Margaret M. Plack

The Reflective Practitioner: Reaching for Excellence in Practice

Reflection is widely accepted as a tool for learning in higher education. It has been addressed in some areas of medical education but not in the pediatric literature.1–8 It is considered essential to professional practice. Reflection allows for the interconnections between observations, past experiences, and judgment to come to the fore in clinical decision-making.9,10 Reflection gives meaning to experience and promotes a deep approach to learning because it encourages trainees to reframe problems, question their own assumptions, and look at situations from multiple perspectives as they analyze their lived experiences.6,9–14 Reflection fosters lifelong learning because it encourages trainees to recognize gaps in their own knowledge and attend to their own learning needs.6 Reflection is particularly important in medicine, in which evidence-based practice and client-centered care require the physician to analyze best evidence while considering his or her values and assumptions vis-a-vis the values, beliefs, and goals of each patient. It enables trainees to recognize their own assumptions and how those assumptions might impact the therapeutic relationship and their clinical decisions. Reflection also helps practitioners develop a questioning attitude and the skills needed to continually update their knowledge and skills, which is essential in todays rapidly changing global health care environment.6 The importance of the reflective process is further acknowledged by the Accreditation Council for Graduate Medical Education (ACGME) as underlying a number of the expected competencies is the development of reflective practitioners.15 Much has been written about reflective practice, particularly with respect to how it can be incorporated into the classroom. However, little has been written about what reflection is, how it can be assessed, or how it can be facilitated in the clinical setting. To enable pediatric academic faculty and practicing pediatricians to facilitate reflective … Address correspondence to Margaret M. Plack, PT, EdD, Program in Physical Therapy, George Washington University School of Medicine and Health Sciences, 900 23rd St NW, Suite 6145, Washington, DC 20037. E-mail: hspmxp{at}gwumc.edu

Learning in a chaotic environment

Purpose – The purpose of this study is to understand how, when, and why emergency medicine residents learn while working in the chaotic environment of a hospital emergency room.Design/methodology/approach – This research used a qualitative interview methodology with thematic data analysis that was verified with the entire population of learners.Findings – Analysis of the data revealed four different types of learning episodes, each with facilitating factors. The episodes varied in intensity, duration, and the degree of motivation and self‐direction required of the learner. One episode could prompt another. Learning occurred both individually and in social interaction in the workplace during the episode, as well as outside of the workplace environment after the experience had occurred.Research limitation/implications – Recommendations for individuals to maximize their learning related to this chaotic work environment are identified, along with associated implications for their trainers. These suggestions a...

Acting on Reflection: the Effect of Reflection on Students’ Clinical Performance on a Standardized Patient Examination

BackgroundLittle evidence exists to support the value of reflection in the clinical setting.ObjectiveTo determine whether reflecting and revisiting the “patient” during a standardized patient (SP) examination improves junior medical students’ performance and to analyze students’ perceptions of its value.DesignStudents completed a six-encounter clinical skills examination, writing a guided assessment after each encounter to trigger reflection. SPs evaluated the students with Medical Skills and Patient Satisfaction checklists. During the last three encounters, students could opt to revisit the SP and be reevaluated with identical checklists.ParticipantsOne hundred and forty-nine third year medical students.MeasurementsChanges in scores in the Medical Skills and Patient Satisfaction checklists between first visit and revisit were tested separately per case as well as across cases.ResultsOn the medical skills and patient satisfaction checklists, mean revisit scores across cases were significantly higher than mean first visit scores [12.6 vs 12.2 (pooled SD = 2.4), P = .0001; 31.2 vs 31.0 (pooled SD = 3.5), P = .0001)]. Sixty-five percent of the time, students rated “reflect–revisit” positively, 34% neutrally, and 0.4% negatively. Five themes were identified in the positive comments: enhancement of (1) medical decision making, (2) patient education/counseling, (3) student satisfaction/confidence, (4) patient satisfaction/confidence, and (5) clinical realism.ConclusionsOffering third year medical students the option to reflect and revisit an SP during a clinical skills examination produced a small but nontrivial increase in clinical performance. Students perceived the reflect–revisit experience as enhancing patient-centered practices (counseling, education) as well as their own medical decision making and clinical confidence.

