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.