Reflective Medical Practice - Dr. Gawad

Reflective Medical Practice
What does it mean?
Different Principles?
How to apply it?
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria - EGY
drgawad@gmail.com

GKA Master Class – Alexandria 2014

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What does it mean?
Why does it exist?
Different Principles/Types
How to Apply Reflective Medical Practice?
Essentials to Apply Reflective Medical Practice
Seniors & Reflective Medical Practice
An Example of Reflective Practice
Benefits of Reflective Medical Practice

What does it mean?
Your daily practice: Contact with:

Patients

Brookfield, 1995
Thiel, 1999
Quinn, 2000
Paterson, Chapman, 2013

Your colleagues

The patient’s relatives

Non medical staff

What does it mean?

Patients

Your colleagues


Non medical staff

Evaluate your own clinical decision making
Evaluate your interactions with patients and team members

Using the results of self-evaluation to influence future
Brookfield, 1995
Thiel, 1999
Quinn, 2000

What does it mean?
• It is the process of learning
through and from experience
towards gaining new insights
of self and/or practice.

• It also tends to involve the
individual practitioner in being
self-aware
and
critically
evaluating their own responses
to practice situations.
Boud et al 1985
Boyd and Fales, 1983
Mezirow, 1981
Jarvis, 1992

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What dose it mean?
Why does it exist?

Why does it exist?
Learning must not be
absorbed by a process of
osmosis when juniors work
closely with more seniors

Smith, C.S. and Irby, D.M. (1997). The Roles of Experience and Reflection in Ambulatory Care Education.
Academic Medicine. Vol. 72. 32-35.

Why does it exist?
Learning must not be
absorbed by a process of
osmosis when juniors work
closely with more seniors
Medical educator must
move from that of
“purveyor of information”
to that of “facilitator of
learning”
Smith, C.S. and Irby, D.M. (1997). The Roles of Experience and Reflection in Ambulatory Care Education.
Academic Medicine. Vol. 72. 32-35.

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What dose it mean?
Why dose it exist?


‘Reflection-IN-action’
(thinking while doing)

(after-the-event thinking)

Where the competent
practitioner uses
knowledge, experience and
judgment to guide decisions
in real life clinical situations as
they are happening.

Schon (1990)

‘Reflection-ON-action’

Which happens after the
experience, enables learning
about clinical practice and
promotes development of
such practice.

You will need the following for practice
reflection:
Reflective notebook
to write notes, non answerable
enquiries and thoughts

A framework
to help the learner adopt the
discipline of reflection

Allocate a supervisor for the learner
to reflect with “provide a sounding
board”
Palmer, A., Burns, S. and Bulman, C. (1994). Reflective Practice in Nursing. Oxford: Blackwell Scientific.

Frameworks – General Idea

Always Ask

Frameworks – General Idea

Frameworks – Gibbs Cycle

Gibbs, G. (1988). Learning by Doing; a guide to teaching and learning Methods. Oxford: Further Education
Unit, Oxford Polytechnic.

Frameworks – Kolb’s Cycle

Frameworks – Rolfe’s Cycle

Frameworks – John’s Cycle

Recommended Template
• Describe a Clinical Issue/Event/Incident/or Error that you have
encountered in your daily work practice. Describe what happened.
• Describe your Reflection-IN-Action: Describe how you reacted, how you
felt.
• Describe your Reflection-ON-Action: Describe your analysis of what
happened.
• Describe your Conclusions.
• Describe what your learned from that experience.
• Describe your action plan to deal with a similar situation in the future.

Critical Thinking

Always support your reflection by critical
thinking and evidence based

Self Awareness

Self Awareness is vital if there is to be any attempt at
a behavior change

28 y old female with lupus nephritis that is controlled long time
ago (on steroids, azathioprine after completing euro lupus regimen with
cyclophosphamide).

She got pregnant, her aPL Abs were positive, we started low dose
aspirin and LMW heparin prophylaxis.
The treating PROF increased her maintenance steroid therapy to
20 mg from 5 mg.
The junior asked him WHY?,
The PROF said in 2ry APS (2ry to SLE) therapy needs more with
immunosuppression rather than just anticoagulation.

