The tragic case of little Jack Adcock, which culminated in Dr Bawa-Garba being found guilty of manslaughter through gross negligence, has thrown the spotlight on reflective writing.
I’ve always been a strong advocate of the practice. It is the focus of my previous blog posts Detach or connect – a medical dilemma? and A prescription for being a better doctor. There are multiple benefits, including exploration of significant incidents and personal learning. It can also play a major part in developing patient connection with emotional control, as opposed to practicing with disconnection, and in developing sustainable resilience. Until recently, a large proportion of doctors who we explored this approach with on our courses found reflective practice very useful. There have always been some who resisted the idea. Often struggled to get past a dislike for the seemingly endless need for reflective statements from training programmes and appraisals which were then never properly utilised. Dr Bawa-Garba’s conviction has now introduced an additional complication: anxiety.
Should doctors be concerned?
There is a commonly held belief that Dr Bawa-Garda’s reflective writings were a key element of her conviction. Yet this doesn’t stand up to scrutiny. To quote from the General Medical Council’s case factsheet:
The Medical Protection Society (MPS), which represented Dr Bawa-Garba at her criminal trial, has made it clear that the doctor’s reflective notes were not part of the evidence before the court and jury.
Modern-day doctors adhere to the idea of practicing evidence-based medicine. This should extend well beyond clinical diagnosis and treatment. An evidence based attitude should extend to to all aspects of practice. So it’s important to pay attention to the facts of the case, rather than hearsay and prevailing opinion.
What is correct, and always has been, is that reflective writings could be used as part of a legal case against a doctor against a doctor. There is no statutory restriction in place. But there never has been. Is that fair?
We have to protect ourselves from a mindset that doctors can do no wrong. Although Dr Harold Shipman is undoubtedly an extreme case he is worth a mention. If we know a doctor can genuinely be guilty of the premeditated mass murder of patients, then it is not difficult to imagine that there is a sliding scale on which, somewhere along the line, there could be examples where manslaughter through gross negligence would be a fair and reasonable conclusion. The public deserves to have confidence in their doctors and no-one can ever be above the law. Any successful criminal prosecution depends upon all relevant evidence being presented and considered. The emphasis has to be on the word ‘all‘. If a doctor’s personal written reflections were to be used in court – and they weren’t in the Bawa-Garba case – then they would constitute only a part of the evidence. There would have to be sufficient corroborating evidence to indicate any guilt.
Consider this: if reflections could be used to support a prosecution then they could also be used to support a defence case. Would there be equal levels of panic used if a doctor wanted to utilise their reflective diary to help evidence their innocence?
An example of defensive practice?
It could be argued that active avoidance of reflective writing has a parallel to the concept of defensive practice. The focus has shifted from what is in the best interests of all concerned to the avoidance of litigation. Unnecessary tests, appointments, referrals and treatment processes for the sole purpose of covering the clinician’s back cost the NHS heavily. The costs to the service are both financial and in terms of efficiency. Ultimately the wider service to patients is compromised. There is also a world of difference between a clinical record which has been written to genuinely communicate the patient’s story and one which is intended as proof and justification in case of complaint. Is there any difference between these self-serving behaviours and making a conscious decision to opt out of a worthwhile self-development activity in the remote chance it could play a part in some undefined litigation?
Simple steps for genuine reflective practice.
Without doubt, the conversation about helping doctors find a way to reflect without fear is a positive one. At the same time, it is clear that many have never actually been taught how to conduct a reflective writing exercise for ‘right’ reasons. Please note: the following description is of reflective writing for your personal benefit, rather than for an appraisal submission.
To be successful, you must be willing to genuinely explore your experiences, thoughts and feelings along with your perception of the experiences, thought and feelings of anyone else involved. Give yourself the time and space for the following:
- Set a timer for 20 minutes
- Using pen and paper, or keyboard, write about your experiences over the past week – or the event in question
- Punctation, grammar, spelling, legibility etc. are irrelevant for this exercise
- Write only for yourself
- Go wherever your mind takes you with curiosity and without judgement – and keep writing, no matter what comes into your head
- When the time is up, throw away the paper or close your digital document without saving
The final point here is nothing to do with the concerns arising from Bawa-Garba case. This is the long established process advocated by James Pennebaker, a leading author on the topic of reflective writing. It is consistent with the original intention: to externalise the information from yourself without fear of repercussion. Refelctive writing slows the mind, creates focus and enables stepping out of the experience to gain perspective.
However, there are other effective methods beyond reflective writing. A coaching-style conversation with a trusted and skilled mentor is one valuable alternative. Speaking can be just as beneficial as writing and a good mentor could help you explore aspects of which you would otherwise be unaware. We will therefore be increasing the focus on the skills required to facilitate such reflection going forward within our Advanced Teach the Teacher: Mentoring Skills for Doctors.
Stephen McGuire – Head of Development
