Demonstrating reflection

Sometimes medical students and doctors may want to discuss or write down their reflections, or may be required to as part of their education, training and development.

Documenting reflective thinking

Reflecting helps an individual to challenge assumptions and consider opportunities for improvement.

Developing the capacity to reflect should focus on the reflective process and how to use it productively rather than on a specific number or type of reflective notes.

Engagement in reflection can be demonstrated in different ways, depending on career stage.

Medical students

A medical student, by the time they graduate, must be able to:

  • explain and demonstrate the importance of engagement with revalidation, including maintaining a professional development portfolio which includes evidence of reflection’ [8].
  • develop a range of coping strategies, such as reflection’ to demonstrate awareness of the importance of their personal physical and mental wellbeing [9].

This skill is often developed by writing structured reflections, commonly with constructive feedback. These are used as part of the evidence that certain curricular outcomes have been met.

Each medical school will have more detailed guidance explaining how the outcomes can be met for their own curriculum.

The opportunity to reflect in practical and clinical settings is also beneficial.

Doctors in training

Doctors in training, as part of their generic professional capabilities, must demonstrate ‘an ability to learn from and reflect on your professional practice and clinical outcomes’ [10]. This is part of the revalidation requirements for doctors in training.

Doctors in training should discuss the experiences they are planning to reflect on, or have already reflected on, with their clinical and educational supervisors. Discussion assists with the learning aspect of the reflective process to make it more meaningful. It also helps to demonstrate engagement in reflective thinking as an educational and professional tool.

Doctors in training should include insights gained and any changes made to practice in their learning portfolio. Supervisors should confirm in the learning portfolio that the experience has been discussed, and agree appropriate learning outcomes and what actions are planned.

Sharing original, non-anonymised information with supervisors is important, but factual details should not be recorded in the learning portfolio.

The Gold Guide (guidance for postgraduate specialty training in the UK) suggests that educational supervisors should assist in developing the skills of self-reflection and self-appraisal that will be needed throughout a professional career [11].

Self-reflective learning logs may be reviewed as part of the Annual Review of Competence Progression (ARCP) process [12]. These should not contain the full details of experiences or events – the focus should be on learning outcomes and action plans.

Doctors engaging in revalidation and appraisal

Revalidation requires all licensed doctors to participate in regular appraisals that consider information drawn from their whole practice. Our Guidance on supporting information for appraisal and revalidation (overarching principlesexplains that reflection is a core requirement for revalidation. It describes how to reflect on learning and development as part of the annual whole practice appraisal [13]. Doctors in training will demonstrate this by meeting the requirements for their ARCP.

Responsible Officers will normally take account of discussions and reflections considered at annual appraisals or with a doctor’s supervisors, when they come to consider their recommendation about the doctor’s revalidation.

A doctor should discuss the experiences they have reflected on with their appraiser, and maintain a note of these discussions. The doctor may be asked to record these in an online appraisal or learning portfolio system approved by their organisation. These notes should focus on the learning identified and any planned actions arising from their reflections. Factual details should not be recorded in appraisal or learning portfolios.

Appraisals should also be used to reflect on the most important things learned or changed over the past year. Responsible Officers and education providers should consider what support is necessary for supervisors and appraisers to help them develop skills in evaluating the quality of reflection.

Anonymising details in reflection

Anonymised information will usually be sufficient for all purposes other than the direct care of the patient, so should be used wherever possible in reflection.

The Information Commissioner’s Office considers data to be anonymised if it does not itself identify any individual, and if it is unlikely to allow any individual to be identified through its combination with other data. Simply removing the patient’s name, age, address or other personal identifiers is unlikely to be enough to anonymise information to this standard [14]. Our guidance Confidentiality: good practice in handling patient information supports how to do this.

Our guidance Confidentiality: disclosing information for education and training purposes gives advice to doctors on anonymising and managing personal data in training records, including when it can’t be anonymised [15]. The same principles apply to reflective notes.

Documenting reflections is not the same as reporting serious incidents

Reflecting on the learning resulting from a significant event or serious incident is an important part of continuous improvement and a requirement of medical education and revalidation. Reflection cannot, however, substitute or override other processes that are necessary to discuss, record and escalate significant events and serious incidents. See our Guidance on supporting information for appraisal and revalidation (significant events) for details about reflecting on significant events [16]. Factual details should not be recorded in reflective discussions but elsewhere, in accordance with each organisation’s relevant policies.

Where there are concerns or questions about the content of reflection, the advice of a supervisor or appraiser should be sought as to whether the information is appropriate. The purpose of the reflection is to indicate learning and, where appropriate, future plans.

The Academy of Medical Royal Colleges’ Guidance for entering information on e-Portfolios recommends that doctors involved in a serious incident should ‘set out the narrative on paper immediately so that the events are recorded while still fresh in your mind, but formally documented reflection is probably better done after some consideration [17].

Being open and honest with patients

All doctors have a professional duty to be open and honest with patients and those close to them where something goes wrong. See the guidance Openness and honesty when things go wrong: the professional duty of candour [18]. Medical students are expected to follow similar advice in Achieving good medical practice [19].

All members of the healthcare team should have opportunities to reflect on and discuss what has happened openly and honestly when things go wrong in a supportive and confidential setting. This is different to an individual’s personal reflections about, and learning from, the incident and what actions they plan to take, but represents a vital aspect of systematic and organisational development.