Abstract
Reflective practice is the core competency required to retain a licence to practice under current medical revalidation regulations. The concept of reflection, however, is often misunderstood. Much of the confusion arises from context. In terms of professional regulation, doctors are considered safe when they demonstrate the ability to self-correct. Self-correction requires both reflection and action. In some contexts reflection without action is entirely appropriate, but in many professional contexts the quality of reflection is judged by the effectiveness of actions arising from it. This article explores the nature of reflective practice and its relationship to professional freedom and regulation.
The GP curriculum and reflective practice
Every doctor is required to engage with annual appraisal and demonstrate they are maintaining their fitness to practice A doctor achieves revalidation by demonstrating they routinely and effectively identify and correct areas for improvement in the four domains of Good Medical Practice, in a manner appropriate to their roles as a doctor. Each core competence in the GP curriculum is linked to one or more domains of the General Medical Council's Good Medical Practice, the framework used for career-long appraisal and revalidation.
Components of reflective practice
Everyone knows what reflection is. The word after all, simply means thinking about something (Roffey-Barentsen & Malthouse, 2013). And yet, the most common reason for deferral of GP revalidations is insufficient evidence of reflection (Sanfey, 2015). Some doctors apparently find it difficult to demonstrate they can think meaningfully about their work. This is especially true for those issues that would benefit most from careful thought, namely, on flaws that might repeat if uncorrected. One reason for the difficulty is the prevailing sense that the regulatory system is a punitive one, intent on blaming doctors who are foolish enough to admit to imperfections in their practice. Sanfey and Ahluwalia (2016) argued that not only is this fear predominantly unfounded, it also diminishes professional autonomy both individually and collectively. If clinicians are not examining and correcting problems, then others must do so on their behalf. Better and more courageous reflective practice on the other hand, would create a virtuous cycle as improving health outcomes reduce the need for intrusive regulation and external control.
In addition to a fear of critical self-reflection, there is also considerable confusion about what actually constitutes good reflective practice. Much of the confusion arises from context. For example, a soulful meditation on the fragility of life can be poignant, inspirational and beautiful; but would be inappropriate as the only professional reflection on the unexpected death of a child. In the latter context, some consequence of reflection is expected. In this sense reflective practice is a combination of reflective thought and output that together form a spectrum of activity. This could range from the qualitative, where shared meaning is left hanging and open to subjective interpretation, to the other end of the spectrum where meaning is measured by the effectiveness of actions taken. Professional insight is the ability to intuitively understand this spectrum. The best way to illustrate what this means in practice is to consider a clinical scenario that can play out in two possible ways, one in which there is good reflective practice, and one in which there is not. Consider Case study 1.
Case study 1.
This practice has two partners (P1 and P2), two salaried doctors (S1 and S2) and today, there are two locum doctors (L1 and L2). There is a manager (PM1) and two practice nurses (N1 and N2).
L1 knocks on the door of P1 at the end of surgery to share concerns about a patient he had seen that morning. P1 had seen the patient 3 days earlier with a 2-day history of vague lower abdominal pain and a little diarrhoea. Miss A (the patient) had been to A&E the previous day. The patient reported that ‘they (i.e. the hospital) did not do much’ and she was sent home without a letter. Presumably, they ruled out things like appendicitis, ectopic pregnancy, etc.
P1 remembers seeing the patient 3 days earlier and had examined her. She was slightly tender in the right iliac fossa, but P1 was fairly sure it was not appendicitis, most likely gastroenteritis. Anyway, now 3 days later, appendicitis can be pretty much ruled out. It sounds to P1 that the hospital has ruled out ectopic pregnancy and confirms with L1 that the patient has a coil in situ. L1 adds that there is no vaginal bleeding. Also, on abdominal examination Miss A had ‘discomfort only’. P1 remembers thinking about a recent snippet of information on the use of antibiotics in appendicitis and now wonders if grumbling appendix really is a clinical diagnosis. This is news to L1 who feels a little embarrassed by his lack of knowledge, and now feels out of his depth. L1 agrees with P1 that it is probably gastroenteritis and that he just wanted to pass it on to the doctor on call, in case Miss A rings back.
Later that day Miss A is admitted to hospital with a ruptured ectopic pregnancy, but made a good post-operative recovery.
SEA-X.
SEA-Y.
Reflection that is confined to group discussion has its place, especially during training and in educational settings. In terms of service development, however, quality improvement requires action. It is also important to look for opportunities to amplify the impact of actions taken by embedding them into system changes. This can ensure that improved actions happen automatically in future.
This comparison of SEA-X and SEA-Y is of course rather contrived and stylised. The plethora of actions taken is implausible, not least because if practice Y were capable of generating so many actions from one simple SEA, it would almost certainly not be identical to practice X in the first place. It would have already made many of the changes identified in the SEA. However, the fact that so many important actions are possible from a simple case study is the important issue to be considered. Contrived it may be, but clinical cases of similar complexity occur every day in every practice. This exercise demonstrates the power of disciplined clinical analysis and its potential to drive change in health care delivery. This has huge implications for re-energising clinical leadership in health care.
