Self-Awareness

Breast Concerns

Robert M. Kliegman MD , in Nelson Textbook of Pediatrics , 2020

Breast Self-Awareness

Controversy exists as to the utility of breast self-examination in the adolescent population. Experts believe that it might be ill-advised to encourage breast self-examination in the adolescent because of a potential for unnecessary anxiety and possible unwarranted treatment in a population that is at low risk for malignant disease. The American College of Obstetricians and Gynecologists (ACOG) endorses breast self-awareness, which is defined as a women's awareness of the normal appearance and feel of her breasts. This can include breast self-examination, and instruction should be considered for high-risk patients. Adolescents should be educated to report any changes in their breasts or concerns to their healthcare providers.

Care of professional caregivers

Brenda M. Sabo , Mary L.S. Vachon , in Supportive Oncology, 2011

Self-awareness as a mechanism for enhancing self-care

Self-awareness involves both a "combination of self-knowledge and development of dual-awareness, a stance that permits the clinician to simultaneously attend to and monitor the needs of the patient, the work environment, and his or her own subjective experience." 7 When functioning with less self-awareness, clinicians are more likely to lose perspective, experience more stress in interactions with their work environment, experience empathy as a liability, and have a greater likelihood of compassion fatigue and burnout. Self-awareness may both enhance self-care and improve patient care and satisfaction. 149 Additionally, when professionals integrate self-awareness into their practice, this may help them to accept limits (including personal vulnerability, personal influence, responsibility and accountability for change, and limits of the known and unknown) and maintain clarity about self in relation to others, in terms of both interconnections and boundaries. 94, 95

Methods of self-care that do not involve enhanced self-awareness, such as maintaining clear professional boundaries, offer protection from occupational stressors and can make possible renewal outside of work. However, exclusive reliance on such approaches to self-care undermines the health care professional's ability to be emotionally available for patients or to find reward in their work. 6, 7 Integrating self-awareness into one's clinical practice supports emotional availability, self-regeneration, and increased personal and professional fulfillment even when faced with difficult and/or emotionally challenging situations. 6, 7, 95 Several practical ways can be used to enhance self-awareness. These include initiatives such as continuing education, 169, 170 peer support (Balint), 171, 172 mindfulness meditation, 168, 173, 174 and reflective writing. 105, 175

Perhaps the most widely recognized means of increasing self-awareness, mindfulness meditation refers to a process of developing careful attention to minute shifts in body, mind, emotions, and environs, while holding a kind, nonjudgmental attitude toward self and others. 176 The practice of mindfulness meditation simultaneously raises the consciousness of one's inner reality (physical, emotional, and cognitive) and of the external reality with which individuals interact. 177 The practice has begun to be utilized and researched in the workplace. Some organizations have used mindfulness meditation as part of a larger intervention, and some have focused on mindfulness meditation. For example, an 8-week mindfulness-based stress reduction (MBSR) program for nurses in a hospital system was introduced and was found to lower burnout and improve well-being. 178 Results from this study showed that the treatment group decreased scores on the Maslach Burnout Inventory, and these changes lasted 3 months. Specifically, significantly decreased emotional exhaustion and depersonalization were noted with a trend toward significance in personal accomplishment. 178 In a matched, randomized controlled trial examining the effect of an 8-week mindfulness-based intervention program for medical students, the authors found that those participating in the intervention experienced less anxiety and depression and greater empathy than those in the control group. 179

Recently, the concept of compassionate silence has emerged as a component of the patient-clinician encounter in palliative care. 180 This ability may come from contemplative practices such as mindfulness-based meditation. Compassion requires active intention—that is, the health care professional not only gives attention, but maintains focus and clarity of perception. "These compassionate silences arise spontaneously from the clinician who has developed the mental capacities of stable attention, emotional balance, and pro-social mental qualities, such as naturally arising empathy and compassion." 180

Writing in a reflective and emotionally expressive way is another form of self-care that enhances self-awareness.

