BACKGROUND
How did that go? How could I have done that better? We use reflection to help us process our feelings, and when something has gone wrong we try to understand why. The extension of this, reflection in medical practice, is a key part of our continuous learning and considered essential for professional competence.
The General Medical Council (GMC) states that doctors ‘should regularly reflect on their own performance’.1 Reflection may be verbal (for example, through discussion with colleagues), internal (thinking about what we have done), or written (unstructured, for example, in a diary, or structured by use of a pro-forma). Most GPs do find reflection valuable, reporting that it is embedded into their daily routines —at work, on the way to and from work, and at home. Some feel that reflection can help with processing thoughts and feelings, describing it as ‘therapeutic’ and ‘cathartic’ in helping to process emotionally difficult situations.
Reflective writing became an obligatory part of licensing and revalidation in the UK because it is thought to provide evidence of reflective thinking2 and show that doctors are continuing to learn. Reflections on learning activities are verified at a yearly appraisal, helping to provide the evidence for the 5-yearly revalidation that allows an individual to continue to work as a doctor.3 The Royal College of General Practitioners recommends that documentation of reflection on learning activities is necessary so that GPs can focus on the quality, rather than the quantity, of their appraisal supporting information,4 though it points out that documented reflection should be brief and to the point.5
GPS’ ATTITUDES TO WRITTEN REFLECTION
Following focus groups with GPs and GP trainees that revealed considerable antipathy toward written reflection,6 two of us undertook a UK-wide study to seek and quantify the views of GPs on the role of written reflection in learning and assessment.7 Following invitations forwarded by local medical committees and postgraduate deaneries, as well as through the British Medical Association, a thousand GPs (both established GPs and trainees) answered our anonymous online questionnaire. Those positive about the role of written reflection in learning and assessment were in the minority: for every unreservedly positive respondent, 10 were critical. In both the established and trainee GP groups, a majority stated that they did not find mandatory written reflection helpful or valuable. Respondents reported that written reflection was time consuming, with an adverse impact on other learning opportunities and their work–life balance.
Three-quarters of those surveyed stated that they saw written reflection as a ‘box-ticking’ exercise and that writing down their reflections was tedious, using words like ‘meaningless’, ‘wasteful’, ‘counterproductive’, and ‘patronising’. Some GPs stated that they could not always write what they felt for fear of being ‘judged’, and that they often self-censored what they wrote to make it more acceptable to their appraiser — in one of our focus groups, a GP trainee stated that ‘you have to think of something you did wrong, but not too wrong’. Free-text comments in the survey were predominantly negative, describing anger, resentment, and frustration about the obligatory written reflection process. Most worryingly, the anger caused by this process was cited by some GPs as a reason for them considering leaving their careers early. One respondent stated that the system for NHS appraisal ‘makes you reflect on reflection and then reflect again, I am fed up and bored with it … and am now retiring early at 55’.
Our survey took place before the case of trainee paediatrician Dr Hadiza Bawa-Garba shook the medical community. Dr Bawa-Garba was found guilty of gross-negligence manslaughter in 2015. There was widespread dismay that a reflective document from her e-portfolio, which she filled in 7 days after the incident, was fed into her trial8 and, more recently, concerns were raised that the GMC’s approach to her case may promote a regressive move from an open culture, focused on learning from errors, to a blame culture.9 We suspect that as a result of this case, if we were to repeat our survey today, even more GPs would have negative views on the role of written reflection in their portfolios.
WHAT WOULD GPS LIKE TO SEE INSTEAD?
The survey gave GPs a list of methods that could be used to assess their performance and learning over the year, and asked them how strongly they would favour each as a component of NHS appraisal. Although 31% of survey respondents favoured an option that appraisers should ‘Trust me and rely on my professionalism’, all but one of the other choices were more popular than this (Figure 1). The exception was ‘An assessment of my written reflection’ — the least popular option, with only 28% of GPs in favour.
A CALL FOR CHANGE
The recent Pearson review of medical revalidation called for an increase in the quality of appraisal and a reduction in the administrative demands on doctors.10 It recommended that the GMC should ‘hear the voice of those doctors that find revalidation to be more difficult, more time consuming and perhaps more arduous than it should be’. In its response the GMC has stated that it needs to reduce unnecessary burdens and bureaucracy for doctors.11 It acknowledges that some doctors feel they have to spend too long preparing for appraisal, and that, particularly to reduce the burden on GPs, the guidance on appraisal should be clarified, while at the same time increasing the value of appraisal.
A SOLUTION?
Appraisals immediately following a GP’s 5-yearly revalidation could be made more flexible and more relevant to each individual doctor’s learning preferences. GPs and their appraisers could make better use of their time together, and the resentment of some towards obligatory written reflection could be avoided. We propose that GPs and their appraisers should agree and choose an option for the following year that would be integral to the individual doctor’s personal development plan. These options could include:
continuing the current model of the reflective learning diary;
appropriate multiple-choice question tests, for example, GP SelfTest (http://elearning.rcgp.org.uk/course/index.php?categoryid=56), not intended as a pass–fail examination but as a point for discussion at the next appraisal and a method of identifying the doctor’s learning needs;
an observation of the GP’s video-recorded consultations, viewed at the appraisal;
verbal reflection, for example, 10 cases discussed in practice meetings or young practitioner groups (the GP would need to provide minutes of these discussions, not necessarily made by the GP her/himself, as evidence that they have taken place); and
a selection of cases to discuss with the appraiser at the next appraisal (the GP would need to submit short descriptions before the appraisal, so that the appraiser could select which ones to discuss).
Appraisers would need suitable training and, although some of the new options would take time during the appraisal itself, the appraiser would no longer have to take time reading through the GP’s written reflections. Other aspects of the current appraisal system would still be obligatory.
Over a 5-year cycle, a GP could choose a different option each year, culminating in a standard ‘revalidation-ready’ appraisal in the fifth year. This would introduce a wide variety of styles of appraisal, each year tailored to the individual GP’s particular circumstances and developmental needs, but still keeping a sufficient standard of quality and consistency.
CONCLUSION
For many GPs, the written reflection mandated for their annual appraisal is an onerous process rather than beneficial to their learning. The Dr Bawa-Garba case has strengthened the need to consider how written reflection is used in appraisals, and the results of our survey will add to this debate. We believe that, for at least some of the 5-year revalidation cycle, doctors should be given a choice of methods to demonstrate their learning and competence. We recommend that this approach is piloted and evaluated for both its acceptability to GPs and their appraisers, and its value in providing evidence to assist Responsible Officers in their revalidation recommendations.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2018