“Double loop” learning

As well as sympathising with the patient, many respondents to this case commentary found themselves engaging in the difficulties faced by the general practitioner.¹ Donald Schon, in Educating the Reflective Practitioner, described a “swampy lowland” wherein lie the problems of greatest human concern and where “messy, confusing problems defy technical solution.”² Schon contrasts beautifully the technical and rational approaches of the theoretical high ground with the reflective approaches we often need in professional practice.

In interactive case reports, readers are asked how they would react to a given situation. The usual response for professionals is to delineate what Schon and his co-author, American psychologist Chris Argyris, call our “theory of action.”³ They describe this as the theory to which a professional gives allegiance, and which, on request, he communicates to others. However, the theory that actually governs his actions is his “theory in use,” which is often quite different.³

One of the fascinating features of Mrs Prior's case is that it reveals, as respondents have noted, not only the unusualness of the way symptoms are presented but also the unusualness of the way in which doctors can respond. Effectiveness results from developing congruence between theory in use and espoused theory.⁴ Thus if we reflect honestly on what we do, and why we do it, we may begin to become more coherent and effective in our clinical practice. The insight into others' processes of clinical reasoning is invaluable in this respect, and I was particularly attracted to the way in which the Taunton group have used this case for learning together.⁵

The record number of rapid responses covered many very useful perspectives, not least of which was the concern about obstructions in the system rather than obstructions in the bile duct. Much of the learning about biliary duct problems was “single loop” learning, when we think out strategies that will work within the governing variables. However, respondents also looked at the difficulties of ensuring that healthcare systems respond with an appropriate degree of urgency to patient needs. In so doing, they are touching on what Argyris and Schon called double loop learning, which occurs when “error is detected and corrected in ways that involve the modification of an organization's underlying norms, policies and objectives.”⁶ This is organisational learning, from which the NHS and patients can benefit.