Chances are that most emergency physicians will never do an open thoracotomy in their entire career.
Or a cricothyroidomy.
Or a perimortem C-section.
Yet, we must know how to perform these procedures competently under all types of high-stakes and high-stress scenarios while foreseeing any complications. What is the best method to prepare ourselves to perform in situations we rarely encounter?
Enter the reflective physician. This is someone who takes the time to play out different scenarios in her mind, envisioning herself going through tough cases and procedures, and difficult situations. She prepares herself mentally by imagining the worst-case scenario and being three steps ahead.
She looks at the patient's anterior neck and finds the cricothyroid membrane before each intubation. She keeps a 15 blade in her pocket and has a bougie and a 6 ET tube ready in case the endotracheal intubation is not feasible and she must act quickly and cut the neck. She communicates a plan with her team so they all know what will take place in case an airway fails. She does this before each intubation and when a patient with anaphylaxis or obstruction presents, and she has practiced the scenario enough times to have it be second nature, even if she's never placed a scalpel anywhere near the neck.
Reflection is not just important for procedures. Consider common scenarios that we will all see as practicing physicians: atrial fibrillation in a hypotensive patient, ventricular tachycardia in the stable patient, a pulsatile mass in a patient with back pain and no CVT available, an intracranial bleed with potential herniation in a facility that transfers all neurosurgical cases, or the consolation of a family after an unexpected death.
Reflective practitioners spend time after difficult cases considering how they could have done better. They seek feedback by reading the literature and speaking with colleagues and experts, and then create algorithms and a plan for the next time they are in a similar situation. The next time they will be better. This is “reflection on action.” It follows the Kolb's cycle of experiential learning, where concrete experiences serve as a basis for feedback and reflection that can then be integrated into an abstract scenario that will ultimately change future actions. (Simply Psychology, 2013; http://bit.ly/2kbdV8g.)
David Kolb, MD, says in his book, Experiential Learning: Experience as the Source of Learning and Development, that “learning is the process whereby knowledge is created through the transformation of experience.” (Englewood Cliffs, NJ: Prentice-Hall, 1984.) Critical reflection of experience is an imperative step in the learning cycle to achieve any form of expertise.
Reflection as a Skill
“Reflection on action” will ultimately make us better doctors over time and prepare us for future experiences, but “reflection in action” is imperative to being the best form of ourselves and making the best possible decisions in the moment. Emergency physicians often have to make complicated, high-stakes decisions in the moment, and we are called upon to make timely evaluations. We must be aware of our own thinking to ensure we consider all relevant diagnoses and plan accordingly. We must be able to troubleshoot complications and the unexpected, and be aware of our biases and self-monitor our own emotions.
Metacognition, the process by which a person thinks about her own thinking, is at the cornerstone of the reflection in action and reflection on action processes. Emergency medicine, more than any other field in medicine, is especially prone to cognitive errors — errors in our perception and thinking. Pat Croskerry, MD, a professor of emergency medicine with a background in experimental psychology, describes metacognition as the best strategy to prevent diagnostic errors and cognitive biases. A metacognitive approach requires a physician to recognize when she may be at risk of bias, and performs a cognitive stop to reflect and examine her thinking. (Acad Med 2003;78:775.)
Metacognition is every emergency physician's superpower. Our specialty is chockful of heroic stories, and the reflective practitioner is behind each of these stories. It is the doctor who is calm under pressure, always has a backup plan, is well prepared, decisive, in control of her emotions, and able to manage any problem or complication that we all admire in the hectic and uncertain environment of the emergency department.
Reflection is like any other skill set. We will not be experts in metacognition unless we study and actively practice this skill set diligently. Reflection is an important practice for medical students and residents to master so they can develop their ability to self-assess, and develop habits for continued meaningful learning long after residency. The benefits of reflection in medical education have been described for many decades, but the use of reflection and how to incorporate it into teaching for emergency medicine education, has gained much attention in recent years. (Acad Emerg Med 2012;19:978.)
Seasoned emergency physicians may have developed their own reflective practice; this comes with the territory of many years of experience, but the longer we practice medicine, the higher our risk of complacency, burnout, and bias. This can be prevented by continual self-monitoring, self-reflection, and situational awareness. Remember, these are skills that need constant polishing. Perhaps more important than any other skillset in our repertoire as emergency physicians is our commitment to monitor and examine our decision-making regularly.