Trainee engagement with reflection in online portfolios: A qualitative study highlighting the impact of the Bawa-Garba case on professional development

Abstract

Background

Reflection is an essential tool for postgraduate medical training, yet fear of exposing incompetence is a known barrier for engagement with reflection. In the UK, this fear may have been amplified by the case of Dr Bawa-Garba, whose reflective e-portfolio entries informed a General Medical Council investigation resulting in the loss of her licence to practice.

Aim

To identify themes GP trainees commonly explore in e-portfolio entries, and whether their reflective e-portfolio entries have changed following the Bawa-Garba case.

Method

A phenomenological approach was applied. Semi-structured interviews continued to data saturation in a purposive sample of trainees (7) and trainers (4) recruited from a South Yorkshire GP training scheme. Transcript data were assigned to a coding framework with iterative thematic analysis.

Results

Dominant emergent themes were ‘difficulty’ and ‘challenge’. All trainees described reluctance to submit significant event analyses (SEAs) on mistakes and near misses for fear of jeopardising their careers. International medical graduates were disproportionately affected by the challenges reflection posed.

Conclusion

Following the Bawa-Garba case, trainees are disengaging with SEAs to reduce the risk of self-incrimination. Further guidance with which trainees can navigate their reflective e-portfolios is required to retain the value of reflection as a tool for professional development.

Keywords:

• Primary care
• medical education research
• postgraduate
• ethics/attitudes
• portfolio

Introduction

Reflection in Medical Education has been defined as a complex metacognitive process that is core for professional identity formation (Wald 2015). The key to this process is an understanding of self (Nguyen et al. 2014). Greater actualisation of transformational learning occurs when reflecting on events that provoke a strong emotional response and therefore challenge fundamental beliefs (Sandars 2009). Clinicians have identified various benefits from reflection: in giving meaning to their work (Horowitz et al. 2003), in development of identity, ideals and values (Johna and Dehal 2013) and in tackling complex problems (Mamede et al. 2008; Mann et al. 2009).

Practice points

• Dominant themes for trainee entries are difficult and challenging.

• Reflection on mistakes and near misses is key for professional development.

• Following the Bawa-Garba case trainees are afraid to submit reflections on mistakes for fear of jeopardising their careers.

• Lack of experience in reflection may leave International Medical Graduates (IMGs) relatively more exposed to medico-legal difficulties.

Donald Schön was among the first to identify reflection as a means for tackling complexity, suggesting that a reflective practitioner identifies when technical expertise alone is not enough and generates an alternate hypothesis through the process of reflection (Schon 1982). It has since been suggested that the use of reflection within medical education has shifted from the reflection-in-action suggested by Schön towards the reflection-on-action (Rolfe 2014) required by reflective writing in portfolios. That is not to say that reflective writing in itself does not have power for both personal and professional development (Bolton 1999), but there is evidence that submitting reflective writing for the purposes of assessment stifles practitioners (Eaton 2016). The imperative to do well academically has even been shown to result in fictionalisation of events rather than honest and open reflection (Hargreaves 2004; Hobbs 2007) thereby compromising and devaluing reflection as a form of professional development (Ng et al. 2015). For the individual, the drive to do well academically may therefore impede the transformative potential of reflection.

An educational environment that is subject to external motivation and surveillance can jeopardise lifelong learning (Hodges 2015). This is especially problematic in large organisations like the National Health Service (NHS), where fear of exposure of weakness or incompetence becomes a significant hindrance to reflection for assessment (Bolton & Delderfield 2018). As Ross describes, the convergence between surveillance, assessment and reflection, specifically in the context of reflection in digital spaces such as online portfolios, can have consequences for learning; ‘rather than revealing and developing a true and unitary self, reflecting online and for assessment produces fragmented, performing, cautious, strategic selves’ (Ross 2011).