Somatic 181–184 and psychological benefits 185, 186 of this practice have been demonstrated in patients and have been extended to promote reflection and empathic engagement in physicians. 187, 188 Reflective writing has been utilized in a meaning-centered psychoeducational group intervention called Enhancing Meaning in Palliative Care Nursing, which was designed to support nurses providing palliative care. 189 This intervention aims to increase job satisfaction and quality of life and to prevent burnout. Based on Breitbart and colleagues' earlier work with palliative patients, 190 (1) characteristics of meaning, (2) sources of meaning, (3) creative values explored in terms of personal historical perspective and a sense of accomplishment at work, (4) suffering as a source of attitudinal change, and (5) affective experiences and humor were explored as experiential avenues to finding meaning. Although the intervention shows promise and has the potential to positively influence quality of life and job satisfaction among other palliative care professionals outside of nursing, more research and evaluation are needed.

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Optimizing Prenatal Support of the Mother and Family

Gil Wernovsky MD, FAAP, FACC , in Anderson's Pediatric Cardiology , 2020

Counselor Self-Awareness Is Required to Limit Bias

Evidence suggests that counselors do not provide unbiased information—Kon et al. found that physician recommendations for hypoplastic left heart syndrome (HLHS) management were based on what the physicians' affiliated hospital provided, even if they believed that higher survival rates would be achieved with a different procedure. 39 Physicians must also be aware of the surgical/interventional outcomes in their own center and results and alternative treatment strategies available in other centers accessible to the patient and openly provide this information to parents.

The experience of the counselor may bias how information is presented. Kon et al. found that surgeons, intensivists, and cardiologists are more likely to recommend surgical options over comfort care compared with neonatologists at the same facility. 39 The team approach to counseling may be more balanced than counseling by a single individual.

It is important that the counselor is aware that the parent may have very different views to him/her, including religion, background, education, and family circumstances, among other factors that will influence decision making. Arya et al. found that 54% of parents opposed termination for religious or moral reasons, while only 2% of physicians opposed termination for the same reasons. 19 Almost half of physicians and nurses surveyed stated they would terminate the pregnancy if their child was prenatally diagnosed with HLHS. 40,41 These predictions of termination by medical personnel are higher than the published termination rates for HLHS. 42,43 The physician's personal opinion of pregnancy termination and whether they think they would choose termination of pregnancy if in a similar situation are hypothetical, related to their personal circumstances, and cannot be extrapolated to or be allowed to influence the couple being counseled. Conversely, if a physician is not comfortable with counseling regarding termination for major CHD, he/she might arrange for such counseling by another. Acknowledging parents' autonomy can make couples feel that their opinions and decisions are being respected and allow for true informed consent.

Physicians must also be aware of their own views regarding neurodevelopmental delay (NDD) for patients with CHD. In an international study of physicians, Paladini et al. found that approximately half of physicians discussed the association of NDD and CHD with parents regardless of the type of CHD, while 32% discussed this association in selected cases. 44 The majority of respondents were aware of the association between NDD and CHD; however, there was a large geographic difference in physicians' prenatal counseling. In North America, 92% of physicians reported discussing the risk of NDD regardless of the type of CHD, while 42% of physicians in Europe, and 22% in Asia did the same. The authors note that it is of interest that despite the North American physicians reporting discussing NDD much more frequently, the termination of pregnancy rates in that geographic region are significantly lower than in Europe and Asia.

