Doctors have an ethical duty, set out in the GMC's core guidance Good Medical Practice (2013) to take part in systems of quality assurance, including regular reflection on their standards of practice and the care they provide to patients (paragraph 13). More detailed guidance for doctors can be found in Continuing professional development: guidance for all doctors (2012). The GMC emphasises that doctors must reflect on all aspects of their professional work and should be informed by discussion with others and by specific evidence, including audit, complaints, significant events, workplace-based assessments and feedback from colleagues and patients (paragraph 17).
However, a case reported by HEE in March 2016 related to a trainee who agreed to the release of their written reflections but then found it used against them in court. Several Royal Colleges raised concerns about the circumstances surrounding legal requests to release information held on e-Portfolios. This was subsequently considered by the AoMRC.
A request for the disclosure of information contained in a trainee's e-Portfolio could arise in a number of ways. For example, the patient may be aware that a trainee has made a record relating to them, and they may subsequently make a subject access request for information under the provisions of data protection law. Disclosures could also be sought in litigation, criminal prosecutions or inquests and potentially ordered by a judge or coroner. In addition, the GMC also has powers to compel the disclosure of information, as does the Ombudsman. But in many cases what is in the reflective note will mirror what is recorded elsewhere, such as a root cause analysis following a patient safety incident, and may not therefore reveal any new information.
The key point in the AoMRC guidance is that doctors should 'anonymise patients as far as possible in their self-reflective logs. This is an educational and not a medical tool and therefore there is no reason to include patient identifiable or personal data relating to a third party'.
When writing reflective notes in e-Portfolios, the AoMRC recommends to word the notes in terms of the following:
- A brief description: what are you reflecting on? Outline the circumstance in general terms. Ensure that you anonymise data. You can describe a situation without including identifiable data. For example use 'Patient X' or 'Dr S' instead of names or patient numbers.
- Feelings: what were your reactions or feelings to the event in general? Try not to be judgemental, both to yourself and others, particularly when your reactions and feelings are still raw.
- Evaluation: what was the outcome? What was good and could have been done differently about the event?
- Analysis: what have you learnt? What steps will you now take on the basis of what you have learnt? This is the most important section and will allow the other sections to be brief, generic and unidentifiable. This section will demonstrate both the learning outcome and reflection.
- Take advice from a senior, experienced colleague when writing reflection about cases that may be contentious or result in an investigation.
We have long advised that it is important that trainees follow the guidance and requirements of the GMC and Health Education England (or national equivalent body) as well as take account of guidance from their relevant Royal College. This includes any requirement to maintain a portfolio of evidence relating to training and evidence of reflection.
Careful and conscientious reflection on professional practice, particularly if things go wrong, can be helpful both in terms of learning lessons and in demonstrating insight.
Portfolio reflections should be anonymised. There is no need for patient identifiable information to be included in a portfolio entry. Trainees should review their reflections carefully, as it is easy to leave in details that could inadvertently identify the patient, particularly when small details are viewed in combination.
The following points may be helpful to keep in mind.
- Avoid referring to the patient’s gender if possible; use they/their/theirs instead.
- Do not refer to a date of birth. In most circumstances, a broad indication of age will suffice (eg a patient in their 60s).
- Using a patient's or colleague's initials does not equate to anonymisation. Use a single letter that is unconnected with their name (eg Mr Smith is referred to as 'Patient X').
- Care needs to be taken when describing a very rare condition or unusual presentation. Such information can often be used to identify a patient.
If you are unsure about what to include in a particular portfolio reflective note, speak to your consultant or educational supervisor for advice.
Finally, if you are asked to disclose information, it’s important to get advice from your medical defence organisation. You can contact the MDU medico-legal helpline on 0800 716 646.
This guidance was correct at publication 21/11/2016. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.