GMC unveils advice on safe reflection in wake of Bawa-Garba case

Reflective notes should only rarely include 'factual details that have not been recorded elsewhere', according to guidance published jointly by the GMC as it seeks to rebuild trust after the Bawa-Garba case.

The guidance, published by the GMC, the Academy of Medical Royal Colleges (AoMRC), the Conference of Postgraduate Medical Deans (COPMeD) and the Medical Schools Council, encourages ‘reflective practitioners’ to focus on learning when making reflective notes and asks them to reflect on both positive and negative experiences in an ‘open and honest’ way.

The advice reiterates that although courts may still demand to see the contents of doctors' reflective notes, the GMC itself 'does not ask a doctor to provide their reflective notes in order to investigate a concern about them'. It adds that the GMC’s focus in fitness to practise investigations 'is on facts and evidence relating to a serious allegation'.

Doctors are advised that 'following a significant event or a serious incident, factual details should not be recorded in reflective discussions but elsewhere, in accordance with each organisation’s relevant policies’.

Group reflection

The guidance also highlights the value of reflection in groups, the need to keep information in reflective notes anonymous, and for reflective notes to focus not on the full detail of an experience, but learning outcomes and future plans.

The GMC faces a huge task to rebuild doctors' trust in reflective practice after a GPonline poll found that 70% of GPs felt recording reflective notes was ‘unsafe’ following the case of Dr Hadiza Bawa-Garba - a junior doctor who was convicted of gross negligence manslaughter and struck off the medical register in January.

Although reflective entries from Dr Bawa-Garba’s eportfolio were not used as evidence against her, notes made by her duty consultant on a meeting he had with her after the incident formed part of his witness statement, which caused some GPs to boycott reflective notes altogether. Dr Bawa-Garba was restored to the medical register after an appeal earlier this summer.

Professor Colin Melville, director of education and standards at the GMC, said: ‘Reflecting on experiences, both good and bad, is hugely important. The GMC doesn’t ask doctors for reflective notes to investigate concerns; in fact we have called for those notes to be given legal protection.

Practical support

‘However, we know there is some uncertainty around reflection, and this new guidance provides practical support to help doctors and medical students.’

Professor Carrie MacEwen, Chair of the AoMRC, said: ‘Being able to reflect on all aspects of clinical care is important to improve the way we look after patients. This guidance and the reflective practice toolkit… should reassure all doctors that it is possible to record events in a way that optimises learning and promotes active change in practice based on this learning.’

The AoMRC and COPMeD have also published a reflective practice toolkit which includes templates and examples of reflective styles and aims to ‘facilitate best practice in the documentation of reflection on a variety of activities and events’.

Dr Caroline Fryar, head of advisory services at the MDU said: ‘As the new guidance points out, a reflective note does not need to capture full details of an experience. It should capture learning outcomes and future plans. We hope the guidance will help reassure doctors and medical students about some of the misconceptions about reflection and the contents of reflective notes, particularly in connection with legal and regulatory proceedings.'

Reflective notes

Dr Fryar urged doctors who are completing reflective notes following a medical error or those who have received a request to disclose the document to others and to contact the MDU for further advice.

RCGP chair Professor Helen Stokes-Lampard voiced hopes that the guidance would help doctors regain confidence in reflective practice following the Bawa-Garba case. She said: ‘Recent events have caused a lot of anxiety amongst all doctors, and particularly trainees, about how and when to reflect appropriately and effectively – and we hope this guidance goes someway to alleviate that.'

BMA junior doctors committee chair Dr Jeeves Wijesuriya also welcomed the guidance but said the union would continue to campaign for reflective notes to receive legal protection.

‘It is imperative that doctors are able to reflect openly and honestly to develop learning and ultimately deliver better, safer care, and this is helpful and clear guidance that directly responds to concerns the BMA has raised with the GMC on behalf of the profession,’ he said.

Key points raised in the guidance include:

  • Reflection is personal and there is no ‘one way’ to reflect.
  • Group reflection often leads to ideas or actions that can improve patient care.
  • When keeping a note, the information should be anonymised as far as possible.
  • A reflective note does not need to capture full details of an experience, but rather learning outcomes and future plans.
  • Reflection should not substitute or override other processes that are necessary to record, escalate or discuss significant events and serious incidents.

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