One of the other tutors mentioned the idea of a penny dropping - in that when we write up a clinical encounter we should pick the thing which captures the imagination. Not just write a description of a case mechanistically but let the experience simmer and then perhaps the key thing for the learner may come into focus and both learning experiences and needs can be more effectively articulated. A further tutor explained the ultimate aim of the electronic portfolio was not just to reflect on practice but that the ultimate aim was to reflect in practice.
This didn't really come clear to me until I was reading this blog for my Curation - and I came across the comment by justin locke December 13th, 2011 at 8:31 pm saying that the most elite practitioners do the boring bits - the drills and scales for a large volume of time and therefore assimilate these skills. Then the penny really dropped and I felt that the practice of doing the reflection on encounters, readings/journals, seminars/tutorials and so on was vital and would lead to me being a natural "professional/structured" reflector within consultations and that some how this was key to my progress.
So armed with the knowledge that this was the thing to do and would make me such a great doctor my only difficulty remained was that I still wasn't sure what reflection was.
From Chart 2 of the ARCP check list from the EOE Deanery site I am pretty sure (as these are marked NOT ACCEPTABLE) that the learning log is not a descriptive list of events. They suggest you may just pass if you use a wider variety of evidence gathering tools for a competency and also reflect on what you have learnt and how you can professionally developed however though you may contextually apply some knowledge and evidence it is limited as is reflection on feedback you have gained.
Finally you are competent if using an extensive range of log entries and discriminating tools to evidence competence; use feed back to critically assess developmental needs; critically reflect on significant events and develop PDP in response to these; and further contextually apply whilst critically appraising evidence to justify decisions and develop.
Unfortunately this didn't really tell me what the reflection actually was though it did add the other interesting word of "critically" which I didn't understand. ONe thing I did learn was that a good learning log was not just that one entry but that each entry was a window on your practice both for yourself and your supervisors and that a key element was action - showing you had done something/doing something i.e. making a reasoned and real change to your practice. Because I now had an extra question and still not enough answers I looked to the luton and dunstable team for the critical appraisal and bradford for reflection. This all made more sense when put into the context of the short GP curriculum statements as well as this helpful guide on how to get the most form the eportfolio again by the awesome bradford team. This last document suggests that the ARCP panel will look for general points to cover competencies but having specific learning points e.g. I will look for X rad flags and may consider Y treatment for some specific Dx; it also says that your feelings are key e.g. anxious about a situation and how reacted, what you did, how you have discussed it and what has changed. For example part of your PDP may be then to go and read about a topic (though I understand the trainer needs to have read the topic first before it gives you the chance to put it into the PDP.
From medical mind maps comes a pivotal map of the competencies and this video explains that it is important to cover the breadth of curriculum while being mindful of the competencies and assign own coverage of competence.
Reading the Bradford VTS explanation of reflection was a good move forwards for the actual reflection - it suggests that learning happens with reflections and drawing on different theoretical models of reflection or previous experiences can lead to different insights. It involves analysis and evaluation as well as an action plan for the future. Another interesting development was its articulation that there are two types of reflection in-action (i.e. on your feet in a unique encounter where previous formal education cannot be called upon to make the decision) and on-action (i.e. retrospectively). It suggests trying to write a mix of both types of reflection i.e. what went on in your head at the time and then "separately" a reflection on the overall encounter and distinguishes this from the depth of that reflection. When looking at the depth of learning it highlights several key areas.
- Use a range of sources to clarify thoughts and feelings as well as other sources of information to put the event into context
- Use well developed analysis of critically thought about evidence to justify or change behaviour whilst describing and trying to make sense of own perceptions, thoughts and emotions
- Demonstrate openness and honesty about performance and consideration of feelings generated. Have insight and seeing performance in relation to what might be expected of doctors. Consideration of thoughts and feelings of others as well as one self.
- Evidence that their is clarification of what needs to be learnt, why and how along side prioritisation and planning of learning.
The RCGP how to produce a good learning log clarified further. I will just bullet point how I think their case study of a clinical encounter (hollow bullet points) fits into their own criteria (filled bullet points) and high light some words/phrases.
- A good quality log entry is one that shows good reflection, which means that it demonstrates your insight into how you are performing and how you are learning from your everyday experiences.
- I felt this baby needed to be assessed as she was not well and eventually the paeds registrar agreed to see the child
- On reflection, the baby arrested while she was in the CED. The parents took her there by car. I could have arranged a blue light ambulance to take her to hospital
- evidence of critical thinking and analysis, describing your own thought processes
- To be aware that accurate assessment of a baby is vital as they can be seriously unwell and only display non-specific symptoms.
