Intended for healthcare professionals

Observations Ethics Man

Knocking out written reflections

BMJ 2018; 360 doi: (Published 02 February 2018) Cite this as: BMJ 2018;360:k546
  1. Daniel Sokol, medical ethicist and barrister
  1. 12 King’s Bench Walk, London
  1. daniel.sokol{at}

Meaningful reflection improves performance, but writing isn’t the best way to do it

In a bid to lose my belly, which has expanded at such a rate that my trousers no longer fit, I have taken up boxing. In my second sparring session I fought “the Viking.” Despite his bulk, he was so elusive that I was unable to hit him. He, on the other hand, punched me so hard and so often around the head that I suffered whiplash for three days.

In the following days I reflected on what happened. Why did I miss? Why was I such an easy target? What could I do differently? Identifying and avoiding mistakes were a priority for me because, frankly, being hit hurts.

Whether in boxing or medicine, meaningful reflection is crucial for improvement. Removed from the heat of the action, we can achieve greater clarity of mind and avoid repeating mistakes.

Meaningful reflection and self awareness undoubtedly benefit doctors. Yet, the recent case of Hadiza Bawa-Garba, in which a trainee paediatrician was struck off the register for her role in the death of a 6 year old from sepsis, has caused many doctors to question the wisdom of putting their reflections on paper. In Bawa-Garba’s case, excerpts from a reflective document in her e-portfolio, completed a week after the incident, were referred to in her hearing at the medical practitioners tribunal.

The practical lesson here is that reflective pieces are not beyond the reach of lawyers. Written reflections are not protected by absolute confidentiality, so be careful what you write.

The case raises a broader question: are compulsory, written reflective exercises the best way to encourage meaningful reflection?

Role of coaching

The surgeon Atul Gawande, in a recent TED talk, spoke about the role of coaching in improving performance. He wondered why professional athletes have coaches, even those at the top of the world rankings, but not doctors. Inspired by a conversation with the great violinist Itzhak Perlman, whose wife gave up her career as a concert violinist to be her husband’s music coach, Gawande asked a retired professor of surgery to “coach him in the operating room.’’ Gawande said, “I didn’t think there would be anything much he’d have to say when we were done. Instead, he had a whole page dense with notes . . . That one 20 minute discussion [with the coach] gave me more to consider and work on than I’d had in the past five years.” As a result of this coaching, Gawande’s complication rate dropped.

More effective and engaging than the written reflective piece would be to offer trainees “coaches” to discuss cases and performances, give insights, and prompt reflection, in one to one or seminar style settings. Coaches may see what we cannot—like Gawande’s coach, who noticed that the light had swung away from the wound and that Gawande was operating under reflected light. They usually have greater knowledge or experience. Face to face meetings with trusted coaches could also reduce the reluctance of trainees to make observations that might be used in subsequent legal proceedings.

All doctors fight in a metaphorical ring, seeking to beat a tough opponent, and will inevitably connect with a hard shot at some point, whether it’s a relative’s complaint, a patient’s death, or a period of self doubt. When that happens, they should reflect on it, not by writing a text but through “coaching sessions”: by talking to, and learning from, someone who knows their way around the ring.

Who is best placed to act as a coach is open to debate. What is plain is that the requirement to reflect should not be a formulaic tickbox exercise but a central aspect of the quest to improve and grow as practitioners of an art of infinite complexity.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Find all The BMJ’s articles on the Bawa-Garba case at

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