Page 83 - Journal of Special Operations Medicine - Winter 2014

assumes that the nature of clinical practice is inher- exemplars gained by mission success and mission fail-
ently algorithmic, can be concretely measured in scope, ure. Therefore, SOF-specific EBP is found within their
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and excludes the need to critically reason and respond “practice-based evidence.” Practice reflections drive pro-
to dynamic challenges in the clinical environment. A fessional development by adding to evidence generation
21
competency-based curricular framework rhetorically and knowledge production. 38
and incorrectly assumes that there actually exists a me-
ticulous and comprehensive record of all competencies EBP is “what ought to happen” and reflective practice
required within clinical practice. 9,21,22 is “what practitioners say happened.” The actuality is
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that EBP is a hierarchy designed to guide incorporating
The issue is that “. . . ‘critical thinking’ has become a research into teaching, but EBP can be an empirical plat-
catch-all phrase . . . it is misleading because it obscures form that is inherently positivist, posing a problem for
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ways that teaching and learning in [practice] need to fo- SOF medics, whose practice is contextual. Contextless
cus on multiple ways of thinking, with a much greater knowledge cannot be methodically and directly applied
emphasis on clinical reasoning.” Instead of shifting to all practice situations, an especially salient point for
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needed focus to clinical reasoning, educators perpetu- SOF medics practicing in unpredictable environments. 39
ate methods and curricula emphasizing abstract critical
thinking alone. While this may be accepted and ap- Those who propose that EBP is the best framework for
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pealing, continuing the status quo does little to develop clinical education and practice see chaos or confusion
clinicians’ reflective practice and interpretive thought. as signs that students or practitioners are performing
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The reality is that SOF medics operate within multifac- inadequately. Those who support reflective practices
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eted contexts that are austere, remote, often ambiguous, contradict this by arguing that clinical practice is inher-
and devoid of resources. 14 ently ambiguous and unpredictable, and that cognitive
dissonance is organic to the practice environment and
Anyone who provides care in complex and abstruse will not be abolished by scientific reasoning. In short,
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circumstances must be able to interpret rapidly chang- allowing confusion and chaos is important in students’
ing variables and prevail upon many perspectives and clinical development.
ways of thinking to make reasonable, sound, clinical
decisions. The ability to reflect on practice and reason SOF medics manage complex clinical situations that
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critically in exigent clinical situations is powerfully pre- are often “a total cluster [mess].” Analyzing clinical
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disposed by experience. For novice SOF medics, their “messes” to determine the root cause, along with the
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lack of experience can be mitigated by using a curricu- notion that managing messes is an important concept,
lum thoroughly informed by the practice reflections of is central to transforming SOF medics’ curriculum, as
experienced medics. complex clinical practice cannot be solved solely by pro-
tocols or through algorithmic methods alone. 42

The Lack of Evidence
The current trend in clinical education is to place pri- Contradictions and Gaps
mary emphasis on evidence-based practice (EBP). EBP in Reflective Practice Models
is based upon valid research and clinical experience. Strategies that use reflective practice are statistically as-
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A pervading misconception is that EBP is based on a sociated with reductions in practitioners’ errors and with
system in which quantitative, randomized controlled tri- clinicians generating more accurate diagnoses. Despite
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als (RCTs) and meta-analyses are of highest value. The this, few studies have used an experimental method to
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use of EBP in clinical education should follow one of determine these associations. Kinsella cautions that
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its earliest definitions: “The practice of evidence-based because the actual concept of reflective practice has been
medicine means integrating individual clinical expertise misunderstood, diluted, and arbitrarily applied to prac-
with the best available external clinical evidence from tice and education, it is in danger of becoming hollow
systematic research.” Even so, a popular rating system and somewhat trivial. The assumption that reflective
36
for the hierarchy of clinical evidence states that the best practice is fully understood within higher education is
“Level I” evidence is a conglomeration of meta-analyses completely false. 46
and systematic reviews of RCTs. 37
In contrast to other literature primarily describing meth-
In contrast, SOF medics’ evidence is often narrative, ods by which individuals can apply reflections to their
qualitative, and practice based; moreover, RCTs are im- own practice, 47–52 reflective practice requires entire orga-
possible and unethical in care delivered in combat. SOF nizations to reevaluate assumptions about knowledge.
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medics’ methods of inquiry are contextual and experi- This point—that entire organizations need to reevaluate
ential, related to the history of practice in war and the assumptions about knowledge—is one the command

Call for Innovation: Practice Reflections and Clinical Curricula 73