Reflection

All doctors at every level are expected to incorporate reflection as part of their everyday surgical practice.  In future all doctors at every level will also be expected to capture such reflection in writing to:

• Drive learning
• Demonstrate proficiency

in previously minimally tested areas eg judgement and professionalism. 

Reflection can refer to a number of different processes from thinking back over events on the way home from work to formal journals to drive learning and assessment.

Effective reflection is of course reliant on accurate self assessment.  It is well recognised that the least able trainees are the least able to accurately self assess. (Coltart et al 2008). Such shortfalls in competence can be identified and managed sooner rather than later.

Interestingly, more junior trainees are engaging better with the process, perhaps because reflection is so firmly embedded in the Foundation e-Portfolio (Goodyear et al  2013).

The best place to start is with an event that captures your imagination: an clinical event that you found challenging, unexpected, rich in learning or unusual.  Once you have realised how easy reflective writing can be and how valuable the process is, you should identify the parts of the curriculum where you lack evidence in your portfolio. You can then start to fill those gaps with reflective writing.  It’s easy to keep on putting it off, but it’s worth starting now.

Somewhere accessible and easy to use FOR YOU

• Embedded within one of the ISCP workplace based assessment tools: in the text boxes.  The reflective case based discussion tool is designed especially for this
• In the “My Journal” section of the ISCP portfolio.  Just call the Curriculum helpdesk if you don’t have enough space
• Within your own portfolio
• You can store pieces of reflection writing for your eyes only or provide access for others if you wish.

You aren’t alone if you consider reflective writing to be irrelevant, fluffy or even a nuisance or a waste of time.  It may be that you won’t ever really enjoy it… However you might not have enjoyed biomechanics or pathology, but you still need to learn about it to be a competent surgeon.  It is a clinically relevant skill you can improve and use throughout your career if you choose to. It is also, though, a GMC requirement for doctors to reflect regularly on their standards of medical practice (2006), and to be able to demonstrate it.

Describe the event in less than 200 words, which can be a challenge but really helps you focus your mind on the most important aspects of the clinical situation.

Consider your role and what you did:

• What did you do well?
• What could you do differently next time to achieve a better outcome?

Be as balanced as you can be with this section.  You don’t need to identify everything, just a couple of the most important elements of each.

What have you learned about yourself as a surgeon?  Consider linking this to your job specification or curriculum if you are a trainee.
What is the next step of development in this area for you?  If you have found a learning gap, it is often tempting to plan to attend a course to fill it. Consider other more effective and efficient options. 

Reflection is considered to be an integral part of being a professional of any kind, and is a vital way of learning from surgical experiences.  If you are unable to critical analyse what you do and improve your practice as a result, you are not safe to practice independently

You will find it increasingly difficult to meet requirements to practice: CCT or revalidation, if you are unable to demonstrate an ability to integrate reflection into your practice.

Some surgical specialties profess to focus more on technical skills than the more abstract judgements required by physicians.  However, Dr. Frank Spencer in 1978, said “A skillfully performed operation is about 75% decision making and 25% dexterity”. Skilled decision-making is underpinned by sophisticated reflection. 

You don’t have to write it down.  You could video or audio record your reflections, as long as your supervisor can access and provide feedback easily, and documentation is available in a portfolio.  If you stop after reflecting and omit a written record, you sacrifice the opportunity to demonstrate: your ability to reflect, along with other non technical skills you will be required to show evidence of.
 

It’s possible, so it is important to anonymise any writing.  You may consider keeping some sensitive events for your eyes only.  They can still be stored in your portfolio but only you or whoever has your permission, can see it.  Take care to remove any patient, colleague or institution identifiers.