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Applied reflective practice in medicine and anaesthesiology

2019; Elsevier BV; Volume: 122; Issue: 5 Linguagem: Inglês

10.1016/j.bja.2019.02.006

1471-6771

Audrey DunnGalvin, Jeffrey B. Cooper, George Shorten, Richard Blum,

Clinical Reasoning and Diagnostic Skills

Reflection is integral to the development of human thought and values; ‘A defining condition of being human is that we have to understand the meaning of our experience’.1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar The ancient Greeks practised ‘reflection’ as a form of contemplation in order to ‘know thyself’.2Lawrence-Wilkes L. Ashmore L. The reflective practitioner in professional education. Palgrave Macmillan, Basingstoke2014Google Scholar There are references also to the power of reflective learning in the writings attributed to Confucius, around 460 b.c.2Lawrence-Wilkes L. Ashmore L. The reflective practitioner in professional education. Palgrave Macmillan, Basingstoke2014Google Scholar Reflection implies thinking about experiences retrospectively in order to learn from them.3Bringle R.G. Hatcher J.A. Reflection in service learning: making meaning or experience.Educ Horiz. 1999; 77: 179-185Google Scholar We use the term Reflective Practice here to provide a clear unifying concept that captures both the process and goals of reflection. Although ‘theory apart from experience cannot be definitely grasped’, Dewey4Dewey J. How we think.Revised ed. DC Heath, Boston1933Google Scholar acknowledges that experience by itself does not necessarily result in learning. Experience becomes educative when critical reflective thought leads to growth and the ability to take informed actions. Reflective Practice is therefore a deliberate way of thinking about experiences: to learn from mistakes; to identify skills and strengths; and to develop options and actions for change and future success, promoting a lifelong process of learning and development.4Dewey J. How we think.Revised ed. DC Heath, Boston1933Google Scholar Any working model, concept, or theory needs to have relevance and face validity for the ‘real world’ diversity and complexity of clinical practice. Evidence supports the contention that reflection is integral to a deep approach to learning and plays an important role in enhancing professional practice.5Kolb A.Y. Kolb D. Learning styles and learning spaces: enhancing experiential learning in higher education.Acad Manage Learn Educ. 2005; 4: 193-212Crossref Scopus (2460) Google Scholar In medicine, reported benefits of Reflective Practice include improvements in undergraduate skills in self-directed learning, improved motivation, and enhanced quality of patient care.6Mamede S. Schmidt H.G. Reflection in medical diagnosis: a literature review.Health Prof Educ. 2017; 3: 15-25Google Scholar Reflective Practice is associated with improved and greater diagnostic accuracy, particularly in challenging cases.6Mamede S. Schmidt H.G. Reflection in medical diagnosis: a literature review.Health Prof Educ. 2017; 3: 15-25Google Scholar Conversely, failure to reflect on one's own thinking processes, including critical examination of reasoning, assumptions, judgement, and decisions, can contribute to diagnostic error and poor patient management practices.6Mamede S. Schmidt H.G. Reflection in medical diagnosis: a literature review.Health Prof Educ. 2017; 3: 15-25Google Scholar Professional colleges and licensing authorities, particularly in the health professions, have focused on how professionals maintain and enhance their knowledge. The Accreditation Council for Graduate Medical Education (ACGME) requires all US residency programmes to facilitate a form of reflective practice,7Accreditation Council for Graduate Medical Education [Internet] Chicago: ACGME Common Program Requirements, approved; [updated 2015 Nov 20]. Available from: http://www.acgme.org (accessed 2018 October 20).Google Scholar and the General Medical Council requires demonstration of proficiency in reflective learning in revalidation procedures for doctors.8General Medical Council (GMC) Good Medical Practice framework for appraisal and revalidation.2012http://www.gmcuk.org/GMP framework for appraisal and_revalidation.pdf41326960.pdfGoogle Scholar These regulatory requirements represent a legitimate effort towards greater accountability, as does the move to competency-based training, definition of the role of a medical professional, and greater transparency in regulatory oversight. The requirements do not, however, address the deficit in evidence that would be necessary to answer the ‘big questions’ on Reflective Practice that a training body, trainer, or trainee might reasonably pose. Nor do the requirements point towards a practical form of training or implementation suitable for scaling and transfer across healthcare jurisdictions. These questions include: (i) What constitutes Reflective Practice and does it have value in education and training across diverse disciplines and clinical contexts? (ii) Is some form of generic training in Reflective Practice of value in medicine? (iii) Is improvement