‘How to Go About Clinical Reflection’
Welcome to ‘more about clinical reflection’.
In this article, I will look at case histories, the concept of audit and patient journals. This is the third article in the series as reflection is something that is a constant interest to me as an author and foot health journalist, trying to bring ideas to clinicians to improve their practice.
Case Histories are a powerful medium for both continuous professional development (CPD) learning and reflection. They entail some research and tend lists events as they occur. The questions you might well ask include:
- How did a condition arise?
- How did I diagnose the condition?
- Was I correct?
- Did I select the most effective treatment?
- Was this treatment delivered without harm?
- Did the condition resolve?
- Was the treatment cost-effective?
The idea behind a case history is to share the experience, often as a single case, sometimes as a series. Many case histories are written purely because they seem unusual. If no-one has heard of a condition then it is reasonable to publish the evidence from your own observations. However, it is not for others but as much for yourself. When I encountered my first reflex sympathetic dystrophy (now called CRPS) I could find no-one with the answer, let alone depth of knowledge. That was in 1988 and I took my case to the USA where their top podiatric specialists were equally dumfounded. You see everyone knew the condition vaguely but no-one knew how to treat the condition. I started my own literature trawl and wrote up the findings and even presented a case review. The whole act is not only cathartic as it makes one feel one is doing something, but it also opens up the field. This is reflective practice at the cutting edge.
Case histories do not rank highly on the research index but then why should it, your reason for carrying out the work is to inform yourself as much as anything. There is no control, as in controlled research, which makes the case history observational. Clinical evidence of action comes from case notes presented as a report which is then translated into a formal review. The learning element comes from the search for as much information and questioning of your own approach. If you fail to question, you fail to reflect. Case histories are popular as many think they are easier than research. Done well a case history can be as effective in some ways.
Audit and reflection
In order to audit you need data and that data is represented by case histories and some order of knowledge of question headings you want to analyse. A spreadsheet, database or word document with tables of information provide order. Next, you need a defined period over which to review the data, cases selected. The selection can be random or include while data.
Once your data is assembled you want to know any problems that fell below your expectations and maybe the patient(s). You also need to know what went well. The idea of making a change to improve something could inadvertently cause an unwanted correction elsewhere. Change for the sake of change is pointless, expensive and self-defeating. You will almost certainly have a set of standards. Those standards become benchmarks against which you will measure. Here are some examples. I want to hit 30 hours of CPD each year but I also want to achieve CPD of quality and add to my skill set positively. A simple table here works well.
Hours of CPD
You might summarise by saying that you achieved 45 hours of which 25 hours brought actions. How many of these actions were positive, how much was recap or revision, how much was mandatory training and how much did you have to pay yourself rather than by another ? How many actions could not be implemented? How many hours were validated with a certificate?
This all sounds straight forward. However, the power of audit is not just to record one set of data but to repeat that data. Using the same criteria you will list the next year and the year after until you have a pattern. Once you have a series recorded in a table you then have more power to analyse your activity. You would then want to ask if you were consistent across the series. Were there any dips?
I worked in a hospital where complaints were recorded. The complaints were published so each consultant was informed of their own, but not those from others. The failure in this method is that while a name should not be published, any consultant wanting to know how they performed against colleagues was not available. This type of audit has limited value to the consultants but would have been more helpful to management who could see all the data.
Benchmarking is valuable because given a set of data each clinician can see how they perform. This works best when the criteria are the same. Let’s say you have an infection rate set at 2% and you would want to review this per 100 or per 1000 cases. If your infection rate was 3% and therefore +1% above the national expected figure you would want to know where the data reflected a change and of course why?. You would need to review all cases with an infection and sub-divide that data down for variables. Was the treatment the same? Did the patient have a medical problem affecting immunity? Were patients all the same age, ethnicity, gender? What were their occupations?
Risk and incident
When we had a series of patients who were sick after surgery following a general anaesthetic we looked at our data and found the normal trend was less than 1% risk for patients. However, during a period when one anaesthetist was on, we tracked the higher risk to the use of morphine at the surgery which had a known risk of increasing sickness. This was used routinely as a prophylactic drug for pain. Given the fact we used regional anaesthetic blocks, this was pointless. The audit was swift and reactionary. We informed the anaesthetist of the problem and the drug regimen for pain was changed and the sickness with unwarranted admission stopped.
The use of journals is not new and can be used to serve many purposes. During the last Afghanistan campaign, Emily Mayhew published the process of managing soldiers injured whilst on your in her book “A Heavy Reckoning: War, Medicine and Survival in Afghanistan and Beyond (Wellcome Collection)”. Because the soldiers were kept unconscious from the arrival of the evacuation team inducing narcosis and pain medication to the arrival in Birmingham, after being stabilised at Camp Bastion in the Helmand region, the journal filled in the gaps as handlers passed the casualty on. Written data became a powerful medium for individuals to reflect on the hours that passed when a soldier was incapacitated.
In 2017 I published my first book Morton’s Neuroma having kept a journal. I provided this information to my surgical colleague who operated on me. He in turn used this to help his trainees. When again I published a further book (Bunion, Behind the Scenes) based on patient diaries I realised the power of the information allowed instructive feedback which could be used to improve patient journeys.
Podiatry does not use patient journals but probably uses pain diaries more often which help to reflect patterns of behaviour, use of analgesia and the benefit of using an orthosis. Additionally, wound diaries can be helpful in charting wound closure. In 2008 I kept a log of a wound caused by suture reaction after two different operations. The reflection led to changing the type of suture material and technique with a reduction in admission back to the theatre.
In the next article (October 2019) I will deal with workshops and meetings as a form of reflection. Stay in touch as a professional podiatrist and sign up to Reflective Podiatric Practice articles issued most months.