The sad case involving Jack Adcock and Dr Bawa-Garba, has cast doubt on the security of reflective writing for assessment, appraisal and revalidation. (Syed 2018) Anxieties have their foundations in the INCORRECT belief that Dr Bawa-Garba’s on line portfolio was part of the evidence in court. According to the MPS, “the court was clear that reflections were irrelevant to the facts to be determined and no weight should be given to remarks documented after the event.”
SO…WHAT IS REFLECTION? Reflection is the ability to critically analyse what we do with a view to doing better. The act of thinking about an activity reinforces it and recording that reflection further enhances learning.
AND WHY IS IT IMPORTANT? Reflection is considered to be an integral part of being a professional of any kind and is a vital way of learning from surgical experiences. If you cannot critically analyse what you do and improve your practice as a result, you are not safe to practise independently.
Whilst surgeons have enjoyed almost unconditional trust for some time, they must now provide evidence that they have what it takes to do their job. You will not meet requirements to practice: CCT or revalidation, if you cannot demonstrate an ability to integrate reflection into practice. Even 40 years ago Frank Spencer (1) said “A skilfully performed operation is about 75% decision making and 25% dexterity”. Skilled decision-making is underpinned by sophisticated reflection.
So, can you:
1) articulate the thinking behind your judgements?
2) prove it?
If we accept that clinical uncertainty is unavoidable, learning how to manage this is a fundamental part of training and practice. Ways of learning and assessing such professional skills have been established but are still used sporadically and often ineffectually, by both trainees and trainers.
The GMC (3) requires us to move the focus of our curriculum more towards the judgement and professional aspects of training and practice, whilst maintaining the more easily taught and assessed knowledge and technical skills. So, the T&O curriculum will be significantly revised and re-launched before the end of the year.
IS RECORDING IT REALLY NECESSARY? If you stop after reflecting and omit a written record, you sacrifice the opportunity to demonstrate your ability to reflect, along with other non technical skills you will be required to show evidence of. You could video or audio record your reflections, as long as your supervisor can access and provide feedback easily, and documentation is available in your portfolio.
Talking is quick and easy, but writing pushes us to be less hasty and more deeply thoughtful. However well discussion is structured, it is ephemeral. It cannot be revised, reshaped or redirected. (de Cossart and Fish 2013) I find that reflections immediately after an event can be improved after a gap of a day, a week or a month. Fresh eyes allow important new insights once fatigue, anger or distress have abated.
According to de Cossart and Fish, the idea of writing about perspectives on a case can fill surgeons with anxiety, such that they believe it is not necessary. Perhaps that is why trainees and colleagues in difficulty are least likely to formally reflect. They, of course, and their trainers stand to gain the most
WHAT ARE THE RISKS? Preventable medical error harms thousands of patients every year. The only way to reduce these figures is to learn from every single untoward event. This is impossible if surgeons fear being penalised for mistakes.
The most important step towards aviation safety was the acknowledgement that a full investigation should precede any judgements about responsibility. An error or near miss looks different when the complex interface between human, machine and system is taken into account by trained investigators. These investigations protect pilots from being scapegoated and thus encourage voluntary reporting of their mistakes and near misses.
The UK judicial system understands the pivotal role of the “no blame” culture and the impact this has had on aviation safety with not a single jet passenger crash globally, this year. Indeed, after the Shoreham Airshow disaster, police sought to subpoena the information confidentially provided by pilots to crash investigators. The High Court wisely refused, ruling that such disclosure would have a “serious and obvious chilling effect” (Syed)
According to the MPS “It would be extremely rare for a doctor to provide the contents of their e-portfolio for anything other than educational purposes.” Information should be anonymised in any event (AOMRC 2017 (2)) 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 doctor’s portfolio is an important part of their professional development. They should bear in mind that not disclosing an incident or reflection during appraisal may lead to a greater risk of allegations of probity and referral to the GMC.”
Clearly, it is important to anonymise any writing. You may consider keeping some sensitive events for your eyes only. They can still be stored in your portfolio but only you or whoever has your permission can see it. Take care to remove any patient, colleague or institution identifiers.
HOW CAN WE GET THE MOST FROM IT? As we are all required to record reflection, consider exploring themes rather than specifics. You can access some valuable insights by writing answers to illuminating questions eg
- How am I helping or hindering colleagues to achieve their goals?
- How might I be contributing to my most difficult relationship, and why?
- How could I have been more effective at a recent meeting?
- What do I consider the challenges to me as a surgeon in this organisation?
- How can I develop myself in order to respond to these?
- What do I need to work on to become an expert surgeon.
- Reflect on a time when
- You felt different from others?
- You had difficulty communicating across cultural barriers
- It was difficult to be empathic
You can also choose cases and situations that:
- Challenged your thinking processes or left you puzzled
- Are straightforward enough to help you get used to the process of reflective writing.
- Are NOT highly complex, contentious or distressing for your first attempts.
- Involved major decisions that were your responsibility
- Showcase your ability to manage the demands made on you.
- Will generate useful discussions with your supervisor or appraiser.
- Require you to take account of the perspectives of others.
It can be tempting to reflect on challenging, conflict ridden and scary events, as these are often good sources of learning. However, it’s important to balance with some successes too, so you are able to identify your strengths and build on them. Details of how to structure reflections and access feedback can be found here. (http://reflection.boa.ac.uk)
The court was clear in the Bawa Garba case; reflections were irrelevant to any judgements made. Although some doubt remains concerning the vulnerability of reflective records, we should pick areas of reflection wisely, record them securely and in an anonymised state. The upside will be that we can maximise the benefits of this invaluable learning and assessment tool. It might also help us to recapture and give evidence of our ability to engage in robust self governance.
(1)F.C. Spencer Teaching and measuring surgical techniques: the technical evaluation of competence
Bull Am Coll Surg, 64 (1978), pp. 9-12