Reflections are an important part of learning as a doctor in the NHS.
This post is all about reflecting as a doctor. I am a medical registrar hence my reflections might be slightly skewed for doctors working in medicine but hopefully, all specialists should be able to get an idea of how to reflect after reading this blog post.
I, as a trainee medical registrar have to reflect on my portfolio. This is part of my training.
I am going to share some examples ( all factitious).
Date
Title
Time (Hours)
Summary of the event
What were the principle learning outcomes
Venue
Example: Teaching on stroke attended via zoom
Date -
enter the date of the teaching session
Title -
Mandatory GIM teaching day on stroke
Time -
4 hours
Summary of the event
This was day 4 of the GIM teaching session which are mandatory for medical registrars.
The topics discussed were:
1. An introduction to stroke
2. How to manage stroke
3. The importance of the MDT
4. What GIM registrars need to know about stroke – acute and long term management
5.New upcoming management of stroke
What were the principle learning outcomes:
1. I learnt about the financial and psychological implications of stroke. As an acute medical registrar, this shows how important it is to consider secondary prevention when we see patients in ACU/AMU whom we get to spend 15 to 30 minutes with.
2. I learnt about the management of acute stroke – sometimes as a GIM registrar, I have to carry the stroke bleep. This will help me assess and manage patients quickly but safely.
3. The complications of stroke – especially the patients who are on the stroke ward who have been admitted for more than 72 hours.
4. The importance of escalation plans in patients with debilitating strokes.
Venue –
Zoom
You have done a taster week in a GP surgery.
Date of clinical event:
Whatever the start date was
Title:
Taster week in a GP surgery
Why was it noteworthy:
I came to the UK in Janaury, 2016. I started as a non trainee and then did my core training. Now I am a ST4 trainee. I have never worked in a GP practice and as a medical registrar, I always wanted to see how GPs function so that when I am on call, I can help them by understanding what resources they have. I may also consider liaising with my local GP surgeries more as a consultant in acute medicine to see if I can offload some medical patients off them to see them in ambulatory care directly.
Hence, for this reason I decided to do a taster week in a GP surgery.
How did it affect you:
I learnt how efficiently GPs work. They not only see medical patients, but also surgery, minor injuries, paeds, trauma and orthopaedics, psychiatry patients.
They focus on acute issues, listen to patients very empathetically and manage them in the community wherever possible, by safety netting them or refer them appropriately to other hospital specialists.
I learnt how I, as an acute medical registrar can help my GP colleagues by ensuring most investigations are done as an inpatient where possible without delaying discharge and then the hospital consultants follow up on any pending outpatient investigations as they would know the patients well anyway.
I also learnt that they sometimes receive communication like discharge letters from the hospital later than expected and urgent bloods, investigations should be requested by the parent team discharging the patient to prevent delays.
I have also seen what an amazing job GPs with specialist skills do – like knee injections, dermatology consults, etc.
How was the patient affected
N/A
How did it affect the team
When I came back to my regular speciality, I met with the clinical lead of acute medicine and we discussed different suggestions I had to improve both primary care and secondary care.
He was pleased that I had a lot of suggestions and suggested we should start implementing some of them like easy access by GPs to ambulatory care for medical patients.
What was learned from this experience?
I learnt how hard working our GP colleagues are
I learnt how we as hospital doctors can help our GP colleague by making clear discharge summaries, being reasonable in follow up requests and clearly mentioning why they need to see the patient in a few weeks time.
I , as a consultant will try my best to work with GPs to improve patient care.
Tips:
ALWAYS anonymise information
Whenever you saw this case
Title
A case of chest pain
Why was it noteworthy
I was working as an ambulatory care registrar. The nurse in charge came to me from the triage room and quickly showed me an ECG – it had T wave inversions in the lateral leads. I immediately went to see the patient and he had chest pain at the moment – crushing, 8/10 , radiating to left arm and jaw. I quickly got him to lie on the couch and started him on ACS treatment. His bloods had just been done but given his high risk of myocardial infarction ( high HEART score, highly suspicious history, age above 65, smoker, T2DM, family history but awaiting troponin result), I started him on ACS treatment and gave him GTN spray, analgesia.
