54 Chapter 3 In addition to that, it remains difficult from this qualitative study to establish a relationship between patient feedback and the act of reflexive practice, as reflexivity was not measured but merely explored through qualitatively analyzing interviews. However, to the authors’ knowledge, no quantitative measures testing reflexivity are currently available. A Dutch study group comes close, as they developed a 23-item self-assessment questionnaire measuring reflective skills. [26] Their survey incorporated items on self-reflection, empathetic reflection, and reflective communication, yet it lacked other reflexivity elements, such as omitting realworld context, or the dialogical space. Another more recent study acknowledged the complexity in measuring reflexivity and used a more formative approach, including mind-maps and trainer-trainee discussions. [27] This study, though, lacks objective quantification of results as well. [27] In the current study, we used a structured approach to analyze our qualitative data. This approach has resulted in important insights for addressing reflexivity in training. Reflection is undoubtedly an essential component of professional and self-directed learning, and therefore it should be part of (continuing) medical education. [13, 28, 29] Without discussing these reflections with others, however, learning effects might not be as strong and sustainable. For example, perceived learning results improved to a larger extent when reviewing written patient feedback with a tutor than when receiving feedback. [30] This pleads for adding a form of facilitated reflection, a dialogical space, when handing over patient feedback to trainees. Although these facilitated reflections were not an intended part of the present study’s intervention, they might still have taken place during study interviews. These interviews facilitated reflections, as residents were invited to reflect upon their actions there and then. In retrospect, it would have been worthwhile to repeat data collection after these first interviews, to test whether this dialogical space had indeed led to improvements residents’ SDM and reflexivity. Furthermore, it is unsurprising that residents seem to forget or underestimate the importance of patients’ opinions. They are faced with the subliminal message that patients’ opinions are not that important. This is exemplified in our interviews: supervisors do not always stimulate SDM practice, and residents tend to follow non-individualized practice guidelines without exploring patients’ wishes. Literature underlines these observations, with doctors focusing on ‘medical’ evidence instead of adjusting their behaviors to patients’ needs. [31, 32] A systematic review of the use of SDM in practice showed that untrained doctors do not use SDM consistently. [33] This pleads for supervisors to be trained in SDM competencies too, in order to facilitate residents developing SDM skills instead of frustrating them. Ideally, it should be included in existing train-the-trainer programs paying attention on how to address SDM in facilitated reflections. A strength of this study is that it has strong patient involvement, both in the study setup and data collection. Interview results endorsed the educational potential of patient feedback. Negative feedback was especially useful to residents and underlined the need for good consultation and SDM skills. Another strength is that the researchers used validated questionnaires. However, only seven out of eleven residents received twenty-five or more completed questionnaires, which is considered the minimum number needed for accurate performance estimates. [34] These
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