'Anxiety, fear and mistrust' surround written reflection, says GP appraiser

The vast majority of appraisal discussions surrounding reflective notes are directly linked to the case of Dr Hadiza Bawa-Garba and there is 'anxiety, fear and mistrust' about written reflection, a GP appraiser has said.

GPC sessional subcommittee chair and GP appraiser Dr Zoe Norris
GPC sessional subcommittee chair and GP appraiser Dr Zoe Norris

Responding to findings from a GPonline survey which showed that 70% of GPs believe it is unsafe to record written reflection in the wake of the Bawa-Garba case, GPC sessional subcommittee chair Dr Zoe Norris said she has seen a definite change in GPs’ attitudes towards reflective notes.

Speaking in her capacity as an appraiser, Dr Norris told GPonline: ‘Most GPs want to discuss what they should and shouldn’t be putting in their reflection and almost all discussions are directly related to the Bawa-Garba case.’

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The poll also found that 60% of GPs have changed the way they record reflective notes as a direct result of the case. ‘Doctors are very anxious that they aren’t penalised for changing how they reflect, but also about how their reflections may be used to implicate them in legal or GMC cases,’ Dr Norris said.

‘Some GPs are writing down bare outlines, and asking to discuss details in the appraisal meeting. Others haven’t written down a huge amount until we have talked through their concerns during the appraisal. There is a lot of anxiety, fear and mistrust.'


This demonstrates the extent to which doctors' confidence in the process of recording reflective notes has been undermined following the Bawa-Garba case - despite entries from her e-portfolio not actually being used in court.

Many GPs responding to GPonline's survey voiced concerns over the use of reflection during appraisals. One said: ‘Should I have a difficult case to reflect on I will keep my reflections private. I would probably discuss with partners [or] my medical defence organisation if necessary but would not put in appraisal.’

Another commented: ‘Written reflective notes are an important learning tool and can be used in discussion for example with an appraiser. Following the Bawa-Garba case I would prefer to verbally reflect rather than document some of my notes.’

Reflective notes

The GMC is currently working jointly with the Academy of Medical Royal Colleges, the Conference of Postgraduate Medical Deans (COPMED) and the Medical Schools Council (MSC) to produce guidance on reflective practice, which is due to be published in autumn.

In the meantime, Dr Norris advises doctors to keep any reflection ‘entirely anonymised’ and written for educational use only.

‘Most of us write entries in the same way we would referral letters to colleagues, with lots of detail,’ she said. ‘I have to re-read my own entries and delete things that actually aren't relevant, and could be used to identify the patient. I also think it's entirely reasonable to put a general outline, and add that you prefer to discuss details in your appraisal meeting.’

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