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Managing the threat to reflective writing
  1. John Launer
  1. Correspondence to Dr John Launer, Associate Editor, Postgraduate Medical Journal, London, UK; johnlauner{at}aol.com

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Reflective writing in medical education is facing a significant threat. This has resulted from a tragic and very high profile case in the UK involving the death of a child.1 Many readers will already be familiar with the case of Jack Adcock, a 6-year-old boy with Down’s syndrome and cardiac problems who died of sepsis. They are also likely to know the name of the paediatric trainee who cared for him, Dr Hadiza Bawa-Garba. The main details of the case are that Dr Bawa-Garba made some individual errors in caring for Jack, in a wider context that also involved mistakes and misunderstandings by others, as well as multiple systems failings and staff shortages. She was subsequently found guilty of manslaughter through gross negligence and given a suspended prison sentence. Initially she was also suspended from the medical register for 1 year but was then struck off following an intervention by the General Medical Council (although this is pending an appeal). These judgements were welcomed by Jack’s family and sections of the British press, but have led to a range of serious concerns among doctors, particularly those in training.

One of these concerns relates to the capacity of courts and juries to make fair judgements about highly complex clinical events.2 Another is the legal risk that individual doctors face when working within depleted or even dysfunctional work settings, as they increasingly do in the UK. However, the reason that reflective writing has come under threat is because some reflections written down in the days following Jack’s death may have contributed in some way to Dr Bawa-Garba’s conviction and erasure. Medical trainees are now questioning whether it is still safe for them to enter reflections on the electronic learning portfolios they keep during the course of their training.3 Similarly, a representative group of general practitioners has called for doctors to disengage from written reflections in their submissions for annual appraisal.4

From an educational point of view, this is unfortunate. Although reflective writing gives rise to mixed feelings among some doctors, it is widely regarded as an effective way of promoting learning and reflective practice.5 It allows practitioners to step back and consider complex or troubling occurrences objectively and analytically. As such, it is particularly useful in relation to critical incidents, significant events and patient complaints, and as a trigger for quality improvement. It would be a sad irony if the case of a child’s death led to the decline of a professional practice that could prevent further deaths.

Significant anxieties

Written reflections are mandatory in the UK for annual reviews in postgraduate training and as part of the process of revalidation for all doctors, so a mass boycott appears unlikely. At the same time, many practitioners now appear to feel nervous about continuing to write down their reflections for others to read.6 They do not seem adequately reassured by current official guidance about how to record their reflections appropriately.7 The case has also had international publicity, so colleagues elsewhere may also be considering how to balance the benefits and risks of written reflections, within their own legal and regulatory systems.

As a starting point, it is worth noting exactly which written reflections played a part in the proceedings against Dr Bawa-Garba and how they did so. These were not in fact taken directly from her learning portfolio, as has been inaccurately reported in some places. Instead, they evidently appeared in a ‘trainee encounter’ form filled in by her supervisor. This apparently included his own account of her reflections as well as some notes by her.8 He reportedly signed it but she did not, as she disagreed with its contents, although he subsequently appended it to his witness statement. The form in question was never actually cited in court or the subject of cross-examination—although it was presumably seen by the prosecution service and by lawyers on both sides and may have informed their thinking.

The significance of these events is twofold. First, as this case demonstrates, anything that a doctor has recorded anywhere about themselves or any of their colleagues can potentially end up as part of an investigation, through a number of possible routes. In that respect, there is nothing special about learning portfolio entries or appraisal submissions. As the ethicist and lawyer Daniel Sokol has emphasised, ‘reflective pieces are not beyond the reach of lawyers’, whatever their source.9 In spite of this, the case also demonstrates that, in reality, reflections of any kind are most unlikely to be crucial in determining guilt. If they are used at all, they are far more likely to figure as just one part of a mass of corroborating or contradictory statements and evidence, leading eventually to a judgement. (In Dr Bawa-Garba’s case, the court did not order her at any stage to produce her reflections, and there is apparently no case of any British court ever doing so. Paradoxically, when doctors have chosen to use their reflections as part of their defence in GMC hearings, this has often led to discontinuance of proceedings.)10 In sum, nothing has changed about the law itself or the way it is being practised, except that there was an eventual outcome in this case that seemed exceptionally harsh to many doctors.

Sustaining reflective practice

If this is the case, it may be worth moving the focus of attention elsewhere. Rather than dwelling on the remote possibility that a single reflection, written down in good faith, might unexpectedly lead to a professional and personal disaster, it might be more useful to ask how we can sustain reflective practice in a climate that has become affected by a sense of injustice, loss of trust and an intensification of fear.

In the first instance, there are some sensible practical measures that educators have been advised to take. For example, as Sokol has also suggested, supervisors might now choose to move their emphasis away from written reflections, and more towards longer and more frequent coaching-style conversations with trainees. That is no bad thing, and probably ought to be happening in any case. The Royal College of Paediatrics and Child Health has advised trainees that any written reflections should be kept brief, anonymised, and focused on feelings, analysis and evaluation. They have also told trainees to check with an experienced colleague before writing anything about a case that might be contentious or lead to an investigation.11 The crucial details of a case will anyway be available for direct scrutiny as part of the patient’s medical record, and good medical practice dictates that this should include everything that might be relevant to a future review, whether clinical or legal.

Beyond this, it appears that there will be a government review of how judicial trials are conducted in cases of alleged medical negligence in the UK,12 and a GMC review of reflective practice and its associated risks.13 However, such processes can take time, and sometimes end in ambiguous or unsatisfactory compromises.

Although concerns about the application of the law have understandably become heightened, I suggest that the task for medical educators remains fundamentally the same. Seeing patients inevitably involves examining the mismatch between what is ideal, and the messy and occasionally catastrophic realities of what actually happens. Reflective practice, along with activities like supervision and appraisal that are designed to support it, has always involved considering the multiple factors that determine our actions and the consequent risks. These include the institutional, economic, social, political and legal pressures we face, as well as the technical and emotional ones. When some of those pressures become greater, as they undoubtedly are in the UK, it makes the need for reflection with trainees and colleagues more important, not less. If reflective writing has itself become the focus of people’s anxiety, educators ought to have the knowledge and skills to manage this in the same way as everything else: reflectively.

References

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Footnotes

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Author note This article represents my own views and has been written in a personal capacity as an associate editor of the Postgraduate Medical Journal, not in any of my employed roles in other institutions.

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