Reflection in clinical practice: guidance for postgraduate doctors in training

Reflection is a cyclical process [1] of understanding and analysis of one’s professional experiences, with the aim of self-improvement within future practice, if a similar event is encountered [2]. Reflection is also understood to have a critical role within the learning cycle [2] and clinicians should feel confident when engaging in its practice, as it allows them to focus not only on increasing their medical knowledge, but also on advancing nonclinical skills [1] such as communication, multidisciplinary work, and leadership and management. Additionally, reflection is considered essential in continuing professional development [3] and this skill must be developed and practised by postgraduate doctors in training (PDiT), and indeed all clinicians, during their professional career.

Models and theories

There are many different theories that guide the practice of reflection. An example is the Kolb cycle [4], which is an experimental learning theory that describes how each stage supports the next, for effective learning. There are four stages in the Kolb cycle, all of which must be completed. These are concrete experience, reflective observation, abstract conceptualization, and active experimentation.

Another example is the Gibbs model [5], which is a commonly used framework for reflection in healthcare. It provides guidance to clinicians in reflecting on experiences and allows for learning and progression. Originally this model was advocated to apply to only repeated situations; however, it is now also used for stand-alone events. Other theories include the Jarvis model and the Allan model [5].

Why is reflection important?

Being able to reflect effectively and honestly with oneself and a supervisor, in a ‘safe space’ where there are trust and nonjudgemental advice, is essential for curriculum progression and aids in increasing knowledge. Reflection serves as an important tool to demonstrate competence and professionalism in clinical practice, as well as being a core component of the Annual Review of Competency Progression (ARCP) for PDiTs [6]. By critically reflecting honestly on one’s performance, it allows clinicians to gain further insight into their practice and identify areas of further development and improvement. It is vital that PDiTs recognize the required level of practice they should aim to achieve; and receiving regular feedback from positively engaged supervisors and the wider team can be very supportive in this process, leading to better clinical outcomes for patients.

Reflection has also been recognized as an important tool in building resilience [5] amongst clinicians. The three main areas associated with reflection and resilience building are:

• (1) Support—trained supervisors, supporting PDiTs with reflection, should ensure that PDiTs feel valued and that the work they contribute is important to the outcomes of the team.

• (2) Critical thinking—assists with clarifying and progression through evolving situations.

• (3) Collaboration—resilient professionals are often highly collaborative and reflection can be used to identify ways that all parties who are actively involved can learn together. This supports team bonding and can improve multiprofessional learning.

What to reflect on?

Any situation or incident [7] can be reflected on. Some situations will only require brief reflection, whereas others may require more time with written records being kept.

Example areas of reflection include:

• a successful or difficult consultation

• breaking bad news

• managing angry patients, employees, family members, or colleagues

• receiving a complaint

• serious or untoward incidents

• improving skills and shared learning in digital hybrid consultations

• delayed learning progression in career, e.g. exam failure or nonstandard ARCP outcome.

Prior to writing a reflection

It is recommended that PDiTs discuss and reflect on their experiences with a trained supervisor or appraiser [6]. The Gold Guide [8] suggests that educational supervisors should assist in developing the PDiT’s skills of self-reflection and self-appraisal, as these will be required throughout their professional career.

It is valuable for PDiTs to seek advice from an experienced colleague, especially if the incident to be reflected on may be contentious or is likely to be the subject of investigation. A verbal discussion forms an important component of the reflective experience and is actively encouraged, as it helps one gain useful insight on areas of development through the use of others’ experience.

It is recommended [6] that if one wishes to reflect on a serious incident or an event with an adverse outcome, then this firstly should be recalled on a piece of paper away from the PDiT’s ePortfolio. This allows time away from the event and is a helpful way to anonymize the entry better, as well as reflect more objectively and dispassionately.

How to write a reflection?

When writing a reflection, it is important that PDiTs consider the steps listed in Table 1.

It is important to emphasize that the PdiT’s ePortfolio [10] is an educational tool and must not be used as a medical record or personal diary. PdiTs must therefore avoid including any identifiable data in their ePortfolio. Anonymizing information [6] that goes into the ePortfolio is very important, because in the rare event a clinician is referred to a medical regulator, e.g. the General Medical Council (GMC), for reasons such as fitness to practise, the clinician may choose to offer their reflection as evidence of insight into their practice. The GMC will not usually ask a clinician to provide their reflection so that they can investigate a concern about them; however, evidence of good reflection can demonstrate insight and remediation which may reduce the need for the GMC to act. Good reflection is therefore likely to demonstrate insight, a level of professional maturity, future learned action points, recognition of additional training requirements, and contribute positively to how the GMC assesses whether a doctor’s fitness to practise is impaired.

Legalities around reflection

Regarding legislative frameworks [10], clinicians must be aware that the Data Protection Act 1998 and the Medical Act 1983 usually govern the way data on the ePortfolio are processed. Under Section 35A of the Medical Act 1983, a request may be made to a postgraduate medical faculty to release information held on an ePortfolio for reasons including fitness to practise, at the request of a court or coroner, at the request of the police for crime prevention purposes, or by a patient (subject access request).

The Data Protection Act (1998) regulates the use of personal and sensitive data. The Data Protection Act does not apply if data are anonymized in such a manner that the patient (data subject) cannot be identified. Therefore, if disclosure of a clinician’s reflection is requested by medical regulators, access is not automatically granted. It is likely that the postgraduate medical faculty will assess the validity of each individual request on its merit, including whether any additional exemptions apply, e.g. under section 7 of the Data Protection Act 1998. It also recommended in these situations that the PDiT consider seeking advice from their employer, legal adviser, medical defence organization (e.g. The Medical Defence Union), a trade union (e.g. The British Medical Association), or a professional association (e.g. The Hospital Consultants and Specialist Association).

Funding

The author received no financial support for the research, authorship and/or publication of this article.

Conflict of interest statement: None declared.

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