Is Written Reflective Practice Dead in the UK?
Last week, I read through six years worth of reflections. Some of my earlier musings made me laugh (apparently I had had a little problem with ABGs) but they certainly showed me just how much I have learnt. Others were difficult to read. They detailed my darkest and most difficult days in Medicine; those patients who I’d tried, and failed to save; the first time I had to tell a man that he had terminal cancer and he was going to die; the solo transfer I spent in the back of an ambulance with a child with a splenic rupture, watching their blood pressure drift down terrified we wouldn’t make it to a Major Trauma Centre. Yes they were all tough, but I had learnt from every single experience, and although many of us see mandatory reflections as a tick box exercise, there is no doubt that reflecting on them has made me a better doctor.
Why, then, do my reflections now read “reflected fully with educational supervisor”? In all honesty, the case of Dr Hadiza Bawa-Garba has made me think twice about what I put on paper. Sadly, many of my colleagues are now refusing to reflect at all. This is a tragedy for the medical profession and a real blow to patient safety. When a patient comes to harm, there are always things that could have been done better. That is the true value of reflection, it allows us to see where we can improve, or flaws that we can address in the system, to make sure that next time, we are better.
I would be lying if I said this was a dispassionate process. We, as doctors, are only human after all; even if I did everything perfectly when a patient dies or comes to harm on my watch, part of me will always feel responsible. There is no doubt that some of this guilt finds its way into what I write when I am trying to debrief a tragic scenario on paper. The thought of these deeply private reflections finding their way into the hands of the prosecution and being shown to a lay jury to prove an admission of culpability fills me with horror. Just because I feel guilty, does not mean I am.
For once, I actually found myself agreeing with Jeremy Hunt on this (well, even a stopped clock is right twice a day). The implications of the Bawa-Garba case are such that it prompted Hunt to tweet this:
Since then, there have been so many conflicting statements regarding exactly how Dr Bawa-Garba’s reflections were used against her that it’s difficult to keep up. The MPS, who represented Dr BG in court, initially stated that her e-portfolio did not form part of the evidence before the court and the jury. Sir Terence Stephenson, the Chair of the GMC, also attempted to reassure doctors of the same.
In an extraordinary intervention Dr Jonathan Cusack, Dr BG’s supervisor, wrote a letter to the BMJ explaining that a “training encounter form’ (part of her e-portfolio) was indeed seen by the prosecution team and therefore fed into the trial. Dr BG was summoned to the hospital canteen by the consultant involved in the case following the tragic death of Jack Adcock, and asked to sign the form, which was completed in his own handwriting, detailing what he perceived to be her errors. She did not sign the form as she did not agree with what was written. For more on the role of the consultant click here: http://www.bmj.com/content/359/bmj.j5534
In a letter to Sarah Wollaston on the 9th of February Charlie Massey wrote that “the GMC never asks doctors to provide their reflective statements if we are investigating a concern about them. They are not used in GMC processes unless a doctor decides to share them”. He does concede, however, that reflections are not subject to legal privilege under UK criminal law and therefore they may be requested by the court.
Incredibly, since then the GMC has made it clear to the Royal College of Paediatrics and Child Health that third parties, holding reflective statements written by doctors, might be required to disclose them. The revelation caused shockwaves throughout the medical profession, with doctors on social media claiming that they would never even take part in written reflective practise.
The Academy of Medical Royal College acted quickly to publish urgent and updated advice for doctors, and their response made for interesting read. Whilst the AoMRC emphasised the importance of reflecting, and stressed that doctors must engage with reflection in order to meet GMC requirements for revalidation, it warned that these are potentially disclosable to courts, tribunals and coroners.Their advice seems to focus on how doctors might engage with reflective practice whilst protecting themselves-such as focussing on what a doctor learnt from an event in a reflection, as oppose to providing a record of exactly what happened. They also advise that reflections be fully anonymised (which is good practice anyway) but perhaps be recorded a time distinct from the incident, perhaps even after a full investigation has taken place.
Yesterday, GPs at the LMC Conference passed a motion, that was essentially a vote of no confidence in the GMC but also included a section the directed the GPC to advise GPs to disengage with written reflection both in appraisal and revalidation until adequate safeguards are in place, with an overwhelming majority.
What does this mean for the future of reflective practice in the UK? Well it seems clear to me that doctors need to be aware that there is no legal privilege for written reflections and that anything that they write could be used against them in criminal proceedings or fitness to practise cases. I am very sad to say it but trainees need to be careful what they write on their e-portfolios and I would hope that supervisors would encourage trainees to continue reflect with them in person instead. Sadly, I think that for many, this will discourage them from reflecting altogether. Perhaps it is time that we campaign for legal privilege of reflections. Until then, please continue to reflect but carefully, privately or fact-to-face; lets face it, sometimes the best debriefs are to be had over a beer with a colleague.