GMC Advocates Safe Reflective Practice

Peter Russell

September 12, 2018

Reflective notes written by doctors should avoid a full discussion of cases, and factual details should be recorded elsewhere, new guidance on the practice says.

Published by the General Medical Council, the Academy of Medical Royal Colleges, the Conference of Postgraduate Medical Deans, and the Medical Schools Council, it sets out key points and principles of reflection.

The guidance has been developed in response to requests from doctors for clearer information on what is meant by reflective practice and for advice on how to use the technique recommended for healthcare professionals to review their actions and engage in a process of continuous learning.

It also follows the controversial Bawa-Garba case, which severely dented trust between the medical profession and the General Medical Council (GMC). The proceedings prompted widespread concerns in the medical community about whether reflective practice notes might be used against health professionals in medical negligence cases.

The Bawa-Garba Case

Dr Hadiza Bawa-Garba was convicted of gross medical negligence (GMN), and later struck off the medical register after a High Court appeal by the GMC against a one-year suspension imposed by the Medical Practitioners Tribunal Service (MPTS).

Dr Bawa-Garba was found guilty in 2015 of GMN over the death at Leicester Royal Infirmary of 6-year-old Jack Adcock in 2011.

The decision to remove Dr Bawa-Garba from the medical register was overturned last month by the Court of Appeal, which ruled that the High Court had been wrong to interfere with the decision of the MPT.

At the time, the British Medical Association (BMA) responded by saying that the GMC had lost the confidence of the medical profession in its role as a regulator.

Commenting on the new guidance, Prof Colin Melville, director of education and standards at the GMC, said: "Reflecting on experiences, both good and bad, is hugely important. The GMC doesn't ask doctors for reflective notes to investigate concerns; in fact we have called for those notes to be given legal protection.

"However, we know there is some uncertainty around reflection, and this new guidance provides practical support to help doctors and medical students."

Reflective Notes and the Law

The guidance makes clear that reflective notes, included in learning portfolios or for revalidation or continuing professional development purposes, are not subject to legal privilege. As such, "disclosure of these documents might be requested by a court if they are considered relevant".

It advises that notes should be anonymised wherever possible and information should only be disclosed to a court when needed, required by law, or when it is relevant to proceedings.

Doctors should seek advice from their employer, legal adviser, medical defence organisation, or professional association in cases where reflective notes are requested, the guidance says.

The main points are that:

  • Reflection is personal and there is no one way to reflect

  • Having time to reflect on both positive and negative experiences – and being supported to reflect – is important for individual wellbeing and development

  • Group reflection often leads to ideas or actions that can improve patient care

  • Healthcare teams should have opportunities to reflect and discuss openly and honestly what has happened when things go wrong

  • A reflective note does not need to capture full details of an experience – it should capture learning outcomes and future plans

  • Reflection should not substitute or override other processes that are necessary to record, escalate or discuss significant events and serious incidents

  • When keeping a note, the information should be anonymised as far as possible

  • The GMC does not ask a doctor to provide their reflective notes in order to investigate a concern about them, but they can choose to offer them as evidence of insight into their practice

  • As reflective notes can currently be required by a court, they should focus on the learning rather than a full discussion of the case or situation, and factual details should be recorded elsewhere

  • Tutors, supervisors, appraisers, and employers should support time and space for individual and group reflection

'Learning, Not Blame': BMA

The BMA welcomed the guidance but said it still wanted to see full legal protection for reflective practice notes. Dr Jeeves Wijesuriya, chair of the BMA's junior doctors' committee, said: "The focus must be on learning, rather than blame, and so clarity that specific factual details are not needed to improve care in the future is welcome.

"Reflection is a vital tool in all doctors' professional development and allows them to look back at events, good and bad, so they can improve their practice and the care they give to patients. 

"We hope this guidance and the accompanying toolkit will give them the confidence to do so safely, securely and effectively."

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: "Reflective practice is essential in order to facilitate doctors’ learning and improvement in practice, and for our patients' safety.

"Recent events have caused a lot of anxiety amongst all doctors, and particularly trainees, about how and when to reflect appropriately and effectively – and we hope this guidance goes someway to alleviate that."


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