Blase, Jo PhD; Hekelman, Francine P. PhD; Rowe, Marla MD
A major research deficit in ambulatory medical education is the lack of knowledge about reflection on teaching behavior. Reflection on teaching behavior is the act of thinking back on a teaching episode in order to discover how teaching actions may have contributed to an unexpected outcome. “`Reflection-in-action' refers to our ability to execute smooth sequences of activity, recognition, decision, and adjustment, without having to say we thought about it.”1 Teaching in the ambulatory environment has been found to be decidedly non-reflective; it is often spontaneous, unplanned, unpredictable, focused on clinical content, and devoid of feedback.2–5 Further, in these kinds of encounters physician—teachers infrequently receive information that leads to improvement in pedagogy.6
Many advocate that reflecting on teaching practice, a form of “self-feedback,” is a viable way to question teaching and learning activities and bring one's teaching actions to a conscious level. It has even been argued that reflection should be a standard professional disposition.1,7–9 To become equally proficient in teaching, physician—teachers must educate themselves in the theory and practice of teaching.10 Irby describes six areas of expertise required of exemplary clinical teachers: expertise in the discipline, case-based knowledge, knowledge of the general principles of teaching, knowledge of the learner, knowledge of the patient, and awareness of context.11
The Case Western Reserve University's Department of Family Medicine program takes an eclectic approach to physician—teacher improvement that includes the study of cognitive elements (information processing and decision making), narrative elements (problem framing of ambulatory teaching events and case studies), and critical elements (ethical and moral reasoning within social and political contexts).12–14
Our program's objectives include providing experiences that enable physician-teachers, including preceptors, to identify their teaching behaviors, develop new conceptual frameworks for teaching, and integrate these new behaviors into their repertoires of clinical teaching practices. In our professional development program on peer coaching, 30 physician—teachers (six per year for the last five years) have enhanced or expanded their teaching repertoires, developed language skills critical to effective pedagogy, and shared information about teaching with colleagues. Participants gain an awareness of effective teaching practices as well as shared “language” to discuss teaching and learning concepts, their own teaching practices, and professional growth. The program's activities include conducting peer interviews, watching teaching videotapes, doing peer observations, attending teaching demonstrations, reading general education and medical education literature, and attending halfday workshops. The exploratory study reported in this article served as an educational intervention for the development of reflective practice behaviors among program participants, which are ripe for investigation among physician—teachers, who, as indicated, are notably articulate about teaching, but not yet sensitized to or adept at reflection.
The purpose of the study was to measure preceptors' use of reflection to bring teaching actions to a conscious level. Those who do so may be better able to plan their teaching behaviors and select alternatives that may prove more productive. This study emerged from our previous work related to research on teaching, including studies of communication patterns in teaching and learning encounters15,16; training in and use of specific micro-teaching skills, such as wait time, feedback, and questioning by physician teachers2; a study of humanistic teaching behaviors among primary care physicians (e.g., compassion, integrity, respect)17; and a study of teacher—learner congruence in applying clinical teaching skills.18
We questioned whether or not preceptors would use higher-level pedagogic strategies if they were given an opportunity for reflection on teaching (e.g., thinking about previous teaching experiences or clinical experiences). If this were the case, their reflection on teaching could enable them to become “more effective … [able to] assume greater responsibility for their own teaching performance, and … [able to] engage more closely and more productively with others in the workplace.”19
The research questions were:
1. Do oral questions posed by the medical educator produce evidence of reflective thinking by precepting physicians?
2. What levels and patterns of reflection are evident in the preceptor?
In 1998, three preceptors from the Case Western Reserve University Teacher Training/Peer Coaching Program were selected to participate in this study. All three participants were women who had volunteered for and participated in the Teacher Training/Peer Coaching Program for one year, were viewed by other faculty as having developed considerable expertise in teaching, and were trained in the theory of peer coaching and the language of pedagogy. In addition, each preceptor indicated that she had learned to teach by watching others (social learning). Prior to their preparation in the peer-coaching program, none of the participants had been observed or had linked pedagogic techniques and planning for teaching to their daily clinical activities with medical students or residents. Although the preceptors were experienced clinical practitioners, they perceived themselves as less confident in their teaching roles than in their roles as practitioners.