These issues have become increasingly pertinent following the case of Dr Hazida Bawa-Garba which came to the attention of the UK media on the 4 November 2015 when she was convicted of manslaughter following the death of a 6-year-old patient in her care (Britton 2015). Jack Adcock had been admitted to Leicester Royal Infirmary with vomiting, diarrhoea and shortness of breath. A series of systemic failures, including problems with the hospital pathology reporting system, led to a delay in the diagnosis of sepsis secondary to pneumonia and he later suffered a cardiac arrest and died (Pulse 2019). Although there were many factors that contributed to Jack’s death, Dr Bawa-Garba’s involvement was the focus of the subsequent investigation.

Dr Bawa-Garba received a 12 months suspended sentence and the General Medical Council (GMC), the UK body responsible for regulating medical education, training and licensing, subsequently submitted an application to remove her from the GMC register. After review of the case the Medical Practitioners Tribunal (MTP), a UK organisation that makes independent decisions about medical practitioners’ fitness to practice, decided only to suspend her licence to practice for 12 months stating that ‘erasure would be disproportionate’. The GMC successfully appealed this decision in the High Court and Dr Bawa-Garba was stricken from the GMC register on the 28th January 2018 (Pulse 2019). This removal was finally overturned on the 13 August 2018, but by then the case had already caused wider repercussions across the medical community following reports that Dr Bawa-Garba’s reflections ‘fed into the trial’ (Cohen 2017). Although the Medical Protection Society (MPS) who provided legal representation for Dr Bawa-Garba confirmed that reflective entries were not presented as evidence in court (Dyer and Cohen 2018), the perception amongst UK doctors remains that reflective entries from Dr Bawa-Garba’s electronic portfolio (e-portfolio) were used as part of the prosecution case against her.

In UK General Practice (GP) training, reflective log entries similar to those submitted by Dr Bawa-Garba, are uploaded to an e-portfolio and used to evidence curriculum coverage and subsequent attainment of GMC appointed competencies for progression to a Certificate of Completion of Training (CCT). Engagement with the e-portfolio is therefore essential to becoming an independently practising doctor in General Practice. The reflective log entries are expected to demonstrate the development of self-awareness as a practitioner, achieved via a continuum of reflective practice inclusive of straightforward clinical scenarios, psychosocial challenges, significant events and critical incidents encountered in practice (Royal College of General Practitioners 2020).

‘Critical incidents’ are thought to be of significant importance due to their potential to influence professional development; it has been suggested that such reflections have a positive impact on educational outcomes when combined with experiential learning (Branch 2005). GP trainees are therefore encouraged to complete, and submit to their e-portfolio, Significant Event Analyses (SEAs) for near misses or critical incidents that caused (or had the potential to cause) patient harm. These analyses involve reflection on the incident, identification of learning opportunities and the formulation of a plan of how to meet these learning needs, with the intention to improve self-awareness and facilitate professional development. However, potential internal conflict can arise: submitting such analyses can be seen as intrusive whilst also subjecting participants to external judgement (Henderson et al. 2003). Cases such as that of Dr Bawa-Garba might make it more difficult to provide reassurances for these sources of conflict, leading to questions about reflection, particularly within the context of postgraduate medical training; has the e-portfolio now become simply an ‘instrument of accountability’ (Goldie 2017).

Dr Bawa-Garba was born in Nigeria and obtained her primary medical qualification (PMQ) in the UK at the University of Leicester. It is well documented that Black, Asian and Minority Ethnic (BAME) doctors are more likely to be referred to the GMC by their employers (GMC 2019). Also at higher risk of referral are those doctors who achieved their PMQ outside the UK; between 2012 and 2017, referral rates to the GMC for non-UK graduate doctors were 1.2% compared to 0.5% of UK graduate doctors (GMC 2019). Alongside challenges of communication and working in an unfamiliar environment (Slowther et al. 2012), research suggests that international medical graduates (IMGs) face difficulties adapting to the differences in learning environment with many being used to a more didactic style of teaching (Hashim 2017). The introduction to more learner-centred teaching methods such as reflection and problem-based learning can therefore be challenging (Pilotto et al. 2007).