Traumatic Brain Injury, Part II

Paul M. Dockree , ... Ian H. Robertson , in Handbook of Clinical Neurology, 2015

Objects of insight in online experiences

Self-awareness or insight has been described as a relational concept in that it can only be understood in relation to some "object of insight" such as a particular type of cognitive or social difficulty that manifests in certain situations ( Markova and Berrios, 2001). With respect to errors in routine actions, patients may become more or less aware of such errors, depending on the context and the available evidence. For example, Hart et al. (1998) asked patients to perform everyday activities such as wrapping a gift or making toast. Such activities gave rise to various types of error, for example, errors that reflected a change in the sequence of actions, errors that entailed substituting incorrect for correct objects, or errors characterized as superfluous actions not relevant to the task at hand. Particular types of error were less likely to be detected than others. For instance, errors that did not impede task completion, such as placing the wrong object in the gift box (substitution error), were less likely to be detected than errors that did impede progress in the stream of action, such as closing an empty gift box with the gift remaining on the table (sequencing error). Thus some types of errors provide more salient or exogenous sources of evidence than others and reach the threshold of awareness more readily.

O'Keeffe et al. (2007b) have also demonstrated that some errors are qualitatively different and arise from different cognitive demands, which influence their likelihood of being explicitly reported in TBI patients. For example, errors to no-go targets embedded within a random sequence of go trials often reflect inhibitory control failures that capture exogenous attention and engage error processing mechanisms leading to normal reporting of errors in TBI patients. By contrast, errors to no-go targets embedded within a predictive sequence are more likely to reflect an inattentive and automatic mode of responding that gives rise to more unaware errors in patients than controls. In neurologically normal participants different electrophysiologic signatures characterize these two types of error (O'Connell et al., 2009). Inhibitory errors reflect a diminished ERP N2/P3 complex, and sustained attention errors reflect greater pre-error α (~   10   Hz) synchronization and a reduced late positive ERP component. Moreover, the error-related negativity did not differ between correct and incorrect responses in the fixed sequence condition but it did in the random sequence condition, supporting the conjecture that only errors in the latter condition arise from a failure to resolve response competition. Thus, the nature of errors provides qualitatively different sources of evidence available for metacognitive appraisal. The ERN, in this case, might provide a marker for a more intact goal representation.

Similarly, in a study with neurologically normal participants (Shalgi et al., 2007), different types of error were induced by a manipulation of response speed that dissociated accuracy and awareness. In one condition participants responded as quickly and as accurately as possible to each go-trial stimulus, and in the other condition they were instructed to time their responding to the offset of the stimulus. Although there were more no-go errors committed when responses were speeded compared to delayed, participants were unaware of proportionately more errors in the easier delayed condition. The authors argue that when speed is emphasized, the task has an exogenously alerting effect and engages error-processing mechanisms following inhibitory errors. By contrast, without the exogenous support induced by response urgency, there is greater reliance on endogenous sustained attention processes that are more susceptible to lapses, thereby reducing the likelihood of error detection. The clinical implication is that tasks that have minimal exogenous support and require delayed responding to stimulus offsets will be more sensitive to inattention and impaired emergent awareness.

Another source of evidence that may mediate error awareness is autonomic information. We have demonstrated that TBI patients show reduced skin conductance responses to commission errors, even when awareness is reported. However, between-subject correlations show that greater skin conductance amplitudes are related to higher levels of error detection but are unrelated to accuracy in TBI patients (O'Keeffe et al., 2004). Separately, it has been demonstrated that autonomic responses are absent on unaware errors (O'Connell et al., 2007; Wessel et al., 2011).

Autonomic responses such as skin conductance and heart rate have been associated with activation in the anterior insula and the amygdala (Mutschler et al., 2009). In a recent review, Klein et al. (2013) highlight the importance of the insula, which is both reliably activated during conscious error detection and associated with processes of emotional and interoceptive appraisal. The anterior insula is also a critical node in the salience network consisting of the anterior cingulate cortex, the amygdala, and the inferior frontal gyrus. The insula, within this network, is responsible for detecting salient stimuli and orchastrating switches to other key networks such as the default mode and executive networks. Recent evidence suggests impaired flexibility between these key networks can be predicted by the amount of traumatic axonal damage connecting the right anterior insula to other nodes within the salience network (Bonnelle et al., 2012). It is possible also that damage to the insula may disrupt processes of interoceptive appraisal, reducing associated evidence that an error has been committed, although this remains to be seen. Having reliable markers for different sources of evidence (e.g., perceptual, autonomic, higher-level goal representations) will be important to dissociate difference factors underlying impaired awareness in heterogeneous clinical populations.

