Conceptual and theoretical aspects of critical reflection and the consequent recommendations for incorporating it into adult education curricula and competency frameworks abound in our modern practice of medical management. But why exactly do we need it? More importantly, how do we translate these into practical means of managing doctors and of managing organisations?
Firstly, it is cited that critically reflexive practice enables us as medical managers, ‘to embrace subjective understandings of reality as a basis for thinking more critically about the impact of our assumptions, values and actions on others... (and thereby) helping us to develop more collaborative and responsive ways of managing organisations’1. Secondly, it is said to allow ‘a means to improve our clinical practice, a means to change and challenge dominant power relations and structures and a means to create possibilities to enable practice in organisational contexts that are not conducive to clinical practice’2. These are only just a few significant and essential theories put forward by experts in the field as to ‘Why’ we need it.
Directing our attention now to the ‘How’, current literature proves somewhat more elusive in clear practical accounts with which these objectives can be translated into everyday practice and from which young doctors who are new to the field can draw upon and relate to.
It is with this intention and of creating that crucial link between theory and practice, that a practical account from an alternative perspective is thus relayed.
At the commencement of my career as a medical management trainee, during a multi-disciplinary meeting, an employee who had been at the health service for a great many years openly contradicted me on a statement I made. This interruption was sudden, vehement and rather blunt while contributing very little to the overall subject matter that was being discussed at the time, and in complete opposition to what I had stated.
In undertaking critical reflective analysis, it is firstly essential to identify the initial reactions and assumptions that will provide the baseline for analysis. Obviously having been caught off guard and feeling rather persecuted, the immediate reflexive internal response to such an event by almost any reasonable person, let alone an inexperienced young trainee, would understandably be to adopt an immediately defensive standpoint. The instant thought process in all likelihood would oscillate between feeling self-righteous indignation of having been unjustly criticised, a sense of immediate threat to one’s ego and pride and a sense of doomed failure and overall anxiety. I was indeed no different. Instinctively, a sudden multitude of reasons conjured up in my mind as to why this individual deserved some form of vocal counter-attack, to be put in their place and deserved to be told exactly what was on my mind in no uncertain terms.
It is at this point that one must identify this as a crucial moment. A moment when our internal reaction will undoubtedly translate into an external response and a point at which critical reflection can equip us with the tools to actively choose which direction that response will go in. It is at these types of precise moments, and especially as trainees of medical management, we need to actively challenge reactive assumptions and put into practice learned emotional intelligence principles, develop self and emotive awareness, restrain impulsivity and cultivate patience and humility in trying to explore alternative ways of behaving so as to minimize further personal and professional damage. It is at these precise moments, that we need to remember those essential theories of experts in the field telling us ‘why’ we need to practice critical reflection.
Several years ago, at an intern teaching session I remember being advised to “develop thick skin as a doctor” and that sentiment proved valuable in this instance as it did back then. Adopting a similar mentality even now as registered practitioners, drawing from prior learnings and adopting the principles taught in reflective analysis, allows us to change our perspective to compartmentalize criticism such as this, as just an individual incident unrelated to the integrity of our sense of self. It allows us to restrain self-imposed projections of criticism as the catastrophic events that we so often assume them to be and to modify our reactions and behaviour in more constructive and contextually appropriate ways.
There are likely to be a myriad of situations and events in our future careers as medical leaders where we may be criticized or humbled, albeit unjustly with inaccurate claims, but taking ill-conceived measures to preserve that immediate sense of pride and sustain the ego in the eyes of other colleagues at the expense of damaging inter-professional relationships is counter-intuitive to the practice of emotional intelligence principles and the greater goal of becoming an inspirational leader and manager. As Morley, C (2007) states, it is through continued practical application, that we are in fact able to “use critical reflection to reconstruct power relations for an equitable interaction (rather than) for an attempt to bolster/defend our position in an organizational hierarchy”.
Practicing these principles and more importantly being aware as to precisely when they should be applied, and making an attempt to actively restrain impulsivity, we are able to grow as leaders and as health professionals. We are then able to show respect for other people’s points of view, adopt non-confrontational language to diffuse tense situations and modify our responses in a more constructive and contextually appropriate manner, even in the face of blunt inaccurate opposition. While “asking critical questions about our previously accepted values, ideas and behaviours can be anxiety-producing… (it is only) as we abandon assumptions that had been inhibiting our development, we experience a sense of liberation .”3
Having now actively practiced the art of critical reflective analysis of responses to many similar and varied incidents such as this, I have a new-found appreciation for the conceptual and theoretical aspects of why we need to continuously engage in and develop the practice of critical reflection as medical management trainees.
Whether we are still at the starting line or well progressed in our medical management journey, reflective analysis allows us to be able to respond from a range of emotional, communication and intellectual styles in order to react in a collaborative, constructive manner and to continuously undergo adaptive change that should underpin the very fabric of our practice as future medical leaders.
Dr Singithi Chandrasiri
1 Cunliffe, A. On Becoming a Critically Reflexive Practitioner. Journal of Management Education. 2004; 28; 407.
2 Morley, C. Engaging practitioners with critical reflection: issues and dilemmas. Reflective Practice. Vol. 8, No. 1, Feb 2007, pp. 61-74.
3 Brookfield, S. D. Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. San Fancisco, Jossey-Bass, 1987.
The Royal Australasian College of Medical Administrators
Dr Singithi Chandrasiri, , p708