Written reflection is dead in the water

Authors: Daniel Furmedge 

Publication date:  20 Jun 2016


The case of a junior doctor’s written reflection being used against them in court has worried many trainees, says Daniel Furmedge

Postgraduate trainees in London recently received a disquieting letter—signed by four postgraduate deans from Health Education England—which revealed that a trainee had been asked to release a reflective log from their portfolio for use in a legal case.

The letter said that this reflection was then used “against” the trainee.

Others have been left wondering how their intimate thoughts, reflections, and learning might be turned against them in court. Rather than reassure trainees, the deans asserted that reflective practice must continue to be recorded in an anonymous way.

This development has caused a wave of anxiety among trainees and concern among trainers. In the open and candid learning culture that supposedly encompasses NHS and postgraduate training, a serious question has arisen. Does formalised written reflective practice—required as part of postgraduate training—pose a threat to trainees?

Although it is unclear how reflections could be used, it is easy to see that a simple reflective entry like the one shown in the box below could be turned against a trainee, or even a trust, focusing on error rather than improvement.

While they may not directly quote specific patient identifiable details, many of the cases featured in reflections might be identifiable in the context of a complaint or critical incident.

Reflection is usually provoked by uncertainly or unease, or by complicated cases or situations.[1] Written reflection, usually entered into portfolios, enables training providers to feel like their trainees are doing enough self-directed learning. Entries are visible to supervisors, training programme directors, and others, and are then rudimentarily checked at the Annual Review of Competence Progression. There is an assumption that learning and development must have occurred.

Enforced written reflections have been a bone of contention among trainees since they were introduced. The requirement for mandatory reflection is growing and has crept into both undergraduate education and revalidation. In some specialties, accounts are reviewed and marked, with trainees criticised for reflections which are superficial or unstructured. Though portfolio templates can be useful, there has been concern that the requirement for reflection has distorted the original intentions of meaningful reflective practice.[2] No study has yet demonstrated any effect on practice or improved patient outcomes.[3]

Compulsory written reflection is unpopular with many trainees and trainers. Many are never read, it often feels like a box ticking exercise, and there is resentment at being forced to write down thoughts and feelings about sensitive or difficult areas. Face-to-face reflection is surely more appropriate for these issues?

The revelation that these deeply personal entries may be used as evidence feels like a violation and undermines a process originally designed to promote development. Instead of writing honestly, it is likely that reflections will become watered down and non-controversial, if done at all. Trainees will actively avoid reflecting on mistakes or serious incidents—the very things they have a duty to reflect on and for which reflection is most effective. The knock on effect will be a weakening of the process, with entries written in such a way that there could be no risk of comeback.

With this new development, meaningful written reflection will be dead in the water. And so it should be. It is time we used a more personalised face-to-face educational process for medical education.

Box: Example excerpt of reflective e-portfolio entry

“[A]nd I was delayed seeing the patient because I was so busy so by the time I got there the early warning score was 10 not 6. I did the sepsis six but it was too late and they died on ICU. Maybe if I had been there slightly earlier, perhaps I could have prioritised better, and maybe that extra half an hour might have made a difference”

I have read and understood BMJ’s policy on declaration of interests and declare that I have no competing interests.

See also Reflection: how to reduce the risks [Link]

References

  1. Boenink AD, Oderwald AK, De Jonge P, Van Tilburg W, Smal JA. Assessing student reflection in medical practice. The development of an observer-rated instrument: reliability, validity and initial experiences. Med Educ  2004;38:368-77. [Link]   [Link] .
  2. Murdoch-Eaton D, Sandars J. Reflection: moving from a mandatory ritual to meaningful professional development. Arch Dis Child  2014;99:279-83. [Link]   [Link] .
  3. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract  2009;14:595-621. [Link]   [Link] .

Daniel Furmedge speciality registrar in geriatric and general internal medicine and honorary clinical lecturer in medical education St Thomas Hospital, London

 daniel.furmedge@gstt.nhs.uk

Cite this as BMJ Careers ; doi: