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Improving Medical Care through Open-Ended Reflections


Researchers recently discovered that physicians can improve care by looking in the metaphorical mirror through "open-ended reflections."

Communication between physicians and patients can be extremely complex. Patients may communicate their concerns for their health indirectly through questions or implied cues, says Allen F. Shaughnessy, a professor of family medicine at Tufts University School of Medicine in Boston. Physicians have to navigate the subtleties of this implicit communication by interpreting these cues in context. For example, communication behaviors such as smiling, a friendly tone of voice, forward leaning, and eye contact might be perceived by one patient as indicative of rapport, while another patient might experience these signs as being patronizing or aggressive. "Every physician needs to develop a range of communication skills," Shaughnessy says. "This development can begin with improved self-knowledge obtained through reflection."

Shaughnessy and his colleagues were curious to see how physicians in training would use the opportunity to write reflections about their interactions with patients, as they believe that medical residency training should also emphasize the importance of subtle and indirect communication. Their findings were published in the July issue of Journal of Health Communication: International Perspectives.

"Our goal for this study was to characterize how regular written reflections by physicians helped them become attuned to the needs of the patient as a person, as well as his medical needs, in order to get a fuller appreciation of the effect of their own communication style," Shaughnessy says. "We found that, when given the chance, physicians in training will take the initiative to analyze their interactions with their patients to gain greater understanding."

Taking a look in the metaphorical mirror i.e., getting below the surface, can benefit physicians in multiple ways, says Ashley Duggan, an associate professor at Chestnut Hill, Mass.-based Boston College, and co-author of the study. For one, it helps physicians understand how the human and artistic dimensions of practicing medicine are linked to the clinical dimension. The ethical aspects of practicing medicine and increasing interest in medical humanities attest that the growing awareness of the multiple dimensions of practicing medicine need to be addressed.


Personal reflection entails more carefully exploring and evaluating an experience, which can clarify meaning and balance functioning, learning, and development. Open-ended reflections allow physicians to better understand how messages - both clear and subtle - can give clues to providing desired patient care, as well as maintaining professional relationships.

"Therefore, a physician's reflections about below-surface communication can help her to better interpret a message's subtle meanings. Being attuned to cues that offer delicate balance enable deeper understanding," Duggan says.

So how can residents incorporate reflecting into their daily tasks? Randi Sokol, a physician and associate professor at Tufts Family Medicine Residency Program at Cambridge Health Alliance, in Malden, Mass., says that physicians need more built-in time or opportunities to engage in active reflection - such as planned time during residency training to participate in a Balint group (a group of physicians who meet regularly and present clinical cases in order to better understand the patient-clinician relationship). Sokol suggests the groups could be facilitated by a psychologist and discuss reflections prompted by preceptors or academic advisors on clinical care or managing stress. Non-resident physicians could also benefit from scheduled time to reflect - for example, during faculty meetings or more intentionally structured faculty Balint meetings. In addition, informal discussions between faculty members about difficult patients or residents can also go a long way in supporting each other.

In medicine, by seeing beyond what's predictable, a physician can discover how patients' candid statements about an illness integrate with subtle clues that hint at broader experiences from having an illness. According to the study, reflective learning in medicine can shift the lens of seeing by internally examining a trigger experience or exploring an issue of concern, creating or clarifying meaning, and changing conceptual perspective.

"Physicians can learn to notice subtle and indirect cues by writing reflections that offer insight into how they interpret stated and implicit aspects of their observations about communication, their subsequent responses, and their anticipated actions," Duggan says.


The study results showed how reflection allowed for personal and professional empowerment. "Reflection slows down the brain and allows time to process very complex thoughts and emotions," Sokol says. "It often allows people to simply 'name' things and acknowledge them in a way that brings closure or helps the physician create a more concrete plan. Slowing down makes the physician feel more confident that he has given an issue the thought it deserves, so life does not feel so rushed and chaotic. It also allows physicians to further explore certain areas they are passionate about or interested in, further breeding mastery of a topic area, which also supports confidence and empowerment."

Burt Howell, director of the Intersections Office at Boston College, views reflection as an effort to understand your experience and find meaning in it. "When you do it as a regular practice, it sharpens attention and increases compassion," he says.

He also believes reflection sharpens awareness because a physician needs to pay attention to his experience in order to reflect on it later. Physicians often improve at this skill the more they look at what is happening.

Howell says reflection increases compassion because the act of finding meaning produces empathy for others and allows one to be more caring toward them. "When reflecting, you often find behavioral patterns you would like to change," he says. "You anticipate these patterns the next time you are in a similar situation and then you are motivated to act with more kindness and competence."

Karen Appold is a medical writer in Pennsylvania. She may be reached via

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