To add breadth to this exploratory study, we selected these preceptors because of their varying degrees of experience. Physician A had formerly been a residency director and had been actively precepting for nine years. Physician B, a recent graduate from residency, had just completed a family medicine fellowship. Physician C had completed residency training five years previously and had been actively involved in precepting.
Case Study Preparation
Two written case studies of different complexity were prepared by one investigator (FPH) following the model developed by Irby.11 The same investigator then pilot tested the case studies with assistance from another physician. Case 1 (less complex) described a third-year male resident treating a 15-year-old juvenile diabetic with a seven-year history of the disease. Case 2 (more complex) involved a first-year female resident treating a 17-year-old patient with a long-standing history of asthma. The cases are detailed in the Appendix.
Frameworks of Reflection
Several theorists have developed operational frameworks that describe levels of reflection (R-Levels), and these differ regarding the specific nature of those levels (see Table 1). For example, Van Manen's categorization included technical, practical, and critical reflection levels, which range from thinking about efficiency and effectiveness to goal attainment and, finally, to moral, ethical, and political—cultural considerations.12 Gilson described “reflection-in-action” as a component of the artistry or intuitive knowledge that develops from professional experience.20 This kind of reflection, according to Alrichter and Posch, includes reflective conversations with oneself and reframing situations according to new data and experience.21 Hatton and Smith described five levels of reflective thinking that range from a relatively simple technical—applicative level to the more complex, insightful, and multidimensional level.22 For our study, we adapted Sparks-Langer and Colton's practical framework to the precepting process found in ambulatory clinical practice.13 The adaptation emphasizes that reflection-in-action is a critique of one's previous experience and addresses “impact” concerns. We note that R-Level 5 reflections occur only after the practitioner accrues experience within the profession as well as experience teaching in the profession.
A protocol for administering the cases was designed by the authors and tested with another physician who was enrolled in the peer-coaching program. Each participant agreed to be audiotaped for one hour, and the two cases were given to each preceptor. Immediately after reading each case, the physicians responded to four interview questions asked by the medical educator (FPH). The first of these questions was posed without further prompts, while the remaining three questions were accompanied by prompts designed to stimulate reflection.
The protocol of questioning the preceptors was designed to include the following elements:
1. Questions regarding the preceptors' thought processes about action as opposed to thought processes that occur in action23
2. Arranging for reflection to occur immediately following planning for the teaching encounter as opposed to allowing extended time to elapse between planning and reflecting on the plan
3. Making the reflection moment problem centered but excluding historical, cultural, and/or socio-political issues that relate to clinical practice24
4. Interviews prior to and after prompting for reflection25
With these guidelines in mind, one author (JB) developed four interview questions to be asked by the medical educator:
1. What do you plan to do in your precepting encounter with the resident?
2. What does that (the chosen activity) mean to you?
3. Why have you chosen that approach?
4. How might you teach this differently?
The same author also analyzed audiotapes of the interviews for reflective behavior as defined by Sparks-Langer and Colton's framework.
Analysis of the transcribed audiotapes revealed a total of 21 reflective statements among the three participants. Inter-rater reliability found agreement between analysts for all but one reflective statement.
Case Study 1 (Third-year male resident treating a 15-year-old juvenile diabetic with a seven-year history of diabetes)
Before being asked by the medical educator questions that prompted reflection, the preceptors' reflective thinking fell primarily at R-Levels 2 (preceptors A and C) and 4 (preceptor B). These levels of reflective thinking range from simple descriptions to explanation using only tradition or personal experience. (See Table 1.) Their reflective processes rose to R-Levels 4 (preceptors B and C) and 5 (preceptor A) once they were presented with prompts designed to stimulate reflection. For example, prior to prompting, preceptor A stated: “I would let the resident see that he isn't confronting the patient's behavior” (R-Level 2). After prompting by the medical educator, however, preceptor A used higher levels of reflective thinking. Preceptor A rose to R-Level 5 (explanation), also using pedagogic principles, when she stated: “How I present this depends on his [the student's] ability, self-confidence, and relationship with me” (R-Level 5).
Preceptor B attained R-Levels 2, 3, and, on one occasion, R-Level 4 prior to prompting. Her statements that indicate these levels were:
I base it on a more holistic view than just the clinical level. (R-Level 2)
I would help this resident figure out why there is a compliance problem. (R-Level 3)
I'd guide the resident through a train of thought that will eventually help him/her think what is the best approach, and not use protocol or something fixed to try and apply to everybody. (R-Level 4)
Preceptor B did not increase her reflection to R-Level 5 after the medical educator prompted her to stimulate reflection.
