How should doctors use e-portfolios in the wake of the Bawa-Garba case?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k572 (Published 08 February 2018) Cite this as: BMJ 2018;360:k572
All rapid responses
The only solution is to do away with written reflection.
It could be replaced in a number of ways, and some would be more educational than the present system.
For example, doctors could be obliged to meet with a mentor to discuss mistakes, etc.
The fact of the meetings would be recorded but no written record kept of matters discussed.
There is ample precedent for this - for example, the three Wise Men were obliged to destroy any notes they took.
Competing interests: No competing interests
GP Appraisal is dead.
The fatal blow was administered by the fallout from the Bawa-Garba case.
We now know the following (1)
1. Even if Bawa-Garba’s reflections “did not actually go on to form part of the evidence before the court and jury” the MPS acknowledged that it “may well have been the case” that the reflections, as The BMJ has stated, “fed into the trial.”
2. Doctor’s reflections are potentially disclosable to courts, tribunals, and coroners, as legal advice obtained by the Royal College of Paediatrics and Child Health points out.
3. The GMC can obtain reflections if it is considering fitness to practise proceedings against a doctor; but it has assured doctors that “the GMC does not ask a doctor to provide their reflective statements if it’s investigating a concern about them.” However, if a deanery reports a trainee to the GMC, it may send along the reflective statements, as happened in a recent case.
4. In April 2016, Health Education England circulated a letter from postgraduate deans in London and the South East which read, “Recently, a trainee released a written reflection to a legal agency, when requested, which was subsequently used as evidence against the trainee in court.”
5. “Doctors in training must continue to write reflections, especially when there are things that do not go well. This is an essential part of training and is needed to progress through a postgraduate training programme.”
6. Failure to record reflections honestly could give rise to a referral to the GMC (so, we are damned if we do and damned if we don’t).
This appalling state of affairs represents a stab in the back and a total betrayal of all doctors who are participating or who have participated in GP Appraisal as Appraisers and Appraisees. I have been both.
I was in the original initial cohort of GPs to be trained as Appraisers in the UK and from 2003-2015 I appraised about 10 GP colleagues annually. At the outset of GP appraisal the endeavour was pitched as a confidential, supportive, reflective, peer to peer process to promote professional development. I well remember that at the outset I and other colleagues raised misgivings about the possibility of ‘mission creep’ and the process evolving from being educational to regulatory, which is exactly what happened. But it is now crystal clear that Appraisal has the potential to be persecutory. This egregious perversion of the scheme’s original aim is yet another grotesque twist in the accelerating death spiral of medical practice in the UK.
Three years ago I took early retirement from General Practice in the UK and am now practising in Australia. Medical practice here is far from perfect, but it’s a libertarian paradise compared to the UK. Unless this matter is rapidly and robustly resolved to restore the confidence of doctors in the purpose and process of GP appraisal I foresee the already steady stream of colleagues who are leaving the UK to practise elsewhere turning into a torrent.
How on earth have our professional organisations allowed this awful state of affairs to come to pass?
1. BMJ 2018;360:k572
Competing interests: No competing interests
I do not think this article has provided any doctor with any reassurance at all about the portfolio. In fact, a consultant’s reflections were used in the Bawa-Garba case which appear to have caused considerable harm. The reality is that, as a lot of doctors have told me (particularly trainees) they are frequently put in an impossible situation with regards to ‘reflection.’
On the one hand one is asked to reflect honestly and on the other hand supervisors specifically order them to document about what they have done wrong. Discussion of systemic errors is described as being non- reflective. There is a fixation about stating what YOU have done wrong and in some cases colleagues have complained to me that they felt coercion to document matters in a fashion that could be self incriminating by their supervisors.
Failure to do so is met with threats to career progression through reporting to ARCP for being non reflective, referral to GMC for failure to adhere to duty of candour and so forth. Furthermore, they have spoken of how supervisors have documented ‘reflectively’ matters in a fashion to apparently apportion blame onto their trainees to cover themselves.
The reflective portfolio has become a tool by which to apportion NHS failings onto doctors. Unless this material is privileged and protected from disclosure for litigation it will be a persistent legal threat to doctors.
Trainees are extremely vulnerable. I could not recommend a career in medicine unless this situation is resolved. Doctors are effectively being told to self-incriminate themselves for systemic failings and to divest blame from senior doctors in a supervising capacity as well as non medical managers. Enter a career into this profession in the UK at your peril.....
Competing interests: No competing interests
Thank you for clarifying the use of reflective documents in this case.
I am concerned about the discussion in the media and in a letter sent by Professor Sir Terence Stephenson to all doctors. In this letter, Professor Stephenson reassures the profession that:
'The question of reflection has been raised by doctors. I wanted to start by addressing one of the key misunderstandings about this case, which the Medical Protection Society has clarified. Dr Bawa-Garba’s e-portfolio did not form part of the evidence before the court and jury.'
From this BMJ article it is clear that a 'Training encounter Form' was indeed seen by the prosecution team and therefore fed into the criminal trial.
I have seen this training encounter form.
Training encounter forms were previously used by the East Midlands Healthcare Workforce Deanery. At the top of the form is the statement that the form will 'guide decisions made about the trainee in their annual review.'
I think most trainees would therefore consider this to be part of their portfolio of evidence.
The intention of this form is to reflect on significant events. The form was completed by Dr O'Riordhan in his handwriting and lists his perception of Dr Bawa Garba's errors.
She did not sign this form as she disagreed with the contents.
Dr Bawa Garba's handwriting also appears on the form and she reflects about areas where she could have improved- she describes her personal learning.
To me then, this is clear. A document intended for supervision and trainee development, containing Dr Bawa Garba's written reflection, was seen by a prosecution QC who subsequently cross examined Dr Bawa Garba in a criminal court.
This document did form part of her training records and I think many trainees will be alarmed about this. I suspect if Dr Bawa Garba had been told at time that any reflective comments made would be seen by a prosecution barrister in a criminal manslaughter case, she may have taken legal advice before writing anything down.
It appears that the GMC letter to all doctors, does not make it completely clear that trainee reflective documents whether part of eportfolio or not, fed into this case and were seen by an adversarial barrister.
Good Medical Practice reminds all doctors that we should admit our mistakes honestly, and Duty of Candour requires us to apologize when something goes wrong. I am sure that the GMC should be held to the same standards.
The GMC were I am sure, aware that this document was seen by the prosecution in court, as they will have studied the case in detail before making a decision to appeal their own Tribunal's findings.
All doctors need to be aware that at present, there is no legal protection and anything that they write could be used against them in a subsequent court case.
Competing interests: I was Dr Bawa Garba's educational supervisor for a number of years after Jack Adcock's death. I work in a different department and was not involved in Jack's clinical care. I have had extensive discussions over many years with Dr Bawa Garba about this case and her reflections on it. I was cross examined for a number of hours at the MPTS tribunal in this case by a QC appointed by the GMC, where Dr Bawa Garba's portfolio and reflection were extensively discussed.