in Reflective Practice likely to produce measurable benefits (in terms of physician well-being or patient outcome)? (iv) Is it possible to provide a practical form of training or implementation suitable for scaling and transfer across healthcare jurisdictions? In effect, we need to agree on what defines Reflective Practice, its value to medicine, and how it is now practiced before we can decide if improvement is needed. If improvement is required, we must be able to reliably measure/assess any changes so that we can know if—and how—this has impacted on learning and practice outcomes. Here, we take some steps towards answering questions (i–iv) to provide a foundation for a strategic, focused, and harmonised implementation of Reflective Practice in medical education. In considering the practical value that reflection can offer to medical practice (and practitioners), we are confronted by a diversity of sources of evidence and an often confusing use of language. As with any theoretical concept, definitions of Reflective Practice convey a basic technical description, but do not explain how and why something operates, nor teach us how to use it. Definitions can, however, provide an agreed terminology and ensure consistency in meaning, providing a necessary foundation for how Reflective Practice can be used for training, learning, practice development, and self-improvement.2Lawrence-Wilkes L. Ashmore L. The reflective practitioner in professional education. Palgrave Macmillan, Basingstoke2014Google Scholar Reflective Practice (see Fig. 1 for definitions) is the use of reflective methods for personal and professional growth. Many theorists1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar, 2Lawrence-Wilkes L. Ashmore L. The reflective practitioner in professional education. Palgrave Macmillan, Basingstoke2014Google Scholar describe the levels of reflective thinking that enable deep learning (the process). These range from simple reflection (contemplation without necessarily having a purpose) to critical reflection (contemplation with evaluation; Fig. 1). The product or goal of Reflective Practice is development of new knowledge and practices that improve professional performance. John Dewey (1859–1952) is seen as the founder of experiential education which he strongly grounded in the scientific process. In How We Think (1910), Dewey described critical thinking as reflective thought, moving reflection beyond contemplation; ‘...Active, persistent, and careful consideration of any belief, or supposed form of knowledge, in light of grounds that support it, and the further conclusions to which it tends….’7Accreditation Council for Graduate Medical Education [Internet] Chicago: ACGME Common Program Requirements, approved; [updated 2015 Nov 20]. Available from: http://www.acgme.org (accessed 2018 October 20).Google Scholar From this perspective, critically and deeply thinking about an experience or event has a clear purpose in encouraging more careful judgements, based on objective grounds. Jean Piaget9Piaget J. Seagrim tr, G.M. The mechanisms of perception. Routledge & Kegan Paul, London1969Google Scholar stressed that experience, reflection, and action are the foundation by which adult thought is developed. Deliberate reflection is needed for learning, and through connection to action comes the development of new understanding and knowledge. David Kolb5Kolb A.Y. Kolb D. Learning styles and learning spaces: enhancing experiential learning in higher education.Acad Manage Learn Educ. 2005; 4: 193-212Crossref Scopus (2460) Google Scholar produced seminal works on experiential learning theory, within a professional training framework (based on what professionals actually do). He described Reflective Practice as ‘…a dialogue of thinking and doing through which I become more skillful…’,5Kolb A.Y. Kolb D. Learning styles and learning spaces: enhancing experiential learning in higher education.Acad Manage Learn Educ. 2005; 4: 193-212Crossref Scopus (2460) Google Scholar with the goal of promoting innovation and professional excellence. Kolb's reflective model is centred on the transformation of information into knowledge. The Learning Process Diagram shows four main stages of the learning process, conceived as a continuous loop: (i) Experience, (ii) Observation/Reflection, (iii) Abstract Conceptualization, and (iv) Experimentation/Experience. In this way, knowledge derived from reflection on one event is continuously applied and reapplied in new situations, building on a practitioner's prior experiences and knowledge.2Lawrence-Wilkes L. Ashmore L. The reflective practitioner in professional education. Palgrave Macmillan, Basingstoke2014Google Scholar, 3Bringle R.G. Hatcher J.A. Reflection in service learning: making meaning or experience.Educ Horiz. 