4. Reflection March 2019

• 4.1. Myth: Reflection is difficult
• 4.2. Myth: Documented reflection must be lengthy
• 4.3. Myth: I must write a separate reflective note for every hour of CPD I do
• 4.4. Myth: Reflection is dangerous if something has gone wrong
• 4.5. Myth: It is OK to make a statement saying that I will provide my reflection separately to my appraiser
• 4.6. Myth: My reflection is privileged data

4.1. Myth: Reflection is difficult

Reflection is a professional habit that all doctors should have. None of us would want to be treated by doctors who never considered how effective their care was or whether it could be any better.  Reflection should be something you do all the time. It is part of your professional training. Like any habit, reflection can be such a subconscious activity that it can be hard to be sufficiently aware of it so you can capture it and write it down. Demonstrating reflection is what some doctors find difficult. You do not have to record all your reflections as this would be disproportionate. It is important to find a method of capturing reflection that works for you and to keep it simple and proportionate. Some people are more natural reflectors than others. You might find it helpful to understand your own preferred learning style. Your appraiser will have training and knowledge to help you, so you should discuss any concerns with them.

You might find that your appraiser helps your reflection through active listening, careful questioning and feedback. The appraisal discussion is an important trigger to generate new reflective insights which can be captured in your appraisal summary. It should build on your own demonstrated reflective practice. Remember: collect, reflect, discuss.

4.2. Myth: Documented reflection must be lengthy

Remember the principle of quality not quantity of supporting information. Documented reflection should be brief and to the point as far as possible. Capturing the key learning points that have influenced, or will influence, your practice, and thinking about any changes that you may make as a result, and what difference they will make, can be recorded in bullet points, a couple of sentences, or a short paragraph. Some doctors are experimenting with recording brief audio reflections or mind maps. Do what is appropriate for the specific reflection. Experiment with a variety of styles. Some methods may work better for some types of learning than others. If you are doing a postgraduate qualification then you might want to include a whole reflective essay, but, in most circumstances, this would be disproportionate. Some doctors find structured reflective templates that walk you through a process of reflection helpful. Others prefer not to be constrained.

We recommend that you keep it simple and record what is meaningful to you. We suggest you focus on what you will do differently as a result of what you have learned, and how you will know if the change is an improvement.

4.3. Myth: I must write a separate reflective note for every hour of CPD I do

You do not have to write a separate reflective note for every hour of CPD, or even every learning activity. This is a change in emphasis from our previous guidance because we found that some GPs were doing far more than was appropriate and writing a page of reflection for every CPD credit. We recommend that you only provide reflective notes for your most valuable CPD.

Ideally, your CPD log should be a record of your most important and relevant learning throughout the past twelve months in a succinct and useful format.

Your appraiser does not want to read a summary of what you looked up online, the whole article, or all that you were taught at an educational event or learned at a conference. If you find it helpful to make notes on the detail, for your own benefit as an aide memoire, you should do so as a personal choice based on your learning preferences, but it is not important to your appraiser. Your reflection should not be not about the factual detail, it should be about the impact of what you have learned on what you already do, or plan to do, so that you can maintain and improve the quality of your practice.

4.4. Myth: Reflection is dangerous if something has gone wrong

The RCGP recommends that professionally documented examples of your reflective practice are your best defence against any concern about whether you are working in line with Good Medical Practice. Things sometimes go wrong, for all of us. Patients and the public are rightly concerned that doctors and organisations should learn from things that go wrong. Your subjective analysis should demonstrate the lessons that you have learned, individually and collectively, and any changes that you, the team, or the organisation, have made as a result. They should provide reassurance that, if something has gone wrong, steps have been taken to ensure that it should not happen again.

The GMC have made clear that they will never require your reflection in an investigation. Sometimes, defence organisations recommend that a doctor submits evidence of reflection as evidence in their defence in the event of an inquiry, but this is a matter of choice for the doctor.

4.5. Myth: It is OK to make a statement saying that I will provide my reflection separately to my appraiser

The GMC requires you to demonstrate that you are a reflective practitioner working in line with Good Medical Practice. It is impossible to do this by proxy. You should include a few high-quality examples that demonstrate your professional habits of reflective practice in your appraisal portfolio. Remember quality not quantity.

The RCGP recommends that original compliments and complaint letters, or the factual data about a significant event, should be provided separately if they cannot be appropriately anonymised - but your reflection on them should form part of your portfolio. Providing reflection separately and expecting your appraiser to summarise it is not appropriate and does not show that you are a reflective practitioner.

Writing your reflective notes professionally and ensuring that they provide supporting information about the way you reflect and use your reflections to make quality improvements is important. During your appraisal meeting your appraiser can help you to complete a second level of reflection through discussion around your own subjective analysis of what you have learned and your thoughts about the impact on your practice, but they cannot demonstrate your initial reflection for you. Your appraiser can also help you to make sure that what you have written is professional and fulfils the requirements for good information governance and maintaining confidentiality

4.6. Myth: My reflection is privileged data

Your written reflection is not privileged data and could be required by a Court of Law if it was felt to be pertinent. This is very unlikely because reflections are not facts in the eyes of the Court; reflection is by definition a subjective analytic process. Courts are primarily interested in the contemporaneous medical records and we are used to writing our clinical notes promptly and accurately with this in mind. 

It is important to document your reflective notes in a professional way, taking care to meet the requirements of good information governance and maintaining confidentiality. Your appraiser should be trained to help you with this and can offer you this advice during your appraisal meeting.