The aims of this research are to use qualitative methodology to identify the themes GP trainees write about in their e-portfolio reflective entries, and to explore whether their approach to this reflection has changed following the Bawa-Garba case.

Methods

Qualitative approach

Considering the aim of the study was to assess the impact of a discrete event on the educational experiences of GP trainees, constructivist theory was applied and a phenomenological approach was adopted. Qualitative data was collected by means of semi-structured interviews.

Sampling strategy

A purposive sampling approach was adopted to ensure a maximum variety sample of participants in terms of gender, stage of training and country of PMQ, especially within the trainee group (Table 1). In the first phase of recruitment, an email invitation was sent to all trainees and trainers on a single South Yorkshire GP Training mailing list and responses were received from 7 participants (4 trainers and 3 trainees). All trainee participants identified at this stage were at the same level of training as the lead researcher. A further stage of targeted recruitment therefore identified participants from different training grades, whilst ensuring a mix of gender and ethnicity.

Table 1. Demographics of the trainees.

Identifier	Gender	Country of primary medical degree	Hours of work	Training year
Trainee A	Male	UK	Full time	1
Trainee B	Male	Nigeria	Full time	1
Trainee C	Male	Pakistan	Full time	1
Trainee D	Female	UK	Full time	1
Trainee E	Male	Nigeria	Full time	2
Trainee F	Male	Nigeria	Full time	2
Trainee G	Female	UK	Part time	3

GP trainers are fully qualified independently practicing General Practitioners who have undertaken a postgraduate qualification in education and specific training by the Royal College of General Practitioners. GP trainers were recruited alongside trainees as they are required to read the reflective personal log entries of their trainees as part of the supervision process and so they are in an ideal position to comment on themes of reflections across a large number of trainee educational portfolios, over time.

Data collection and processing

Data collection by semi-structured interview with both trainees and trainers took place over a period of 4 months from March 2018 to June 2018 using an interview schedule devised by the lead researcher with reference to the literature and feedback from the supervisory team. Coverage of broad topic areas rather than specific structured questions allowed flexibility and exploration of emerging themes. Interviews were recorded and transcribed verbatim. Participants did not identify themselves at any point during the interview process and the recorded data was anonymised at transcription. Trainee interviews were assigned a number from 1 to 7, and trainer interviews a letter from A-D with which they are referenced throughout this paper.

Data analysis

Thematic analysis was performed. A coding framework was defined to allow reduction of the data (Attride-Stirling 2001) and analysis was then undertaken iteratively, identifying basic themes, organising themes and finally global themes. Analysis of dominant themes was through both the number of occurrences and the strength of feeling demonstrated. To give an example of this with respect to concerns about reflection, words such as ‘fear’, ‘anxiety’ and ‘scared’ were given greater weighting than ‘uncertainty’ or ‘frustration’ because they express a more visceral response and greater depth of feeling. The themes identified by the primary investigator were checked and verified independently by TH.

Ethical issues

Ethical approval for the study was obtained from the University of Sheffield and written consent was obtained from participants prior to commencement of the interview.

Results

Difficulty, challenge and complexity trigger reflection

Difficult, challenging and complex situations which prompted a deeper more considered approach underpinned the reflective entries of trainees. Examples of themes reported by GP trainers included medical complexity, working under pressure and problems with colleagues or patients.

…that’s certainly a theme, kind of adversity, difficulty, conflict, so whenever something has been difficult, it's more natural for us, probably all of us to kind of… be left with some complex feelings, and then need to go and explore that. Trainer 3

These themes were also reported by trainees themselves when asked to provide examples of their recent reflective entries, with trainees recognising the potential to learn from these difficult scenarios.