CiAO
The differences between the two SEAs are summarised (see Table 1) by the acronym CiAO, which stands for:
Essential conceptual elements of event analysis: CiAO.
Earned autonomy
Individual autonomy
It is surprising how often reflection of a quality comparable to SEA-X actually appears in appraisal portfolios. Doctors tend to emphasise what they have done well, presenting evidence that portrays them in a good light. As described above, they often skirt past issues they feel nervous about exploring in depth, fearing professional damage if they reveal flaws in the care they provide. There are two reasons why this inhibition is particularly harmful for patient care. First, although it is important that we celebrate good practice, the thing that makes us safe as clinicians is the ability to correct flaws in clinical practice, particularly those that would repeat if uncorrected. The second reason why poor reflection is unfortunate is that innovation in health care can only come about when someone finds a way of doing something better, and this can only be achieved by thinking about flaws. Clinicians are best positioned to reflect on the things that matter, and if we do not do it, external auditing and control becomes inevitable (Sanfey & Ahluwalia, 2016).
Assessment of a doctors’ fitness to practice both in relation to revalidation regulations, and also when concerns have arisen about their practice, is based on an evolving understanding of what constitutes good reflective practice. This makes revalidation a good tool to study what reflection means in medical practice.
In revalidation, GPs earn the autonomy of a licence to practice, and permission to remain on the GP performers list by demonstrating reflective practice in the four domains of Good Medical Practice (GMP) in a manner appropriate to their roles. In effect, they are showing they can be trusted to monitor and maintain their own fitness to practice by participating in an annual, facilitated self-review of their own performance (NHS England, 2013). Assurance of patient safety is achieved when doctors demonstrate that they routinely identify and correct issues that ought to be improved in each of the four domains of GMP. Let us take a closer look at what evidence of reflective practice might look like for each of the four domains of GMP.
Domain 1: Knowledge, skills and performance
Reflection knowledge, skills and performance domain.
Description 2 is not only shorter; it is also much stronger evidence of reflective practice. It is an example of a show not tell approach, where actions speak louder than words. That having been said, description 1 is probably better than many examples that doctors include in their appraisal portfolios.
Description 1, however, does not actually contain any evidence of reflective practice in the writing. It amounts to a summary of the learning points, which is pretty typical in appraisal portfolios. An appraiser or a revalidation lead would need to enquire further into whether or how this has changed practice, which can make an appraisal discussion seem like a tick-box exercise. Description 2, on the other hand, ticks all the boxes for reflection with a concise action that is appropriate to whatever learning must have taken place. When doctors add subsequent reflection on the impact of the actions taken, they are also ticking other GMP boxes, such as the application of knowledge and quality improvement. Furthermore, the actions in description 2 lend themselves to audit and further dissemination of good practice. It is easy to see how the description 2 doctor might audit the outcome of the change in practice and discover a safety technique that could be recommended to all GPs or embedded in computer systems to transform the safety profile in cases of abdominal pain presentations.
Domain 2: Safety and quality
There is often confusion about the difference between significant events and case studies, and whether a two-cycle audit is required. The confusion is not helped by the General Medical Council (GMC) guidance on the issue (GMC 2013). In practice, case studies and SEAs are pretty much interchangeable in terms of evidence for appraisal, but with one important proviso. A serious untoward event, that involves actual harm or a near-miss event with real potential to recur and then cause harm, must be included in the appraisal for patient-safety reasons. The choice of particular case studies on the other hand, is much more discretionary and depends on the particular issues a doctor wants to tease out and analyse, with or without colleague discussion.
On the question of what constitutes an audit; we can draw on the core principle of reflective practice. Evidence of reflection in the safety and quality domain of GMP comes from the identification of issues that have safety or quality relevance, taking action likely to correct the concern, and then evaluating the outcome. A formal audit is exactly this course of action, with perhaps a robust if not exactly quantifiable assessment of before and after. Most responsible officers do not insist on a formal two-cycle audit in the 5-year revalidation cycle, provided there is robust and frequent evidence of reflective practice. This should be defined in terms of appropriate actions to fix problems that are both relevant and significant with regular evidence of reflection on the outcomes of actions taken. The latest RCGP guidance on revalidation endorses this view of quality improvement (RCGP, 2016),
Domain 3: Communication partnership and teamwork
The difference in the two SEAs, X and Y, highlights the evidence required to demonstrate reflective practice in this domain. The whole focus of the practice Y team is to improve outcomes. There is evidence of discussion, of working together to devise sensible actions appropriate to likely causation of problems or concerns identified. There are agreed plans and timetables for implementing most of those actions and subsequently; they take the time and effort to assess the impact of their actions. They are also conscious of the wider environment and are willing to engage outwardly to ensure the maximum impact and sharing of any changes made.
Domain 4: Maintaining trust
Reflection in this domain often entails responding to feedback, including complaints. Doctors need to be aware of the key aspects of this domain, such as showing respect for colleagues and patients, of being non-discriminatory, honest and open, etc., and being alert to any opportunity to reflect on an issue in a case or feedback that might help provide written evidence in this domain. Here too though, the core principle of reflection is that when possible it should be judged by action or better still, by outcome.