Reflective Practice: A Model for Facilitating Critical Thinking Skills within an Integrative Case Study Classroom Experience

Background and Purpose. Reflection is the hallmark of professional practice. Professionals reflect in action, assess outcomes, and seek continuous improvement. This article presents a model by which all aspects of reflective practice can be facilitated within an integrative case study classroom experience. Description and Evaluation. Physical therapy students from Stony Brook University participated in a week‐long integrative case study course following their first semester of professional studies. This course served to enhance critical thinking skills as students integrated and applied course material in preparation for clinical practice. Paper patients, video patients, and interactions with residents from a local nursing home provided the experiential bases for reflective activities. Students worked through the patient/client management model in developing a plan of care and providing interventions for a number of residents. Each experiential component was followed by a reflective activity. Students worked independently and in small faculty‐mentored groups, and participated in large group discussions. Faculty mentors encouraged questioning and the exploration of assumptions and alternative perspectives. Problem lists, evaluations, care plans, student‐generated metaphors, group presentations, and summative reflective essays confirmed the types and levels of reflection that occurred throughout the week and provided evidence of critical thinking, integration, and professional development. Outcomes. This model demonstrated how the reflective process can be incorporated into an integrative classroom experience to prepare students to meet the demands of practice as they begin to take on the role of a reflective practitioner and lifelong learner. It demonstrated the ease of facilitating integration, critical thinking skills, and professional behaviors in a classroom setting. Discussion and Conclusions. Professional practice requires physical therapists (PTs) to function efficiently and effectively within a dynamic environment. Literature suggests that reflective practice is valuable in the development of a practitioner who can engage in ongoing learning and professional development, and continually reassess and modify care. This model offers a mechanism in which theory meets practice in the classroom setting in preparation for clinical practice.

The Evolution of the Doctorate of Physical Therapy: Moving beyond the Controversy

&NA; A great deal of debate has surrounded the newest professional (entry‐level) degree in physical therapy, the Doctorate of Physical Therapy (DPT). This article provides a historical view of the evolution of physical therapy education from its earliest technical roots to the current status it holds within academia. Political, social, and economic factors that have influenced the growth of the field and the development of physical therapy education are explored to give perspective to the transition to an entry‐level DPT degree. A presentation of different viewpoints on controversial issues surrounding the DPT highlights the challenges currently facing the profession, which the adoption of new entry‐level educational standards may address. Weighing the historical advances of the field with consideration of the challenges todays health care environment present, the authors recommend elevating the rigor of entrylevel educational standards and validating academic outcomes to support the credibility of the DPT.

Assessing Reflection and Higher-order Thinking in the Clinical Setting Using Electronic Discussion Threads

Background and Purpose. Students learn both theory and practical application in the classroom. However, for many, these aspects of clinical practice are not fully comprehended until students encounter real‐life situations that require them to analyze, evaluate, modify, and apply what they know. Reflection can help students connect classroom knowledge to clinical practice and enable students to engage in higher‐order thinking, moving beyond knowledge and comprehension to analysis, synthesis, and evaluation critical for practice. Integral to effective clinical teaching is the ability to assess outcomes. While the literature offers strategies to facilitate reflection and higher‐order thinking, little has been written about the assessment process. The purpose of this study was to design and test a method of assessing reflection and higher‐order thinking evident in electronic discussion board threads of students involved in virtual action learning sets in the clinical setting. Subjects. Seven entry‐level physical therapist students on their final full‐time clinical internship participated in this study. Participants were engaged in a collaborative model of clinical education on an acute rehabilitation unit. Methods. Participants were assigned to 2 groups based on the timing of their internship. Both groups received a 2‐hour in‐service on reflective practice, submitted critical incidents to an electronic discussion board, and participated in an electronic discussion for 4 weeks. Following the discussion board activity, discussion threads were downloaded and analyzed for the presence of the elements of reflection and levels of higherorder thinking using coding schemas previously reported in the literature. The submissions were coded independently by 3 raters and interrater reliability was assessed by percent agreements and kappa statistics. Results. Moderate to almost perfect levels of agreement between raters were achieved for most of the coding schemas used, with interrater prevalence‐adjusted bias‐adjusted kappa coefficients that ranged from 0.38 to 0.92. Discussion and Conclusion. This study provides a reliable method of assessing reflective thinking and higher‐order processing in the clinical setting through the use of electronic discussion boards.

Development of an undergraduate pharmacogenomics curriculum.

