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Learning from reflective practice andmetacognition – an anaesthetist’sperspectiveMark Barley aa Department of Anaesthetics, Queens Medical Centre,Nottingham, NG72UH, UKPublished online: 14 Feb 2012.

To cite this article: Mark Barley (2012) Learning from reflective practice and metacognition – ananaesthetist’s perspective, Reflective Practice: International and Multidisciplinary Perspectives,13:2, 271-280, DOI: 10.1080/14623943.2012.657792

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Learning from reflective practice and metacognition – ananaesthetist’s perspective

Mark Barley*

Department of Anaesthetics, Queens Medical Centre, Nottingham, NG72UH, UK

(Received 5 April 2011; final version received 9 December 2011)

Within medicine, the concept of reflection is becoming a fashionable componentof lifelong learning and revalidation. It remains poorly practised and misunder-stood with scant guidance available on the benefits, methodology or foundingprinciples. Using the intrinsically unsafe state of anaesthesia as a clinical exam-ple, the stages of reflection are discussed in context. Components of metacogni-tion (‘thinking about thinking’) are also clinically contextualised. Barriers toreflection and metacognitive practice are discussed, emphasising the need formedical regulators to deliver clarity on the processes they propose clinicians touse to reflect. Opportunities to promote reflective practice from clinicians’ exist-ing working patterns are proposed.

Keywords: reflective practice; metacognition; anaesthesia; lifelong learning;continuing medical education

Introduction

Medicine is becoming increasingly complex; societal expectations increase, medicaltechnology advances and the mass of medical knowledge doubles every five years,of which 85% is obsolescent within 15 years (Ryan, 2010, citing Robinson, 1993).Medical practitioners face a ‘knowledge dilemma’; doctors are no longer able toconfront and absorb this tsunami of information but must become proficient inassessing, interpreting, applying and communicating knowledge from their disci-pline through a habit of lifelong learning and curiosity (Ryan, 2010). Despite everincreasing technological and knowledge resources, medical error is still prevalent.Vincent, Neale, and Woloshynowych (2001) estimated that 10% of hospital admis-sions in the UK are associated with an adverse incident; a figure comparable to thatannounced in the landmark publication from the Institute of Medicine, To err ishuman: building a safer healthcare system (Kohn, Corrigan, & Donaldson, 2000),which estimated 98,000 deaths following adverse incidents occurred annually in theUSA. Moving healthcare towards the error-rates of ‘high reliability’ industries suchas aviation, nuclear power and rail transport is a noble goal, requiring culturalchange in healthcare delivery with a focus on measuring and consistently improvingthe quality of care.

At the forefront of advances in patient safety is anaesthesia, a profession thathas strived to reduce mortality from 1:5000 to 1:200,000 over the past two decades

*Email: mark_barley@mac.com

Reflective PracticeVol. 13, No. 2, April 2012, 271–280

ISSN 1462-3943 print/ISSN 1470-1103 online� 2012 Taylor & Francishttp://dx.doi.org/10.1080/14623943.2012.657792http://www.tandfonline.com

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(Hallinan, 2005). However, the state of anaesthesia is intrinsically unsafe (Davis &Aitkenhead, 2001); the multiple steps required to achieve this vulnerable conditionexpose the patient to potentially significant morbidity and mortality. Unique toanaesthesia are problems encountered during advanced airway management – theunique ‘core’ skill of the anaesthetist (i.e. intubation). Data from the NationalHealth Service Litigation Authority from 1995 to 2010 reveal 90 claims from com-plications of airway management, with specific intubation difficulties noted in 33%,of which 63% resulted in death or hypoxic brain injury (McLeod & Yentis, 2011),with a mean settlement cost of £650,000. Although rare, such injuries are devastat-ing to the patient, their families and the ‘second victim’ – the anaesthetist and the-atre team.

This risk has been recognised by the Royal College of Anaesthetists (RCoA),and the curriculum (RCoA 2010, p. B-38) reflects the need to acquire the necessaryknowledge and practical skills to mitigate these risks. Following Flexner’s (1910)seminal report on the state of American undergraduate medical education, appliedbasic science has become the keystone of medical education and the pre-eminentlyvalued basis of medical practice (Mann, 2011); however, such science is frequentlylearnt away from the context in which it will ultimately be applied. Postgraduate‘professional’ practice implies an obligation that the knowledge base establishedduring the formative years is maintained and ‘upgraded’ (Bridgley Young, Little-johns & McEwan, 1997). This assumes that all clinicians can match scientificknowledge to a broad range of clinical situations, but as Bridgley et al. (1997)noted, specialist academic knowledge only becomes professional knowledge whenit is applied practically in particular clinical contexts.