In view of the abovementioned findings demonstrating that both sustained attention and automomic responsiveness, a potentially salient source of evidence for an error, are reduced in TBI patients, a possible rehabilitation strategy to enhance these factors and, in turn, increase awareness is self-alert training (SAT). During SAT, participants learned to produce self-generated increases in alertness via online changes in electrodermal activity. Initially, a participant produces enhanced skin conductance responses (SCRs) to a periodic auditory cue, this is then phased out and replaced by the participant's own self-generated commands giving rise to enhanced SCRs. Training is reinforced via a visual feedback cue conveying the magnitude of each self-alert through online changes in skin conductance. Comparison of pre- and post-training data has shown that SAT increased levels of autonomic arousal and reduced attentional errors in both healthy controls and adults with attention deficit hyperactivity disorder (ADHD) (O'Connell et al., 2008). By contrast, participants in a placebo condition exhibited a linear reduction in arousal over time and no improvement in sustained attention performance. It remains to be seen if SAT can indirectly enhance emergent awareness in clincal groups who exhibit such impairments. However, given the close relationship between sustained attention and online awareness, this is a testable hypothesis.

Discrepancy measures to assess loss of insight after brain injury have addressed different objects of insight across cognitive, affective, and psychosocial domains, each contextualized with different everyday examples. By contrast, online awareness, in multidimensional investigations of brain injury, has perhaps been narrowly operationalized as the reporting of errors in routine action as exemplified in the previous section. An important approach to further our understanding of impaired SA, therefore, is to derive declarative reports from metacognitive experiences across a range of experimental contexts to explore the different foundations upon which online awareness may be impaired.

Recognition of the breadth of objects of insight is apparent in an influential cognitive model of metacognition (Nelson and Narens, 1994) that proposes a two-level structure in which there are multiple object-level processes, such as perceptions, actions, memories, and decisions measurable in laboratory paradigms, which are under subordinate control from meta-level processors. Shimamura (2008) extended this model within a hierarchical neural framework in which meta-level processors in prefrontal cortex monitor and control numerous object-level processes that are instantiated in posterior cortical regions. Within this model (Fig. 32.4), meta-level control is applied through a filtering mechanism that amplifies task-relevant neural activity and suppresses task irrelevant activity. This framework shares commonalities with models of executive attention (Fernandez-Duque et al., 2000) and cognitive control (Botvinick et al., 2001) insofar as top-down prefrontal mechanisms for monitoring and control are central to it.

Fig. 32.4. Schematic adapted from Shimamura (2008) illustrating a neural characterisation of Nelson and Narens' metacognitive model. Meta-level processors in prefrontal cortex control numerous object‐level processes that are instantiated in posterior cortical regions and also monitored, in turn, by prefrontal processors.

From the point of view of meta-level processes controlling a gating mechanism for different object-level processes, it is possible to see how different kinds of unaware error might emerge. For instance, unaware errors in routine action are often characterized by a failure to flexibly redeploy attention to some important change in a task rule or stimulus feature. However, other forms of unawareness are revealed, not as failures to detect change, but as failures to maintain cognitive set in the face of irrelevant distracters. Goldberg and Barr (1991) make a distinction between these two failures of awareness in online situations. Perseverative behavior and unawareness of error in routine action are described as failures of behavioral plasticity, while an inability to maintain task set without succumbing to distraction by irrelevant information is described as a failure of behavioral stability. Goldberg and Costa (1986) describe a striking example of the latter in a patient with bilateral prefrontal brain injury. The patient was instructed to listen to a story for later recall. He subsequently recalled the details of the story correctly but then, inadvertently and without apparent awareness, proceeded to embellish the story with irrelevant features from the broader context of the testing room. For example, a tape recorder in the room used to record the session was incorporated into the verbal monologue of the patient.

