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Reflective Learning, Mindful Practice, and Professional Competence


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Title: Reflective Learning, Mindful Practice, and Professional Competence

Reflective Learning, Mindful Practice, and
Professional Competence
  • Ronald M. Epstein, MD
  • Professor of Family Medicine and Psychiatry
  • University of Rochester
  • January 2003

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
Uninvited Guests in Medicine
  • Ambiguity and uncertainty (Schon)
  • Conflict between the needs of patients and
  • Strong emotions the patients and ones own
  • Technical errors
  • Contradictory evidence
  • Unanticipated serious illness
  • Impermanence of knowledge
  • Illusion of competence
  • Lack of control

  • 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

  • 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

  • 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

Practice-based LearningandSystems-Based Care
  • Problem Case 1Pseudo-Dehydration Cured by
    Foley Catheter

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

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

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

Habits of Mindful Practitioners
  • Attentive observation
  • observing the observer while observing the
  • peripheral vision
  • pre-attentive processing
  • Critical curiosity
  • asking reflective questions that tend not toward
  • Tolerating (and enjoying) being wrong
  • Beginners mind
  • informed flexibility
  • willingness to set aside categories and examine
  • 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

Goals of Mindfulness in Medicine
  • Attentive observation
  • Critical curiosity
  • Beginners mind
  • Presence
  • Clinical reasoning / EBM
  • Technical skills
  • Relationship-ctrd. care
  • Ethics

Problem Case 2 PE WNL
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

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

Professional Competence and Mindfulness
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.

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

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
  • Developmental (Dreyfus)
  • student ? novice ? advanced beginner ? competent
    ? proficient ? expert ? master

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

From Competence to Capability (Frazer BMJ
  • 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

Complexity and Uncertainty (S Frazer. BMJ
Mindful Practice
  • Attentive observation
  • Critical curiosity
  • Beginners mind
  • Presence

Cultivating Mindfulness
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

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

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
  • If there were relevant data that you ignored,
    what might they be?

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.

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
  • 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?

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

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

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
  • Write quickly, without worrying about spelling or
    repeating yourself.
  • Gelb, MJ. How to Think Like Leonardo da Vinci,

  • 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.

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.

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

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

Millers Pyramid
Shows How
Knows How
Assessment in the Real World
What we tend not to assess -- causes of common
errors -- habits of mind -- systems, teamwork
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
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

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

Poor Communi-cation

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

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

High-Reliability SystemsCreating Mindful
  • 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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