I had a series actually of quite complex young women with learning difficulties and contraception… they are sort of the ethical dilemmas… where you decide what you need to do, and you probably discuss with your supervisor and it was still challenging. Trainee D

…when I face, like a difficulty with a patient, in that I don't know what to do and I feel it's something I think I will learn from, that's when I start putting these things in the e-portfolio. Trainee E

Trainees recognised reflection on critical incidents had the most potential for shaping their professional development. Significant Event Analyses (SEAs), are structured log entries used to reflect on critical incidents, and this form of reflective entry was discussed by all trainees during the interview without the need for specific prompts. Often these SEAs were tied to events where a mistake had been made which had the potential to harm a patient:

I’ve had a SEA, about a prescribing error… someone else made the mistake but basically they gave a drug that I’d already given and prescribed, and recorded properly. Trainee A

The fact that I have to go back home and think of what I did wrong and what I think I can do better… that makes me a better doctor, again having the confidence to admit your mistake, reminds you not to make those mistakes again. Trainee B

Impact of the Bawa-Garba case on the reflective approach to SEAs

The impact of the Bawa-Garba case was raised in association with these SEAs as trainees expressed how this had led to a significant change in their practice:

… I felt like I had made a significant error… I thought this has actually gone wrong, what could I have done to prevent that, and… those are the most useful reflections I've done, the ones where I've actually made a mistake that I could potentially have avoided, and I won't do those anymore which is a shame. Trainee D

Considering that trainees tend to write about complex and difficult scenarios they have encountered in practice, especially significant events where they or a colleague have made a mistake, it would therefore seem logical that the Bawa-Garba case would have had a significant impact on their practice.

Though none of the participant information mentioned the Bawa-Garba case, all participants were aware of it. In one interview there was no need for specific questioning on this topic as discussions naturally led round to the issue. In the other six trainee interviews the interviewer used the prompt ‘a high profile case in the media regarding reflective practice’, and responses indicated that not only were trainees familiar with the details of the case, but that they had all modified their practice as a result.

… I think it has changed everybody's practice regarding what they put in the e-portfolio… because nobody wants to get struck off, nobody wants to go to jail because of what they feel was meant to be helping them. Trainee E

Yeah, I definitely feel that my practice has changed, for one things for sure I'm not going to put anything that might compromise me in any… so because of that I have to be careful about what I put in, especially when it comes to significant events. So I'm very cautious and obviously that's not helpful because I’m not learning if I'm being cautious. Trainee F

Trainees clearly recognised that this was likely to have a detrimental effect on their learning and limit their professional development; however, the fear of jeopardising their careers was the prevailing issue. Trainees could all identify scenarios from their clinical experience where they could have found themselves in a similar position to Dr Bawa-Garba:

…it scares me, there’s been times recently where I've been worried that… if we were a little bit more busy had a couple more admissions who were acute and need an immediate attention, that could happen to anyone. Trainee A

…I think it is all about the Freedom of Information Act… This is very scary, because you don't know whether they just might pick up on something… they could use against you in the future, and your means of livelihood is done forever…. Trainee E

Trainees felt trapped, they identified that reflection is useful for learning from complex presentations and problems, but their forum for this learning was no longer safe. The lack of confidentiality was felt to be intrusive and an invasion of privacy; something that trainers also recognised when considering reflective writing for their appraisals:

I think when you reflect it's, it’s how you see it it's not… a perfect timeline of events and I think for evidence in court it's quite scary to think that your internal monologue can be used that way because not many other people at risk of having their internal monologue being put out of there as evidence. Trainee A

I put some quite personal reflection about myself, about my family, about my practice, my partners and stuff in my appraisal, and I wouldn't have done that if I thought that was coming out anywhere ever… but I think it's a reflective thing to do, and because it's something I'd thought about a lot, I thought it's important to put it down… but if I ever thought that was going to be shared with people, I wouldn't have put it down. Trainer 4

Indeed, trainers had also changed in the advice they were giving to trainees about their reflective log entries as a result of the Bawa-Garba case:

…the SEAs that are reasonably minor, or safe, or unlikely to have implications medico-legally… are fine to put on e-portfolio, but in terms of the potential implications of those being… used against you, I might suggest that you don't put those sorts of entries in really, which is sad, but it's a reality and, you don't want to…. put yourself … at risk. Trainer 3

When asked how the situation could be improved, both trainees and trainers felt that the General Medical Council, or the British Medical Association (BMA), the UK doctors union, had fallen short in their guidance and reassurances about the confidentiality of reflective log entries on online portfolios:

I think there needs to probably be very clear guidance from the GMC and BMA as to, this reflection cannot and will not be used in court, under any circumstances because otherwise you’re stuffed. Trainer 4

Some participants took this even further, describing a loss of trust especially concerning the GMC’s handling of the case.