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Intervention

Moses N. Ikiugu PhD, OTR/L , in Psychosocial Conceptual Practice Models in Occupational Therapy, 2007

Transparency

Mosey identified self-awareness as "the ability to recognize, with a reasonable degree of accuracy, how one reacts to the outside world and how the outside world reacts to oneself" ( p. 202). 63 She asserted that this self-awareness is a crucial characteristic of successful therapeutic use of self. This suggests continuous vigilance and self-auditing by the therapist, achieved through constant reflection on personal experiences. This allows the therapist to be authentic, or to demonstrate what Rogers referred to as genuineness. 73 This characteristic is emerging as a theme in current therapeutic relationship literature. It emphasizes that "it is important to listen to your own thoughts in the same way that you listen to" the client's ideas, "staying curious about your own process" (p. 18). 31 This means "reflectiveness in the therapeutic use of self" (p. 18). 31 When you are reflective and are conscious of your own psychic processes as a therapist, you are likely to collaborate more effectively with your clients.

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Ethical and Legal Issues in Neurology

Adam Zeman , Jan Adriaan Coebergh , in Handbook of Clinical Neurology, 2013

Self-consciousness as self-monitoring

This form of self-awareness involves the ability to monitor our past and present and predict our future behavior and experience, thus extending self-perception in time, and in depth, by allowing organisms to represent their own experience and actions to themselves. It includes the ability to recall the actions we have recently performed ( Beninger et al., 1974) and the ability to predict our chances of success in tasks which challenge memory (Hampton, 2001) or perception (Smith et al., 2003): we undoubtedly possess these metacognitive abilities, and ingenious experiments in comparative psychology (Beninger et al., 1974; Hampton, 2001; Smith et al., 2003) suggest that many other animals have them too. The remaining senses lie closer to what we normally have in mind when we speak of self-awareness.

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International and Multicultural Issues

Adrian EG Skinner , Gary Latchford , in Online Counseling (Second Edition), 2011

1.

Increase self awareness of

a.

The influence of your own culture

b.

Your assumptions about other cultures

c.

Your feelings about working with clients from other cultures

d.

The potential impact of your own culture on clients with different cultural backgrounds

2.

Develop knowledge of different cultures; for example,

a.

Acknowledge the importance of the cultural context for the individual

b.

Acknowledge the influence of culture on beliefs about health/mental health

c.

Acknowledge the influence of culture on experience and expectations of counseling

3.

Develop culturally sensitive interventions; that is,

a.

Respect individual beliefs and cultural differences

b.

Acknowledge limitations as a counselor

c.

Actively seek knowledge and advice/supervision

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Self-Awareness and Insight: Foundations for Intervention

Glen Gillen EdD, OTR, FAOTA , in Cognitive and Perceptual Rehabilitation, 2009

Models of Self-Awareness

The pyramid model of self-awareness was developed by Crosson and associates 18 (Figure 4-2). This model includes three interdependent types of awareness.

1

Intellectual awareness: The ability to understand at some level that a function is impaired. At the lowest level, one must be aware that one is having difficulty performing certain activities. A more sophisticated level of awareness is to recognize commonalities between difficult activities and the implications of the deficits. Crosson and associates 18 hypothesize that factors that may contribute to impaired intellectual awareness include decreased knowledge of the manifestations of brain injury, deficits in abstract reasoning, and severe memory loss. Refers to knowing you have a problem.

2

Emergent awareness: The ability to recognize a problem when it is actually happening. Intellectual awareness is considered a prerequisite to emergent awareness in this model because one must first recognize that a problem exists (knowing you are experiencing a problem when it occurs). Emergent awareness is included in the concept of online awareness or monitoring of performance during the actual task.

3

Anticipatory awareness: The ability to anticipate that a problem will occur as the result of a particular impairment in advance of actions. Intellectual awareness and emergent awareness are considered prerequisites to anticipatory awareness in this model because one must first recognize that a problem exists and be aware that a problem is occurring to successfully anticipate a potential problem (knowing in advance you have a problem that will affect future function). Anticipatory awareness is included in the concept of online awareness.

