‘I feel many of my reflections are forced’: International medical graduates’ perspectives on reflection in UK general practice training: a mixed methods qualitative study

Summary

This study analyses the combined free-text responses from national survey data and data from follow-up interviews with IMGs working within UK GP training, to better understand the experiences of reflection for this group of individuals. IMGs described how overall they felt positive about reflection as it provides an effective learning approach, is helpful for self-assessment and personal development, and is a method with which they were able to develop self-awareness.

The most common challenge to reflection was the time taken to complete entries, often compounded by a lack of familiarity with reflection and the challenges of English as a second language. The mandatory aspect of reflection within assessments was a concern; for example, having specific numbered requirements and the pressure to tick off curriculum items made entries feel forced, with many trainees describing ‘tailoring’ their entries. There was recognition that this could devalue reflection. It also seems that the effects of the Bawa-Garba case¹² are still being felt by many IMGs who expressed concerns about confidentiality and fear of medico-legal consequences.

Strengths and limitations

The analysis in this study triangulated themes from a large sample of qualitative verbatim data from two open questions in a survey and data obtained from purposive in-depth interviews. It is striking that the richness and depth of free-text survey comments mirrored the richness of the verbatim data from the interviews. These two methods of data collection produced the largest qualitative dataset to date on the experience of reflection by IMGs. Our sample of IMGs shows both sex balance and ethnic diversity.

Interview participants were initially recruited from a pool of survey participants who had expressed an interest in further involvement in the research. As trainees self-selected for interview, it is possible strong negative or positive views regarding reflection are over-represented in the data. However, for the purposive second phase of recruitment, the participants had a more general interest in research involvement rather than having specific views on reflection. The large proportion of survey responders who chose to complete optional free-text questions on the best and worst aspects of reflection means the data comes from a wide diversity of participants from across the UK. Considering this diversity, our findings are both credible and transferable.

Interviews were conducted by the lead researcher (LE), who at the time of interviews had recently completed GP training (CCT January 2022). This near-peer approach of data collection, along with the anonymity of transcripts, seems to have allowed trainees to express negative views without fear of repercussions. Participants were also aware that LE was the only person to have access to identifiable data.

In order to maintain reflexivity, field notes were taken, and an iterative approach to data collection and analysis was maintained through regular team meetings (LE, BJ, CM), with findings subjected to critical interpretive challenge. Self-awareness about disciplinary bias was crucial during analysis as BJ and CM are academic GPs who are also GP trainers with experience of supervising IMGs. A stakeholder group comprising doctors with experience of working and training abroad was involved at all stages of the research including development of the interview schedule and analysis of data.

Comparison with existing literature

According to the AMEE guidance for reflection in medical education, reflection is key to self-regulated life-long learning and the development of professional expertise. This is because it enables greater understanding of the self and situation that then informs future actions.¹³ Certainly there is considerable overlap with the themes from our data, which suggest that IMGs see the potential for professional development through assessment of the self and clinical situation as key benefits of reflection.

IMGs are known to have less experience of reflection as a learning approach in their undergraduate training than their UK-trained colleagues,⁹ and it has been suggested that early introduction to and understanding of reflection could be beneficial to their progress in training.¹⁴ The data presented here suggest that although reflection may be unfamiliar for IMGs, they have a good understanding of the benefits of reflection in respect to GP training. Difficulties encountered in engaging with reflection are unlikely to be related to a lack of understanding of these benefits, more so that reflection is time-consuming, especially when reflection itself is unfamiliar and required to be submitted in writing when English may be a second language.

It is, however, important to remember that this group is by no means homogenous; individual trainees will each have different experiences of education. Indeed, the term IMG simply relates to people who have obtained their medical qualification in a country other than the UK. Some may have been educated to secondary school level in the UK before choosing to complete their medical degree abroad, others may have extensive experience of the NHS through foundation training and previous specialty posts before embarking on GP training.

Previous literature has made clear that when reflective writing is submitted as a form of assessment, this changes the nature of what is written; students write what they think their assessors want to hear, rather than a true account of their experiences.^2–4 Our study suggests this is the case for many trainees, that having curriculum competencies that they need to evidence, and numbers they need to fulfil, means that entries are perceived as forced. Some change what they write depending on who will read it. It could be argued that this negates the benefits of reflection as a tool of personal and professional development entirely, instead creating the ‘reflective zombies’ described by de la Croix and Veen.¹⁵

Concerns about confidentiality of reflective entries and fear of medico-legal consequences seem related to the effects of the Bawa-Garba case;¹² specifically reports in the media that the doctor’s reflections from their online portfolio were used as evidence against them in court.¹⁶ Several trainees made direct reference to this case in their responses. This correlates with the findings from a previous study in which GP trainees’ engagement in reflection post-Bawa-Garba showed considerable anxiety about confidentiality of entries, with international graduates in particular being identified as more vulnerable to the medico-legal consequences of reflection owing to their lack of familiarity with this method of learning.¹⁰

Implications for research and practice

This mixed-methods study provides important insight into IMGs’ views of reflection as part of GP training. Although most IMGs are unlikely to have experienced reflection as part of their undergraduate training, our study suggests that they are aware of the benefits of reflection for personal and professional development.

In order for IMGs to engage effectively in reflection, we need to support them in the development of this important skill, taking into account some of the difficulties highlighted in this research. We would encourage GP training educators to focus on quality rather than quantity when making their recommendations for number of written reflections expected of trainees in their portfolios. From interview data, requirements varied across the UK; for example, numbers of written reflections expected ranged from one entry every fortnight to 3–4 per week. Mandating high numbers of reflections from trainees is likely to contribute to the sense of entries feeling forced, adding to time pressure and potentially limiting learning from reflection.

On an individual level, GP educators are encouraged to engage in a discussion with their trainees about their experiences of reflection and their confidence in written reflections. The data show that within this group of individuals there is diversity in experience and enjoyment of written reflection. Where there is less experience of reflection, trainers may find that engaging in a reflective conversation with trainees will assist in their understanding, allowing trainees to be guided through a case or experience with questions and feedback.

Medico-legal concerns continue to be a main barrier to engaging with reflection. To address this, we suggest approaching reflection from a more theoretical perspective as described by Moon.¹⁷ The focus on reflection from a theoretical perspective is on the reaction to an event rather than the description of it, and is therefore less problematic from a medico-legal viewpoint. Several local schemes in the Yorkshire and the Humber GP school have adopted Moon’s exercise ‘The Park’¹⁸ in their reflective training, and LE has produced a series of 3–4-minute videos and short exercises to guide reflection according to Moon’s principles. We would recommend that further research aims to identify and evaluate such resources for supporting reflection so that recommendations for best practice can be made and adopted nationally.

Ultimately, we would suggest that the RCGP considers its use of reflection as a means to evidence curriculum coverage carefully, because by using reflection in this way, we risk devaluing reflection as a tool for professional development. In the meantime, we hope these evidence-based practical tips will be adopted by GP trainers to help their IMGs overcome the challenges presented by reflection.