The requirement for ‘knowledge’ is but one facet of a medical professional’sjourney to expertise – indeed intelligence alone is not enough to meet the practicalskills, attitudes and behaviours demanded by a holistic health service. Using exam-ples from anaesthetic practise, the application of reflective practice and metacogni-tion to lifelong learning will be explored.

Reflective practice

Reflective practice has become a ‘buzz word’ in medical curricula. Tomorrow’s doc-tors (21, p. 26, GMC, 2009) specifically states that practitioners must ‘continuallyand systematically reflect on practice and, wherever necessary, translate that reflec-tion into action’. Mann (2011) acknowledges that reflection and reflective practiceare complex concepts, and although the critical analysis of experience is an impor-tant learning tool, this is a shift away from Flexner’s (1910) original pedagogy.

The concept of ‘reflection’ borrows from three well-established epistemologies:positivism, interpretive theory and critical theory (Kaufmann & Mann, 2010; Schön,1983). The positivistic view of science (the only source of knowledge), describesthe acquisition of theoretical knowledge as an academic pursuit, which is unrelatedto practice. Untestable propositions are felt to be emotive utterance or nonsense; itis the predicative value of knowledge which has practical use. Reflection proposesthat theory and practice are intertwined and modify each other. One can accept thattheoretical knowledge becomes interwoven with clinical practice; clinicians revise,test and modify their knowledge based on experience; the interpretive model sug-gests such knowledge is interpreted with respect to the clinician’s previous experi-ences and the current clinical context. Thus ‘theory’ guides action and

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understanding (Kaufman & Mann, 2010). Critical theory and reflection share theobservation that theory is related to practice by a process of critical thought andself-examination; as ‘experts’ we can break-free from concrete patterns of thought,reformulating our practice and the way in which future problems and challenges areviewed. The context in which our knowledge is applied, the outcome and our emo-tional response all reframe the dry theory; knowledge becomes something that lives,breaths and evolves.

Schön (1983) has made a significant contribution to understanding of reflectivepractice (Ghaye & Lillyman, 2000). However; Dewey (1933, p. 6) defined reflectivethought 50 years previously thus:

Active, persistent, and careful consideration of any belief or supposed form of knowl-edge in the light of the grounds that support it and the further conclusions to which ittends.

Schön based his works on the study of professions (i.e. engineering, medicine,music). He described practitioners of science-based professions (such as doctors)confronting a problem as ‘engaging in a very limited kind of on-the-spot inquiry’,inattentive to phenomena not fitting their intuitive thoughts. He proposed that thereflective practitioner, thinking ‘have I selected the right diagnosis from my rangeof differentials’ or ‘have I selected the right problem-solving technique [treatment]from my stock of known techniques?’ would notice the problem not fitting recog-nised patterns and engage in deep thinking to diagnose and treat.

Schön observed that mapping the signs of the present situation onto knownproblems and solutions can become extraordinarily complex (Schön, 1983, p. 169).However, with new, unique or ‘messy’ problems, this mapping does not occur, andthe process becomes more artistic – constructing a manageable problem from thesituation and self-monitoring by reflection. Work on expert performance suggeststhat the concept of reflective practice is a primary mechanism of expertise acquisi-tion (Mamade & Schmidt, 2004).

Schön (1983) proposed four components of reflective practice: Reflection beforeAction; Knowing in Action; Reflection in Action; and Reflection on Action. Thesewill be discussed as applied to anaesthesia, with advanced airway management as aclinical scenario.

Reflection before Action (RbA)

A key part of airway management is planning – clinical examination may suggestthat intubation may be difficult, but bedside tests lack positive predictive value,generating a significant number of false positives (Yentis, 2002). This does notdetract from their value, as ‘be prepared’ is the anaesthetist’s motto. However, clini-cal decision making under cognitive load is plagued by cognitive biases; the infre-quency of impossible intubation and our subconscious awareness of the fallibility ofbedside tests leave us exposed to familiarity heuristics where we erroneously predictfuture states based on prior experience (‘it will be alright, it always is’) and withincreasing clinical experience and chronological age we recall relatively more posi-tive than negative events (Mather & Carstensen, 2005).

Prior to inducing anaesthesia, there is much for the anaesthetist to take intoaccount:

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• Am I the best person for this patient; is my fatigue, mood or skill below par?• What are the benefits and risks to the patient of my chosen techniques?• What equipment do I need to give myself the best chance of success first

time?• What do I expect to see with the laryngoscope?• How will I know when I am out of my depth?• Who should I call if I need help?