1999; 77: 179-185Google Scholar Donald Schön's1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar The Reflective Practitioner (1983) focused on professional Reflective Practice and the role of the reflective practitioner. Reflection-in-action (‘thinking on your feet’), together with reflection-on-action (considering an action already taken, in terms of what worked and what could have been done differently) form a reflective process for decision-making and professional growth. For Schön, professional growth really begins when an experience is viewed through a critical lens, leading to surprise, puzzlement, or doubt. These are ‘light bulb’ moments in that doubt about one's action(s) is useful and necessary to bring about a different way of thinking and of framing situations. More recently, Mezirow10Mezirow J. Associates Learning as transformation – critical perspectives on a theory in progress. Jossey-Bass, San Francisco2000Google Scholar and Moon11Moon J. Reflection in learning and professional development—theory and practice. Routledge Falmer, Abingdon, Oxon1999Google Scholar have defined Reflective Practice as ‘a set of abilities and skills to indicate the taking of a critical stance, an orientation to problem solving or state of mind’. Both see reflective practice as transformational. The goal or product of the process is the same as for the other theorists discussed above—that is to guide future action more effectively and appropriately. Reflective Practice is adaptable as a set of ideas and can also be used alongside other related concepts for training, learning, personal development, and self-improvement. Schön's model of reflection is built on the theory of single-/double-loop learning.12Argyris C. Schön D. Organizational learning: a theory of action perspective. Addison-Wesley, Reading, MA1996Google Scholar Single-loop learning occurs when a practitioner or organisation, even after an error has occurred and a correction is made, continues to rely on current strategies, techniques or policies when a situation again comes to light. Double-loop learning involves the modification of objectives, strategies, or policies so that when a similar situation arises, a new framing system is used. This perspective is similar to dual-processing theories, which have frequently been applied to clinical reasoning and diagnostic error in medical literature13Norman G.R. Monteiro S.D. Sherbino J. Ilgen J.S. Schmidt H.G. Mamede S. The causes of errors in clinical reasoning.Acad Med. 2017; 92: 23Crossref PubMed Scopus (242) Google Scholar and to Schön's1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar and Kolb's5Kolb A.Y. Kolb D. Learning styles and learning spaces: enhancing experiential learning in higher education.Acad Manage Learn Educ. 2005; 4: 193-212Crossref Scopus (2460) Google Scholar concept of the purposes of reflection-on-action. Kahneman and colleagues14Kahneman D. Slovic P. Tversky A. Judgement under uncertainty: heuristics and biases. Cambridge University Press, Cambridge1982Crossref Google Scholar describes mental life using the metaphor of two agents, System 1 and System 2, ‘fast and slow thinking’, respectively. In an applied context, System 1 (unconscious, fast, automatic) selects relevant aspects of presented information, leading to an automatic and very rapid selection of a mental model, and hence to a decision. System 1 reasoning may be useful during straightforward events in which quick action is required; however, it may lead to errors particularly in more complex situations.6Mamede S. Schmidt H.G. Reflection in medical diagnosis: a literature review.Health Prof Educ. 2017; 3: 15-25Google Scholar, 13Norman G.R. Monteiro S.D. Sherbino J. Ilgen J.S. Schmidt H.G. Mamede S. The causes of errors in clinical reasoning.Acad Med. 2017; 92: 23Crossref PubMed Scopus (242) Google Scholar System 2 (analytic, reflective) may, or may not, intervene to revise this initial System 1 mental model if appropriate (by generating alternative hypotheses or potential solutions). As our processing capacity is limited, we are likely to be satisfied with an initial intuition. As in Schön's model,1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar with increasing experience the knowledge network becomes more coherent and System 2 reasoning is invoked more appropriately. Thus, reflective practice may benefit not only the speed and accuracy of System 1 by continually informing it, but may also provoke System 2 reasoning when required. In Figure 2, we summarise a model that might inform standard medical education and training programmes using existing formats. The individual progresses from experiencing an event through to an evaluation of the event, to new learning and application. The process simplifies what is usually a more complex event. Inevitably, individuals will have been primed by many diverse previous experiences overlaid upon one's working model or ‘schema’9Piaget J. Seagrim tr, G.M. The mechanisms of perception. Routledge & Kegan Paul, London1969Google Scholar of a task or situation. Boud and Walker15Boud D. Walker D. Promoting reflection in professional courses: the challenge of context.Stud Higher Educ. 1998; 23: 191-206Crossref Scopus (501) Google Scholar describe the impetus for new reflection coming from ‘a whole series of occurrences over time eventually causing a sense of dissatisfaction which leads to reconsideration of them’. The hallelujah moment, and the event which produces it, are the