…we have a very weak union, apparently a very aggressive General Medical Council… so… yeah it feels like we're as a profession quite unsupported and not respected. Trainee A

Perceived challenges for international medical graduate in reflective practise

Four of the seven trainees interviewed were IMGs (Table 1). These trainees identified closely with Dr Bawa-Garba, with the impact of the case extending much deeper, having the potential to impact on their future plans to stay in the United Kingdom:

…I cannot deny that the Bawa-Garba case is always on my mind, given that I'm in a minority and I’m a foreign trained doctor. Trainee B

… a lot of black migrant doctors feel that… she (Bawa-Garba) was harshly treated, a good number of them, might have their careers or have their long-term plans in the UK affected due to that case, and I find it shocking… that given the impact of that case the GMC has not done a poll of the effect of that case in clinical practice amongst trainees…. Trainee B

Three of the four trainers interviewed identified IMGs as a group whose entries included more facts and details but less depth of reflection, and could therefore be considered more vulnerable medicolegally than their British trained counterparts. Along with linguistic barriers, different teaching styles were suggested as contributing factors:

I become increasingly conscious of where international medical graduates don't have English as a first language, the expectations that we put on them, of what we require of them in the reflective entries in e-portfolio this is incredibly high. Trainer 3

They’ll just say this happened and it was bad, they don’t think any further than that….it’s often overseas graduates, and that’s not because they’re not reflective it’s because they’ve not been taught in a reflective way. Trainer 4

This difference in teaching style was also recognised by the trainees themselves, though feedback from their trainers made the transition into this new form of professional development easier:

In the medical school there is nothing (reflection), it's not like here… I think that everything was based on feedback from exams and from all the tests, and everything you do for the ward round. Trainee E

…after my educational supervisor, my trainer had a read of a few of my entries, she thought I was doing the right thing so I think that gave me a bit of confidence that I was doing the right thing. Trainee B

Discussion

Limitations

It is acknowledged that this is a single site study based in the United Kingdom. However, themes emerging from the data show concordance with previous larger studies suggesting credibility in the context of reflective learning.

Additionally, though the number of participants is relatively small, this is often appropriate in qualitative research. Crouch and McKenzie argue that when considering individual experience within a social context, the intensity of the interview process requires a small sample size so that the emerging data can be held in the mind of the researcher throughout all stages of the process (Crouch and McKenzie 2006). Though the initial intention had been to recruit 15 participants, early saturation of themes in a maximum variety sample of participants (by stage of training, gender, trainer and trainee) meant that further sampling was halted.

The potential for cognitive bias as a result of participant activism to skew data within a limited sample is recognised (Jones 2020). It is acknowledged that participants who responded to the email invitations to interview may have more strongly held views regarding the topic area. However, if this was the case, one would expect that more participants might have specifically mentioned the Bawa-Garba case themselves during the interviews before prompting, particularly as they were all aware of it. This would suggest that although the Bawa-Garba case was a significant factor in changing their reflections, trainees did not participate in order to make this case. It was also recognised that those trainees responding to the first e-mail would have known the lead researcher who was at the same stage of training. As such, steps were taken to ensure that further purposive sampling included participants in later stages of training with whom the lead researcher had not previously had contact.

