The art of reflection

REFLECTIVE practice divides opinion like Marmite: doctors either love it or hate it. Mention reflection, and you’re bound to get an emotive response. Some argue it is a box-ticking exercise, that it does not improve patient outcomes and leaves doctors vulnerable to criticism. But it is something we are professionally obliged to engage with. Recently, the argument against this practice was invigorated when a doctor’s reflections written in their NHS e-portfolio was used against them in a legal case. This prompted the Academy of Medical Royal Colleges (AoMRC) to issue detailed guidance – more of which later.

What is it?

Reflection involves carefully considering a personal experience. It goes beyond a description of the incident, rather exploring your actions as well as the circumstances at the time, your thoughts on it with the benefit of hindsight and the comments of others, and what impact it has had on you going forward.

Reflecting is not telling a one-sided story. It is a process of interpreting your, and others’, thoughts about an event. It is a critical analysis of your involvement in the scenario and includes an acknowledgement of your feelings, opinions and attitudes as a result.

Why reflect?

The GMC reminds doctors, in its Leadership and management for all doctors guidance, 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. Doctors are obliged to be reflective, and 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.

How do I reflect?

There are many different approaches and methods to reflective practice. This article does not aim to summarise these (or propose one over the other); rather it seeks to provide a broad overview.

Reflection happens in our everyday practice often without us realising it. By looking back at our actions we can learn from them with the advantage of hindsight. As a starting point, doctors may wish to consider which structured approach they will adopt. If new to reflection, you may find it helpful to try a number of different methods to determine which works best.

First, describe what happened (setting out both the positives and negatives: What went well? What went badly?) and why (What were the contributing factors?). Then consider how the incident affected you, as well as others. Finally, present a clear action plan (this is possible only with a good understanding of why the event occurred).

It may be helpful to use established criteria when setting a goal or objective in your action plan. You must be able to outline, for example, what action you will take, who will assist with this, how you will achieve this and assess progress, and in what period of time.

Once the action plan has been put in place, the event (and the associated reflection) should be revisited to ensure learning has taken place, change has occurred and there is improvement as a result. New action plans may then follow such reviews.

Reflection is not a one-off event – it should be seen as a cycle that can be repeated as necessary. A doctor should consider the impact of their frame of reference at the time of the incident and subsequent reflections, what others have said, how their thoughts and emotions have changed as time has passed, and how they would act in a similar circumstance in the future.

The following three steps should get you on your way:

1. Ask for guidance from a colleague or look at examples of reflective writing.
2. Write about something that stood out in your day.
3. Practice makes perfect.

Confidentiality

This leads us back to the issue of concerns over doctors’ reflections potentially being accessed by a third party and used to criticise them. Under the Data Protection Act 1998 (DPA), a person (or their representative) can make a subject access request to obtain any personally-identifiable information that is held about them. It is advisable that doctors appropriately anonymise their reflections.

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 AoMRC’s new legal guidance on the disclosure of information in e-portfolios to third parties suggests the following:

• Anonymise all patient details as far as possible in reflective writings, including any distinctive medical facts. Healthcare professionals and other parties involved should also not be readily identifiable.
• If a subject access request is made and if it is established that the information within the log is a patient’s personal data, it can be argued that a doctor’s self-reflective log is exempt from disclosure under the DPA.
• In the event of litigation, the doctor could request a court order as their reflective writing contains third party information.

If in doubt, contact MDDUS for more detailed advice.

Dr Greg Dollman is a medical adviser at MDDUS