• The junior searched the pubmed and found a very
good review telling that the basic treatment will be
LDA + LMWH or unfractionated heparin
• As it's her first pregnancy there is no need to increase
her steroid level as long as there is no complications
yet, also steroids are associated with preterm
delivery, HTN, gestational diabetes.
• He returned back to the PROF with the info, then he
decreased her steroid level again.

Don’t Hesitate to Reflect Your Senior’s
Practice & Actions

Teaching Matrix

Doctors who work as
educators must reflect
themselves too

Feins, A., Waterman, M.A., Peters, A.S. and Kim, M. (1996). The Teaching Matrix: A Tool for organising Teaching and
Promoting Professional Growth. Academic Medicine. Vol. 71. 1200-1203.

Teaching Matrix

Feins, A., Waterman, M.A., Peters, A.S. and Kim, M. (1996). The Teaching Matrix: A Tool for organising Teaching and
Promoting Professional Growth. Academic Medicine. Vol. 71. 1200-1203.

Teaching Matrix
• Who are the target
audience?
• What is the time
allowed for me for
presentation?
• Is it educational or
state of the art and
appraisal?

Just to Remember the Recommended
Template
• Describe a Clinical Issue/Event/Incident/or Error that you have
encountered in your daily work practice. Describe what happened.
• Describe your Reflection-IN-Action: Describe how you reacted, how you
felt.
• Describe your Reflection-ON-Action: Describe your analysis of what
happened.
• Describe your Conclusions.
• Describe what your learned from that experience.
• Describe your action plan to deal with a similar situation in the future.

Clinical Issue/Event/Incident
• 27 years old married female on hemodialysis since 2 years from
well functioning AVF, 3 times per day, 4 hrs each session.
• She is not DM, HTN. She has no immunological disorder (SLE). The
cause of kidney disease is unknown.
• She is on ESA therapy adjusted to her body weight. Her TSAT is 35%
and S.Ferritin is 550. Hb level is 9.5 g/dl, although she is on ideal
ESA dose according her body weight.
• She is complaining of continues sense of fatigue, nausea and
vomiting.

What is your reflection IN action?

• You raised her ESA dose by 25% and after one month
her Hb level is 10g/dl, and there was no
improvement in her symptoms.

What is next?
• You raised her ESA dose again by 25% (total 50%) and
after one month her Hb level is 10.2g/dl, and there
was no improvement in her symptoms.

What is next?

All causes of resistant anemia are
excluded
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Her anemia is normocytic normochromic.
Her platelets and WBC are normal.
No evidence of hemolysis.
S.Vit B12, folate levels are normal.
No evidence of infection.
Her PTH level & trend are accepted.
Her thyroid function is normal.
ESR is not too high.
She is not malnourished.

What is next?
You decided to search the literature?

What are the key words you will use to search?
resistant

anemia

female hemodilaysis

What are the key words you will use to search?
resistant

resistant

anemia

anemia

female hemodilaysis

female hemodilaysis

So which test you will use to
confirm her pregnancy?
Beta HCG

So which test you will use to
confirm her pregnancy?
Beta HCG

As CKD patients have different hormonal
physiology than normal population
So, You decided to search the literature?

What is your Reflection On Action?
• Did you diagnose the case late?
• Did you use the appropriate test for diagnosis?

• What is your future plan when you face a CKD
female of child bearing age?
• Any other Reflection?

Conclusions & What you learned
• Although the incidence of pregnancy in child bearing females on HD is
low, you have to put it in mind all the time.
• Diagnosis of pregnancy in CKD patients needs a high degree of suspicion.
• Because beta HCG is removed by the kidney, beta HCG levels are higher at
each stage of gestation than in women with normal renal function So
pregnancy diagnosis must be by US.
• Always discuss with your child bearing aged HD females the risk of
pregnancy and advice her about contraception.
• Pregnant CKD patient (whether on HD or not) is a special category of
patients and need special care and follow up.

You have to reflect your medical
practice

To covert short
term memory to
long term one

practice

For Better
Performance

practice

So you will not
loss resources
or waste time

practice
So you will be
able to choose
the best
solution for
your difficult
situations

practice

To develop your
own way of
management

Reflective Medical Practice - Dr. Gawad

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