Reflective discussion with appraiser


In this example, a doctor uses the 'What, So what, Now what' template to note down their thoughts on an experience that challenged them, and holds a reflective discussion with their appraiser.

Image shows an equally split pie chart with the headings:- what (thinking), so what (feeling) and now what (doing).

The reflection

What? (thinking)

Focuses on thoughts at the time of an experience. It explores how those may have impacted on actions and feelings and on what has been learned.

What was I thinking when I took the actions or made the decision that I did? What do I think now?
Image reads "what (thinking)"

A middle-aged patient with a lifelong learning disability was brought in by his family as he had recently stopped receiving Disability Living Allowance (DLA) and had applied for the Personal Independence Payment (PIP). The assessor had awarded him zero points and made some comments in the summary backing up the decision that had upset the family.

I thought the comments reflected a profound lack of understanding of intellectual disabilities and that the decision was entirely inappropriate. My patient has no physical disabilities, but he is incapable of feeding himself appropriately on his own and needs help and supervision with daily living.

I thought that I could help the family by writing in support of an appeal, as I know that a very high proportion of PIP assessments get appealed and are successful.

So what? (feeling)

Involves considering the significance of what happened as well as the values and feelings that may influence future learning or actions.

So what did I feel at the time of the experience? So what do I feel now?
Image reads "so what (feeling)"

I felt very frustrated on my patient's behalf when I heard the story and read the report.

I harnessed that emotion to write a very focused response going through each of the PIP criteria in respect of my patient, and reached a score of more than 50 points. I pointed out that there was a very big discrepancy between over 50 points and zero and asked that the assessor be made aware of my comments so that there would be some learning from the case.

Now what? (doing)

Looks at learning from the experience, identifying future actions, reflection on those actions, and how to use these to develop further.

Now what can I learn from or do differently next time? Now what will I do next?
Image reads "now what (doing)"

I have learned a lot about the PIP assessment process, the various criteria and how many points are awarded for each by working through the appeal form.

I have developed a template for myself to use when I write in support of a PIP application. I am aware that in the past I may have described what my patient can do in terms that are too vague to award points - I will be more effective on behalf of all my patients because of what I have learned from this case.

Frustration is not always a negative emotion - I have recognised that I can use it to energise me. I really felt productive when I was writing my appeal response and very pleased with the result.

I already had the habit of leaving things for 24 hours and re-reading them, especially when I felt strong emotion. I was delighted when I re-read this that I did not feel the need to tone it down (or up) or change any wording.

The discussion

Dr EE has a reflective discussion with the appraiser (Dr ER)

ER
Doctor discussing

Your reflection on your patient's PIP application was very interesting. Tell me more.

EE
Doctor explaining

It feels unjust when system changes backfire on my patients.

My patient looks as if there is nothing wrong with him but he will never be able to lead an independent life because of the brain damage just after he was born. I'm still frustrated by it.

ER
Doctor discussing

(echoing) You really are frustrated - and you seemed to imply that was useful to you.

EE
Doctor explaining

Yes, when I came to reflect on it, I realised that how this incident made me feel was a powerful energiser for action. I have rarely produced a PIP appeal report as quickly or effectively. I really felt that every word came out how I wanted it to.

ER
Doctor discussing

Do you have a strategy to avoid firing off e-mails or letters in haste?

EE
Doctor explaining

I do - I always type my response up and then leave it for 24 hours to re-read it once I've had time to reflect on it. If I am unsure, I ask one of my colleagues to 'read it for tone' and sense-check what I am saying. In this case, I was even more pleased with myself when I re-read it, because it said exactly what I wanted professionally and succinctly.

ER
Doctor discussing

That sounds very satisfying (affirmation).

EE
Doctor explaining

It was. It's even more satisfying because I had a phone consultation booked in last week with this patient's mother. She wanted to let me know that the appeal has been successful and my patient has been awarded the full backdated benefit. I was thrilled for them - and pleased with myself.

ER
Doctor discussing

So what is the main thing you have learned from this?

EE
Doctor explaining

I think that feeling that something is unjust can be harnessed for good things.

ER
Doctor discussing

Now what will you do differently as a result?

EE
Doctor explaining

I've set up a PIP appeal file on my private desktop to keep the guidance notes and some key phrases I used. I am more efficient now when I get an appeal. This discussion has also reminded me of the importance of leaving anything written in haste and emotion and re-reading it later, or even getting someone else to read it. I have discussed it with my colleagues at our regular learning events analysis meeting.

ER
Doctor discussing

OK. So, what did you share with them?

EE
Doctor explaining

The data file so that they can also be quicker when they have appeals to support.

ER
Doctor discussing

That sounds really helpful (affirmation).

The appraiser's notes

The appraiser enters a summary note of the discussion in the appraisal documentation

'Dr EE had chosen to reflect on a case where they developed a template to use when writing in support of a Personal Independence Payment (PIP) application, to help applications get through the assessment process. In discussion, it was clear that although frustration can be an uncomfortable emotion, it can also create energy and lead to positive action and change. Dr EE also reflected on the importance of allowing time before sending e-mails or letters in haste and so the discussion and learning went beyond the trigger incident. Sharing the learning points and future actions of the case with colleagues is an example of good practice.'

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