2018 has not been the best year for reflection. Despite reassurances from numerous bodies such as the GMC & MPS, junior doctors around the country are abandoning formal written reflection, largely supported by their consultants. Whilst most forums have focused on rota gaps, support networks and legal concerns, there has been limited in depth discussion about how we reflect, and why we reflect.

I recently took part in a Twitter debate on this very issue on TASME’s #MedEdForum on ‘how can we rescue reflection’. From the outset, it was clear that feelings were very strong, on the background of recent events. Numerous people stood aghast, asking why we should save reflection at all. I couldn’t help but imagine the Pythonesque nature of the question: ‘what has reflection ever done for us?’

An important step in answering this question was kindly provided by Dr Colin Melville Director of Education and Standards at the GMC, who wondered whether reflection was a skill, a behavior or a form of knowledge. He suggested that it was a ‘metacognitive process, leading to affective change’: in essence it’s not about how you reflect, it’s about being a reflective practitioner.

Those who question reflection, and those who, like me, loved Jason Walker’s article on ‘Reflection Made Simple’, likely do not doubt the impact of good reflection. Instead there is disquiet on its practical application, and specifically how it is recorded. These concerns are not without merit. In an age of online portfolios and appraisal, anything and everything is being used to ‘score’ doctors. This is as if there is some way that ‘good, safe practice’ could be measured in a binary way. Reflection sits uncomfortably in the assessment process in training. Effective reflection takes time, effort and willingness to question oneself (Aronson, 2010): can a portfolio really capture this?

The #MedEdForum trainees argued that reflection has no place in assessment. Perhaps instead assessors should ask practitioners to demonstrate how reflection has informed or changed their practice. Furthermore, in the context of the contentious legal environment, must this take a written form? Surely the real art of reflection is being challenged in conversation, questioning your decision-making alongside a more-experienced peer?

So what has reflection ever done for us? Done well, reflection should facilitate support from peers and supervisors, not used as a tick- box exercise. In this way it facilitates positive teamwork and mentoring. Reflecting has been demonstrated to advance practice and promote development as both clinicians and individuals(Sandars, 2009). If we all practice what we preach, we shouldn’t require a reflection generator, a tool to jump through hoops. Perhaps it’s time to reflect on our mandatory portfolios, on the format of our appraisals and on compulsory reflections. I’m off to run that reflection through the generator to see what happens…

References

Aronson, L. (2010). Twelve tips for teaching reflection at all levels of medical education. Medical Teacher, 33(3), pp.200-205.

Sandars, J. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), pp.685-695.