Reflective entries for GP appraisal - what do the MDOs advise?

The case of junior doctor Dr Bawa-Garba has raised concerns among the profession about whether they are exposing themselves to risk by documenting mistakes, and how they plan to learn from them, in reflective notes. But are GPs required to engage with reflective practice?

The case of Dr Bawa-Garba, the junior doctor who was struck off the medical register after the GMC won a High Court case last week, has led to concern among the profession about reflective practice that is required for appraisal and revalidation.

Yesterday GPonline reported that GP pressure group GP Survival had written to BMA chair Dr Chaand Nagpaul warning that ‘hundreds of colleagues’ had told the organisation they would no longer take part in meaningful written appraisal.

Medical Protection, which represented Dr Bawa-Garba, said the junior doctor's e-portfolio was not, in fact, part of the evidence used at the criminal trial. 'The court was clear that reflections were irrelevant to the facts to be determined and that no weight should be given to remarks documented after the event,' Medical Protection said.

However, there is still concern that the case could lead to doctors being less likely to openly discuss mistakes or errors because of the serious personal consequences as demonstrated in this case. Doctors in Unite warned that the case had set a dangerous precent and rould be ‘directly harmful to improving patient safety’.

‘Honest and open discussion of errors is essential to building a culture of safety. A system where people are afraid to admit mistakes due to potential personal consequences is the antithesis of what we need,’ said Doctors in Unite chair Dr David Wrigley.

So where do GPs stand when it comes to reflective practice? Are they required to engage with this process and provide written evidence that they do so?

GPonline asked the medical defence organisations for their view on the issue.

The MDU

Dr Caroline Fryar, MDU head of advisory services said: ‘As Jeremy Hunt has recently pointed out: "For patients to be safe, we need doctors to be able to reflect completely openly and freely about what they have done, to learn from mistakes, to spread best practice around the system, to talk openly with their colleagues".

‘Reflection is a big part of this and is also an ethical duty, set out in the GMC's core guidance Good Medical Practice.

‘We have long advised GPs that it is important to follow the guidance and requirements of the GMC and Health Education England (or national equivalent body) as well as take account of guidance from the RCGP. This includes any requirement to maintain a portfolio of evidence relating to training and evidence of reflection. 

'Guidance was produced by the Academy of Medical Royal Colleges in October 2016 and is available here. Careful and conscientious reflection on professional practice, particularly if things go wrong, can be helpful both in terms of learning lessons and in demonstrating insight.

‘Portfolio reflections should be anonymised. There is no need for patient identifiable information to be included in a portfolio entry. Doctors should review their reflections carefully, as it is easy to leave in details that could inadvertently identify the patient, particularly when small details are viewed in combination.’

The MDU provides this guidance on e-portfolio reflective notes to its members.

The MDDUS

Dr John Holden, MDDUS joint head of medical division, says: ‘We have previously encountered cases where members have expressed concerns that they might be incriminated and left vulnerable to criticism as a result of reflective practice.

‘However, doctors are professionally obliged to engage with reflective practice. The GMC reminds doctors, in Good Medical Practice and its guidance on continuing professional development and leadership and management for doctors, to reflect regularly on their performance and professional values.

‘This is an essential part of maintaining and improving patient care, as well as helping a clinician’s self-development. Those who reflect on their everyday practice are considered to be insightful.

‘Medical professionalism requires that doctors learn from their experiences and put patient safety, care and quality improvement first. It is important that doctors are able to reflect honestly and openly without fear of it being used against them.

‘It is advisable that doctors appropriately anonymise their reflections. This will minimise the risk of proper reflection being used to criticise the practitioner.

‘The GMC recognises that using information about patients is essential for education and training purposes and allows the use of anonymised data in these circumstances. Clearly in some cases the context alone may identify a patient. The Academy of Medical Royal Colleges has legal guidance on the disclosure of information in e-portfolios to third parties, which suggests the following:

  • Anonymise all patient details as far as possible in reflective writings, including any patient identifying data. Healthcare professionals and other parties involved should also not be readily identifiable.
  • If a subject access request is made by a patient and if it is established that the information within the log is a patient’s personal data (i.e. it has not been appropriately anonymised), a doctor’s self-reflective log may require to be disclosed under the Data Protection Act.

‘This guidance also highlights that there are other circumstances in which disclosure of reflective learning logs may be requested (i.e. in the course of GMC proceedings, by order of the Court, Coroner or by the police). Whether disclosure can be mandated in any of these scenarios will turn on the individual circumstances of each case and MDDUS members are urged to contact us to discuss specific requests with us.’

Medical Protection

Dr Pallavi Bradshaw, senior medicolegal adviser at Medical Protection, says: 'It would be extremely rare for a GP to provide the contents of their e-portfolio for anything other than educational purposes. Information should be anonymised in any event and if doctors are approached to disclose such information they should seek clarification from their medical defence organisation as to whether they should comply with such a request or not.

‘Our advice on the use of e-portfolios is, and remains that a GP’s portfolio is an important part of their professional development. They should bear in mind that the risk of not disclosing an incident or reflection during appraisal leads to a greater risk of allegations of probity and referral to the GMC.’

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