Reflection in maintaining trust domain.
Response A is understandable enough, but essentially defensive and defeatist. Response B on the other hand generates an answerable question and suggests a strategy for exploring, if not answering it. Despite not mentioning an apology, and with a very clinical approach to reflecting on a complaint, Dr B has nonetheless demonstrated respect for the person giving feedback by taking the issue seriously, and has taken action, which is likely to prevent similar problems recurring in the future. Words are cheap: actions speak louder.
Insight
A word that has recurred several times already in relation to the assessment of reflective practice is appropriate. The word likely also appears in ‘actions likely to prevent occurrence’. Ought appears in the sentence ‘assurance of patient safety is achieved when a doctor demonstrates that they routinely identify and correct issues that ought to be improved in each of the four domains of GMP’. These words seem subjective and it may horrify some to realise that revalidation decisions and other judgements about a colleague’s fitness to practice might be based on inter-subjective judgement. On the other hand, the concept of peer-referencing is an intrinsic component of professionalism and professional empowerment (Sanfey & Ahluwalia, 2016).
Consider the following definition of reflection, which is used by the London revalidation leads.
Reflection: Thinking about something to learn from it.
How can such a simple definition of reflection be of any use in making judgements about a doctor’s fitness to practice? The answer of course is that the thinking must be appropriate, which is something that can only be judged by peer-to-peer subjective referencing. Consider this definition of insight, which is currently in use by the London revalidation leads:
Insight: The degree to which the subject and outcome of reflection is considered appropriate to one’s peers.
In the context of appraisal and revalidation the word ‘reflection’ really means appropriate reflection, and the word ‘appropriate’ refers to insight. In practical terms, the assessment of reflection is actually an evaluation of the professional insight of the thinker in question. In the context of appraisal, appraisers and responsible officers have to judge whether a doctor is thinking about issues that need to be considered, and in a way that is considered professionally appropriate. Of course, it goes without saying that such peer-referencing can only provide an effective assurance of patient safety when we are willing to challenge each other when we notice flaws in health care delivery.
This principle applies in all areas of professional behaviour, including daily clinical practice, and is not confined to appraisal and revalidation. If we come across clinical behaviour or decision-making in a colleague that makes us concerned about patient safety, we have a duty to act upon it. That does not mean we must report a colleague within clinical governance frameworks. It simply means that we help each other to learn from and correct issues that could be better. In some cases, however, we may be concerned that a colleague’s lack of insight poses a risk to patient safety, and in those circumstances we are expected to ask for help.
The same is true at all levels of the clinical governance system. There is a widespread perception that we practice medicine in a culture of blame, and that the GMC or NHS England investigations are punitive. That is actually not the case in practice. Although clinical governance investigations should and generally do focus on minimising the risks to patient safety from a recurrence of whatever is being investigated. As long as a doctor is open and truthful, has sufficient insight to understand the probable cause of the event in question, and has the will to take appropriate action to minimise the likelihood of recurrence, then in those circumstances, there will be no negative impact on the doctor or their career. In some cases measures may be put in place to ensure that the actions taken have been effective (Sanfey, 2015). Once again, reflection is the key, where reflection is judged by effective outcomes.
In the case study above, practice X were simply concerned with ticking some imaginary box to show they had reflected. They heaved a sigh of relief and concluded that the risk of a complaint was low. In practice Y, on the other hand, the focus was on maximising the learning from their analysis without any fear or thought of complaint. If a complaint or investigation had arisen from this case study in practice, it is pretty obvious which practice would be considered safer by any sensible investigating body, and which one would be commended for their professional approach.
System autonomy and innovation
Reflection is not just about demonstrating safety or fitness to practice, and is certainly not just a box to tick for revalidation. The ‘i’ in CiAO refers to innovative action. Just as appropriate thinking is necessary to effectively reduce risks to patient safety, then high-quality reflection is the necessary foundation for implementing health care change based on the experience of practitioners at the sharp edge of health care. If we cannot think effectively about our work, then service development can only come from people not engaged in the actual practice of clinical health care. The better we become at analysing clinical work, the more likely future change in the health service will be clinically relevant and appropriate to the realities of front-line health care.
We have seen in the two SEAs from the case study above, and in some of the examples under the four domains of GMP that good reflection lends itself to service improvement and the generation of research questions. High-quality individual reflection should provide a platform for clinically led health care.
Appraisal and revalidation are not ends in themselves, and certainly not mere hurdles to be overcome. They both measure and develop that essential quality necessary for clinically led service development, namely reflective analysis. Reflective analysis, however, is just the beginning. Action and outcomes are the units of measurement for reflective practice, but more importantly, they are the components of innovation and a service development built upon scientific analysis of the practicalities of patient care, by those who provide it.
Key points
Evidence of appropriate reflective practice in the four domains of GMP is necessary for successful revalidation Reflection is measured by actions and outcomes Quality improvement is the natural end-product of effective reflection The impact of quality improvement is amplified by changes to systems System-wide change arising from good quality individual reflection is the defining characteristic of professionally led health care