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Theme 1: The value of reflexivity 1a ‘Having learned more about it I'm convinced that reflexivity is important for promoting inclusion. This is beyond reflection. This is about us consciously thinking about our values, our judgments and our perceptions and changing them. […] That’s crucial in the context of the IMG workforce.’ (GP9-Interview) 1b ‘I thought we were reflecting on why we hadn't recruited, […] but actually, I've been thinking about what it is about me that meant we haven't recruited to the roles that we wanted to recruit to. I think that was myself trying to work out what being critically reflexive is.’ (GP5-Focus group) 1c ‘The more I read [about reflexivity], the more I realised, it is about doing what most of us already do — become thinking doctors. We think about patients, … our interactions with colleagues.’ (GP12-Focus group) 1d ‘I said to him [...], “Well, the elephant in the room is you’re a white male, and she was expecting to see someone of colour.” Ten years ago there’s no way I would have had the confidence to say, “It’s because you're a white heterosexual man that this Black African woman did not get on with you” He just couldn't believe it.’ (GP10-Interview) 1e ‘If anyone with alcohol or drug dependence comes in, I spend a lot more time with them. […] I feel they should have the time because they don't often get it. But when I thought about it, I realized that actually it’s because one of my relatives was an alcoholic.’ (GP7-Interview) 1f ‘Although I came to this country as a teenager, I'm not an IMG. I'm a UK graduate so I can only have some experience of the journey [the IMGs] might be taken through, not fully.’ (GP9-Interview) 1g ‘I didn't realise that the perception was that I'm quiet [...] I'm never short of words so I was quite surprised! Because in meetings — I thought — who wants to listen to the trainee? But it was cultural. I didn't realise — I was expected to speak and share.’ (GP11-Focus group) 1h ‘I think [reflexivity] increases with awareness of self. How much we know, how much we don't know, and how much we're willing to grow to get to that point of finding value through reflection, I suppose.’ (GP4-Focus group) 1i ‘Sometimes I can do it because I understand how my culture and my thought process can influence my consultations. Unless I have an appreciation for their culture and background, it might be difficult for me to signpost that trainee to challenges that they're having.’ (GP7-Interview) 1j ‘If you’re feeling. “Oh, I can't reflect on this. I have to reflect on things that do not bring out my biases or vulnerabilities”, perhaps those things might not come out and they might be huge barriers to learning or someone’s professionalism in the future, if you've not been picked up quite early on.’ (GP4-Focus group) 1k ‘It’s allowed me to, particularly when there’s a tough situation a trainee is in, to push a pause button and have a template, a go-to process that you refine over time and keep improving on. [...] And I always feel that that if it allows me, my trainees, my colleagues, to move forward and grow, then I think there’s immense value.’ (GP14-Focus group) Theme 2: Revealing unfairness through reflexivity 2a ‘In places like India and Africa you need to be highly, highly academic to get into medical schools. So, these motivated trainees, when they move to the UK, because of the systemic and institutional issues they face, they're being challenged. There’s a perception that these trainees are somehow not good enough.’ (GP9-Interview) 2b ‘I think it’s a really important part of our role as educators to recognise the power we hold, and the vulnerability that goes with that. People can feel very vulnerable in this unless we create very clearly a safe space.’ (GP12-Focus group) 2c ‘We work on a deficit model. We're only looking for things that you're not getting right, rather than things you are getting right. It’s hard to admit to not doing things well when you're working in a structure where those things are going to be jumped on.’ (GP8-Interview) 2d ‘Well, the exams [...] are racist. It must be quite demoralising to know, “I'm sat next to someone who’s got a 98% chance of passing first time. And I've got a 40% chance”.’ (GP10-Interview) 2e ‘That’s the institutional bias, because as inclusive and understanding as I might want to be about my trainee’s way of practicing because of their background and influences, I'm still assessing them based on what the mark sheet says.’ (GP7-Interview) 2f ‘We know that primary care is systemically racist, possibly more even than hospital.’ (GP8-Interview) 2g ‘There were some in the room that were really shocked. “Well, it’s not that. You're calling me and my organization, and my country racist!” They weren't willing to engage in the thought that it could be something to do with discrimination rather than ability.’ (GP10-Interview) 2h ‘So, you got a brown Prime Minister, a brown Home Secretary and lots of BME people in leadership who haven't improved the outcomes for the community that they've come from. That’s partly because of structural racism, because if you act in a different way to the organisation you're part of, you're side-lined. Even the organisations that are supposed to represent doctors have issues with leadership and structural racism.’ (GP9-Interview) 2i ‘In [named city] now there are more GPs who are BME than are white. But whether that’s changed the power structures at all, it'd be interesting to know’. (GP8-Interview) 2j ‘I have trainees traveling miles in order to come to my training practice [...] just because they have lower scores I guess [...] They are just set up to fail, really.’ (GP3-Focus group) 2k ‘It’s the inverse care law of education, isn't it?’ (GP10-Interview) 2l ‘Their insights got less after [Bawa-Garba]. They stopped being self-aware. They stopped talking about their emotions.’ (GP13-Focus group) Theme 3: Tokenistic reflection versus creative reflexivity 3a ‘There’s pressure in this “factory” to produce a “package” at the end of 3 years; the pressure on these wonderful young men and women, who have a lot of potential, can be quite erosive.’ (GP14-Focus group) 3b ‘Get rid of recruitment scores and mix it all up. And by diversifying, it’s better for patients, better for the training program.’ (GP10-Interview) 3c ‘I think IMGs have lots more anxiety because they feel that they're not doing well, just because they're not writing this wonderful prose for the trainers to look at.’ (GP3-Focus group) 3d ‘A few years ago, I would have been very positive about reflective writing, but now it’s become a “something that you have to do in an e-portfolio” that people are going to mark. And actually, realistically people don't even read it.’ (GP8-Interview) 3e ‘We moan and [in panel] someone might make a comment like “I think your entries could be more reflective,” but I've never heard of a trainee failing for not being reflective.’ (GP1-Focus group) 3f ‘I think we'll move away from reflective writing because of ChatGPT, and start having “assessed reflective conversations,” which I don't like the idea of either. Your supervisor will say “We're going to have a reflective conversation and I'm going to assess you on it”.’ (GP8-Interview) 3g ‘What you feel today, you might feel even tomorrow, but actually [...] in 5 or 10 years’ time, who wants that fairly inane thing you may have written down with great feeling, to still exist?’ (GP2-Focus group) 3h ‘Maybe we should get much better at verbal reflection and reflexivity, [...] because if somebody else listens and really hears, that is terribly important in the moment.’ (GP3-Focus group) 3i ‘Sometimes when you're talking out loud about problems, you arrive at the answer yourself without having needed anyone else to be involved in that conversation.’ (GP7-Interview) 3j ‘Or an AI bot saying, “Did this consultation go this way because of you, and how you come across, what you stand for, your culture, your way of learning, your way of practicing medicine.?” [...] It starts the conversation.’ (GP10-Interview) 3k ‘If you have an experienced facilitator who can include the views of the quietest member of the group. I feel that there’s empowerment implanted there.’ (GP14-Focus group) 3l ‘Let’s mix these groups up … at least you've got the diverse conversations now. You don't have to be friends, but you listen to each other’s different opinions because you're not alike now.’ (GP13-Focus group) 3m ‘When I was a trainee, I didn't see the value of small group work. But when I became GP, I was so glad to be part of those discussions, because that’s where you kind of unpack. [...] Even for like 20 minutes once a week where you kind of bring in some cases, to discuss, reflect on, in a very safe space.’ (GP9-Interview) Findings Recommendations GP educators are generally unfamiliar with the concept of reflexivity but are aware how their culture and background affects the judgements they make
They are keen to know more and expressed concern about the need for a more reflexive and less prejudiced workforce
GP educators are comfortable with reflexive narratives, instinctively linking their own experiences to their work as clinicians and educators
They recognised the value of reflexivity in educator–learner relationships, using it to tease out blind spots and sharing their own limitations to help disentangle challenging moments
Embed teaching on reflexivity into current training programmes for educational supervisors
Consider teaching about reflexivity in conjunction with current diversity teaching
Continue to support and fund peer-mentoring groups such as trainers’ groups
Prioritise the weekly tutorial, identified in the research as one of the most fertile areas for promoting reflexivity
GP educators were very concerned about the vulnerability of their learners in their written reflections, particularly following Bawa-Garba
They call for more reassurance around psychological safety for learners
They identified that structures often unfairly impacted on IMGs
Several educators identified a lack of organisational reflexivity and identified structural racism withing GP training structures
Educational and clinical supervisors to recognise the vulnerability of their learners
Easier access to existing wellbeing services
Consider more targeted support for IMGs around induction, linguistics, and seeking help that continues throughout the training
RCGP and DHSC to consider how to encourage more diverse leadership within primary care
GP educators have concerns about mandated reflective writing, and believe it adversely impacts IMGs who do not have the linguistic capital
AI could upskill IMGs’ writing, but there is concern that the reflections would no longer be genuine or reflexive
GP educators often prefer reflective conversations that feel safer or private reflections that are not shared
They suggested creative and innovative alternatives, for example, voice notes, AI, and other creative projects to encourage reflexive thinking
Although learners often prefer lectures, GP educators felt that group work was superior and could develop more reflexive thinking
GP educators would like to see structural change such as free exams, or no exams, more diversified training schemes by abandoning the recruitment scores, less time in hospital and longer training
RCGP to consider the value of mandated written reflection in the era of ChatGPT
Continue to support the value of tutorial discussions and the case-based discussion in promoting reflexivity
Medical faculties to recognise the value of innovative and creative educational tools and promote these in TPD conferences and educator workshops
Prioritise group work with good facilitation in the half-day release
Consideration of longer training for GPs and abandon the use of assessment scores in recruitment and allocation of GP trainees
AI = artificial intelligence. DHSC = Department of Health and Social Care . IMG = international medical graduate. RCGP = Royal College of General Practitioners. TPD = Training Programme Director
Suggested solutions to foster reflexivity Opportunities Drawbacks Encouraging reflexive conversations Tutorials and role play
Adapting the case-based discussion to encourage critical self-examination
Learners may be vulnerable and exposed if educators not reflexive in response
Concerns around privacy and security, for example, notes of conversation
Embedding reflexivity into new educator training Introduce modules on reflexivity into new educator courses
May result in superficial reflexivity
Developing reflexivity in existing educators Using trainer groups
Workshops in training programme director and educator conferences
Educator cynicism and burnout
Encouraging more group work Established technique
Can be integrated into existing VTS sessions
Needs expert facilitation to encourage reflexive thinking
Needs protected time
Not valued by learners
Identifying mentors Highly valued by vulnerable learners
Informal mentoring already takes place
Costs involved identifying, recruiting, training, and renumerating mentors
Ensuring everyone has access
Creative or artistic projects Collaborating with artists, actors, musicians, and so on
Scepticism from learners
Educators maybe reluctant to lead sessions
Using AI Using AI to improve reflective writing
Using AI to pose questions to explore critical self-examination
Concerns regarding inauthenticity
Concerns regarding privacy and data security
Voice notes Quick, easy, authentic
Can be uploaded into the eportfolio
Needs transcription (but AI should help with this task)
AI = artificial intelligence. CBD = case-based discussion. VTS = Vocational Training Scheme. TPD = Training Programme Director
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