Wednesday, 16 July 2014


Last year (2013) as my thank you for the BAPIO Award for “Outstanding contribution to the health services in the NHS and abroad” I had put together the compendium of my reflective writings over the last 25 years in the NHS (download here It contains my writings on various aspects of health services (not my research publications) and range from a one pager to very substantial documents like the Milroy Lecture. Now it was not until much later, years after I started writing, that I realised that what I was doing was reflection – the term reflective practice was not much in use then and indeed even now. I sort of fell into it, mainly as a way of improving my writing skills which were (are) essential for public health practice, and once I got the ‘bug’ I kept going and tackled increasingly complex subjects including my observations on medical leadership and about my time as the GMC Council member. I had discovered that writing made me think and make sense of what I had observed or done and most importantly how I could improve. 

The publication of the compendium has provided further impetus and I now want to find out more about reflective practice. I realised that I had approached the subject back to front. Until very recently I had very limited knowledge of the theory of reflective practice and I basically did what I felt like! I did not know ‘Reflection on Action’ from ‘Reflection in Action’. 

The definition that I find useful now is from Boud et al who define reflection as ‘‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’’ (p. 19). Schon introduced the concept of the ‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. (from 1) 

Simply put, critical reflection is the process of analysing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice). (2)

Now, you must wonder why I am being so self-indulgent, and what does it mean for clinicians.

In this regard, this analysis probably sums it up

“If we take the example of a medical mistake, a superficial, educationally ineffective reflection will consist of a description of the events or a description accompanied by reasons such as the team/clinic was busy and other people failed in their responsibilities. A more useful and deeper reflection would include consideration of how and why decisions were made, underlying beliefs and values of both individuals and institutions, assumptions about roles, abilities and responsibilities, personal behavioural triggers, and similar past experiences (‘‘when pressed for time, I . . . ’’), contributing hospital/clinic circumstances and policies, other perspectives on the events (frank discussion with team members, consultation of the literature or other people who might provide alternative insights and interpretations), explicit notation of lessons learned and creation of a specific, timely, and measurable plan for personal and/or system change to avoid future similar errors. Effective reflection, then, requires time, effort and a willingness to question actions, underlying beliefs and values and to solicit different viewpoints. This ‘‘triple loop’’ approach moves beyond merely seeking an alternate plan for future similar experiences (single loop) or identifying reasons for the outcome (double loop) to also questioning
underlying conceptual frameworks and systems of power.” (2)

In essence, reflection is the basis of patient safety and is about learning from mistakes and putting things right. It is a bit like the “5 Whys’ approach to investigating incidents whereby one keeps asking why at each stage of questioning until you understand the root cause. 

Now, look at your, and others, practice- how far up this triple loop scale are you? When you make notes after CPD are you being critical/reflective enough? Is revalidation in danger of becoming a tick box exercise? Are we really doing enough for patient safety – do we know the root causes in our settings and are we addressing them, and why not? Are we ‘learners’ and able to constantly innovate and improve?

These are some fundamental questions facing us as doctors. We have to provide the leadership in these challenging times in the NHS, and central to being a leader is insight, self-awareness and ability to reflect and learn. In any case, the future of medicine is self- and life-long learning, and without a good grounding in reflection it will be difficult to cope with increasingly demanding jobs. 

So what could/should we do – can we do something together? Do you think we need more reflective practice in the NHS? Can you help me in my journey? Can I help you? Shall we form a group – virtual or real – to develop this further?
I will be very interested to hear from you- contact me at

16 JULY 2014

  1) Mann K, Jill AE, Macleod A. Reflection and reflective practice in health professions education: a systematic review. Adv in Health Sci Educ (2009) 14:595–621
 2) Aronson, L. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher 2011; 33: 200–205