- however, although I thought she was unwell, I did not expect such a serious underlying problem and she was certainly not looking like a baby that was about to arrest.
- self-awareness demonstrating openness and honesty about performance along with some consideration of your own feelings
- I am very glad that I insisted on sending the baby to hospital despite the objections of the paediatric registrar.
- It felt very awkward at the time, but it has taught me to trust my judgement and I will find it easier to be more assertive next time.
- evidence of learning, appropriately describing what needs to be learned, why and how
- Need to refresh my memory re: congenital heart disease & its presentation in neonates. GP notebook & paediatric textbook, in the next couple of weeks.
- learnt to be aware that accurate assessment of a baby is vital as they can be seriously unwell and only display non-specific symptoms
So by this time I had a fair understanding of the different elements of the learning log to make it reflective. One final document I read to bring it all together was the Being a Reflective GP by Arthur Hibble from the EOE website.
In this I learnt that it was important to not be journalistic but also reflective so observe and note the less obvious about the situation - question the situation and find the unfamiliar. Take responsibility and own your sensations and feelings about the experience (self-awareness). Self regulate by being mindful of when experiences/behaviours sit in relation to competence. Note the internal conversation of how the feelings relate to these perceptions. Seek feedback against standards by being open and honest about performance. Clarify what needs to be learnt and why you need to take it on through statements of learning and planned impact on performance and then plans for review.
This document suggest printing out an log and practicing with others to get feed back on how to improve. It offers some other general concepts:
Being reflective enlables the transitions from knowing, knowing how, being shown how and doing.
The success of techno-rational science has been in the revelation of detail; the success of humanities has been to reveal the complexity of the whole. The language of reflexivity has as much to do with the humanistic as the scientific traditions. Medicine as a discipline bestrides both of them.
The Data, Information, Knowledge, Wisdom (DIKW) theory of knowledge starts with facts or data as a raw element that is fashioned into information. Individuals take information and transform it into knowledge. Knowledge is then synthesised and analysed through experience into wisdom. In this model knowledge does not exist outside of a person, it is either data or information until it is internalised by the individual and processed so that it has an impact on performance. Reflection is part of the processing, it is the iterative reviewing element that enables the individual to incorporate good practice, build on good practice and discard obsolete practice.
Some more specific advice of the types of things to improve upon would be (e.g. of a ?child abuse case you didn't confront with the mother behaving oddly providing an explanation for a bruise "too quickly":
- What happened
- include descriptors e.g. anxious single mum
- include awareness of others e.g. she felt her son was XYZ, she was reluctant to show me XYZ, claimed XYZ
- include what you did e.g. refer to Health visitor
- Subsequently happened
- Spoke with X they have arranged Y
- Once established plan of action is undertaken we will do Z e.g. joint visit
- Spoke with trainer
- What was learnt?
- Felt unprepared
- Uncomfortable with particular consultation skill e.g. of raising issue
- Managed medical difficulty using time and referral to gather more information
- Found out about local champion on particular issue
- Not just - learnt how to refer a case
- Do differently?
- Involve trainer, champion, HV at time of consultation e.g. not just refer earlier
- Further learning needs:
- not generic e.g. find out about huge topic
- find out about local referral process and people, case meetings and review
- ask tutors to have group based discussion on half day release
- use learning time to go to social services for half a day
- Addressing them
- read protocols in the next month
- volunteer to lead a GPST xx on topic
- make appointment to see social services in next two weeks.
So some potential questions to ask are:
What could I have done better?
What did I do well? Some people would like you to answer this one first, experience usually works the other way around.
How do I feel?
Why do I feel this way?
What is the feeling telling me?
What words can I use to describe the feeling?
Who should I speak to?
What are the boundaries of my competence?
What have I leant, been made aware of?
How can I develop my competencies?
How will I put them into practice?
How will I know that I am developing?
A conclusive nice poem which has put me at ease again that I can relax and not get too hyped by the whole thing:
I KEEP six honest serving-men (They taught me all I knew); Their names are What and Why and When And How and Where and Who.
I send them over land and sea, I send them east and west; But after they have worked for me, I give them all a rest.
I let them rest from nine till five, For I am busy then, As well as breakfast, lunch, and tea, For they are hungry men.
But different folk have different views; I know a person small- She keeps ten million serving-men, Who get no rest at all!
She sends'em abroad on her own affairs, From the second she opens her eyes- One million Hows, two million Wheres, And seven million Whys!
The Elephant's Child