Those with brain injuries may be impaired across all three awareness domains 51 or may present with better skills in one or more domains of awareness. Crosson and associates 18 further applied this model to the selection of compensatory strategies and categorized compensations appropriate to each type of awareness (Table 4-3). They classified compensatory strategies according to the way their implementation is triggered:

•

Anticipatory compensation: Applied only when needed, this term refers to implementation of a compensatory technique by anticipating that a problem will occur (i.e., requires anticipatory awareness). An example is a person who needs groceries for the week and is aware that because busy environments result in increased memory and attention deficits decides to defer shopping until 7 pm when the local store is not as busy.

•

Recognition compensation: Also applied only when needed, this term refers to strategies that are triggered and implemented because a person recognizes that a problem is occurring (i.e., requires emergent awareness). An example is asking a person to speak slower because you realize that you are not processing information quickly enough and are having difficulty following the conversation.

•

Situational compensation: This term applies to compensatory strategies that can be triggered by a specific type of circumstance in which an impairment may affect function. The strategies are taught to be consistently used every time a particular event occurs. An example is a student who, secondary to memory impairments after a traumatic brain injury, tape records all lectures in class. Although there are times when this may not be necessary (e.g., a particularly slow-moving and limited-content lecture), the strategy is used anyway because this type of compensation does not rely on the judgment of the client. Intellectual awareness is necessary to use this strategy because one must be aware that a deficit exists in order to integrate a strategy to overcome it.

•

External compensation: This type of compensation is triggered via an external agent or involves an environmental modification. Examples include alarm watches, posted lists of steps related to meal preparation, and so on.

Abreu and colleagues 1 empirically tested the hierarchy proposed by Crosson and associates 18 in a study of self-awareness after acute brain injury. They examined awareness related to performance of three functional tasks (dressing, meal planning, and money management). A series of questions rated on a Likert scale were used to ascertain awareness: "Are you aware of any changes in your ability to perform the following task since your injury?" (intellectual awareness), "How well do you predict you will do on the following task?" (intellectual awareness), "How well do you think you did on the task?" (emergent awareness), and "How do you think your performance on the task might affect your ability to live independently, work, and have fun?" (anticipatory awareness). Their analysis revealed significant differences for all levels of self-awareness across the three tasks. Although their findings did not support the proposed hierarchy, the authors caution that the questions used in their study may not have been sensitive to the levels described in the model and other means of operationalizing the levels of awareness are necessary. A recent study documented a strong association between emergent and anticipatory awareness. 51

This model was constructively criticized and expanded on by Toglia and Kirk. 91 Their model, the Dynamic Comprehensive Model of Awareness, suggests a dynamic rather than a hierarchic relationship. The model proposes a dynamic relationship among knowledge, beliefs, task demands, and the context of a situation based on the concept of metacognition. This model differentiates between metacognitive knowledge or declarative knowledge and beliefs about your abilities prior to the task (incorporating aspects of intellectual awareness) and online monitoring and regulation of performance of tasks (i.e., during task performance), which integrates aspects of emergent and anticipatory awareness (Figure 4-3). A study that incorporated Toglia and Kirk's 91 model into a comprehensive, multidimensional approach to assessment of impaired self-awareness supported the authors' categorization of awareness into metacognitive knowledge versus online awareness. 57

Finally, Fleming and Strong 27 discuss a three-level model of self-awareness:

1

Self-awareness of the injury-related deficits themselves such as cognitive, emotional, and physical impairments (i.e., knowledge of deficits).

2

Awareness of the functional implications of deficits for independent living.

3

The ability to set realistic goals; the ability to predict one's future state and prognosis.