I then got a CXR immediately which unfortunately showed widening of the mediastinum. Now I was concerned about ? dissection. I immediately called the radiology registrar who approved the CT aorta immediately and that showed that he indeed did have an aneurysm but fortunately did not have a dissection. I called the cardiology registrar who agreed that this was likely a NSTEMI with incidental finding of aneurysm. He was taken over by cardiology immediately. His chest pain settled and I kept an eye on him till he was transferred.
I followed this patient later on. His angio the following day showed triple vessel disease and he was for a CABG along with aorta repair after MDT discussion with cardiology and cardiothoracics.
How did it affect me
I learnt about the differentials of chest pain and although this one was very obvious, I realized how important a CXR is. I discussed this with the cardiology registrar and he said that he would have done the same – ie ACS treatment ASAP.
How was the patient affected?
He was very grateful for the triage nurses prompt response to the abnormal ECG and how quickly we managed to get all investigations done.
How did it affect the team?
We had a small debrief session and the nurse was a bit shaken. I assured her that her management saved this patients life. I also updated her with the clinical situation of the patient after a few weeks and she was very glad he was doing well post surgery.
What was learned from this experience?
Not delaying ACS treatment however getting a CXR promptly.
Calling the necessary specialists early
Looking out for your colleagues – the nurse in charge was a bit stressed and I had to sit with her and debrief her. I assured her that she did really well.
Tips:
1. ALWAYS anonymize patient identifiable data
This post is all about reflecting as a doctor. I am a medical registrar hence my reflections might be slightly skewed for doctors working in medicine but hopefully, all specialists should be able to get an idea of how to reflect after reading this blog post.
I, as a trainee medical registrar have to reflect on my portfolio. This is part of my training.
Some useful links:
Improving Feedback and Reflection to Improve Learning | JRCPTB
Improving Feedback and Reflection to Improve Learning | JRCPTB
I am going to share some examples ( all factitious).
ATTENDANCE AT ORGANIZED TEACHING
This section includes these sections:Date
Title
Time (Hours)
Summary of the event
What were the principle learning outcomes
Venue
Example: Teaching on stroke attended via zoom
Date -
enter the date of the teaching session
Title -
Mandatory GIM teaching day on stroke
Time -
4 hours
Summary of the event
This was day 4 of the GIM teaching session which are mandatory for medical registrars.
The topics discussed were:
1. An introduction to stroke
2. How to manage stroke
3. The importance of the MDT
4. What GIM registrars need to know about stroke – acute and long term management
5.New upcoming management of stroke
What were the principle learning outcomes:
1. I learnt about the financial and psychological implications of stroke. As an acute medical registrar, this shows how important it is to consider secondary prevention when we see patients in ACU/AMU whom we get to spend 15 to 30 minutes with.
2. I learnt about the management of acute stroke – sometimes as a GIM registrar, I have to carry the stroke bleep. This will help me assess and manage patients quickly but safely.
3. The complications of stroke – especially the patients who are on the stroke ward who have been admitted for more than 72 hours.
4. The importance of escalation plans in patients with debilitating strokes.
Venue –
Zoom
Tips:
Reflecting upon such teaching sessions shows that you have learnt something from it.
Reflecting upon such teaching sessions shows that you have learnt something from it.
You do not need to mention a lot of details.
This proves to the ARCP panel/appraisal team that you are involved in continuous professional development.
1. Attachment
2. Interesting case
3. Clinical incident
4. New clinical experience
The sections of each type is the same:
Date of clinical event
Title
Why was it noteworthy
How did it affect you
REFECTION ON CLINICAL EVENT
This has 4 different types of clinical events:1. Attachment
2. Interesting case
3. Clinical incident
4. New clinical experience
The sections of each type is the same:
Date of clinical event
Title
Why was it noteworthy
How did it affect you
How was the patient affected
How did it affect the team
How did it affect the team
What was learned from this experience/what would you do differently next time
ATTACHMENT
An example:You have done a taster week in a GP surgery.