For the novice these questions are conscious thoughts, for the expert practitionerthese are tacit, but there is awareness of cues indicating a deviation from priorexperience. Such ‘pre-reflection’ is critical in medicine as it prepares our thoughtsand forms our plan for when an unexpected circumstance arises (Ong, 2011).Indeed, many anaesthetists will have mentally rehearsed plans for serious situations,and guidelines aiding decision making are widely circulated.

The cognitive mechanisms used by experts to respond to ‘surprises’ in manage-ment plans are described by Schön as Knowing in Action and Reflection in Action.

Knowing in Action (KiA)

The way a professional thinks on his feet and responds subconsciously to variationsin practice is particularly important in time-critical situations. Klein (1999, p. 24)describes this naturalistic thought process as recognition-primed decision making.Gladwell (2005, p.14) summarised the need for this process succinctly: ‘there aremoments, particularly in times of stress, when haste does not make waste, whenour snap judgments and first impressions can offer a much better means of makingsense of the world’. Intuitive thinking is an instantaneous process – fast, automaticand subconscious; it is a hard-wired ‘survival’ instinct vital for emergency situa-tions, from evading a sabre-toothed tiger to medical emergencies. Despite the valuein KiA, as it is a rapid, subconscious emotional decision, it is subject to bias anderrors which can lead to incorrect decisions.

Within our clinical situation, KiA may be as simple as noting a ‘difficult’ laryngo-scopic view and executing pre-learned strategies to improve it – application of cricoidpressure, an alternative laryngoscope blade or use of a bougie. These are all‘expected’ rapid responses requiring minimal cognitive outlay for the expert, but con-scious thought and decision making for the novice, which increases cognitive loadand stress.

Reflection in Action (RiA)

Whilst ‘intuitive’ KiA produces rapid reflex decision making in response to a varia-tion in normality, RiA occurs in response to a surprise or to the unexpected when onerecognises that the situation is ‘unique’. Schön (1983) described three components:

• reframing and reworking the problem from different perspectives;• establishing where the problem fits into existing knowledge and experience;• understanding the implications of the problem, the solution and their conse-

quences.

These observation and critical reasoning skills are a greater cognitive load than the‘easy’ KiA reflexes. When confronted with a clinical ‘surprise’ (for example, an

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unanticipated difficult intubation) one must rapidly decision-make and problem-solve in parallel. Because of the higher cognitive awareness of these processes theyare less likely to be biased by emotion and subjectivity. Piaget (1952, cited byRyan, 2010) concluded that that the highest order of intelligence included the abilityto anticipate and reflect on one’s own behaviour.

Returning to our clinical situation, RiA occurs as our anaesthetist recognises thatdespite reflex ‘quick fixes’ (KiA) he is unable to obtain a satisfactory laryngoscopicview. This is an unexpected difficult intubation (incidence 1–4%; Klock & Ben-umof, 2007). He recognises that help is required, and invokes the planning createdat the RbA stage. He also reframes the problem; intubation is difficult so attentionmust focus on oxygenation. The implications of failing to oxygenate are well under-stood, and although this problem is new to this anaesthetist, active cognition andreflection have prevented fixation on intubation and the exclusion of oxygenationand a potential harm event.

Reflection on Action (RoA)

This occurs after the event, and is what most clinicians think of by ‘reflection’. Thereis a delay between the index event and the reflection, which involved a careful exami-nation of the experience, action, interactions and emotions. The details are recalledand analysed to give fresh insight into perceived individual and team performance,and can be a stimulus to prompt new knowledge or reinforce what is known.

It is not just clinical problems that can benefit from reflection; ethical problems,communication issues, complaints and interpersonal relationships can all be exam-ined – reflection on action explores our emotional intelligence (our ability to con-sider our own, and others’ thoughts, feelings and values). Some individuals findsuch empathy easy, but others may be less intuitive. The emotional substrate thisform of reflection exposes makes it the richest, yet the riskiest form of reflection forthe practitioner. RoA is a component of revalidation for anaesthetists (RCoA, 2010)which is more a retrospective narrative than true reflection with an emotional com-ponent; however, a move away from just tick-box technical assessments may give adeeper understanding of a practitioner’s insight into their knowledge and practice.However, RoA is not without critics; the value of medical ‘morbidity and mortality’(M&M) meetings has been criticised, as they do not seem to prevent future errorsby examining and assigning blame for events in the past. Superficial excuses like ‘Iwas tired’ or ‘the patient was uncooperative’ really do not explore our own incon-venient truths about our personal deficiencies (‘I did not assess the airway, I havenever had a problem before so I assumed it would be okay’).

