Intended for healthcare professionals


Audit should be more than e-portfolio fodder

BMJ 2016; 353 doi: (Published 04 May 2016) Cite this as: BMJ 2016;353:i2311
  1. Thuvaraka Ware, year three specialty trainee in general practice
  1. Parliament Hill Medical Centre, London
  1. thuvaraka.ware{at}


Thuvaraka Ware argues that, to be effective, audit should be borne out of need and intrigue

As doctors, we are trained to follow orders. We learn our pathology, complete our assessment forms, and prepare for the annual review of competence progression or revalidation. Audit may sometimes feel like just another box ticking, CV building exercise.

How did the thirst for discovery and the creative spark we all had as medical students get channelled into these rigid pathways simply for training purposes? This is something I experienced recently when I conducted an audit based solely on updated guidelines, not on clinical interest or need. As a consequence, my patients could sense my ambivalence and apathy. The implementation of change—and thus the audit cycle as a whole—was rendered suboptimal.

As Iona Heath predicted, words such as “imagination, wonder, and courage” are slowly disappearing from the healthcare professionals’ vocabulary to be replaced by words like “regulation, inspection, and competition.”1

It might be time to take stock and consider both the original role of audit—as a tool for improving clinical practice—and the fact that the clinician is more than the sum of their e-portfolio. Bringing a part of ourselves—our interests and opinions—to areas like clinical governance can humanise and transform an often esoteric process.

Understanding audit and the purpose of re-audit is a necessary part of personal reflection, refining practice, and evaluating healthcare systems.2 But completing the cycle is only meaningful if it is based on something practical, relevant to our patients and our work, and led by curiosity.

Importantly, an effective audit is borne out of need: after something goes wrong, requires improvement, or evaluation. Performing this process while investing in an area of personal intrigue—the “I wonder why this is happening” philosophy—can be a catalyst for real innovation. This belief and commitment will be visible to patients and other members of the team which in turn can make the execution, reach, and impact of the audit more significant.

Barriers can include factors that are often beyond the clinician’s control, such as workload, time, and environment. Addressing these is far more difficult, not least because of the current crisis in recruitment and morale within the profession as well as the discord and disconnect between clinical and political agendas.3

There needs to be a cultural shift within medicine to give doctors at all stages space and time to practice, reflect, and grow. Then we might start to recapture the idealism and imagination that was once nurtured at the start of our careers—like the character Andrew Manson in The Citadel,4 who moved back into autonomous practice and his research area of interest after the frustrations and injustices of working within a system he recognised as faulty but was unable to change.

Therefore, in its own way, completing an effective audit, in which one is personally invested, can be a step towards gaining autonomy over and shaping how we practice medicine on a day-to-day basis: it has real potential to be far more than e-portfolio fodder.


  • I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.