Conscientious GPs have always looked back on consultations and considered what went well and what didn’t. Reflection is a core feature of medical practice and an ethical duty.1 Formal reflective writing is however an increasingly important aspect of medical training and professional development.
This has many positive aspects. Most importantly, reflection, either individually or as part of a team helps consolidate learning and identify opportunities to improve patient care or address patient safety concerns. And reflection has long been an important part of the remediation process for doctors whose conduct or performance has been called into question.
The case of Dr Bawa-Garba has understandably raised concerns about the implications of reflecting on an error or serious clinical incident and the MDU has been contacted by a number of GPs who worry their written reflections might be used to incriminate them.
New guidance from the Academy of Medical Royal Colleges (AoMRC), the Conference of Postgraduate Medical Deans (COPMeD), the GMC and the Medical Schools Council will help to reassure doctors of the value of reflection and how best to approach it. The Reflective Practitioner2 addresses why reflection is important, how to demonstrate reflection and the disclosure of reflective notes.
The following pointers, based on the new guidance, should help you develop your skills as a reflective practitioner.
Recognise the benefits
A common misconception about reflection is that introspection is a distraction from patient care but it is actually an essential and beneficial part of professional practice. The guidance says that reflection 'is vital to personal wellbeing and development and to improving the quality of patient care. Experiences, good and bad have learning for the individuals involved and for the wider system.'
Make it relevant
The guidance includes examples of a range of experiences that you can choose to reflect on, including clinical interactions, complaints or compliments, attending a meeting, team debriefs or exploring an emotional reaction.
For an experience to be a meaningful subject for reflection it should relate to your professional practice with the intention of examining previous beliefs or assumptions, gaining insight, and using the lessons learned to develop your practice.
The guidance says: 'Developing the capacity to reflect should focus on the reflective process and how to use it productively rather than on a specific number or type of reflective notes.'
Develop a process
There are no hard and fast rules for reflection and the guidance says your approach may be influenced by the nature of your practice and personal learning style. However, this is not simply a piece of descriptive writing so it makes sense to develop a systematic approach.
The AoMRC and COPMeD have produced a reflective practice toolkit,3 which should be considered alongside the guidance. It includes links to resources to help effective reflection, including templates and examples. In addition, the guidance includes a simple framework called 'What? So what? Now what?' which poses the following questions to prompt reflection:
- What was I thinking when I took this action or make this decision?
- How did I feel at the time and after this experience and why was it important?
- What can I learn from the experience or do differently next time?
Be prepared to discuss your reflections
As reflection is a core requirement for revalidation, you may be required to discuss the experiences you have reflected on as part of your annual whole practice appraisal. This will be considerably easier if your reflective notes are succinct and clearly set out what you have learnt.
The guidance says that 'tutors, supervisors, appraisers and employers should support time and space for individual and group reflection.'
Keep your reflections anonymous
The GMC does not ask doctors to disclose their reflective notes in order to investigate a concern, although it may be in a doctor’s interests. However, the courts can still request disclosure of documents that are considered relevant and the GMC's confidentiality guidance says information must be disclosed 'if it is required by statute, or if ordered to do so by a judge or presiding officer of a court.'4
By anonymising a case as far as possible in reflective notes, your reflection will still be a valuable experience but you can avoid any difficulties if the note is disclosed. The Information Commissioner’s Office considers data to be anonymised if it 'does not itself identify any individual and that is unlikely to allow any individual to be identified through its combination with other data.'
Doctors are advised to follow the GMC’s guidance on anonymising personal data in training records as simply removing the patient’s name, age, address or other personal identifiers is unlikely to be enough.
Crucially, the new guidance points out that a reflective note does not need to capture full details of an experience. Rather, it should capture learning outcomes and future plans.
Reflection is not a substitute for investigation
In addition to reflecting on an incident, you should still participate in other processes for recording and investigating clinical incidents and be open and honest with patients when something has gone wrong.
Don’t file away your reflective notes following an appraisal as they should also inform your personal development. It is usually helpful to return to your reflections at a later date to see how your practice has developed.
The MDU or your own medical defence union can advise you on completing reflective notes after something has gone wrong or responding to requests to disclose a reflective document.
- GMC. Good Medical Practice, Paragraph 22b. 2013.
- Academy of Medical Royal Colleges (AoMRC), the Conference of Postgraduate Medical Deans (COPMeD), the GMC and the Medical Schools Council. The Reflective Practitioner. September 2018.
- AoMRC and COPMeD. Reflective Practice Toolkit. August 2018.
- GMC. Confidentiality: Good practice in handling patient information, Paragraph 17. 2017.
- GMC. Confidentiality: Disclosing patient data for education and training purposes 2017