Pre-covid, Thursdays were academic days for me, where mid-afternoon I would often wander down to academic midwifery colleagues for a gentle gossip and check in. Each time I would pass a light filled room where one of the midwifery tutors would facilitate a reflective practice with students, gently taking them through events or situations that they had encountered during the previous week. Each time I would walk past and think how lovely that was, and then move on in the conviction that as a doctor that wasn’t for me.
Writing that last sentence is quite embarrassing now; it comes across as arrogant, patronising and, dare I write it, slightly smug. Threatened by the apparently negative outcomes of reflection as shown in the case of Bawa-Garba, haughty in my apparent ability to deal with the emotional implications of the profession, and ignorant of the wealth of evidence supporting reflection in the medical profession, I kept walking and returned to my work. If we use reflection at all in medicine, I thought, well let’s keep it to the technical issues, using a framework unconsciously similar to that of Kolb’s learning cycle: after a concrete experience (an inability to complete a task, for example) reflect on it, think in the abstract, and try again. As doctors, we would use logic and evidence, leaving emotions and formal reflection for others. Those sections left at the end of our continuous professional development forms for reflection would remain blank for me.
Several events over the last year have begun to slowly change my mind on the value of reflection. We introduced Schwartz rounds into our hospital, facilitated by a team of talented, wonderful, caring people who realised the importance of the hospital team coming together to reflect on the emotional impact of our work. As part of an entrepreneurial educator course I was exposed for the first time to the concept of Balint groups, and began to wonder if these would work for me. In another medical education course where we must submit reflection as part of our assignments, I realised that while reflections can be quite painful to complete, in that pain comes real learning, learning that is deep and lasting and perhaps more profound than referencing to the taught material on the curriculum.
Though having informally done reflection over the years, I realised that formal reflection could be more than reflection on learning, but also the formal reflection on a therapeutic or professional relationship, and the development of professional practice. I learned about single loop, and double loop and triple loop reflection, asking questions about why something happened, and what it could show within our learning and our practice. I learned about guided reflection, and the importance of ethical practice so not as to cause vicarious trauma or re-traumatising someone. While the strongest reflection is mixed often with emotion, there is a balance to be set where reflection must be facilitated with care and with an eye on when more professional support may be required. And in all this learning about the real value of reflection, the pandemic began.
The last few months have been life changing for us all. All of us are reflecting in some way or another on how this has affected us, how reflection can help us be more aware and understanding of not only how this situation is affecting us, but what decisions we will make in the future as a result of it—in our professional and in our personal lives. Never before in medicine have I seen such emphasis on the mental health of healthcare professionals, with discussions on occupational moral injury, on how to maintain our relationships with patients despite the restrictions of protective equipment, of how to protect ourselves from unprecedented and relentless work pressure. We are encouraged to regularly discuss decisions and check on our wellbeing.
In a world we none of us ever anticipated with, we struggle with how we can continue in our relationships with patients, why people from ethnic minorities were disproportionately represented in covid related morbidity and mortality (and what we can do about it), what we must plan for before we can come out of lockdown, how we can support medical students, of how even experts in infectious diseases are learning at the same rate, and sometimes unfortunately by taking the practical course. It is not just the virtual opinion pages of The BMJ that hold these necessary reflections, but in magazines, newspapers, television programmes and social media. Reflections occur in the editorials of learned journals and the teenagers having a socially distant chat in the park, the bus driver on their break and the Olympic athlete training in their sitting room at home. Reflection, I get you now. Maybe the midwives will invite me to learn more when some normality returns?
Mary Higgins is an obstetrician working in Dublin.
Competing interests: None declared.