How did reflective practice become less like a mirror and more like a hammer?

#GPFUQ 139 How do you learn most from your experience? Some form of reflective practice usually improves learning. In modern times Donald Schön in The Reflective Practitioner (1983) promoted learning through reflection. Different writers suggest different models that can structure your reflection. The simplest is to ask yourself three questions: What? So What? What now?

#GPFUQ 140 How did reflective practice become less like a mirror and more like a hammer? If the only tool you have is a hammer then everything starts to look like a nail. Reflection has been seized as an essential tool for appraisers and written reflection the hammer to nail all learning when no theory, evidence or rule supports this use.

The GMC’s ‘Ready for revalidation - Supporting information for appraisal and revalidation’ says that good medical practice requires you to reflect on your practice and whether you are working to the relevant standards. When using supporting information in appraisal you should, through reflection and discussion at appraisal, have demonstrated your practice against all the attributes outlined in the GMC guidance ‘Good medical practice Framework for appraisal and revalidation’. This will make it easier for your appraiser to complete your appraisal and for your Responsible Officer to make a recommendation to the GMC about your revalidation. It is not necessary to structure the appraisal formally around the GMP Framework, or to map supporting information directly against each attribute. However, some doctors may prefer to do this and some appraisers may find it useful to structure the appraisal interview in this way. In discussing your supporting information, your appraiser will be interested in what you did with the information and your reflections on that information, not simply that you collected it and maintained it in a portfolio. Your appraiser will want to know what you think the supporting information says about your practice and how you intend to develop or modify your practice as a result of that reflection. For example, how you responded to a significant event and any changes to your work as a result, rather than the number of significant events that occurred.

The RCGP Guide to Revalidation v 8 Sept 2013 says you need to ensure that each of your annual appraisals covers the requirements for revalidation, and that you are sharing the required supporting information with your appraiser.

Your appraiser is key to your revalidation. Your appraiser reviews your supporting information with you and offers your responsible officer reassurance that your supporting information and your reflection on it are appropriate.

Personal Development Plan - It is very important that you reflect on the objective, the development achieved and any reasons for not achieving the objective. This reflection is an important attribute of your fitness to practise.

In summary you do need to be able to reflect on your practice with your appraiser but you don’t need to write reflective statements about everything that you record.

#GPFUQ 141 What sort of reflection aids learning? The theory is that you compare your current performance with desired competencies - by self assessment, peer assessment, or objective testing (see #GPFUQ 142)– then plan your education accordingly. Reflection on action is an aspect of experiential learning and involves thinking back to some performance and identifying what was done well and what could have been done better. The latter category indicates learning needs. Reflection in action involves thinking about actual performance at the time that it occurs and requires some means of recording identified strengths and weaknesses at the time. Self assessment by diaries, journals, log books, weekly reviews are an extension of reflection that involves keeping a diary or other account of experiences. However most people only write nearer the time of their review than the time of the activity being recorded.

#GPFUQ 142 What sorts of activity are best used for reflection? Feedback fuels reflection.

Peer review: involves doctors assessing each other's practice and giving feedback and perhaps advice about possible education, training, or organisational strategies to improve performance. There are five main types of peer review internal, external, informal, multidisciplinary, and physician assessment. The last is the most formal, involving rating forms completed by nominated colleagues, and has validity, reliability, and acceptability.

Observation: In more formal settings doctors can be observed performing specific tasks that can be rated by an observer, either according to known criteria or more informally. The results are discussed, and learning needs are identified. The observer can be a peer, a senior, or a disinterested person if the ratings are sufficiently objective or overlap with the observer's area of expertise (such as communication skills or management).

Critical incident review and significant event auditing; Although this technique is usually used to identify the competencies of a profession or for quality assurance, it can also be used on an individual basis to identify learning needs. The method involves individuals identifying and recording, say, one incident each week in which they feel they should have performed better, analysing the incident by its setting, exactly what occurred, and the outcome and why it was ineffective.

Practice review A routine review of notes, charts, prescribing, letters, requests, etc, can identify learning needs, especially if the format of looking at what is satisfactory and what leaves room for improvement is followed.

What is GP research?

#GPFUQ 134 Whats the difference between research, evaluation, and audit ? Research - generates new knowledge (see #GPFUQ 136). Evaluation - answers the question 'what standard does this service achieve?' Audit - answers the question 'Does this service reach the set standard?'

