Case reports, reflective practice and learning to succeed

“I've missed more than 9000 shots in my career. I've lost almost 300 games. Twenty‐six times, I've been trusted to take the game winning shot and missed. I've failed over and over again in my life. And this is why I succeed.”

– Michael Jordan.

Performance is a key pillar of professionalism, and reflection is a vital cornerstone in improving and achieving consistent high level performance. Expert practitioners and other elite performers are able achieve high levels of performance due to the ability to work through elaborate mental models quickly and react to situations in a faster and more effective way. Malcom Gladwell popularised the idea of needing an average of 10,000 h of practice at something to achieve these levels of mastery [1]. However, the act of simply doing the task over and over again is not enough to achieve ‘elite’ or ‘master’ status. As the ancient Greek poet Archilochus wrote, “we don't rise to the level of our expectations; we fall to the level of our training”; more simply put: practice makes permanent, not perfect. So how do we, and the teams we work with, ensure we are getting the most out of the ways we practice or train?

Sanders points to the fact that in medical practice the processing of the ‘mental models’ mentioned above does not come simply from repeated exposure to a variety of clinical scenarios and situations, but also through ‘reflection‐on‐action’ of these scenarios and their own beliefs and perceptions of the events and outcomes [2]. It is obvious then that being able to reflect on our performances, in both our successes and failures are an important factor in improving performance and performance outcomes.

However, if these processes or events are seen as too formalised – or, worse, as merely a means to progression in training, there can be a reduced motivation for meaningful engagement [2]. This can result in missing out on not only development opportunities, but opportunities to enhance individual and team performance and ensure we develop a medical workforce that are more resilient in coping with failure and setbacks [3].

In this editorial, we will consider how best to encourage and foster these moments of reflection, with a focus on the benefit of preparing and reviewing clinical cases, and how case reports can act as a tool for reflective practice.

Fostering the right culture

Meaningful and purposeful reflection, be it alone, with a mentor, or as a whole team can be a challenging experience, especially if things have gone wrong. A recent editorial in this journal highlighted the benefit of the use of case reports for reflection of errors or adverse outcomes [4], so that we may all learn from each other's experiences. Notably, the authors rightly pointed out that revisiting the trauma of the event may pose as a barrier in offering cases where errors or adverse events have occurred, because of the effects it has had on those involved. It comments on how those involved in adverse cases may become ‘second victim’ due to feelings of guilt, blame or shame. This, and other cultural barriers prevent from maximising the benefits of reflection. Feelings such as guilt, shame or failure and fear of blame can lead to avoidant behaviours and mean these events can go undiscussed, analysed or reported [5]. This results in individuals and teams not only missing out on important learning points and opportunities, but also opportunities to improve team performances and patient safety.

It is clear that the environment and culture in which reflection takes place is important, to not only remove potential barriers but also increase the quality of reflection that occurs. A culture that supports effective reflection is based on a foundation of psychological safety: improving team performance through collaboration, understanding and fostering a growth mindset.

First, what is psychological safety? By definition, psychological safety is a “shared belief that the team is safe for interpersonal risk taking” [6, 7]. In reality, it means individual team members feel safe and secure within a team, to the extent that they feel comfortable to speak‐up, raise concerns and critique others' work without fear of punishment for doing so. This clearly has important impact and benefit regarding the reporting and reflection of patient safety events such as errors or near misses. The act of coming together and collaborating to reflect on events to write a case report may help harness and foster psychological safety within your team and help improve future performances and outcomes.

Psychological safety enhances performance through improved ability for team members to provide feedback on each other's performance and importantly for individuals receiving that feedback to process it in a constructive manner. As pointed out by Wachter and Pronovost, a systems focused approach in healthcare should not take away from the need for individuals to be accountable for their performance within the system or team [8]. Therefore, in the circumstances where debrief or reflections identify the need for improved individual performance or accountability to be taken, a psychologically safe team is much more likely to engage constructively in these potentially‐uncomfortable conversations and moments.

Finding the right mindset

Individual reflection should not only be left to these moments when errors or adverse events occur. As lifelong learners, and members of a profession that is constantly searching for improved levels of performance we should always be asking ourselves “how could I have done that better?” The next challenge to be addressed then, is how to ensure that the individual can process these moments of reflection and use them to be better the next time around. One critical aspect is the ability to foster a ‘growth mindset’, where failure is seen not as reflection of a lack of ability that never will be improved upon, but as an opportunity to learn from, and improve on at the next attempt. A ‘growth mindset’ is the opposite to a ‘fixed mindset’ where one thinks that one's ability is static: if you fail at a task once, it means you will never be able to accomplish it. It is clear to see why those with a growth mindset will get much more from reflecting on events and seeing where they can improve the next time. In contrast, those with a fixed mindset have been shown to actively avoid challenges where they think they might fail, as this failure takes away from their self‐worth, and can impact hugely on how they react to adverse events or errors [3].

In the context of case report authorship, the process of coming together to reflect on clinical events requires a narrative to be told and accountability to be taken. The maintenance of a psychologically safe environment during this process allows this to happen in a way that seeks to identify opportunities for improved individual and team performance. Many case reports are co‐authored by experienced consultants and trainees, and upon publishing commonly receive feedback from others who have experienced similar scenarios. This kind of feedback and discussion can help to reinforce a growth mindset, and further encourage reflective practice [3].

Reflective practice in action

Reflective practice in medicine has been integrated into many postgraduate curricula, and indeed as part of revalidation processes by regulatory bodies such as the General Medical Council [9]. How we integrate reflective practice into our busy working lives can often be a significant barrier, with the question often raised – “is it even worth it?”. Stripped away, reflective practice permeates how we work, learn and develop as professionals and without realising it, is something we already do to varying degrees. Asking yourself the simple question “How could I have done that better?” is a core tenant of reflective practice and an example of ‘reflecting on action’ [10].

The reflective process can take both individual or group forms, but in essence is a continuum. Individual reflection can include written reflective essays, audio recordings or visual creations to guide a person's reflection. Written reflections have been incorporated into healthcare education programmes, and there is evidence that these written reflection tasks enhance the learner's skills in diagnostic thinking [11]. However, undertaking reflection without a framework, mentoring or being part of a formal assessment has been shown to reduce engagement [12]. A common framework to facilitate reflective practice is Kolb's learning cycle which is broadly used for undergraduate medical education reflective practice [13]. A detailed explanation is beyond the scope of this editorial, but in short it guides the person in reflecting on an experience, be it an adverse event or near‐miss, and critically thinking on this experience to understand their actions, reactions and those of others and coming full circle into using this learning for managing future experiences [2].

The experiential learning framework described by Kolb almost 40 years ago is also a common framework for group or interpersonal reflective practice. We have noted above that group reflection can often be a challenging experience, and how fostering a psychologically safe working environment can enhance engagement in reflection. Morbidity and mortality meetings are a form of group reflective practice, but they often fail to provide the psychologically safe environments that would allow true learning and meta‐cognition to occur. Meta‐cognition is a reflective process that occurs before, during and after an event that looks to deepen our understanding and shape our behaviours in future similar experiences [2].

Other group reflective practices, beyond the sometimes‐adversarial arena of morbidity and mortality meetings include Schwartz rounds, Balint groups and Learning from Excellence (LfE) meetings. Schwartz rounds are a forum where healthcare staff can listen and engage with their colleagues' personal reflections. They are ultimately designed to facilitate reflection and improve patient experience by supporting and educating healthcare staff [14]. While there is a dearth of evidence that Schwartz Rounds alter practice or patient care, a recent National Institute of Health evaluation identified ‘ripple effects’ in process changes and quality improvement initiatives following their implementation [15]. The LfE format is more recent, starting in 2014. The concept underpinning LfE is that healthcare professionals have untapped learning and reflective opportunities in events that go well within our systems [16], not only in the realm of quality improvement but also to improve cultural change. Reflecting on positive events have significant learning opportunities, but also remove some of the well described barriers previously. In essence, ‘pay it forward’.

Despite an increasing body of research into the effects of reflective practice on medical practitioners, the evidence fails to show conclusively that reflection positively impacts patient care and improve clinical competence, though these are notoriously difficult effects to ‘prove’ [17]. There is a clear consistent message in reflective practice articles, highlighting that it promotes deeper understanding of oneself and your practice, identifies new learning needs and supports self‐directed, lifelong learning [18].

From the above, it is clear to see that authoring and publishing case reports provides a useful space for reflection and growth to occur. First, they provide a structured format or canvas on which to follow reflective methods such as Kolb's learning cycle [13]: authors reflect on the event, review the literature for best practice guidelines or similar case reports and summarise what happened and what could have been done better. Second, once published, these case reports have the power to engage a wider audience of varied and diverse backgrounds for a richer discussion and reflection, than if the case was only presented within a hospital or department. Indeed, the use of social media has only proven to strengthen the power of case reports as a tool of reflection, once appropriately moderated, as discussion and debate can take place in almost real‐time and information can be rapidly distributed.

Two excellent examples of the use of case reports as a means of reflection can be found within this journal. Davidson et al. and Newington and Barker reflect upon rare and complex events, and give not only a narrative of the event, but also provide a thoughtful assessment of potential contributing factors and how they may be addressed to prevent or attenuate future adverse outcomes [19, 20]. These reports give excellent real‐life examples of Kolb's learning cycle outlined above [13].

Case reports need not only focus on errors or adverse events to be useful or beneficial, as highlighted by Learning from Excellence, format we can learn equally from our successes and our failures [16]. In medicine, we succeed far more than we fail, therefore learning opportunities are probably greater in number when we reflect on our successes. When cases go well, we should look to see what elements existed that lead to a successful outcome, so that they can be repeated. Reporting cases where a novel technique is used with success can allow us to reflect on this [21, 22, 23]. It is important that we model ourselves on excellence as much as we try to evolve from error.

When reflecting, we should not ask ourselves “what was the outcome?” but instead ask ourselves “how did we arrive at this outcome”. The ideas of deliberate practice and the growth mindset underpin this, which brings us back to the opening quote from Michael Jordan and the idea of the 10,000 h rule. It is not simply the repetition of the act or how many hours we spend honing our practice, but HOW we spend those hours. It is not the successes or the failures we encounter along the way, but how those events will affect how we practice going forward.

Next time you ask yourself the question, “could I have done that better?” that is the first step to reflective practice.