Date of clinical event:
Whatever the start date was
Title:
Taster week in a GP surgery
Why was it noteworthy:
I came to the UK in Janaury, 2016. I started as a non trainee and then did my core training. Now I am a ST4 trainee. I have never worked in a GP practice and as a medical registrar, I always wanted to see how GPs function so that when I am on call, I can help them by understanding what resources they have. I may also consider liaising with my local GP surgeries more as a consultant in acute medicine to see if I can offload some medical patients off them to see them in ambulatory care directly.
Hence, for this reason I decided to do a taster week in a GP surgery.
How did it affect you:
I learnt how efficiently GPs work. They not only see medical patients, but also surgery, minor injuries, paeds, trauma and orthopaedics, psychiatry patients.
They focus on acute issues, listen to patients very empathetically and manage them in the community wherever possible, by safety netting them or refer them appropriately to other hospital specialists.
I learnt how I, as an acute medical registrar can help my GP colleagues by ensuring most investigations are done as an inpatient where possible without delaying discharge and then the hospital consultants follow up on any pending outpatient investigations as they would know the patients well anyway.
I also learnt that they sometimes receive communication like discharge letters from the hospital later than expected and urgent bloods, investigations should be requested by the parent team discharging the patient to prevent delays.
I have also seen what an amazing job GPs with specialist skills do – like knee injections, dermatology consults, etc.
How was the patient affected
N/A
How did it affect the team
When I came back to my regular speciality, I met with the clinical lead of acute medicine and we discussed different suggestions I had to improve both primary care and secondary care.
He was pleased that I had a lot of suggestions and suggested we should start implementing some of them like easy access by GPs to ambulatory care for medical patients.
What was learned from this experience?
I learnt how hard working our GP colleagues are
I learnt how we as hospital doctors can help our GP colleague by making clear discharge summaries, being reasonable in follow up requests and clearly mentioning why they need to see the patient in a few weeks time.
I , as a consultant will try my best to work with GPs to improve patient care.
Tips:
ALWAYS anonymise information
Keep it brief and concise - specific to your speciality.
INTERESTING CASE
Date of clinical eventWhenever you saw this case
Title
A case of chest pain
Why was it noteworthy
I was working as an ambulatory care registrar. The nurse in charge came to me from the triage room and quickly showed me an ECG – it had T wave inversions in the lateral leads. I immediately went to see the patient and he had chest pain at the moment – crushing, 8/10 , radiating to left arm and jaw. I quickly got him to lie on the couch and started him on ACS treatment. His bloods had just been done but given his high risk of myocardial infarction ( high HEART score, highly suspicious history, age above 65, smoker, T2DM, family history but awaiting troponin result), I started him on ACS treatment and gave him GTN spray, analgesia.
I then got a CXR immediately which unfortunately showed widening of the mediastinum. Now I was concerned about ? dissection. I immediately called the radiology registrar who approved the CT aorta immediately and that showed that he indeed did have an aneurysm but fortunately did not have a dissection. I called the cardiology registrar who agreed that this was likely a NSTEMI with incidental finding of aneurysm. He was taken over by cardiology immediately. His chest pain settled and I kept an eye on him till he was transferred.
I followed this patient later on. His angio the following day showed triple vessel disease and he was for a CABG along with aorta repair after MDT discussion with cardiology and cardiothoracics.
How did it affect me
I learnt about the differentials of chest pain and although this one was very obvious, I realized how important a CXR is. I discussed this with the cardiology registrar and he said that he would have done the same – ie ACS treatment ASAP.
How was the patient affected?
He was very grateful for the triage nurses prompt response to the abnormal ECG and how quickly we managed to get all investigations done.
How did it affect the team?
