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How can GP supervisors better facilitate reflective practice in their registrars?
What is reflective practice?
‘The aim of all supervision and feedback is to make learners reflect on their practice’.
Clinical practice is far from straightforward. GPs practice complex competencies in a clinical world rich with uncertainty and where the textbook knowledge only provides some of the answers. Clinical decision-making therefore requires GPs to combine experience-based knowledge with evidence-based knowledge, but also to constructively process both formal and informal feedback.
The ability to reflect is necessary for efficient use of feedback and essential when performing complex competencies in practice. It has been argued that the ability to reflect on one’s own role and performance is the key factor in expertise development – indeed, that the aim of all supervision and feedback should be to facilitate the learner’s reflection on their own practice.
What is the difference between ‘clarifying supervision’ and ‘expanding supervision’?
‘Clarifying supervision’ is based on direct instruction and confirmation of a decision, whereas ‘expanding’ or ‘broadening supervision seeks to generate reflection through questions that create ‘productive struggle’, link knowledge with practice, or broaden the case. The nature of the registrar and situation may determine which type of supervision is most appropriate, but expanding supervision allows for significantly greater reflection and professional development.
How do I enhance reflection? Asking good questions is the key. For example:
INVESTIGATIVE QUESTIONS
- What are your considerations?
- Why did you choose… (to give an ACE/these tests)?
- Why do you think she seeks the doctor just now?
- Is this normal for… (people at that age)?
- Did you ask about… (symptoms/concerns)?
- Is that a high ALAT value?
CHALLENGING AND BROADENING QUESTIONS
- What could have made you choose to refer the patient?
- How does this situation differ from..
- What if… (the patient had a fever)
- Would it affect your decision if you knew that…?
- What would be the next step?
- What would be your second choice in case of side effects?
- What else could it be?
Reflective questions can be used at all times of case discussion, even in the brief corridor consultation.
WHAT ARE THE PITFALLS?
It is important to not ‘examine’ the registrar and make them feel uncomfortable.
WHAT ARE THE KEYS TO SUcCESS
- Time
- Registrar preparation
- Choosing the right material (e.g. patient case)
- Thinking about what they need your help with
- 40-20-40 model (40% of the learning happens before the session (preparation) and 40% afterwards (implementation))
How can we assess reflection? What is the GAR tool?
Some competencies require discussions broader than a series of patient cases. It is important to assess reflection because of its link to good clinical practice. A new tool has been developed called the Global Assessment of Reflection Ability (GAR) (Lillevang et al. BMC Medical Education (2020) 20:352).
The GAR is a tool for formative and summative assessment of the ability to reflect. It works in two parts.
Part 1 – Preparation:
This begins with the trainee presenting his/her mind map/written presentation which then is the basis for a structured discussion between trainer and trainee that includes references to the concrete experience that the trainee has had.
Part 2 – Structured discussion:
The trainee produces a mind map or similar written presentation in a concept formation process addressing a concrete, complex competency. The trainee is given 1-2 weeks for the preparation and uses the description of the competency in the curriculum.
During the discussion the trainer assesses the following:
- Does the trainee show ability to reflect on the problem/competency and on his/her own role as a GP according to the matter?
- Does the trainee demonstrate relevant analytical skills concerning the problem/competency?
- Is the trainee able to participate in an open-minded dialogue and demonstrate relevant flexibility?
The focus of the discussion is on formative aspects leading to a plan for further learning, but it also includes a summative assessment of whether the competency is successfully achieved.
What are the three most important take away points?
- The aim of all supervision and feedback is to make learners reflect on their practice
- Reflection is facilitated by asking good questions
- Preparation by the registrar (where able) significantly enhances learning
What are some useful references and resources?
- Lillevang, G., Ibsen, H., Prins, S.H. et al. How to enhance and assess reflection in specialist training: a mixed method validation study of a new tool for global assessment of reflection ability. BMC Med Educ 20, 352 (2020).
- Global assessment of reflective ability (GAR)
- GPSA How to…assess and teach clinical reasoning
- GPSA How To Do.. Problem Case Discussion
Date reviewed: 15 February 2025