exceptions rather than the rule. The function of our model is to allow the learner to assemble (or organise) experience, memories, interpretations, and the emotions that go with them in a way that is useful for learning. By proposing such a model, we are attempting to enable a trainee to piece together ideas, feelings, and observations (drawn from different stages) in a constructive way and to make explicit how existing frameworks are suitable to the specific setting of medical training. This integrated framework is explained and applied using a hypothetical case study (Case Study; Box 1). The case study shows how Reflective Practice can be a powerful tool to reduce diagnostic errors and increase diagnostic performance. For this to happen, reflection-in-action must be triggered to interfere with initial diagnostic reasoning, which requires confrontation. If Reflective Practice is systematically taught, the use of deliberate reflection makes it is more likely that System 2 reflective reasoning will intervene when necessary and double-loop learning will occur. In time, the knowledge network will become richer, and the practitioner will become more proficient in practice, developing a ‘repertoire’ or toolbox.10Mezirow J. Associates Learning as transformation – critical perspectives on a theory in progress. Jossey-Bass, San Francisco2000Google Scholar Thus, Reflective Practice may produce professionals who are more adaptable and innovative.Box 1Case study exampleA male resident accidently administered the incorrect drug. System 1 had selected relevant aspects of presented information (e.g. a group of symptoms), leading to an automatic and very rapid selection of a mental model, and to a quick decision by the busy resident. This fast, automatic process can be useful, particularly in routine, less complex contexts.17Blum R.H. Boulet J.R. Cooper J.B. Muret-Wagstaff S.L. Simulation-based assessment to identify critical gaps in safe anesthesia resident performance.Anesthesiology. 2014; 120: 129-141Crossref PubMed Scopus (43) Google Scholar, 20Wald H.S. Borkan J.M. Taylor J.S. Anthony D. Reis S.P. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing.Acad Med. 2012; 87: 41-50Crossref PubMed Scopus (204) Google Scholar On later discussion with the attending, the resident tells her that ‘I will never do that again!’ The attending then prompted him to reflect more deeply by asking ‘What could you do to prevent that from happening again. What else might you do?’ Double-loop learning involves the modification of objectives, strategies or policies so that when a similar situation arises a new framing system is used.12Argyris C. Schön D. Organizational learning: a theory of action perspective. Addison-Wesley, Reading, MA1996Google Scholar Schön1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar describes how puzzlement or doubt about an action, event, or experience can move us on from reflection-in-action to reflection-on-action. If reflection-in-action had been triggered in the resident through the Reflective Practice process, it would interfere with the initial reasoning, and cause a switch to System 2.14Kahneman D. Slovic P. Tversky A. Judgement under uncertainty: heuristics and biases. Cambridge University Press, Cambridge1982Crossref Google Scholar Reflection-on-action (deductive thinking or backward reasoning) will then take effect. The resident will think more deeply about any special issues or factors encountered during the clinical assessment that may have impacted his decision.1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar He then considers issues such as the way he lays out drugs, does not draw up a drug until needed particularly for the most potent drugs, and/or he double checks with a colleague. Through careful planning and systematic elimination, a new understanding is synthesised, ‘What should I do differently next time’? In this hypothetical example, the reflective process may result in modification of initial assessment procedures, protocols, and/or routines that in turn may allow for better solutions that benefit both clinician and patient. A male resident accidently administered the incorrect drug. System 1 had selected relevant aspects of presented information (e.g. a group of symptoms), leading to an automatic and very rapid selection of a mental model, and to a quick decision by the busy resident. This fast, automatic process can be useful, particularly in routine, less complex contexts.17Blum R.H. Boulet J.R. Cooper J.B. Muret-Wagstaff S.L. Simulation-based assessment to identify critical gaps in safe anesthesia resident performance.Anesthesiology. 2014; 120: 129-141Crossref PubMed Scopus (43) Google Scholar, 20Wald H.S. Borkan J.M. Taylor J.S. Anthony D. Reis S.P. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing.Acad Med. 2012; 87: 41-50Crossref PubMed Scopus (204) Google Scholar On later discussion with the attending, the resident tells her that ‘I will never do that again!’ The attending then prompted him to reflect more deeply by asking ‘What could you do to prevent that from happening again. What else might you do?’ Double-loop learning involves the modification of objectives, strategies or policies so that when a similar situation arises a new framing system is used.12Argyris C. Schön D. Organizational learning: a theory of action perspective. Addison-Wesley, Reading, MA1996Google Scholar Schön1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar describes how puzzlement or doubt about an action, event, or experience can move us on from reflection-in-action to reflection-on-action. If reflection-in-action had been triggered in the resident through the Reflective Practice process, it would interfere with the initial reasoning, and cause a switch to System 2.14Kahneman D. Slovic P. Tversky A. Judgement under uncertainty: heuristics and biases. Cambridge University Press, Cambridge1982Crossref Google Scholar Reflection-on-action (deductive thinking or backward reasoning) will then take effect. The resident will think more deeply about any special issues or factors encountered during the clinical assessment that may have impacted his decision.1Schön D.A. The reflective practitioner: how professionals think in action. vols. 102–4. Basic Books, New York1983Google Scholar He then considers issues such as the way he lays out drugs, does not draw up a drug until needed particularly for the most potent drugs, and/or he double checks with a colleague. Through careful planning and systematic elimination, a new understanding is synthesised, ‘What should I do differently next time’? In this hypothetical example, the reflective process may result in modification of initial assessment procedures, protocols, and/or routines that in turn may allow for better solutions that benefit both clinician and patient. Although reflection is often used intuitively, skills for deliberate Reflective Practice can be enhanced through the teaching of strategies and informed experiential learning. Perkins and colleagues16Perkins D. Jay E. Tishman S. Beyond abilities: a dispositional theory of thinking.Merrill-Palmer Q. 1993; 39: 1-21Google Scholar propose that a practitioner would need to have ‘the inclination to be reflective about their practice; awareness of a personal stance; awareness of the occasions or opportunities when reflection is warranted; and the ability or know how to follow through with reflection in order to develop future practice’. The models, theories, and research findings described here provide us with evidence on how Reflective Practice can be applied in medicine and in anaesthesiology. To be effective, the reflective process must be deliberate, strategic, and systematic. The overall framework described in Figure 2 may be introduced in the undergraduate classroom, with fictitious cases used in small group sessions to confront the student's System 1 reasoning and to illustrate the operational steps of reflective practice and its value. Reflective Practice may be taught using real-world scenarios, which are contextualised, scientific, and meaningful to constructively challenge students and to trigger the reflective process. High-fidelity simulation sessions offer an ideal setting in which reflection-in-action (Stage 2) can be practised and developed safely. It is likely optimal if the students are informed, motivated, and engaged with Reflective Practice in advance. Over time, reflection-on-action (Stage 3) becomes a constructive habit, to be practised regularly after a day in the operating theatre, ideally facilitated by a clinical supervisor. Discussions with colleagues at clinical audit and morbidity/mortality meetings may provide material for hypothetical experimentation (Stage 4) and reasoned extension of one's clinical repertoire. In this ideal scenario, the benefits of a reflective practice are not simply learned, but experienced, engendering a culture of reflective practice over time. If the need to incorporate some form of training in reflection in the continuum of medical education is generally accepted, then the starting point for change is to identify important deficiencies in training within specific disciplines that appear amenable to correction by reflective practice. The overall goal is that physicians should have a clear set of skills and strategies for Reflective Practice. Blum and colleagues17Blum R.H. Boulet J.R. Cooper J.B. Muret-Wagstaff S.L. Simulation-based assessment to identify critical gaps in safe anesthesia resident performance.Anesthesiology. 2014; 120: 129-141Crossref PubMed Scopus (43) Google Scholar, 18Blum R.H. Muret-Wagstaff S.L. Boulet J.R. Cooper J.B. Petrusa E.R. Harvard Assessment of Anesthesia Resident Performance Research Group. Simulation-based assessment to reliably identify key resident performance attributes.Anesthesiology. 