#GPFUQ 135 Whats the difference between innovation, improvement and invention? Innovation is doing something different and better and usually using a novel idea or method whilst improvement is doing the same thing better. Invention is the creation of the idea or method. 

#GPFUQ 136 What is GP research? Research finds out what we ought to do when the existing knowledge can’t give a clear answer. It’s the attempt to derive generalisable new knowledge by addressing clearly defined questions using systematic and rigorous methods. Clinical research is based primarily on patients or ex-patients and designed to answer a question about disease (aetiology, concomitants, diagnosis, prevention, outcome or treatment). There are two main types of research in primary care, commercial (or industry) and non-commercial (or academic). Non-commercial research is usually funded by the NHS, research councils, charities or grant giving bodies and covers a wide range of activities motivated by knowledge rather than commercial gain. Commercial research is usually funded by pharmaceutical companies undertaking clinical trials of new medicines.

#GPFUQ 137 What should be the research priorities in GP? Find the most effective ways to improve processes and outcomes, and reduce unnecessary interventions.

#GPFUQ 138 What is GP Educational research? This is like a forgotten Cinderella that is waiting a makeover and an invitation to the ball for improving quality of teaching and learning. Too many educational processes are based on the mistake of ‘trying to fill buckets’ with information rather than ‘lighting a fire’ of learning. The literature has too many studies that are observational, address only local questions, are small scale, repetitive, lack any theoretical basis, and do not build on the knowledge base. In planning a project it’s helpful to start by writing a ten sentence abstract of the completed project that includes the practical problem that you are trying to solve, the theoretical problem you are trying to solve (the theory should include an explanation a prediction and a testable hypothesis), the methodology (what data is needed, is there a defined outcome, where is the data obtained, how is it collected, how many subjects, how is the data recorded and stored), the analysis (how will the results be analysed) and the findings (what do you expect to find including the practical and theoretical implications).

Is a capacity crisis looming in NHS general practice?

#GPFUQ 127 Is a capacity crisis looming in NHS general practice? Like global warming all the signs suggest a crisis is coming (see #GPFUQ 128, 130)

#GPFUQ 128 Will there be enough GPs in the future? Not without a miracle. Patients visit their GPs more and bring more problems each time. In a balanced system about 50% of the doctors need to be GPs. Only about one third of junior doctors are being trained to be GPs. NHS workforce planning (see #GPFUQ 129) has failed to provide enough GPs for the growing demands of the population for health care and it needs to steer more doctors into GP careers. We know that general practice is the high volume low cost gateway to higher cost and lower volume secondary care and we should use primary care to soak up the most of the demand and manage most of the risk and then act as vigilant gatekeepers to the rest of the NHS. Increasing GP workload with a decreasing GP workforce will reduce effective gatekeeping and overwhelm secondary care.

#GPFUQ 129 Why is there a gap between health rhetoric and reality?

The politicians must always be seen to promise and NHS managers must always be seen to plan a better service. But without better promises and plans that follow the rules of continuous quality improvement (see #GPFUQ 18), or some luck, a better service doesn’t result.

#GPFUQ 130 Will we have the right sort of GP in the future? Are we training GPs who can and will want to work for their NHS patients for the next 30 years? The GP workforce is changing. There is a new attitude to professionalism that sees being a doctor as a lifestyle choice rather than a way of life. Broadly the new attitude values quality of work and leisure time more than the older values of service and endurance. The GPs we are training may not have the right mix of knowledge, skills, and attitudes needed to service the high demands in primary care and provide high quality general practice (see #GPFUQ 4). GP training currently concentrates on aims and ouputs, but neglects its outcomes and impact. If we have trained the new generation of GPs to need more time for each patient, be more risk averse, investigate more and also refer patients to secondary care more often then we may have trained them to feel more comfortable practising outside of the reality of NHS general practice. The newer cohorts of GPs will gradually lose their value to the NHS as efficient and effective GPs but find more reward as a concierge type non-NHS GPs. We are heading toward private GP work and different ways of providing primary healthcare for the masses.

#GPFUQ 131 Can we cope with so many GPs doing part time working? There are two main types of newly qualified GPs. The minority are those who want a traditional career path and want to work full time and to become partners. The majority are those who want to work part time as salaried GP and many are likely to have unavoidable career breaks for about 10 years. We don’t have any choice we have to cope with the workforce available. We do need to find new career options that balance the needs of part time workers, and their career breaks, with the needs of the patients, the employing practice and the NHS (see #GPFUQ 131). Practices must accommodate both full time and part time workers better. Part time GPs can be employed for 4 session (half days) over 3 days each week. By limiting them to 4 sessions the job is more attractive and family friendly to applicants, minimises the disruption if the GPs take career breaks, but create a stable 4 sessions job with a happy productive GP for 10 years and after that hopefully have either a reliable salaried GP or potential partner who can take on more sessions or more responsibilities in the practice.

