The role of reflection in dealing with uncertainty
The article by Bluebond-Langner et al. and the editorial comment by
Marron highlight the role of uncertainty in the communication of
prognosis to parents of children with cancer.1,2Uncertainty is intrinsic to medical practice. It is present from the
moment of diagnosis and persists—in varying degrees—through the
course of disease, treatment, and recovery or death. Learning to accept
and manage ambiguity is a crucial task in the professional development
of physicians. Fascinatingly, a physician achieves the highest level of
competence when he/she acknowledges uncertainty and engages reflection
as described by Carracio.3
In this context, reflection is the conscious act of reviewing one’s own
experience with the aim of learning and improving performance. In
medical practice, reflection is usually triggered by circumstances where
the “best” course of action is unclear or the outcome is not
predictable, especially those situations that evoke strong
emotions.4,5 Interestingly, the medical care of
children with cancer - where it is difficult to exactly forecast the
response to treatment or the development of therapy-associated
complications - includes all the elements that should prompt reflection
in physicians.
Reflection usually involves taking time in the midst of high-stakes
situations to review data and decisions carefully. This practice can be
enhanced by consulting with experienced colleagues or, when available,
working with a trained facilitator. Reflective practice can also be
incorporated into training curricula for those entering the field. For
example, over the past 25 years our program has offered first year
fellows a “Reflective Practice and Leadership Seminar,” which provides
dedicated time and resources for fellows to reflect on complex
situations encountered during their training.6 The
seminar provides a confidential opportunity where fellows can examine
their own knowledge, emotions, beliefs and management strategies
critically. A facilitator guides the discussions in collaboration with
2-3 experienced pediatric hematology/oncologists. Uncertainty
surrounding the treatment and prognosis of pediatric cancer patients is
a typical challenge presented by the fellows. Both the fellows and
faculty have found these sessions useful in understanding and managing
these scenarios.
We agree with Bluebond-Langner and colleagues that uncertainty plays a
pivotal role in communicating difficult news to parents of children with
cancer. Failure to recognize and effectively manage uncertainty may lead
the practitioner to experience anxiety and/or burnout, and may impact
the quality of patient care. Although the capacity to deal with
uncertainty may be acquired through long-term exposure to complex
cases7, we believe that providing routine, methodical
opportunities that support reflective practice help both trainees and
seasoned physicians to embrace uncertainty and to communicate with
patients and their families more empathetically and effectively.
References:
1. Bluebond-Langner M, Hall N, Vincent K, Henderson EM, Russell J,
Beecham E, Bryan G, Gains JE, Gaze MN, Slater O, Langner RW, Hargrave D.
Parents’ responses to prognostic disclosure at diagnosis of a child with
a high-risk brain tumor: Analysis of clinician-parent interactions and
implications for clinical practice. Pediatr Blood Cancer
2021;68(3):e28802.
2. Marron JM. Communicating uncertainty: A step in the right direction?
Pediatr Blood Cancer 2021;68(3):e28849.
3. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational
bench to the clinical bedside: translating the Dreyfus developmental
model to the learning of clinical skills. Acad Med 2008;83(8):761-767.
4. Murdoch-Eaton D, Sandars J. Reflection: moving from a mandatory
ritual to meaningful professional development. Arch Dis Child
2014;99(3):279-283.
5. Winkel AF, Yingling S, Jones AA, Nicholson J. Reflection as a
Learning Tool in Graduate Medical Education: A Systematic Review. J Grad
Med Educ 2017;9(4):430-439.
6. Frugé E, Mahoney DH, Poplack DG, Horowitz ME. Leadership: ”They never
taught me this in medical school”. J Pediatr Hematol Oncol.
2010;32(4):304-308.
7. White G, Williams S. The certainty of uncertainty: can we teach a
constructive response? Med Educ 2017;51(12):1200-1202