A guest post by Dr Emma Kennedy of Queen Mary, University of London as part of the #HEblogswap initiative, now in its third year.
The case of Dr Hadiza Bawa-Garba, originally struck off the UK medical register after being convicted of gross negligence manslaughter over her role in the death in 2012 of 6 year-old Jack Adcock, was recently in the news again, as the Court of Appeal ruled that she should be reinstated and allowed to practise again. The case provoked protests around the world from doctors and raised a number of issues in the profession – from the ability of the General Medical Council (GMC) to appeal to the High Court against tribunal decisions, to the conditions under which junior doctors are forced to work. A central issue distinguishing this case from others, however, was that of the role of trainee reflections.
The central reflections in this case were part of a ‘trainee encounter’ form that Dr Bawa-Garba was asked to fill out by the duty consultant Stephen O’Riordan five days after Jack Adcock’s death, reflecting on what had happened after the incident and what she could do differently. She was sent home immediately after she had filled this out: the form next appeared when it was appended to Dr O’Riordan’s witness statement. The GMC has denied that Dr Bawa-Garba’s reflections were used in any of the trial itself, but expert witnesses had access to elements of her e-portfolio, and Dr O’Riordan’s notes on their post-incident discussion were made available. Even if reflection was not directly mentioned in the judgements, it’s clear that there is a link – and given the stakes, a link that would be hard for any trainee to ignore.
It is unsurprising, than, that there has been a sea change in how junior doctors (and many senior ones) now view the risk-benefit balance of the reflective e-portfolio. I’ve had personal experience of this: the first I heard of the GMC vs Bawa-Garba case was when junior doctors attending my workshop on e-portfolios made me aware of their role in a disciplinary hearing. Clare Dyer and Deborah Cohen report a similar shift, not just because of the Bawa-Garba case itself but because legal advice obtained by the Royal College of Pediatrics & Child Health confirmed that doctors’ reflections could be disclosed to a tribunal, court or coroner as part of an investigation. Daniel Furmedge summed up this view in June 2016, writing of the sense of violation and the risk that compulsory written reflection will become a tick-box exercise.
Professional organisations have rushed to quell any fears over the use of e-portfolios. Charlie Massey, Chief Executive of the GMC, wrote that ‘Reflecting regularly on your practice is a core aspect of professionalism and reflection is linked to improved learning and performance’ while the British Medical Association (BMA) has published new guidance on reflective practice, having obtained assurance from the GMC that it will not use e-portfolios as evidence in investigations. However, while many doctors agree on the necessity of reflection – in fact, Dr Bawa-Garba herself wanted to use her e-portfolio in her defence, to show how much she’d learned from the incident – this will still leave them wary of truly honest reflection. Daniel Sokol suggests a move to reflective dialogues, akin to coaching, in order to retain meaningful reflection while also avoid the potential liability posed by a written format.
While I wouldn’t deny the benefits of good coaching and mentoring, however, I don’t think they should replace written, or otherwise permanently stored, reflection. A recent meta-analysis (study of studies) on stress and episodic memory – the recall of events – showed that stress experienced during an event makes it harder to remember. Coaching and mentoring after the event will be less effective if the mentee cannot remember the details of the event in question. Written reflection, in contrast, allows the mentee to write down his or her experiences closer to the time of experience, in order to refer to them for any coaching or mentoring later – making that dialogue much more effective. An e-portfolio also allows mentees to reflect on any coaching or mentoring they may have had, using the dialogue to plan further practice.
A 2015 study found that reflective ability correlated with clinical performance in trainee midwives, and this may well be due to the way that reflection allows trainees to process what they are learning, planning improvements to integrate into practice. This is particularly important in cases such as the death of Jack Adcock, where mistakes were made that should not have been: if anything positive can come from such a tragedy, it is surely that it those involved reflect deeply on their mistakes and do their level best to ensure it never happens again. (It’s also true that many of the mistakes in question were down to structural issues – systemic underfunding of the NHS, overwork among doctors, potentially a lack of communication – but these are outwith the scope of the e-portfolio).