#GPFUQ 132 If the only way to cope in the future is by doing things radically different, what does that mean? The leaders in each general practice have to be part of a collaborative learning culture (i.e. everyone is always asking and answering questions about what they do and why they we do it) making sure they are looking at current practice and actively addressing problems and making improvements in all of the following: building better teams, coordinating better care in the different settings (health, social care, community, home), increasing better self care of patients, providing better preventative health for the population and targeted ‘at risk’ groups.

#GPFUQ 133 Should medical schools recruit more men? We are moving from a male dominated profession to a female dominated profession. Arguably both are wrong and we need to recruit a more balanced workforce that reflects the sex and the ethnicity of the population. The NHS is the major employer of medical graduates and this should be part of NHS workforce planning discussion with the medical schools.

How often does a patient need to see a GP to review their care?

#GPFUQ 124 How often does a patient need to see a GP to review their care? It’s usually less often but sometimes it's more often. Many patients can get over serviced and are seen more often than needed whilst the ‘hard to reach patients’ remain underserviced.  There are different ways to bring about a change. Patients often know what they need, they just need to be told when they are due for something and help getting it scheduled. A simple way is to always ask the over serviced patient ‘When do you want to be seen next, and then ask gently why?’ If the reason for the next attendance can be handled just as well without a face to face consultation with the GP then the next face to face consultation can be postponed. Another way is for the GP to ask his/herself ‘What’s the longest time before the next face to face consultation is needed and why’ and stretch out the intervals between consultations. Similarly the hard to reach and under serviced patients needs to be asked what they want and give the GP permission to use more assertive outreach when needed to get them reviewed. 

#GPFUQ 125 How can GPs improve the way hospitals work?

Most hospitals are efficient and effective but some individuals and departments work less well or push parts of their work over into general practice. For example they may expect GPs to provide the following for their patients: sick notes for hospital procedures, patient transport requests, chasing up the delayed hospital appointment, to do or chase investigations ordered by secondary care, make referrals on behalf of hospital consultant teams because they think GPs can get them seen sooner, prescribe nutritional supplements advised by dieticians, re-referrals because the hospital can't police it's own ‘did not attend’ problems. If GPs do nothing then the problem just gets worse for everyone and the patients get involved in the frustrating hospital-GP game of ping-pong. 

Suggestions for action

·      Engage with hospitals so they have a simple process for feedback e.g. SMS text messaging, or email process to inform them of breaches of best conduct

·      Collect notifications of breaches and if nothing improves escalate the feedback to hospital management or the commissioner of services

·      Plan an in reach service regarding the care of patients in hospital. In many countries GPs visit patients in hospital; this is very popular with patients and we would have a lot to offer in terms of discharge planning, it is however foreign to UK hospital culture

·      Hospitals should stop seeing people after hospital outpatients to give them results. The consultant should send a copy of the letter / result directly to the patient unless there is an overwhelming reason not to.

·      Have a system for taking messages during surgeries from hospital doctors about patients if you don't know the patient then the message could be given to secretary instead.

·      Agree a process with hospital about misdirected letters - hospitals should realise the importance of writing back to the doctor who wrote to them!

·      Set up a local sponsor one consultant scheme. Improve collaborative working with hospital consultants  to provide greater collaborative working among GP and consultants, including communicating each others knowledge, skills, understanding and attitudes which may allow faster dissemination of better practices for joint working and patient care – a buddying/sponsoring system between a GP and a consultant. A GP works with one local consultant to help him/her provide the important information for GPs and patients and robust contact details.

• Have a local triage service for GP referrals before they get to secondary care. This ensure a roughly uniform criteria for referral, educates GPs and limits unnecessary referrals to secondary care

#GPFUQ 126 How do you rate yourself as a GP?  Probably incorrectly! If you think you are better than average then how many doctors do you know who are worse than you? We are always likely to rate ourselves above average. Your knowledge, skills and attitudes need constant refreshing. Your knowledge won’t keep much better than fish! Filling in knowledge gaps is not continuing professional development (CPD) or continuing medical education (CME), it’s the result of an established skill. CPD is acquiring new skills. If you were the pilot of a commercial jet you would check the weather at your destination before you tried to land; this is not discovering a new knowledge (i.e. the current weather) its an essential part of using the skill needed to land an airplane safely.  Keeping your knowledge up to date used to be like knowing the climate now it can feel like checking the weather forecast frequently

Suggestions for action

·           Have a simple system for keeping your knowledge reasonably up to date eg using memory prompts like Patients Unmet needs PUNs and Doctor Educational Needs DENS to remind yourself to check something or using the network of on line prompts and learning whilst your patient is with you.

