119 General discussion these steps are rooted in reflective learning principles. ‘Reflective observation’ centers on introspecting one’s own experiences with a new concept, while ‘abstract conceptualization’ emphasizes the application of newly acquired insights. Our research underscores that these critical phases are frequently inadequately addressed or even overlooked in SDM training, significantly undermining training effectiveness. Given these insights, let us delve deeper into the concept of reflective practice. Reflective practice has been a part of educational theory for nearly half a century. [23-25]. Although it may have slightly different definitions and interpretations between authors and over time, all agree that reflective practice commences with a triggering event, a perceived need, or a disruption in one’s usual routine. For instance, in Chapter 3, the intended triggering event was receiving patient feedback. Following this trigger, the individual engages in a purposeful process of examining the event to derive learning from it. Past studies have shown that the ability to reflect can be cultivated through practice and specific stimuli. [26] Furthermore, the learning environment, particularly the behaviors of mentors or supervisors, can either encourage or hinder reflective thinking. [26, 27] Research indicates that teaching reflection skills to trainees can lead to increased engagement in reflective practice in the future. [28] Moreover, employing reflection in the actual workplace, within the learners’ social environment, can effectively counteract unwanted learning effects stemming from the hidden curriculum. [28] Nonetheless, it is crucial to advocate for reflective practice that goes beyond the ritualistic fulfillment of reflection requirements to truly be effective. The prevalence of perfunctory reflections in formal training underscores the importance of emphasizing more meaningful and impactful reflective practices. [29] In the context of Chapter 3, the lack of a discernible impact from receiving patient feedback might have resulted from the absence of facilitated reflections with a mentor, as the participating residents had not, or had not yet, developed the skill to reflect on their actions automatically. The endorsement of reflective practice is evident within the field of medical training as well. This advocacy has resulted in more research on its incorporation into training interventions. For example, a 2022 review focused on whether reflexivity in SDM-promoting interventions improved their effectiveness. Unfortunately it found only modest improvements in intervention effects, from 33% to 43%. [30] Considering the enduring negative influences from the workplace, this meager result is not entirely surprising. Nevertheless, it remains crucial to continue integrating reflective practice throughout training, as it can aid in uncovering those elements that contribute to an individual’s cognitive dissonance, providing an opportunity to address and resolve these dissonances. Hence, to effectively train doctors, whether they are junior or seasoned professionals, it is imperative to facilitate reflections on the practical realities of their profession. These reflections should explicitly include prevailing, often negative, perceptions regarding the applicability of SDM often found within the clinical workplace, as illustrated by our practice observations and interview results. Only by comprehensively understanding the cognitive processes of clinicians and how these processes are influenced 7
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