Interviews were conducted by the lead researcher. Reflexivity was enhanced by reflective field notes and ongoing analyses subject to critical interpretive discussion with supervisors. Although this could be considered as an area of potential bias, it could also be argued that personal experience as a near peer is a strength of this study through shared experience and understanding (Lincoln and Guba 1985). The literature suggests that when submitting reflections for assessment purposes participants will often say or write what they think their supervisor will want to read rather than their actual views and opinions (Hargreaves 2004; Hobbs 2007). We argue that it is likely that the same would apply within the context of interviews. The experience here was that trainees were open in their responses, perhaps more so than they would have been to an outside researcher, especially if the researcher had been perceived to be in a position of authority.

Difficulty, challenge and complexity as key themes

There was significant overlap in trainer and trainee perceived influences on key themes concerning ‘difficulty’ and ‘challenge’. Themes identified after data saturation showed significant concordance to those identified in previous research, suggesting that the interviews had successfully identified dominant themes. For example, this study identified that health professionals use reflection to tackle complex problems which correlates with findings of previous studies (Mamede et al. 2008; Mann et al. 2009).

Impact of the Bawa-Garba case on trainee engagement with SEAs

It was with regard to engagement with SEAs that trainee reflective practice had changed most dramatically following the Bawa-Garba case. Trainees were afraid to submit reflections involving mistakes to their e-portfolio, which was considered a permanent record, open for anyone to access, that had the potential to jeopardise their careers. Fears over confidentiality overtook their drive for learning and professional development. This goes further than just amending entries (as previous research has suggested) (Hobbs 2007), instead trainees were purposefully disengaging from the use of the portfolio to reflect on near misses. In a profession that values honesty and self-awareness, this is especially damaging and has the potential for serious repercussions for professional development (Nguyen et al. 2014). The impact of this case and the consequences this has for probity and professional development have not yet been fully addressed by the medical profession.

Potential impact on professional development

Trainees identified that reflection on near-misses or critical incidents, usually in the form of a significant event analysis, provided particular and significant potential for learning and professional development, supporting previous literature describing the transformative potential of reflection (Sandars 2009). It has been suggested that the use of reflection for the purposes of assessment can lead to strategic responses (Hargreaves 2004; Hobbs 2007), thereby devaluing reflection as a form of professional development (Ng et al. 2015). However, much of the previous research is based on students and professionals submitting their reflective writing as an assignment to be marked.

It would be assumed that reflection in the context of a formative e-portfolio would be less likely to suffer these negative effects, but the findings from this study suggest that trainees felt that their reflections were not only being used to assess them in a professional capacity, but that they might also be used to make judgements about their character in a high stakes legal context. The requirement to reveal their ‘internal monologue’ to others was felt to be intrusive and presented a significant barrier to engagement, which supports previous research findings in this area (Henderson et al. 2003). This detrimental effect on lifelong learning through reflection associated with high stakes surveillance has previously been described (Hodges 2015).

Perceived challenges for international medical graduates

One particular group of trainees who were identified by trainers as disproportionately affected by the negative consequences of reflection were IMGs. Consistent with previous findings, the IMGs in this study self-identified as being less proficient at the practice of reflection due to their previous experiences of education (Pilotto et al. 2007; Hashim 2017). As such, they valued feedback about their reflective entries and often sought reassurance and assistance from both their peers and supervisors. Their reflective writing often focused on facts and details rather than engagement in a deeper reflection and could therefore leave them more vulnerable when considering reflection in a medicolegal context. Experiences of IMGs suggest that a lack of support can make trainees feel marginalised and at risk (Slowther et al. 2012). This is not only reflected in the data but also appears to have been heightened following the Bawa-Garba case, with some IMG trainees going so far as to reconsider their residence in the UK.

