In the first article on reflective writing, we covered the components and composition of a structured reflective account.
This second article covers how log entries are assessed and discusses the typical comments given by trainers. Having spent time and effort crafting an entry, the trainer’s comments may sometimes seem critical but it is important to remember that trainers are helping you to develop new ideas or different perspectives.
This article explores how I mark reflective entries and gives examples of comments I make. Trainers differ and judgments are subjective so please bear in mind that this is just one trainer’s perspective.
Again, I will use the log entry of a fictional trainee to illustrate concepts.
A summary of trainee’s log entry
I consulted in routine clinic today with a 29-year-old unmarried lady whose partner was told by a GP last week that he had penile warts and was advised to tell his partner to 'get checked out'. I was a bit confused by the advice to be 'checked out'.
I explored the patient’s agenda, I undertook a vaginal and speculum examination following which I reassured the patient that she did not have genital warts. After the patient left I remembered that different strains of HPV are responsible for genital and cervical infection, so I looked up an online resource to learn further.
I read that up to 30% of patients with genital warts could be co-infected with another STI. Should I have advised or screened for Chlamydia? If I encounter this again, I will consider the medical conditions it is important not to miss, the so-called red flags, as this is an important part of a GP’s job.
I will share my thoughts about red flags with the patient and her expectations of medical management may alter.
What is assessed
One of the objectives of workplace-based assessment is to develop analytical GPs, capable of thinking critically, who are able to apply their learning to clinical situations, and to solve clinical dilemmas.
How will I recognise 'critical thinking' in a piece of reflection? At its simplest level, I am looking for the trainee to examine the assumptions they made by asking themselves searching questions.
In the above example, the trainee assumed that performing a patient-centred consultation involved meeting the patient's expectations. The patient expected a cervical examination for genital warts; she performed the examination and discussed her findings with the patient.
The trainee then asked herself searching questions: 'Were there important conditions that I missed? Would other GP s do what I did?'
To answer these questions, she did a bit of online reading. At the end of the reflective account, the trainee concluded that she should have given the patient some medical information about STI risk, empowered the patient and altered her expectations.
The trainee showed evidence of critically examining her assumptions of what constitutes 'patient-centred consulting'.
At a deeper, more detailed level of assessment, when I mark a log entry I ask myself what knowledge (medical theory), cognitive skills (understanding, application, analysis, synthesis and critical evaluation) and communication skills this entry has demonstrated.
I also judge how well trainees have selected, organised and presented their knowledge and understanding.
Therefore, when marking the above example, I would consider:
- What medical knowledge does the trainee demonstrate?
The trainee demonstrates some understanding of patient-centred consulting, an ability to perform and interpret vaginal examinations, and the ability to communicate medical concepts to the patient. Some skills are developed to a greater degree than others.
- What cognitive skills does the trainee demonstrate?
1. How well did the trainee look at what was going on beneath the surface? When we look at the trainee’s understanding of the situation, we find that despite, at first glance, having a ‘satisfied and complimentary patient’, the trainee recognised that she had a deficiency of knowledge about the natural history of genital warts that led to self-doubt about how well she had managed the case.
2. Did the trainee apply theory to practice? She accessed, read and evaluated GP guidance on STIs and asked herself how this information applied to her patient.
3. What did the trainee find when she revisited the case with the new information (analysis)? She found that she had not assessed STI risk globally.
4. How well did the trainee apply new ideas to her thinking? She decided that it wasn’t good enough to meet the patient’s expectations. She concluded that a safe GP would also look for red flags and, if needed, influence the patient’s expectations.
5. Finally, how well did the trainee develop her own practice (critical evaluation)? I would say that the trainee used a simple case to illustrate a complicated idea about the duties of a doctor in meeting patient expectation.
- How well did the trainee select, organise and present her learning?
The trainee selected an appropriate case, organised her thoughts logically and presented the information succinctly, all of which are useful communication skills for GPs.
The feedback I give in the comments section highlights what I liked about the trainee’s reflective account and guidance on how to improve their critical reasoning skills in future.
Trainees often misunderstand feedback, thinking I am commenting on their medical management of the patient whereas I am commenting on cognitive processes they employed in coming to an understanding of the situation.
Also, I have learnt that the endless questioning and comment can seem harsh and sometimes simply praising the good entries is enough to stimulate learning from the next event.
Writing better reflective entries
Now that trainees are aware of how their reflective accounts are assessed, the could review their log entries and ask themselves:
- How happy was I with the decisions I made made during this interaction?
- If I discussed the issue with colleagues, or researched the topic, what alternative perspectives did I gain?
- Have I communicated clearly any changes in beliefs or understanding?
- Have I discussed what specific, small actions I will take to acquire greater competence or confidence? or
- How I will revise my practice?
Writing about the experience again, from an alternative viewpoint, can be worthwhile.
- Dr Naidoo is a GP trainer in Oxford