Preceptor C used higher levels of reflective thinking after prompting, similar to preceptor A. Prior to prompting, preceptor C stated: “I would go into the patient's room with the resident” (R-Level 2). After being prompted by a question from the medical educator, preceptor C stated: “From my experience, I learned also from watching people model, so I think modeling would be best” (R-Level 4).
In two of the three preceptor interviews, higher reflection levels were realized with simple prompting.
Case Study 2 (First-year female resident treating a 17-year-old boy with a long-standing history of asthma)
In their responses to Case Study 2, the more complex of the cases, none of the preceptors increased their levels of reflective thinking after prompting to stimulate reflection. Preceptor A achieved R-Level 3 prior to prompting, while preceptors B and C each achieved R-Level 2. After the medical educator prompted them, preceptors A and B each attained R-Level 2 and preceptor C attained R-Level 1. Prior to prompting, the three preceptors' statements were:
I would guide the resident's thought processes to the diagnosis using questions. (Preceptor A, R-Level 3)
I would avoid seeing the patient with the student. Students rely too much on somebody else. (Preceptor B, R-Level 2)
I would go into the patient's room with the resident. (Preceptor C, R-Level 2)
After prompting, the three preceptors' remarks included:
Another tool I'd use is having the resident do extra reading. (Preceptor A, R-Level 2)
I would go over the medicine, revisit the psychosocial implications and build on the next visit. (Preceptor B, R-Level 2)
I can't think of a different way to approach it. (Preceptor C, R-Level 1)
These findings, although exploratory, suggest that the preceptors might remain at low levels of reflective thinking during their precepting sessions, could improve their reflective thinking with prompting to stimulate reflection, and might use lower levels of reflective thinking in more complex cases, with or without probing to stimulate reflection.
Our results indicate that questions posed by the medical educator do stimulate reflection when preceptors are planning a teaching encounter. Further, preceptors used lower-level, descriptive patterns before they were prompted with questions by the medical educator. Although with prompting the preceptors increased their R-Levels for Case Study 1, none of them increased their R-Levels for the second, more complex case study. The lack of increase in R-Levels in the more complex case study may be attributed to the preceptors' limited experience with using reflection as a strategy for enhancing teaching. These lower R-levels could also indicate that preceptors are oriented to be more internally reflective than externally non-reflective. Fuller and Brown define reflective orientation as a tendency to structure situations, question what is happening and why, identify what learning is desired, evaluate the learner's level, and build a sense of self-efficacy.26 Given the constraints of the sample, the limitations of the questions used by the second investigator (FPH), and the content of our chosen case studies, the preceptors' use of reflection may have been limited.
The medical literature describes the ambulatory teaching environment as a milieu of variability, unpredictability, and discontinuity, which often results in less focused teaching. The spontaneity of the ambulatory setting makes it difficult for preceptors to think, plan, or reflect on their teaching practice or on their selection of specific teaching activities. In addition, in the clinical setting, the preceptor's greatest concern is for the immediate needs of the patient. How to increase the probability that clinical teachers can or will integrate reflection into their planning and teaching is an area that certainly deserves further inquiry. Our preliminary findings indicate that instructional activities to encourage reflection in or on teaching would be useful for supporting teacher improvement in the ambulatory setting.
The medical education literature also suggests that teacher improvement programs, such as the Stanford Faculty Development Program27 and the peercoaching program at Case Western Reserve University,2 improve a teacher's repertoire of micro-teaching skills. Further demonstration of the benefits of reflection may result in its becoming a tool for supporting improved planning, practice, and feedback among preceptors.
The use of case studies and the all-woman sample may have limited the outcomes of this study. In retrospect, we feel that the medical educator's prompts may have increased the respondents' capabilities to move to higher levels of reflection. Also, since the participants are themselves accustomed to learning from modeling, such techniques as using simulation or role-play may have resulted in higher R-Levels after prompting for reflection. We also feel that, although there may be some danger in over-generalization about the value of reflection, this exploratory study may be instrumental in addressing other critical questions regarding improved teaching practice in the ambulatory setting, specifically that dedicated coaching time is essential to supporting the reflection process.
