In his report 'Taking revalidation forward', Sir Keith Pearson said, 'The introduction of revalidation means every doctor who wants to maintain their licence - regardless of their field of work - must regularly demonstrate they are reflecting on how to improve their practice and taking steps to keep their knowledge and skills up to date.'
Reflection is a requirement of revalidation, as set out in the GMC's 'Good medical practice', and yet a report to the Revalidation Advisory Board in June 2016 showed that in a survey, a third (1,299) of the appraisers who responded had concerns about one or more of their appraisees, and the most frequently raised concern was about the doctor's lack of reflective practice.
Most of these concerns were dealt with within the appraisal and not escalated, but lack of reflective practice is a significant component of insufficient evidence. Between 2012 and 2016, the GMC approved 37,433 recommendations to defer revalidation due to insufficient evidence. This was 1.8% of all GMC-approved recommendations.1
Why is it that reflection is sometimes found wanting? All medical students make assiduous notes to remind themselves of learning points, but later in their careers, a significant minority of doctors seem to lose the habit - and that includes those who are apparently in all other respects committed to life-long learning.
Sir Keith Pearson also said in his report that, 'I have also heard that doctors dislike filling in forms or having to document their reflection. I'm not sympathetic to those objections. An evidenced process of reflection and appraisal, drawing on experience and learning to identify personal development goals, is a given in almost every profession. It is the minimum the public should expect of doctors.'
Mythbusting reflective writing
Anecdotally there are a number of factors, both real and imagined, which may contribute to poor reflection by some doctors.
- Reflection is bureaucratic. This is true, but that can be partially overcome by using resources like the GMC's free app, My CPD. This enables doctors to make reflective comments during a lecture or meeting itself, which can then be exported as supporting information before an appraisal. The app also helps to categorise Continuing Professional Development (CPD) claims, and by asking specific questions for each event, such as, 'What did you learn from this activity?' or, 'What steps will you take to change your thinking or practice?', helps to cover the various requirements of reflection.
- Reflection is an embarrassment. Some doctors feel understandably exposed when committing their reflections to paper, particularly if the reflection is brief, subject to distractions, or is a hastily-written, contemporaneous note. However, revalidation is not a competition and it is not an exam. In the normal course of events it is confidential. There is no need to feel diffident or embarrassed about writing reflective notes.
- Reflection in writing is not necessary. This is not true because verbal reflection alone is not enough. Since 2012 the GMC has been clear in its guidance that doctors must [my emphasis] reflect on what they have learnt from their CPD activities and record whether their CPD has had any impact.
- Reflection is pointless if you have a certificate of attendance. A certificate of attendance at an event is, of itself, insufficient evidence of keeping up-to-date. In the last year or so, this understanding has changed. NHS England no longer requires certificates of attendance, but written reflection in the supporting information for appraisal is expected - with or without a certificate. The Royal College of General Practitioners recommends that CPD attendance certificates be no longer routinely scanned.2 If the certificate includes an assessment or test of knowledge gained, then it may, of itself, be evidence of learning and not require further comment.
- Reflection is a waste of time. This is true for both appraisee and appraiser when quantity is confused with quality. Some doctors claim several hundreds of CPD points in one year, with hundreds of pages of detailed learning points to back it up. There is no upper limit, but 250 CPD points per five-year cycle are sufficient, and there is no accolade for exceeding that number.
- Reflection is a 'tick-box exercise'. This is a serious misconception, because precisely the opposite is true. The misconception can be dangerous because it may tempt some people to justify on moral grounds the 'cutting and pasting' of part of someone else's reflection and passing it off as their own. This has the potential to give rise to a question of probity, which in turn could contribute to putting their registration at risk.
- Reflection standards are inconsistently applied. This is true. By definition, reflection is thinking about something to learn from it, and the degree to which both topic and outcome of reflection are considered appropriate is determined by one's peers. Inevitably different peers will have different views. There is no clear definition from the GMC, NHS England and its equivalents or the medical royal colleges and faculties of what standard of reflection is or is not acceptable, or how brief or detailed it has to be. One of Sir Keith Pearson's key recommendations is that guidance on the supporting information needs to be clear on what is mandatory and what is sufficient.
- Reflection is not for everyone. Some people are reflective by nature whereas others are 'doers'. However, even for 'doers', some degree of reflection is essential for learning according to the definition given in the point above.
- Reflection can have adverse legal consequences. Concerns have been expressed about the disclosure of reflective notes for use in civil litigation against a doctor. The risk of being compelled to disclose a written reflection is vanishingly small if it is properly anonymised. Fear of disclosure is not normally considered an adequate reason for omitting reflection on an adverse incident or a significant event in supporting information for an appraisal. Detailed advice on this topic has been published by the AoMRC and the MDU.
For all that, most doctors provide reflection of a high standard.
Models of reflection
In their 1995 study of reflection in teacher education, Hatton and Smith described four models of reflection3.
- Descriptive writing: a simple factual description of an event with little educational value.
- Descriptive reflection: evidence of deeper consideration, but no notion of an alternative viewpoint.
- Dialogic reflection: literally, 'learning through dialogue' - stepping back and considering the quality of judgments and alternative views.
- Critical reflection: multiple perspectives, including ethics, systems, policies and socio-political considerations.
According to a survey of 118 appraisal portfolios4, most doctors in 2016 did not progress beyond descriptive writing. GPs tend to be better than hospital doctors at descriptive reflection and dialogic reflection, but as yet, few doctors attempt critical reflection.
The scope and sophistication of written reflection in supporting information has a wide range and it appears in many different contexts. There should be reflection on one's Personal Development Plan, CPD, Quality Improvement activity, significant incidents, colleague feedback, patient feedback where appropriate, and complaints.
The NHS Appraisal Support Group has devised a number of structured reflective templates. These include a template for significant events, data collection/audit, and complaints. The template for reflection on a significant event includes questions such as, 'What went well?', 'What could have been done better?' and 'What changes have been agreed?', as well as 'Final outcome after discussion at appraisal'.
As a profession we have had a slow start, but the last two years has seen a significant improvement in the application of reflective practice. Nevertheless, we still have some way to go.