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1a
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‘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) |
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1b
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‘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) |
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1c
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‘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) |
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1d
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‘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) |
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1e
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‘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) |
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1f
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‘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) |
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1g
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‘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) |
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1h
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‘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) |
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1i
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‘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) |
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1j
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‘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) |
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1k
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‘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) |
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Theme 2: Revealing unfairness through reflexivity
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2a
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‘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) |
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2b
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‘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) |
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2c
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‘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) |
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2d
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‘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) |
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2e
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‘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) |
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2f
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‘We know that primary care is systemically racist, possibly more even than hospital.’ (GP8-Interview) |
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2g
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‘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) |
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2h
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‘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) |
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2i
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‘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) |
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2j
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‘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) |
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2k
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‘It’s the inverse care law of education, isn't it?’ (GP10-Interview) |
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2l
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‘Their insights got less after [Bawa-Garba]. They stopped being self-aware. They stopped talking about their emotions.’ (GP13-Focus group) |
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Theme 3: Tokenistic reflection versus creative reflexivity
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3a
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‘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) |
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3b
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‘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) |
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3c
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‘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) |
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3d
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‘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) |
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3e
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‘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) |
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3f
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‘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) |
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3g
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‘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) |
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3h
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‘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) |
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3i
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‘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) |
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3j
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‘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) |
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3k
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‘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) |
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3l
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‘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) |
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3m
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‘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) |