The findings of our pilot study support earlier findings by the National Institute on Teacher Education's Report Six, Teaching as Clinical Information Processing.28 Shulman developed a rationale for, defined the assumptions about, and identified a domain for developing a research agenda on teachers' thinking. We hope that future education research will include preceptors' thinking, planning, and reflection in an effort to gain insight into the demands of teaching in the ambulatory setting. The desirability of having clinical teachers whose development is quantifiable and whose experience and previous knowledge demonstrate the ability to make a qualitative shift in order to function at higher cognitive levels is essential to supporting teacher improvement in the ambulatory setting. Indeed, we need to describe what novice as well as expert teachers do so that we are better able to adjust the fit between what they teach and how they teach, while at the same time we support teaching improvement with greater consistency between teaching practice and learning theory.
In conclusion, our findings suggest that prompting increases preceptors' reflection during clinical teaching. Independent reflection during clinical teaching, especially prior practice without a coach, can compromise the reflective nature of teaching. The coach plays a critical role in fostering the systematic use of reflection. A preceptor's reflection on teaching can lead to self-examination—i.e., taking responsibility for one's own growth as a teacher—that can, in turn, result in progress through cognitive developmental stages, from novice to expert, and enable the preceptor to view teaching from a more interpretive and critical perspective. Future directions for research on reflection-on-teaching behaviors include expanding the sample, studying reflection in planning, and producing more qualitative research in this area.
Texts of Case Studies Used in Measuring Physician—Teachers' Levels of Reflection
Case Study 1 (Third-year male resident treating a 15-year-old juvenile diabetic with a seven-year history of the illness)
You are percepting in the general pediatric practice. Tom, a third-year resident six months into his final year, asks to present a “tough patient” to you. You have had a moderate amount of contact with this resident in the past. He is technically skillful and has excellent knowledge of pathophysiology but is somewhat superficial in his evaluations.
Tom's case presentation
I am seeing Jamie, a 15-year-old girl with a seven-year history of insulin-dependent diabetes mellitus who is here for diabetes follow-up. She has missed a number of appointments over the past two years. The last time I saw her was for a hospital follow-up after an admission for DKA. She is here with her mother today. Her mother is concerned because the patient frequently comes home from school complaining of a headache and fatigue. The patient denies this.
Jamie says she takes 40 NPH/12 regular every morning and 12 NPH and 12 regular at supper. She says she does not bother with carbohydrate exchange and frequently skips breakfast, preferring to eat a large meal at night. Most dates in her blood sugar diary had no entries.
Today, she has normal vitals and blood pressure. Her weight is down about five pounds from her last visit. Her physical exam is all normal except for some lipodystrophy in the thigh where she usually injects her insulin. Toay's blood sugar is 325.
It seems to me as if she is behaving like a “typical adolescent.” She says she is “tired of having diabetes” and “wants to be normal.”
I told her she has to “face the facts” or she is going to kill herself. I recommended that she test her blood sugar three to four times a day for the next two months so that we can collect enough data to appropriately change her insulin. I would like you to come in, see the patient, and back me up on this.
Case Study 2 (First-year female resident treating a 17-year-old boy with a long-standing history of asthma)
Your are working in your office and supervising a first-year resident, Maria, who has been with you for her continuity experience for her entire first year. Maria is a dedicated, thoughtful physician who has excellent interpersonal and clinical skills.
Maria's case presentation
I am seeing a young man named Michael. He is a 17-year-old boy with a long-standing history of asthma. He is a cross-country runner. As the weather this fall has become increasingly cooler, Mike says that he is having more and more trouble with his breathing. He uses a metered-dose β-agonist inhaler before practice and meets but complains of severe nighttime cough. He also reports a great deal of nasal congestion, itching, and postnasal drip. He occasionally uses some over-the-counter antihistamines, with improvement in his symptoms, but this makes him too drowsy to compete. He reports that his coach pushes him harder when he complains of asthma symptoms, telling him that he has to “push through the pain.”
Today, on exam, he is afebrile with a respiratory rate of 18, heart rate of 58, and a BP of 112/56. His physical is remarkable for marked conjunctival injection, nasal mucosa edema, and clear rhinorrhea. He has some mild sinus tenderness. His throat and neck are normal. On lung exam, he has diffuse inspiratory and expiratory wheezing accentuated by deep breathing. I think this boy may have a sinus infection making his asthma worse. I may want to get an x-ray of his sinuses, and am pretty sure I should adjust his medicines, but I do not know exactly how. Would you take a look at him with me?
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