challenge can help develop resilience. Finally, the protective factor model postulates that protective factors such as the ability to manage emotions, self-reflection and self-esteem contribute indirectly to the development of resilience.
Due to the challenging nature of their course, medical students experience more stress(Firth, 1986 ) and have higher rates of mental health issues such as depression in comparison to other members of the population. Therefore, developing resilience is crucial to reducing the prevalence of stress-related mental health problems amongst medical students and is included GMC guidance for medical students (GMC, 2016). Dyrbye et al (2010), which analysed resilience in 792 medical students across 5 medical schools and examined various factors that affected it, found that ‘resilient’ students were less likely to suffer from mental and physical health problems and more likely to recover from burnouts than those that did not exhibit resilience. Medical students who weren’t employed, hadn’t experienced traumatic events in life, had a good perception of their learning environment and had good social support were more likely to be resilient. The results suggest that a potential challenge to developing resilience could be the influence of external factors such as social support, which are beyond an individual’s control. Hence, medical schools should provide emotional support to students and encourage peer support. This approach would demonstrate the compensatory model as social support is directly associated with the reduced likelihood of experiencing burnouts.
In my experience, resilience was important in the transition from school education to medical school, significantly because of the monumental increase in workload and independent learning. The new challenges I faced led to stress and lower levels of self-confidence. However, I overcame the challenge through improved organizational skills: I started to use my planner more and prioritized tasks according to their deadlines. This exemplifies the protective model because improving my organizational skills reduced stress and consequently I was more productive The transition into life as a junior doctor will be more different to this example because simply improving organizational skills may not necessarily help with coping with the increase in responsibility, I think developing a good network of social support would be more important to developing resilience then.
Moreover, developing resilience will be key to facing phases of low morale in my future career; a BMA quarterly survey found that 42% of the doctors who had responded had ‘low’ morale ( BMA, 2018). This is rather problematic and can put patient safety at risk. According to a 2018 systematic review of techniques of developing resilience, the most effective way of building resilience is a combination of both Cognitive behavioral therapy ( CBT) and mindfulness ( Joyce et al ., 2018) . Although there is currently no ‘gold standard’ method of measuring resilience, this review of studies does provide empirical data to suggest these methods may be effective. CBT constitutes of therapy sessions, which encourage people to confront their emotions and develop more positive mindset ( NHS, 2018 ). . Although I have never tried CBT, I think developing a positive attitude has helped me to be more resilient when I experience setbacks. However, CBT requires a lot of cooperation and extra work from the individual, this might prove to be difficult for doctors or medical students who already have large workloads. It can also be difficult people experiencing severe mental health problems to confront their emotions. Mindfulness is a meditative technique that helps individuals to increase self-awareness. Personally, I didn’t find mindfulness useful as it was difficult to focus. However, the success of both methods are variable and depends on the individual involved.
After examining the literature and my own experiences, it’s apparent that resilience is crucial in overcoming challenges faced by doctors and medical students and reflection helps them to learn from this process. Developing good reflective skills and resilience is an extended process, involving both intrinsic qualities and external factors such as support from peers, which prepares medical students for their career as a doctor. Both of these factors contribute to lifelong learning and ultimately improve the quality of care.