We had a small debrief session and the nurse was a bit shaken. I assured her that her management saved this patients life. I also updated her with the clinical situation of the patient after a few weeks and she was very glad he was doing well post surgery.
What was learned from this experience?
Not delaying ACS treatment however getting a CXR promptly.
Calling the necessary specialists early
Looking out for your colleagues – the nurse in charge was a bit stressed and I had to sit with her and debrief her. I assured her that she did really well.
Tips:
1. ALWAYS anonymize patient identifiable data
2. Reflect upon cases you found interesting - instead of every case you see.
CLINICAL INCIDENT
Date of clinical event
Whenever the clinical incident happened
Title
Title
A case of missed radiological finding on a CT scan
Why was it noteworthy
I saw this elderly lady was admitted with a fall. Her CT head, spine, chest, abdomen, pelvis was performed as a trauma CT. I reviewed the report and as it was normal, discussed this with the consultant who agreed and discharged her after being seen by physiotherapists.
Why was it noteworthy
I saw this elderly lady was admitted with a fall. Her CT head, spine, chest, abdomen, pelvis was performed as a trauma CT. I reviewed the report and as it was normal, discussed this with the consultant who agreed and discharged her after being seen by physiotherapists.
The following day, another consultant approached me and mentioned that I had missed the finding of maxillary antral fracture on the CT scan. He requested me to talk to the maxfax team and I promptly contacted them - they suggested conservative treatment and advised her not to blow her nose for 2 weeks.
I then called the patient and informed her about the broken bone and what the maxillofacial team had advised. She was grateful for my call and did not have any further questions.
How did it affect you
1. Sometimes a swiss cheese affect happens - I missed a fracture on the CT report and so did my consultant.
2.It is important to call the relevant specialities ASAP which I did.
3. Call the patient ASAP which I did.
How was the patient affected
The patient was grateful that I called her and informed her about the scan results.
How did it affect the team
N/A
What was learned from this experience/what would you do differently next time
1. I will make sure that I will read the report carefully. I am also aware that sometimes scans are reported by trainee registrars and the report is sometimes amended by a consultant which could have been the reason behind this incident. 2. To continue seeing unwell and complicated patients , doing an A to E assessment, make a management plan and chase the investigations in a timely manner.
3. If there is an error, openly accept it and talk to the patient ASAP which I did here.
Overall, it was a good learning experience for me as this shows how important it is to reflect and communicate openly with colleagues and patients.
No harm was brought to the patient and she was pleased that I called her and informed her about the scan result and gave advice on the management plan.
TIPS:
1. Always anonymise patient identifiable details.
1. Always anonymise patient identifiable details.
This is a nice guide:
New guidance on e-Portfolio reflective notes - The MDU
New guidance on e-Portfolio reflective notes - The MDU
2. E portfolio reflections can be used in court as mentioned here:
Academy_Guidance_on_e-Portfolios_201916-5.pdf (aomrc.org.uk)
Academy_Guidance_on_e-Portfolios_201916-5.pdf (aomrc.org.uk)
So be careful on what you mention it. Try not to blame yourself too much but also be honest and accept your mistake, what you have learnt from it and what you would do differently
NEW CLINICAL EXPERIENCE
Date of clinical event
Mention the date you saw this case
Mention the date you saw this case
Title
An interesting case of head injury
Why was it noteworthy
I saw this young patient who was admitted with confusion. I read his ambulance sheet which mentioned that he was found on the couch by his friend with drowsiness. When the paramedics arrived, they noticed that he had a low GCS, respiratory rate and was difficult to arouse. They immediately gave him naloxone and he improved.
When he was brought to ED resus, it was noted that despite naloxone, he was still having episodes of drowsiness.
I immediately requested a CT head which confirmed that he had a subdural haematoma. I then referred him to neurosurgeons and they accepted him for burr hole surgery. He remained well post operatively and was then discharged a few weeks later.
How did it affect you
How did it affect you
I learnt how important it is not put the patients symptoms down to recreational drugs especially if the antidote is not working.