Dustin Wax puts it most eloquently: “when we write […] we are putting some degree of thought into evaluating and ordering the information that we are receiving. That process, and not the notes themselves, is what helps fix ideas more firmly in our minds, leading to greater recall down the line.” Of course, the idea of a reflective e-portfolio is not greater recall per se, but nevertheless, the act of writing forms an important part of processing events. Dr Bawa-Garba had been coming to the end of a 12-hour shift, with no break, covering six wards across four floors. Of course, this should be an exceptional circumstance, but as Sheri Brown has written, this is becoming all too common for doctors in the NHS. Even in better circumstances, a 12-hour shift will involve a great many patients and incidents, and that’s just one out of several that each doctor will do each week.
Doctors have (they hope) a long career, much of which is spent in training and all of which – ideally – is spent learning. Of course,a lot of that learning will be short-term and on the job, and plenty is formal too, through the many examinations they are required to take. However, experience gives one the kind of learning that cannot be taught – a deeper understanding of the patient experience and the hospital environment. A 2014 review of over a thousand studies found that reflective writing increased doctors’ empathy, which makes sense: being able not only to reflect in the short-term (changing focus from the immediate survival instinct to reflecting on others’ perspectives), but also to view one’s career in the longer term, allows doctors to review their cumulative experience at leisure, then bring the insight gained from that back into the workplace. The e-portfolio format especially allows for long-term collection of writings, especially when reflection is typed – making it text-searchable – and there is a tag facility. Keeping an e-portfolio and regularly reviewing it allows doctors to link events that they may not have linked in the moment, both identifying trends and creating narratives from their career. A 2014 study on knowledge amassment – that is, how new knowledge acquired over time is integrated into existing knowledge – showed that e-portfolios had a significantly positive effect on the amount of knowledge that students acquired, integrated into their existing knowledge and remembered.
So the value of written reflection is clear, but what’s less clear is how we can help trainees feel secure and reflect authentically as possible. A 2014 study revealed that for trainee therapists one of the most important factors influencing their learning from self-reflection was ‘Feeling of Safety with the Process’. In that particular case, the ‘process’ involved much more than writing – specifically, group and individual therapy – but nevertheless it’s key to the success of all reflection that trainees feel able to be honest. Only when they feel able to admit to their mistakes can they reflect on the cause of those mistakes and plan ways to avoid them in future. Dr Pallavi Bradshaw makes the excellent point that not disclosing something in a reflection, and then signing a declaration that your reflections are honest, is far more legally risky than declaring your mistakes honestly. However, trapping trainees between two legal risks instead of one is not necessarily the way forward in the long term.
I’d suggest two, linked ways forward. Firstly, make learning about digital professional identity a core part of the medical training process. The GMC’s most recent Outcomes for Graduates stress the duty of ‘maintaining a professional development portfolio’ and ‘develop[ing] a range of coping strategies, such as reflection’, both of which rely on the e-portfolio. Doctors are already made aware of the importance of reflection: the Academy of Medical Royal Colleges has produced a useful Guide to Feedback and Reflection as well as a Reflective Practice Toolkit. However, the JISC guidance on e-portfolios suggests that students are trained not only in using e-portfolios for reflection, but in thinking deeply about the role of digital records in building a professional identity. Too often, I meet NHS staff who use ePortfolios because they have to, and are deeply committed to using reflection to improve patient care, but have not thought about the practical notion of having a digital identity. They know the risks, and avoid the most risky aspects – such as having a public Twitter account – but have not been given the tools to think positively about what they do want. If we want trainees to feel comfortable with ePortfolios and online reflection, we need to give them these tools.
The second thing is more of a technical and legal issue. As the Academy’s Guidance on E-Portfolios states, trainees are currently advised that information in their ePortfolios can be requested by four parties: the patient, if they are identifiable (though trainees are strong advised to anonymise patient data in their reflections); a court order or coroner; the GMC, in a fitness-to-practice case; and the police, if they feel it would help prevent crime. This can’t be avoided, and in the case of the police, is mirrored by the ability of a healthcare professional to report a patient if they pose a significant risk to others. However, greater transparency on the circumstances in which this information would be requested, linked to more transparency on the cases themselves, would help trainees to feel secure in their day-to-day use of the portfolio. It seems as though the Bawa-Garba case struck a chord not just because of the circumstances, but because it was precipitated by an act of reflection – an act which is still presented as professionally beneficial.
