Monthly Archives: August 2016

Is it time we reflect on the true value of reflection?

Edward Schwarz

Edward Schwarz

Ed Schwarz is a GPST1 in Cornwall. He has just returned from New Zealand where he was working for a couple of years and has a keen interest in medical education and palliative medicine.
Edward Schwarz

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stones on a mirrorIt is a Sunday evening. I look across at my GP ST1 wife and see her feverishly tapping the keyboard. I enquire what she is doing. “I have to do a couple of reflections, I’ve only done one this week.”

Reflection has become a major part of trainees and GPs’ lives alike. Most follow tried and tested models such as Gibbs1, to look back on an experience, challenge one’s own performance or thinking and see if this has led to learn new things or perhaps shape the way one behaves in the future. Sometimes, it may involve a patient whom has made a complaint, or an error you have made, or a system has failed and just like with the aviation industry that encourages transparency, can provide a platform with which to voice your thoughts and feelings.

As a guide, you are expected to do two reflections a week as a GP trainee. This helps form the basis of evidence to demonstrate competence in a certain curriculum area. So there lies another quandary – you may feel competent in an area but unless you have recounted an experience that demonstrates this adequately you will not pass. Recently, a reflection by a doctor was used by the prosecution in court against them.2. Since then, there have been numerous press releases by governing bodies, including Health Education England that have tried to reassure trainees that reflection is here to stay and as long as patient identifiable data is removed, will continue for the foreseeable future.

This case has now exposed prescriptive reflection for what it is – a cheap way of monitoring and ensuring training is completed. If one cannot be completely open and honest without the threat of it being used against you, then the result is not true reflective practice. If writers are not expressing their innermost thoughts and challenging themselves completely open and honestly, then they are providing just the right mix of intrigue to satisfy the college but without really engaging in the process. It becomes merely a tick box exercise – “I have been told I should reflect, I don’t want to be too honest and I have been given an arbitrary figure of two reflections per week so I better complete them.” This is just as bad as making a reflection up to fit into a curriculum box and both would contradict the GMC recommendation, “being open and honest”.

So is it time to move away from this model? Can reflection simply be spontaneous? My parents, both retired doctors, and their friends find it laughable that so much of our time is taken up by reflection. They were brilliant doctors and yet their personal learning wasn’t filled up with recounting their experiences on paper. Their reflection came in different formats. Sitting with a glass of wine and discussing your day either to a medical or a non medical friend or relative is valid reflection. It gives the opportunity to voice out loud one’s feelings and evaluate what you think you did well or could do better. The listeners can offer their own insights based on their experiences.

Some experiences may affect you so much, that they are good discussion points with which to base tutorials on with supervisors without the need for committing it to paper. If people find it useful to write down their experiences, they could keep a diary. There is a very real risk that training is shaping doctors to all conform to the same mould and dissuading really intelligent and reflective doctors into embarking on a career that requires them to complete these exercises.

No one has been able to tell me why reflection has such recent success and emphasis, or where its popularity came from. I want to be a brilliant GP who makes a real difference to my patients but I am worried my time will be focussed on completing these reflections in place of learning and keeping myself up to date. We have been advised to just embrace it – something my wife is struggling to do on her Sunday evening off. In a world of evidence based practice, where is the evidence that reflections are making us better doctors?

So what in place of prescriptive reflection I hear you ask? Well, I don’t have the answer to that question, but I need to finish my second reflection for the week so I’ll try and tackle it then – this is portfolio gold.

References

1. Gibbs G. 1988. Learning by Doing. Oxford.
2. King AM. Trainee’s portfolio ‘used as evidence against them’ in legal case. Pulse. Apr 2016

Tales of the Saudi causeway

David Misselbrook

David Misselbrook

David Misselbrook was a South London GP for 30 years. He was involved with GP training, CPD development and medical ethics. He now teaches Family Medicine and ethics for RCSI Bahrain.
David Misselbrook

IMG_3931The island Kingdom of Bahrain, sits like a hotter, sandier version of the Isle of Wight in the sparkling blue waters of the Arabian Gulf. It is joined to the Saudi mainland by a 25 kilometer causeway. There is a certain soap opera fascination about driving in Bahrain. Cars weave in and out on the multi-lane highways, undertaking, overtaking, wombling free. I admire their skill. Leave a foot more than a car’s length in front of you and another car will cut in. And before stopping at a red light check in your mirror whether or not the guy behind looks like he might stop too. One drives defensively and gets used to it.

Driving in the Middle East is one of the last legal blood sports. You are three times more likely to die in an RTA in Bahrain than in the UK. But this brings us back to Saudi, where you are ten times more likely to die than the UK. (Top tip – when your taxi driver in Riyadh smilingly tells you not to worry that the seat belt isn’t working, find another taxi.)