Requirement for further guidance

Guidance from the Academy of Medical Royal Colleges published following the Bawa-Garba case stated that is an essential requirement to ‘participate openly and meaningfully with the appraisal process by continuing to use e-Portfolios for genuine and detailed reflection that adds value to learning’ (AoMRC 2016). ‘The Reflective Practitioner’, published jointly by the GMC and AoMRC in 2018, makes it clear that reflective entries can be requested by a court, or that a doctor can choose to provide them as insight into their practice as part of a GMC investigation (AoMRC et al. 2018). Rather than offering reassurances regarding confidentiality, the guidance provided is that clinical information should be anonymised, and that reflections should capture learning outcomes rather than the ‘full details of an experience’. It is unlikely that this publication will allay the fears expressed by trainees, and such guidance could be considered counterintuitive when considering openness is stated as a pre-requisite for reflection by the same institution.

Despite the publication of the above guidance, all of the trainers interviewed felt they had not had sufficient reassurance about the confidentiality of e-portfolio reflective entries and were therefore unable to give trainees the reassurance they needed. Trainers described adapting the advice they gave trainees about the content and approach to their reflections as they too were fearful about the confidentiality of the entries. Trainees also expressed concerns about the lack of guidance, perhaps expecting that this would come directly from the Royal College of General Practitioners (RCGP) rather than the AoMRC. The trainees also described significant reservations about how the GMC had handled the case, describing their actions as ‘shocking’ and ‘aggressive’, but more importantly expressing a loss of trust in this important regulatory organisation.

Conclusion

Reflection is an essential tool for developing the skills required for managing difficult, complex and challenging situations encountered in all areas of medicine. In addition, self awareness and the ability to admit and learn from mistakes is seen as a measure of professional integrity. The Bawa-Garba case truly rocked the UK medical profession, but as yet the consequences have not been fully acknowledged. Following the Bawa-Garba case, trainees are reluctant to engage in reflection, especially that which involves mistakes or near misses, for fear of jeopardising their future careers. Trainers have also adapted the advice offered to trainees about the content and approach to their reflective entries with a view to reducing the risks of self-incrimination. IMGs have been disproportionately affected, highlighted by their trainers as at risk of the medico-legal consequences of reflection, possibly due to lack of previous exposure to reflection as a form of learning and professional development.

The impact of the Bawa-Garba case also has implications for the wider international community where reflection is increasingly used for medical education, postgraduate training and continuous professional development. Although the benefits of reflection are often described, the potential negative effects are less well understood (Mann et al. 2009) but must be considered so that appropriate safeguards are in place, especially when requiring health professionals to engage in ‘reflection as confession’ (Hodges 2015) as regards their mistakes. Although many negative effects might be assumed to arise from the process of reflection itself, this case highlights the importance of external sources; the actions of regulatory bodies and reporting in the media, both of which have the potential for an unintended and undesirable impact on important training strategies. Support and guidance from governing bodies are required for both trainees and their trainers if reflection is to retain its value for professional development, as otherwise the reflective portfolio is reduced to an ‘instrument of accountability’.

Glossary

Reflection: Is a metacognitive process including connecting with feelings that occurs before, during, and after situations with the purpose of developing greater awareness and understanding of self, other, and situation, so that future encounters with the situation including ways of being, relating, and doing are informed from previous encounters.

Wald HS. 2015. Refining a definition of reflection for the being as well as doing the work of a physician. Med Teach. 37(7):696–699

Significant event analysis: Is a qualitative method of clinical audit that is reportedly based on a synthesis of traditional case review and the research principles of the critical incident technique. Application of the technique should involve an in-depth, structured analysis of an event identified to be ‘significant’ by a health care team. Mostly this occurs when care is suboptimal, although excellent health care practice can also be identified and shared.

Bowie P, Pope L, Lough M. 2008. A review of the current evidence base for significant event analysis. J Eval Clin Practice. 14(4):520–536.

Acknowledgments

Authors thank Caroline Mitchell for her advice and support.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Laura Emery

Laura Emery, MBChB, MEd, is an Academic Clinical Fellow in General Practice.

Ben Jackson

Ben Jackson, BSc (Hons), MBBS, MRCP, FRCGP, MMedEd, is a GP partner and Director of Primary Care Teaching.

Tim Herrick

Tim Herrick, BA, PCHE, MA, MEd, PhD, is a Senior University Teacher in the School of Education.