By Len D'Cruz, Dento-legal advisor, BDA

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The issue of reflection, the subject of a joint statement1 from the healthcare regulators, is one that has been newsworthy for some time. The statement itself does not allude to the backstory that led to this statement, but it is worth making a brief mention of it to put it into context.

Jack Adcock, a 6 year-old boy, died tragically in 2011 whilst under the care of Dr Hadiz Baba-Garwa. She was subsequently found guilty of gross negligence manslaughter by a jury and was given a two-year suspended jail sentence but the MPTS (Medical Practitioners Tribunal Service) panel ruled she should be allowed to work after a period of a year. This was appealed and the Appeal Court upheld the General Medical Council's application to have her name erased from the medical register. After further legal challenges she will be allowed to return to practice under close supervision, after a new panel of the MPTS found 'extensive and substantial' mitigating factors in her case, including remorse, insight, and remediation, as well as the support of her employers and the East Midlands Deanery. It imposed a range of conditions on her practice for a period of two years, beginning in July 2019, when her current suspension ends.2

What troubled the medical profession in particular was the suggestion that at Dr Baba-Garwa's criminal trial that led to her conviction, her personal reflections in her electronic training-portfolio were used in evidence before the court. This turned out not to be the case as the GMC3, her medico-legal advisor for her defence organisation4 and the QC who prosecuted the cases all confirmed that this was definitely not the case. Doubts still remained in the minds of many healthcare professionals that the regulators could still demand to see a clinician's reflections to investigate a case. The Williams Review5 also considered the importance of reflective material and proposed that royal colleges and professional regulators should clarify their approach to the use of reflective material in considering a registrant's fitness to practise.

This statement is now the definitive position in this this matter since the regulators jointly say:

'We will not ask those who are on our registers to provide their personal written reflections in order to investigate a concern about them. Registrants can choose to offer them as evidence of insight into their practice'.

Each regulator has set out separately what they require in terms of reflection and the GDC have embedded it into the enhanced CPD system requiring registrants to reflect on what they have learned through the process. They regard themselves as not being 'prescriptive with how professionals should reflect or record reflection' and expect registrants to reflect in the way that suits them best.

What is particularly important is to appreciate reflecting from professional experiences, rather than learning from formal teaching

Reflection of course goes far beyond the mere contemplation of a course that has been attended or whizzed through online.

At its most basic, reflection is a review of your personal experiences. This may be an internal monologue, or it may take the form of a conversation with friends and family. We do it all the time when we have a new experience, good or bad, we decide we will or we won't do that again or if we did, we might do something different. This is informal, unstructured and often superficial. Google reviews are a stripped-down version of refection.

Refection as a healthcare practitioner needs more structure to get the most benefit out if it. It is beyond 'that was a great lab, I must use them again' or 'that root filling wasn't as good as I thought it was going to be, I'll try something different.'

If the process of reflection does not come naturally especially if you have to write it down for a particular reason and you are not familiar with the ideas, it can seem to be a bit formulaic but structure certainly helps as an aid to hang your thoughts on. The most useful is the Kolb model of experiential learning6 and the Gibbs reflective cycle.7

Reflection has been defined as the active process of reviewing, analysing and evaluating experiences, drawing upon theoretical concepts or previous learning, in order to inform future actions.8 What is particularly important is to appreciate that reflecting from professional experiences, rather than learning from formal teaching, may be the most important source of personal professional development and improvement.9 It is used widely in Foundation Training with varying degrees of success and also when registrants are facing regulatory enquiries as part of a remediation process. These are two sides of the same coin- one is part of a training programme, the other is a demonstration that the clinician has shown some insight into the shortcomings they may have that prompted the investigation against them. Somewhere in between is the dentist doing their job and learning deeply from what they are experiencing by careful and structured reflection and striving to deliver empathetic, consistent and appropriate care for their patients. This joint statement should reassure them it is all a worthwhile effort with only positive benefits.