·           Don’t pretend that poor quality sources of information are the same as useful knowledge eg Pharmaceutical representatives marketing information, Opinion based medicine.

·           Improve informed patient choice by increasing your understanding of evidence and Risk management. If patients know and understand the numbers needed to treat (NNT) and numbers needed to harm NNH they will make better choices about their care (and often decline care).

Why don’t GPs know and do everything?

#GPFUQ 121  Why don’t GPs know and do everything? Every week there is a media report that complains ‘GPs need to be better trained at what they need to do’. GP knowledge about specific but different conditions is deemed inadequate and an extra training programme recommended as the answer to most problems. This is the ‘why can’t a generalist be more like a specialist’ story. The story fails to accept that it’s impossible to train all GPs in everything or ever have enough specialists to see everyone, and it ignores the benefits of a duel system of primary care generalists and secondary care specialists (see #GPFUQ 98). General Practice can either be considered very easy because GPs don’t need to have a depth of knowledge about anything or very difficult because GPs need to know something about everything.  A patient kept agitating to be referred to a specific super specialist. On arrival at the super specialist clinic the specialist said to the patient ‘I just hope you’ve got what I treat! Each specialist deals just with only a very narrow area.  Someone (usually the GP) needs to have an broad overview and co-ordinate the care of the patient.  There can never be a defence for bad general practice but good general practice is not about knowing everything its about providing easy access to good quality advice and treatments at lower costs than all the alternatives.

#GPFUQ 122 If GPs don’t do the work – how will it get done? Nothing is impossible as long as you don’t have to do everything yourself. Delegation is not abdication. Many simple tasks can safely be done by others.

Practices are different in their organisation and how and to whom jobs will be delegated will vary according to circumstances.

Suggestions for action

Restructure the primary care team to enable patients first point of contact with practitioners to be the most appropriately trained to provide care. For example with minor musculoskeletal problems – get patients to book in to see a physiotherapist directly for anything that could be handled by physical therapy first.

Use administrative staff to sweat the interface with hospitals. For example arranging admissions to hospital ‘trying to admit someone to hospital’, chasing up hospital regarding appointments, results, clinic letters etc, Phone call tag – ‘repeated phone calls to get hold of people who can’t get hold of you’. Get your staff to arrange telephone appointments at specific times through direct phone lines

Stop doing things individually. Stop treating patients individually if its not needed. Consider more group sessions for education of new hypertensives, musculoskeletal problems, contraceptives.

Review and notify patients of routine investigation results automatically via online access to their records or email.

Stop routine follow ups, especially monitoring of stable patients

#GPFUQ 123 How can GPs cope with the overload of information? The information highway is too busy. There are too many unsorted, unsolicited and uninformative emails, guidelines and protocols that arrive each week. Too much information leads to fatigue and the emails being ignored.

Suggestions 

·               Practices should return unsolicited or unstructured medical email to the sender and ask for improvements (see below)

·               Non-urgent information should be sent ‘batched’ in a weekly or monthly email. The email should be structured with an informative title about its purpose, the intended audience followed by a one-line summary of each item with a hyperlink to more detailed information. The author of the document should be contactable, there should be an ability to give feedback about the information and to subscribe and unsubscribe from circulation lists

·               Practices have these waves of guidelines and protocols coming from different local and national NHS organisations and each practice needs to keep up to date by loading on its intranet. Instead a local centre (eg a CCG based webpage) could keep all these up to date and reduce the work for practices. All the healthcare and other organisations should load important information on their own websites so that GPs can link to relevant information rather than have to load a complete set of document on a practices intranet

·               Stop the constant changing of NHS websites addresses so that the weblinks get out of date.

·               Stop the invention of the wheel in each practice. For example if the Chief Medical officer writes a letter describing who should be offered a flu jab - they should include the appropriate READ or SNOWMED CT codes searchers for each GP clinical system

·               The RCGP should publish a template for best practice for the dissemination of information to practices