2018; 128: 821-831Google Scholar elicited informed opinion on the patterns or domains which characterised underperforming anaesthesiologists in three Harvard Medical School residency programmes. The investigators undertook validation of behaviourally anchored rating scales as part of a multi-scenario simulation-based assessment system and applied these to the five domains identified as critical gaps in skills and behaviours required for adequate competency before completion of their training. Significantly, resident performance in two of the domains studied (‘identifies ways to improve performance’ and ‘recognizes one's limits') did not improve with experience during training. Although the training programme may not have been effective here, these are two areas in which formal training in Reflective Practice might reasonably be expected to improve performance. The domain of ‘identification of ways to improve performance’ is directly related to reflection-on-action and the domain of ‘recognition of one's own limits' is related to reflection-in-action. Both are likely to counteract physician overconfidence which contributes to medical errors, and promote a more patient-centred approach to management. This provides one example in which a carefully designed intervention could address an objectively identified and important deficit of current training. Furthermore, the methodology and outcome measures required to examine such an effect are in place. Based on this preliminary work, we believe that a detailed, reliable evaluation of the reflective ability of anaesthesiology trainees may be needed. A baseline would inform about the current state of resident reflective ability, identify specific aspects of reflection for which interventions can be designed, and allow for comparison of change. The greatest methodological challenge to building an evidence base is the development of a practical, valid, and reliable assessment tool suitable for use by clinicians. It seems likely that reflective writing will provide one important source of material (data) to be assessed.19Chalmers P. DunnGalvin A. Shorten G. Reflective ability and moral reasoning in final year medical students: a semi-qualitative cohort study.Med Teach. 2011; 33: e281-e289Google Scholar The forms of reflective writing assessment currently in use require examination for validity, reliability, and generalisability before any can be accepted as ‘gold standard’ in specific clinical contexts (such as anaesthesiology training). This requires extension of the valuable early work of Wald and colleagues,20Wald H.S. Borkan J.M. Taylor J.S. Anthony D. Reis S.P. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing.Acad Med. 2012; 87: 41-50Crossref PubMed Scopus (204) Google Scholar where a marking rubric was found to demonstrate adequate inter-rater reliability, face validity, feasibility, and acceptability, and Mitchell,21Mitchell R. The development of the cognitive behavior survey to assess medical student learning.Teach Learn Med. 1994; 6: 161-167Google Scholar where factor analysis was used to examine the construct validity of subscales for a Reflective Practice measure. To conclude, promoting Reflective Practice in medicine generally, and in anaesthesiology, can contribute to professionally competent clinical practice, including problem solving, patient-centred management, and strategies for accurate diagnosis. A systematic evaluation approach to Reflective Practice is needed for anaesthesiology trainees to promote a culture of consistent and good quality feedback and provide for competency-based training. More than token efforts at training for reflection will be required to substantively alter behaviour. It will be necessary to develop feasible, coherent, and effective training programs which can be applied to simulated and real-world clinical settings. Valid and reliable forms of assessment are required as are clinical trials to determine what benefits result in terms of physician and patient outcomes. Medical training is an ideal environment in which to benefit from Reflective Practice, and medicine offers abundant opportunities to learn through one's clinical work. The residency model developed by Halsted22Osborne M.P. William Stewart Halsted: his life and contributions to surgery.Lancet Oncol. 2007 Mar; 8: 256-265Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar and others ensures that one experiences ‘real world’ and high stakes encounters regularly; the value of these rich experiences may be optimised if trainees practice reflection. Currently, we are aware of little activity aimed directly at improving reflection on or in action. What is required now is valid assessment of current reflective practice amongst medical students, trainees, and practitioners in several different countries and disciplines in order to establish authentic baselines with the ultimate goal of the systematic use of Reflective Practice. These baselines, we suggest, are prerequisites to determining if and how formal training programmes should be altered to incorporate Reflective Practice and how any resulting benefits/costs might be evaluated. We believe the potential value of such training demands more study for how best to do it and on how to assess its impact. Writing paper: ADG. Revising paper: GS, JC, RB (main editor) All authors read and approved the final version of the editorial. ADG: National Children's Research Centre (NCRC), DBV Technologies (France & USA), Aimmune Therapeutics (UK & USA), Atlantia Food Trials (Ireland). The other authors have no conflicts to declare.