How was the patient affected
N/A
How did it affect the team
How did it affect the team
The ED team was pleased that we found a cause behind his symptoms and that he was transferred to the appropriate speciality.
What was learned from this experience/what would you do differently next time
To continue basing myself in ED as a medical registrar as it helps making medical decisions and management plans for patients referred to medicine from there.
REFLECTION ON LEADERSHIP AND MANAGEMENT
We as doctors are always involved in leadership and management in some way or the other.
Examples include:
1. Leading a CRASH call
1. Leading a CRASH call
2. Talking to HR/management to improve things - by escalating concerns and providing solutions
3. Leading the ward MDT
4. Leading a QIP with a team of colleagues
5. Attending management meetings
Date:
Mention the date of the event
Mention the date of the event
Title:
Leading the SAMBA audit
Description of experience:
Every year, the Society of Acute Medicine ( SAM) does an audit nationally and compares different acute units all over the UK. This is called the SAM benchmark audit ( SAMBA).
This year, my consultant approached me and asked if I am happy to lead it. As I led a few QIPs previously, I was quite keen to do this.
First, I printed out the documents and read them in detail so that I knew what I was supposed to do which was fairly simple:
1. Have a team of health care professionals
1. Have a team of health care professionals
2. Ask them to take study leave on that day
3. Come at 0900 AM, fill out proformas of all patients admitted from midnight that day
4. Go home once done
So I met with the consultant, we discussed this plan and I asked various doctors and ACPs if they are interested in participating in a national audit.
Luckily, I got a very good response and managed to have 3 ACPs and 6 FY1s to ACCS trainees on the team.
We managed to audit more than 60 patients that day.
I ensured everyone's morale was high by ordering pizzas for them to keep them going- I always find this motivating.
I then sent each one of them an email thanking them for their participation in this national audit and that they could use this email as proof that they have participated in a national audit - to upload onto their portfolios.
I then audited the remaining notes and uploaded the data onto the electronic database.
What did you learn from this experience:
When I was a SHO a few years ago, I noticed how registrars would sometimes not participate in a project they were leading. I did not want to do this- hence I did most of the auditing and helped my colleagues.
I also ensured they did not have any clinical duties by asking them to take this day off as study day/audit day and spoke to my consultants to confirm that it will be approved.
I learnt a lot about these 'small things' which make a massive difference, especially ordering food for the team.
What impact did the experience have on your team or organisation?*: The audit team was very pleased and impressed with how well managed everything was. I was part of the team auditing with them instead of just supervising and did not let them get overwhelmed.
They also appreciated the fact that I immediately emailed each one of them after the project was complete so that they could upload this as evidence rather than waiting for weeks or months for a certificate.
Would you do anything different next time?*:
I will continue to lead national audits and QIPs. I have learnt a lot from this experience.
TIPS:
As you can see, there is so much you can reflect on here.
REFLECTIVE PRACTICE AFTER EVENTS
Date of event :
Mention the date of event here
Event:
A case of haematuria
I chose to focus on _______________ (e.g. Observation, Knowledge etc.) because*:
Knowledge of recognizing red flags and approaching the right specialties, which in this case was urology.
The event:
I saw this gentleman in ambulatory care. He was admitted with haematuria. I went through his notes and found out that he had TURBT and bladder biopsies 3 weeks ago. A MDT 2 weeks ago confirmed that he had grade 3 papillary urothelial carcinoma. He was due for a CT urogram as an outpatient and was also awaiting re-TURBT in 6 weeks. His background included: AF- on edoxaban, T2DM. I saw him in ED and he walked with me to ambulatory care unit. I then requested blood tests and requested a CXR as he mentioned that he was feeling short of breath. He also mentioned that he had dizziness and ongoing haematuria since the operation but it had got worse on that day. Examination was unremarkable. His HB came back to be 96, WCC of 13.6 and his CXR was normal. He went to reassess him and he mentioned that he had on and off pedal oedema and orthopnoea. Hence I discharged him on oral furosemide 20 mg and oral antibiotics for LRTI. I also advised him not to take his edoxaban for 3 days and safety netted him. He walked out of ambulatory care.
