Diagnostic errors and reflective practice in medicine.
ABSTRACT Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that as far as it explains reasoning processes involved in clinical judgements. The literature has indicated the capability of critically reflecting upon one's own practice as a key requirement for developing and maintaining medical expertise throughout life.
This article explores potential relationships between reflective practice and diagnostic errors.
A survey of the medical expertise literature was conducted. Origins of medical errors frequently reported in the literature were explored. The potential relationship between diagnostic errors and the several dimensions of reflective practice in medicine, brought to light by recent research, were theoretically explored.
Uncertainty and fallibility inherent to clinical judgements are discussed. Stages in the diagnostic reasoning process where errors could occur and their potential sources are highlighted, including the role of medical heuristics and biases. The authors discuss the nature of reflective practice in medicine, and explore whether and how the several behaviours and reasoning processes that constitute reflective practice could minimize diagnostic errors. Future directions for further research are discussed. They involve empirical research on the role of reflective practice in improving clinical reasoning and the development of educational strategies to enhancing reflective practice.
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ABSTRACT: The capability to reflect consciously upon one's professional practice is generally considered important for the development of expertise and, hence, for education. However, to our knowledge no empirical research has been conducted to date into the nature of reflective practice in medicine. To study the structure of reflective practice in medicine. A questionnaire based on the literature was developed and administered to a group of primary care doctors. The data were subjected to confirmatory factor analysis using structural equations modelling. A 5-factor model of reflective practice emerged. It consisted of the following factors: deliberate induction; deliberate deduction; testing and synthesising; openness for reflection, and meta-reasoning. The model fitted the data sufficiently. A multidimensional structure of reflective practice in medicine was brought to light by the study. Its components in terms of reasoning processes, behaviours and attitudes were identified and measured among doctors. Once conceptualised and measured, reflective practice can be studied to gain a better understanding of its relation to expertise development in medicine. In addition, training students to apply reflective practices may become a goal in medical education.Medical Education 01/2005; 38(12):1302-8. · 3.55 Impact Factor
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ABSTRACT: Clinical reasoning allows physicians to move from areas of clinical uncertainty to points where the medical literature offers guidance, and is equally important in deducing whether the results of clinical trials are applicable to an individual patient. However, studies in the field of cognitive psychology indicate that the reasoning skills of clinicians are imperfect. Moreover, clinicians may be aware of their mistakes but often do not understand the cognitive processes underlying their errors. Greater understanding of the reasoning process has the potential to improve patient care but independent study of clinical reasoning can be difficult, as the literature is complex and unfamiliar to most physicians. This article provides an introduction to diagnostic reasoning and highlights some of the cognitive factors that lead to errors in clinical problem solving. Clinical scenarios are used to illustrate key points and place the material in a readily accessible framework.Medical Teacher 04/2003; 25(2):177-81. · 1.82 Impact Factor
Article: Mindful practice.[show abstract] [hide abstract]
ABSTRACT: Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.JAMA The Journal of the American Medical Association 10/1999; 282(9):833-9. · 29.98 Impact Factor