Intended for healthcare professionals


Reflection: how to reduce the risks

BMJ 2016; 353 doi: (Published 20 June 2016) Cite this as: BMJ 2016;353:i3249
  1. Marika Davies, medicolegal adviser,
  2. Dan Kremer, medicolegal adviser
  1. Medical Protection
  1. marika.davies{at}


Marika Davies and Dan Kremer explain how to avoid some potential pitfalls in the process of reflection

The need for reflection has become a familiar feature in the working lives of doctors. Opinion on its effectiveness may be divided but advice from the General Medical Council (GMC) is clear—doctors should regularly reflect on their performance.1

Reflection is a requirement when completing trainee portfolios or appraisal documentation, and is considered good practice after any unexpected incident or adverse outcome. It can be a helpful addition to a response to a complaint, or in an investigation by an employer.

Demonstrating reflection is essential for doctors appearing before the GMC—not only does it show insight into the concerns under investigation, but it may be invaluable after an adverse finding when the regulator considers whether a doctor’s fitness to practise is impaired.

Taking a constructive approach to reflection is clearly in the interests of doctors who may face criticism, but there are some potential pitfalls in the process that should be avoided.

A balanced approach

In the stress of the moment doctors may react in a way that could be unhelpful in the long term. Instinct may trigger a “fight or flight” response (see box).

Some doctors might feel threatened and will defend their actions vigorously and unceasingly, meaning they could miss opportunities to learn. A doctor who appears to be failing to reflect properly could be criticised for lacking insight, making an employer or regulator consider them a risk to patients.

Doctors may also want to admit fault in order to avoid confrontation, or possibly out of a sense of guilt. A doctor who accepts all criticisms without proper consideration also loses an opportunity to learn and is more likely to become disheartened. They may decide to change their practice unnecessarily and without any evidence, which could lead to overwork and burnout. The proper, safer, and more balanced approach is to consider the incident or criticism objectively and look for any learning points.

Demonstrating adequate reflection

Reflection can be defined as letting future behaviour be guided by a systematic and critical analysis of past actions and their consequences.2 Reflection alone is not enough: you need to be able to demonstrate that you have done so adequately.

In practice, after an untoward incident it is helpful to make a list of all the potential criticisms and review the standards applicable to those concerns. The aim is to determine what, in the circumstances, you should have done. This might involve taking time to review relevant guidelines, policies, protocols, regulations, texts, or articles.

Discussing the case with a respected senior colleague is an important part of the learning experience and can assist you in reflecting constructively. Undertaking a significant event analysis and relevant educational activities are also helpful steps to take.

The number of activities necessary will depend on the seriousness of the potential criticism. It is important to make sure any activities you undertake and log are relevant to the concerns, in order to demonstrate you have a good understanding of the issues. Keep a note of all reflective activities and how they have informed your thoughts on the events. Reflections should be carefully written and focus on positive learning points.


A recent case, in which a trainee’s reflections in their portfolio were used as evidence against them in a claim, caused understandable concern among doctors.3 In theory, the contents of a portfolio or appraisal could be used as evidence in a case, but this would only be admissible if the entry identified a patient.

As such, you must be careful to ensure that all records are anonymised. GMC guidance on confidentiality says that the use of information about patients is essential to the education and training of medical and other healthcare students and trainees. “For most of these uses, anonymised information will be sufficient and should be used whenever practicable,” it says.4

If you are asked to provide documents that contain your reflections as part of an investigation or case in which you think you may be vulnerable, you should seek clarification from your medical defence organisation about the amount of detail you are obliged to pass on.

The fight response

● Contradicts all criticisms

● Attacks the criticiser

● Does not want to change

The flight response

● Accepts criticisms unnecessarily

● Withdraws from the situation

● Makes unnecessary changes