I was shocked when I received an email from the trust legal team stating that this gentleman passed away from hemorrhage from the site of resection of carcinoma of urinary bladder. I was asked to do a statement. I went through his notes which were all scanned onto the system and realized that I had failed to recognize that his symptoms were actually due to his anaemia. His Hb had dropped from 147 to 96. Although this did not warrant a transfusion, I should have called the urology team for advice. I felt terrible about this. I then decided that I am going to ensure that this did not happen again. So I spoke to the lead consultant running ambulatory care and suggested that we should make a haematuria pathway and I started doing informal teaching sessions on this. I now want to devise an official pathway on this, do formal teaching and share my mistake with everyone to prevent this from happening again.
I also mentioned this in my statement: Since his death, I have reflected on my role in his care, and have discussed my reflections with the Lead Investigator to the Trust’s internal investigation. On reflection, it is my view that I should have placed more weight on the decreased haemoglobin results, and should have spoken to a urologist before deciding that he could be discharged. The urology team are based not in this trust but in another trust, which is part of the same Trust. I do not know whether a urological consultant would have advised that he should be transferred to that trust for surgical assessment, but by failing to make that call, I did not maximise his opportunities, and I would like to apologise to his family for this. Since this event, I have been teaching my colleagues to avoid this mistake from happening again. I have informed my TPD, educational supervisor and the consultant running
ambulatory care unit.
UPDATE:
I have not been criticized in the inquest and after discussion with my indemnity insurance, ES, CS, TPD, SI lead and trusts legal team it has been agreed that this case is now closed and I do not need to self refer to the GMC.
EXPERIENCE/MOTIVATION: What is the most important thing you learned about yourself from the event?*:
I have learnt that everyone makes mistakes - I learnt from this incident and then taught other colleagues as well.
VALUES/CONFIDENCE: What is the most important thing you learned about yourself from the event?*:
The importance of being safe and getting specialist advice in such cases.
My priority for action is*:
1. Teaching - done. I have attached evidence in the form of feedback from my teaching sessions in my e-portfolio.
2. Reflection - done
3. Avoid repeating this again
I would like to discuss the following with my supervisor / teacher *:
I have already discussed this with the SI lead, my TPD and ES.
TIPS:
1. As mentioned above , avoid sharing any patient identifiable information.
2. Be factual and what you learnt from it
3. I had to attend an inquest for this case - I kept my reflections factual and basically stated what I had mentioned in my statement.
4. Do not blame yourself too much - these reflections can be used against you in court.
TEACHING YOU HAVE DELIEVERED
Date of teaching
Mention the date of your teaching session
Title:
Teaching session on medical errors- learning from mistakes: a case of haematuria
Type of event:
Presentation
Location:
Wherever you led this teaching session.
Immediate thoughts:
This was a session describing my experience of my inquest. I felt like it would have helped me a lot if someone had done such a teaching session on this.
Thoughts now:
I am very glad I did this teaching session.
The feedback was very humbling and the audience were really interested in this session. I have been asked to do more sessions with a wider audience so my place is to do something similar on a national level.
What did you learn:
To teach what I would have liked to be taught when I was a newly qualified doctor. And to continue teaching my colleagues.
To teach what I would have liked to be taught when I was a newly qualified doctor. And to continue teaching my colleagues.
Future considerations:
1. To continue teaching sessions - my next session will be in September with a new team of doctors.
2. To consider presenting at a national level.
TIPS:
1. Do not forget to ask colleagues to fill feedback forms:
Evaluation form for teaching and presentations | JRCPTB
1. Do not forget to ask colleagues to fill feedback forms:
Evaluation form for teaching and presentations | JRCPTB
I hope this post helps. I can give a lot of other examples but these should give you a basic idea on how to reflect, what to reflect on in a safe and anonymous way.
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