Pharmacogenomic biomarkers are becoming increasingly common in medicine and drug development. However, there is a genuine concern that the healthcare workforce will be ill-equipped to translate this information to clinical practice. As a result, a major effort is underway to educate future healthcare professionals on pharmacogenomics. This paper describes the development of a year-long course that aims to instill the fundamental concepts of this rapidly growing field into the minds of undergraduate students. This course offers the advantage of exposing students to the concepts of pharmacogenomics prior to their enrollment in PhD, PharmD or MD/DO graduate programs.

Computer-Assisted Instruction versus Traditional Instruction in Teaching Human Gross Anatomy

ABSTRACT: The purpose of this study was to determine whether first‐year entry‐level students in a physical therapy masters degree program who were taught human gross anatomy by traditional instruction methods showed a significant difference in their level of gross anatomy subject knowledge from those taught by the use of lecture, computer‐assisted instruction (CAI), and prosected cadavers. An ex post facto design was utilized to compare outcomes of 48 entry‐level physical therapy masters degree students in 1996 and 1997 using CAI and prosections with outcomes of 102 entry‐level physical therapy masters degree students in 1996 and 1997 using traditional cadaver dissection in learning human gross anatomy. The same instructor taught each group. Four written examinations, five practical examinations, and final course grades were analyzed to determine whether there was any significant difference in subject knowledge gained between groups. This investigator found that there was no significant difference between groups on subject knowledge gained in human gross anatomy as determined by the four written examinations, five practical examinations, and final grades for each course. The findings support evidence from the fields of medicine, nursing, and other allied health professions that the use of CAI and prosections is as effective as traditional dissection in teaching human gross anatomy to first‐year entry‐level physical therapist students.

How learning transfers: A study of how graduates of a faculty education fellowship influenced the behaviors and practices of their peers and organizations

Purpose Faculty development programs have been criticized for their limited assessment methods, focused only on the learners and limited to satisfaction measures or self-reported behavior changes. Assessment of organizational impact is lacking. This study explored the impact of faculty education fellowship graduates on their organization and how that impact occurred. Method The design was a qualitative study of 13 departments across three institutions, partnered with the George Washington University School of Medicine and Health Sciences. In-depth interviews with 13 supervisors and 25 peers of graduates were conducted in fall 2012 to examine graduates’ organizational impact related to program purposes: enhancing teaching skills, pursuing scholarship in education, and developing leadership potential. Triangulation, purposive sampling, rich descriptions, and member checks minimized bias and optimized transferability. Results A model of how graduates of a faculty education fellowship transfer learning to peers and their organizations emerged. Analysis of interview responses showed that in the presence of environmental facilitators, graduates exhibited enhanced confidence and five new behaviors. Graduates raised peer awareness, leading to changes in individual and group practices and development of shared peer understanding. Analysis suggests they facilitated a culture of continuous learning around teaching, scholarship, and leadership. Conclusions This study enhances traditional assessment of faculty education fellowship programs by examining the impact that graduates had on peers and work groups. A model is proposed for how graduates interact with and impact work group processes and practices. This model can facilitate more comprehensive program assessments, which can demonstrate program impact beyond the individual participant.

Peer-Facilitated Virtual Action Learning: Reflecting on Critical Incidents During a Pediatric Clerkship

OBJECTIVES Action learning (AL) facilitates reflection, critical thinking, and learning while solving real-world problems. Virtual AL is an asynchronous collaborative process that encourages students to analyze their critical incidents and learn from these experiences. The researchers sought to: 1) determine whether medical students engaged in peer-facilitated virtual action learning (VAL) demonstrated reflection and critical thinking around complex issues during their pediatric clerkship; and 2) identify challenges students face during their clerkships. METHODS Seventy clerkship students were introduced to reflection and participated in VAL by using an electronic discussion board. Each posted 1 critical incident and group members responded with thought-provoking questions and comments to facilitate reflection and analysis. Weekly, students who posted incidents revisited their incidents, pondered the questions posed, and wrote essays summarizing their reflections and insights gained. Data were analyzed using qualitative methods. RESULTS Seventy incidents, 210 responses, and 70 revised incidents/essays were analyzed. Outcomes included broadened perspectives (44/70), questioned assumptions (12/70), and reconfirmed thinking (14/70). Content themes included communication, role identification, medical treatment concerns, and limited voice and power. CONCLUSIONS Most of the students engaged in VAL demonstrated reflection on complex clinical issues. Themes portrayed struggles encountered and exposed issues in the hidden curriculum, suggesting a lack of voice and power that may lead to missed learning opportunities. Discussion threads offered the clerkship director insights into the overall student experience to improve future clerkship experiences.