For our anaesthetist, reflection may be informal during a quiet moment, writtenas a piece for a learning portfolio or mentored with a trusted colleague. It is a chal-lenge to reframe existing knowledge in the light of new events and identify areasfor personal and professional development.

In this form, experience modifies pre-existing knowledge directly; insights andlearning from one experience may be incorporated into future knowing in action.

Metacognition

Schön described how a professional responds to ‘surprises’ with KiA and RiA,while Quirk (2006) referred to them as intuition and metacognition. Metacognitionis described as the experiences and knowledge we have about our own thought

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processes (Schwartz and Perfect, 2002, citing Flavell, 1979). The InternationalAssociation for Metacognition is more succinct: ‘knowing about knowing’.

There are a number of thought processes to metacognition:

• Specialised Knowledge: a foundation of factual knowledge is required, as areprofession-appropriate psycho-motor skills and a commitment to learning.

• Emotional Intelligence: also used in RoA, the ability to think about their ownand others feelings, emotions and values – understanding the nature of peopleas fellow cognitive creatures.

• Perspective Taking: the ability to explore a problem from the patient’s per-spective – anticipating their needs and advocating on their behalf (Quirk,2006).

• Experiential Learning: the ability to learn from experience – challenging priorassumptions by asking questions and to recognise subtle patterns and visualcues in complex situations whilst overcoming biases. Kolb and Kolb (2005,citing Kolb, 1984), developing the work of others, produced a holistic modelof the experiential learning process. Their Experiential Learning Theorydefined learning as ‘the process whereby knowledge is created through thetransformation of experience’ (Kolb & Kolb, 2005, p. 194).

• Self-regulation: The ability to control one’s thoughts and feelings in order tothink well – we make more errors when tired or distracted. For the anaesthe-tist, eternal vigilance is the price of safety, and one needs strategies to counterstress, fatigue, overwork, interruptions and distractions as well as having theinsight to recognise the impact these may have on performance.

• Self-Awareness: being self-aware is an important life-skill; this can be pro-moted by setting aside time and space for reflection, and practising attentive-ness, curiosity and patience.

Both Schön’s description of reflection, and metacognition appear to be valuablestrategies to reduce our biases, clarify our thoughts and optimise learning from newexperiences, putting into context our prior learning, but to what use? Although thereis widespread advocacy for these techniques, encouraged in both the undergraduateand postgraduate curricula driven by the GMC and Royal Colleges, are there actu-ally any proven benefits to practice and patient safety or are these assumptionsbased on hopes that ‘humanistic’ doctors can do no wrong? Mamade and Schmidt(2004) described this as a ‘new professionalism’, with a key factor being the abilityof physicians to critically reflect on their own decisions.

Several studies have examined diagnostic accuracy with reflective versus non-analytical reasoning. Mamade, Schmidt, and Penaforte (2008) demonstrated a posi-tive effect when reflective practice was used in the diagnosis of complex, unusualclinical cases but non-analytical reasoning was just as effective for routine clinicalcases. In a study of Brazilian internal medicine residents Mamade, Schmidt, Rikers,Penaforte, and Coelho-Fildo (2007) demonstrated that complex cases triggered aswitch from automatic to reflective reasoning; an extrapolation may be thatreflection aids diagnostic accuracy. Despite these encouraging studies, there are norandomised controlled trials demonstrating a patient outcome or mortality benefitfrom reflective clinicians (‘hard evidence’: Driessen, van Tartwijk, & Dornan,2008). Despite this, there is evidence to support the notion that reflection helps usto learn from our experiences, identify our learning needs and stimulate learning

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which is focused on comprehension and understanding (Grant, Kinnersley, Metcalf,Pill, & Houston, 2006).

If our curricula are to produce reflective practitioners, how is this to occur? Atpresent, reflective practice is perceived as a negative emotional process for the ref-lectee, focused on the minute dissection of action and thought following an adverseclinical event. Blinded by hindsight this becomes a process of atonement rather thanlearning. During departmental M&M meetings, clinicians deliver narrative descrip-tions of events and processes, which are scrutinised out of context by peers – agladiatorial process. Our regulatory authorities diktat of ‘compulsory’ reflection aspart of a hectic revalidation process makes this an onerous process, perceived as the‘fluffy stuff we have to do for revalidation’ rather than a continuous process ofdevelopment of expertise. Time pressured senior clinicians typically have six hoursa week allocated for continuing medical education, audit, service evaluation anddevelopment as well as their teaching and research interests; these are all activitiesrequired by our regulatory authorities for revalidation, of which reflection plays avery small part.