The BMA has led the way here in securing a commitment from the GMC not to use reflective statements in investigations. However, there is much further to go, not only in legal and technical terms, but in emotional terms: in supporting the community of junior doctors who have understandably been shaken by this case. The GMC has a clear duty here, both to enhance digital training and to provide greater clarity for trainees. However, seniors also have a duty to support honest reflection – and to support trainees who feel as lost as Dr Bawa-Garba did. If we are to avoid tragedies like Jack Adcock’s death – and we must – then doctors like Hadiza Bawa-Garba need to be better supported. Structural reform, yes – but also individual. Check up on your trainees. Support them to reflect. Help them to use the ePortfolio to its full potential – not merely as a tool to meet professional obligations, but to help them develop, and take control of, a full career.
Academy of Medical Royal Colleges. (2016). Guidance for Entering Information Onto E-Portfolios. Retrieved from https://www.rcog.org.uk/globalassets/documents/careers-and-training/resources-and-support-for-trainees/training-eportfolio/4ii–academy-guidance-on-eportfolios.pdf
Academy of Medical Royal Colleges. (2017). Improving feedback and reflection to improve learning: A practical guide for trainees and trainers. Retrieved from http://www.scotlanddeanery.nhs.scot/media/79868/improving_feedback_0517.pdf
Academy of Medical Royal Colleges. (2018). Academy and COPMeD Reflective Practice Toolkit. Retrieved from http://www.scotlanddeanery.nhs.scot/media/226897/academy-reflective-practice-toolkit-august-2018.pdf
Bennett-Levy, J., & Lee, N. K. (2014). Self-practice and self-reflection in cognitive behaviour therapy training: what factors influence trainees’ engagement and experience of benefit?. Behavioural and Cognitive Psychotherapy, 42(1), 48-64.
British Medical Association (2018). Reflective Practice. Retrieved from https://www.bma.org.uk/collective-voice/influence/key-negotiations/training-and-workforce/the-case-of-dr-bawa-garba/reflective-practice
Chang, C. C., Liang, C., Tseng, K. H., & Tseng, J. S. (2014). Using e-portfolios to elevate knowledge amassment among university students. Computers & Education, 72, 187-195.
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Dyer, Clare. (2018). Hadiza Bawa-Garba wins right to practise again. BMJ; 362 :k3510.
Embo, M., Driessen, E., Valcke, M., & van der Vleuten, C. P. M. (2015). Relationship between reflection ability and clinical performance: A cross-sectional and retrospective-longitudinal correlational cohort study in midwifery. Midwifery, 31(1), 90-94.
Furmedge, Daniel. (2016). Written reflection is dead in the water. BMJ; 353 :i3250.
General Medical Council. (2018). Factsheet: Dr Bawa-Garba’s case. Retrieved from: https://www.gmc-uk.org/-/media/documents/20180424-factsheet—dr-bawa-garba-case-final_pdf-74423019.pdf
General Medical Council. (2018). Outcomes for Graduates 2018. Retrieved from: https://www.gmc-uk.org/-/media/documents/dc11326-outcomes-for-graduates-2018_pdf-75040796.pdf
JISC. (2016). E-Portfolios. In Technology and Tools for Online Learning. Retrieved from: https://www.jisc.ac.uk/guides/technology-and-tools-for-online-learning/e-portfolios
Kaffash, Jaimie & Gregory, Julia. (2018). Revealed: how reflections were used in the Bawa-Garba case. Retrieved from: http://www.pulsetoday.co.uk/news/gp-topics/legal/revealed-how-reflections-were-used-in-the-bawa-garba-case/20036090.article .
Massey, C. (2018, January 30). “We are committed to making health services a place for learning, not blaming”. [Blog post]. Retrieved from https://blogs.bmj.com/bmj/2018/01/30/charlie-massey-we-are-committed-to-making-health-services-a-place-for-learning-not-blaming/ .
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Sokol, Daniel. (2018) Knocking out written reflections. BMJ; 360 :k546