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Sleep: Dreaming Data and Theories☆

Katja Valli , Antti Revonsuo , in Reference Module in Neuroscience and Biobehavioral Psychology, 2019

The Dream Self

An element present in almost every dream is the dream self. Usually, we experience our dreams from the embodied first person perspective, in a similar fashion than we experience our waking reality. The dream self most often possesses a body-image much like the one we have while awake, and the dream self is positioned in the centre of the dream world, actively taking part in the dream events. In this respect, the dream self is not all that different from the waking self. Sometimes, however, we can have a camera-like perspective on dream events, and observe the dream and even ourselves from a third person's point-of-view.

What is different between the waking self and the dream self are memory lapses, confabulation and lack of insight into our own deficient cognition. The dream self often has a limited access to his or her autobiographical memory, suffers from transient amnesia, and is disoriented to time and place. While we may remember some autobiographical facts concerning our lives correctly when dreaming, often we lose the ability to contemplate whether the events, persons, places, or objects in our dreams are possible. For example, we can meet dead friends and relatives without the realization that they have, in fact, died years ago. We can also create false memories in our dreams, and not be able to reflect on the peculiarity of the dream. For instance, we can confabulate characteristics for dream persons known from waking life which they do not have in reality, like a different hobby or profession. Sometimes we manage to create "friends" or "relatives" that we do not have in our waking reality, and we have no insight into the fact that these people do not exist in real life. Simply, we are often unable to reflect upon the credibility of our own beliefs in our dreams.

The lack of full self-awareness can extend to ourselves as well, although this is quite rare. Although the dream self in most dreams appears much the same as during wakefulness, in a small proportion of dreams the self appears in an altered form. The milder variations include cases in which the dreamer is the same person, but appears in strange clothing or is of a different age, say, a small child in the dream. In a more distorted form, we can appear as a completely different person, sometimes of the opposite sex or different ethnicity. In very rare occasions, we can even transform into an animal, as in the following dream excerpt.

I lived in a small house in the countryside, and I had several dogs [not true at the time the dream took place]. I let the dogs out, to roam free. They run into a nearby field, and then I saw the reason for this: a huge elk with magnificent antlers was standing in the middle of the field. My dogs wanted to hunt down and kill the elk, and suddenly I was one of the dogs, the leader of the pack. I felt myself running on four legs through the hay, fast and strong. Then I realized that I and the other dogs were no longer dogs, but fierce wolves. Bloodlust was filling my mind, I could almost taste the raw elk meat in my mouth, and drool oozed between my sharp canines. The elk started to run away from us, and we followed, hunting in a coordinated fashion to bring down our prey.

First author's dream, reported August 11th, 2007.

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Clinical Reasoning

Mark A. Jones , in Clinical Reasoning in Musculoskeletal Practice (Second Edition), 2019

Metacognition

Metacognition is a form of self-awareness that incorporates monitoring of yourself (e.g. your thinking, your knowledge, your performance) as though you are outside yourself observing and critiquing your practice. There is an integral link between cognition, metacognition and knowledge acquisition that facilitates learning from clinical practice experience ( Higgs et al., 2008a; Marcum, 2012; Schön, 1987). This self-awareness is not limited to the formal hypotheses considered and treatments selected; metacognitive awareness of performance is also important. This, for example, underpins the experienced clinician's immediate recognition that a particular phrasing of a question or explanation was not clear. Similarly, metacognitive awareness of the effectiveness of a physical procedure enables immediate recognition that the procedure needs to be adjusted or perhaps should be abandoned as, for example, when cues such an increase in muscle tone or the patient's expression signal the procedure was not achieving its desired effect. Lastly, metacognition is important to recognizing limitations in knowledge. The student or clinician who lacks awareness of his or her own knowledge limitations will learn less. Experts not only know a lot in their area of practice, they also know what they don't know. That is, experts are typically very quick to recognize a limitation in their knowledge (e.g. a patient's medication they are unfamiliar with, a medical condition, a peripheral nerve sensory and motor distribution) and act on it by consulting a colleague or appropriate resource.

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