We have a duty to highlight that critical analysis of experience is an importantlearning tool, and this should happen from early in adult education. However, con-scious reflection is not a process that comes naturally for many people. Reflectiveskills can be taught and mentored – a process which requires investment in staff andtime. Simulation-based medical education has acknowledged the principles of reflec-tion as a powerful learning modality; considerable care is taken to produce a safeand supportive environment for adult learners prior to the learning event, where ahigh-fidelity human simulator or an actor is used to emulate a realistic clinical situa-tion, testing their diagnostic, practical and ‘non-technical’ skills (communication,decision making, teamwork). Following the event, a debriefing or after-action reviewprovides an opportunity for the participants to reflect together, dissecting the eventsand processes observed, offering critique or praise for aspects of the performanceand crucially generating strategies to counter difficulties encountered. The goal is toallow the participants to explain, analyse, synthesise information and emotionalstates to improve performance in similar situations in the future (Rudolph, Simon,Rivard, Dufresne, & Raemer, 2007). Anecdotally, this works well with a good groupdynamic and careful attention to creating the right learning environment; however,small group simulation sessions are costly in both clinician time and infrastructure.

Reflective diaries, narratives and portfolios can be used to encourage reflectioncost-effectively, but they risk producing rather self-congratulatory and self-indulgentpseudo-reflection (Epstein, 2008) unless used as a stimulus for discussion with amentor or as part of a small group reflective session. A busy medical curriculumwith teaching and learning as lectures, opportunistic bedside and operating theatreteaching give little time for this to occur, as both under- and postgraduates perceivethe acquisition of clinical knowledge of paramount importance as this is a prerequi-site of academic success. Are our undergraduates ready for an education enrichedby reflection and experiential learning? Kolb and Kolb (2005) postulate that learn-ing styles are influenced by personality, education, career choice, current role andtasks. Kolb’s experiential learning theory development model chronicles three stagesfrom acquisition (birth to adolescence), specialisation (formal schooling to earlywork) and integration (mid-career and later life) where there is increasing integra-tion of reflective observation and active experimentation. It may be that reflectionneeds to be practised in a different way at each stage.

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Nevertheless, an education that can integrate science, technology and reflectiveinquiry is needed (Ryan, 2010) if we are to have intelligent, fast thinking, driven,ambitious problem-solving doctors who can also listen and communicate. Collec-tively we must emphasise the importance of reflection, highlighting by example theneed to scrutinise our work practices and the dangers of rigid assumptions.

A reasonable, cost-effective approach is to integrate reflection into existingworking patterns, learning from the failings of our M&M meetings – where clini-cians put up defences when reflection yields insight, challenging their self-percep-tion, competence and hierarchical position. As demonstrated in simulation-basededucation, we must work to provide a safe learning environment with facilitationand mentoring from a credible clinician with an interest in education, reflection andnon-judgemental debriefing (Rudolph, Simon, Dufresne, & Raemer, 2006). It iswith the creation of this environment that reflection can flourish, and a supportivegroup can help individuals manage negative emotions. Similarly, team-based brief-ings and debriefings offer a valuable opportunity for small group reflection, enhanc-ing effectiveness and teamwork (TEA, 2011, Vashdi, Bamberger, Erez, & Weiss-Meilik, 2007) and perhaps modification of a team or organisation’s norms, policiesand objectives (Argyris & Schön, 1978).

Reflective practice and metacognition can give us an awareness of our thoughtprocesses; with this insight there is the possibility to reduce our subconsciousbiases, make ‘better’ decisions and engage in true constructivist experiential learn-ing. However valuable we think reflection is, concrete evidence is lacking, andimplementation of ‘reflective’ practice in postgraduate education seems to be atoken exercise, where it may be difficult to tell real reflection from that produced totick a box at a revalidation exercise.

I see many parallels between reflection, metacognition and experiential learning,and personally feel these are useful topics for interested, insightful individuals. Wehave a duty to emphasise that reflection is a part of our routine clinical practicewith a potential to make us safer, more considered physicians.

‘The unexamined life is not worth living’ (Socrates)

Note on contributor

Dr Mark Barley is a Specialist Registrar in Anaesthetics and Clinical Fellow in MedicalEducation and Simulation. His clinical interests are difficult airway management, emergencysurgery and major maxillofacial surgery. Non-clinical interests include improving PatientSafety within emergency surgery and Human Factors in clinical practice. He is involved inundergraduate and postgraduate medical education.

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