The Saudi causeway is best seen from above, after one takes off from Bahrain International Airport. Its elegant curves show exactly what oil wealth plus a few good engineers can achieve. In fact, it is much better seen from above; the first rule of driving in Bahrain being don’t go across the Saudi causeway. It carries over 20 million people a year, but most traffic is at the morning and evening rush hours. Try it at 8pm and you might do it in 30 minutes. Try it at 8am and expect to take 3 hours. (The record in 2014 was an eight-hour traffic jam.)

IMG_7997A colleague, a local Ophthalmologist, told me of the shrewdest use of the causeway. He removed a cataract from a wealthy Saudi in a private Bahraini hospital. The Saudi was so delighted that he insisted on giving my colleague a camel – a high status gift. Sure enough the Saudi drove across the causeway, with the camel in a large horsebox. But camels are not allowed across the causeway, so he was stopped at the customs island, half way across. So my colleague was phoned and had to drive across the proximal half of the causeway to greet his patient (and of course the camel), with much hand shaking and back slapping all round, for it would have been a grievous insult not to have gone. With expressions of great regret they both agreed that every effort had been made, and the camel returned to the endless Saudi sands. So if you want kudos for a valuable gift without the expense, remember where you heard it first.

The point of this tale is that it is absolutely true. With such cultural disparity why should we be surprised by different attitudes to safety? Why should I be surprised to see families driving at speed with young children’s heads through the sunroof, or toddlers sitting on the driver’s lap? Cars have mounted the pavement at speed on three occasions approaching the roundabout outside our apartment. Well, whoever would think that you might have to stop? Although of course roundabouts make excellent parking spots (but only double park on a roundabout on a Friday). I have seen a driver reverse around this busy roundabout whilst talking on his mobile phone. The rate of road traffic accidents in the Middle East isn’t going to reduce any time soon.

So, back to the causeway. It is a dual carriageway, accessed by half a dozen toll booths with passport controls on both sides. So six lanes at the toll booth go into each two lane carriageway. There is no British queueing or alternate merging, it is just a free for all. And at rush hour it becomes anarchic. A friend, let’s call him Tom, told me of his first time across. He was in an unpropitious lane and had to push in to another to actually move forward. The cars were bumper to bumper and no one would let him in. In his mirror he saw the queue behind him building up as his inability to push in timed out his remaining credibility. Eventually an Arab in the car behind got out and approached. He wound his window down, expecting an angry tirade. The Arab reached out and put his hand sympathetically onto Tom’s shoulder. “Be strong my friend, be strong” he said, and got back into his car.

You’re the Doctor

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
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When a patient says ‘you’re the doctor’ it can mean several things. Sometimes it means ‘I trust you and the advice you’ve given me’, sometimes it means ‘I don’t like what you’re saying but I don’t feel like I’m in a position to argue’, and sometimes it means ‘just get on with it and do what you’ve got to do’.

Whatever it means when a patient says this, it always feels like a kick in the teeth to me. Since my first day at medical school, the day on which I underwent my Balint lobotomy, I’ve been told to be patient centred. I’ve been taught that there really are no doctors and patients just symbiotic, therapeutic alliances from which mutually agreed treatment plans will emerge.

So when a patient tells me that I’m the doctor I feel like they’re not playing the game. When a patient says this, my inner consulter screams, ‘No! I’ve handed over to you now, just like Roger Neighbour told me to, we need to share this decision like Pendleton suggested, and then we’re going to modify your health seeking behaviours like Stott and Davies wanted’. But an astonishing number of my patients haven’t read any of Neighbour’s work. Even fewer seem to be familiar with the Cambridge-Calgary model, which may explain why some of them don’t seem to get in when I’m ‘closing the session’ and seem instead to want to talk about more problems.

A recent BMJ article, written by a patient, talked about this experience from the other side. The author spoke of feeling bemused and uncomfortable when her GP asked her questions like ‘what do you think is wrong?’ or ‘what do you think we should do about this?. Interestingly, the author found the relentless pursuit of her ‘ideas, concerns, and expectations’ was actually damaging to the therapeutic relationship as it resulted in her losing faith in her doctor.

This is unsettling but not surprising news. The fact that a number of patients simply want to be treated as a patient is obvious to us all from everyday practice. Many people simply want to be told what’s wrong with them and what to do to make it better.

There is an assumption in medical education that this dynamic, the one in which the doctor is in control, comes naturally to all doctors and so doesn’t need to be taught. But even if this type of consultation does come naturally to many doctors, we spend years of training disempowering doctors from taking on an authoritative role in a consultation by punishing them every time they do so in an exam situation.

The current paradigm for the medical consultation is heavily weighted towards eliciting ideas, concerns and expectations, and the MRCGP clinical skills assessment mark scheme reflects this. This encourages rigid adherence to consultation models so that the appropriate boxes can be ticked on the mark scheme. And this can be really detrimental to the natural communication skills that many doctors already possess, turning them from instinctive consulters to consulting play actors.

Articles such as that in the BMJ are evidence that we need to ensure that our doctors can consult flexibly, are able to recognise different consultation dynamics, and are able to be the doctor when that is what the patient wants them to be.