Reflective Writing in GMC Cases – Showing Insight

Demonstrating Insight in GMC Cases

The General Medical Council (GMC) requires all doctors who are going through the Fitness to Practise (FTP) process to demonstrate that they are fit to practise medicine, where they have previously fallen short of the standards and conventions that they should have worked to.

The GMC Case Examiners, who assess whether a case can be closed on paper or should be referred to a fitness to practise hearing, at the Rule 7 stage, are greatly helped, in their assessment of a doctor’s fitness to practise, if a doctor submits insightful reflections in writing. The same can be said about the Rule 4 and preliminary enquiry stages. Many doctors fail, however, to properly evidence their defence case or their points of mitigation, and in so doing they will miss the opportunity to influence the process and the outcome of the case. A costly FTP hearing might then follow, which could have been avoided had the doctor spent time on formulating a considered response, including a detailed reflective statement.

Likewise, at a fitness to practise FTP hearing, the MPTS panel will be greatly assisted if the doctor is able to provide evidence in mitigation, and evidence of personal insight – at the impairment stage and/or sanction stage of the FTP proceedings.  A doctor should write out their reflections, giving careful thought to what they want to say, with a view to submitting their writings to the FTP panel. The exercise will also assist the doctor in presenting their case when they give oral evidence.

Where things have gone wrong this should be accepted (“Embrace the conduct” – to take ownership of it), where appropriate (if the alleged conduct is admitted). Reassurances will need to be given, that there will be a negligible risk of repetition or that any ongoing risk can be properly managed. If a doctor has taken steps to remediate their shortcomings, this will be relevant to the GMC’s assessment of the doctor’s suitability to practise. The doctor will need to demonstrate an understanding of how the (mis)conduct came about, how they have reflected on events, and what they would do in the future if they were to get into difficulties.

Note that some admissions might also be relied upon as a formal admission in law, being admissible in civil or criminal proceedings. Legal advice should be taken on this.

A reflective piece can be relevant to health cases as much as misconduct and deficient performance cases. Where ill health has contributed to the doctor’s difficulties, the history of events should be explained and the future management of any ongoing condition or risk of relapse will need to be considered.

Before writing a reflective piece, doctors should read the GMC’s/MPTS’s Sanctions Guidance. The following flowchart, which identifies some of the principle factors to be considered, may, also assist doctors in their task.

The image above can also be downloaded in A4 size as a pdf format document: Demonstrating Insight in GMC / MPTS Cases

The above flowchart has been compiled by lawyers at Doctors Defence Service who have had many years of experience of representing clinicians before their regulators.

MPTS panels look at  thevarious underlying themes and public policy considerations connected with the allegations that a doctor is facing. In our experience, the tribunal will look at a number of factors, including: how and why the incident or incidents came about; the personal circumstances of the doctor; the duration of time the conduct complained about took place over; the lessons that the doctor has learned since; the steps of remediation that they have undertaken or are intending to undertake; the future risk of repetition; and whether the doctor has shown genuine regret or remorse. This list is not exhaustive but will be of assistance to doctors reflecting on their past (mis)conduct, and future ambitions.

Doctors should consider, in turn, each of the allegations that they are facing, asking themselves whether their conduct has undermined the confidence and trust that patients and the public ought to be able to put in doctors. And, whether there are any safety or public protection issues that the doctor must explore, in order demonstrate that they have thought through the implications of their conduct, have taken remedial steps, and can evidence insight. A written reflection is an important part of any doctor’s defence or mitigation case. It should be a carefully crafted and well considered piece of writing. It should take into account the obligations placed upon doctors by the code of conduct for doctors Good Medical Practice (GMP).  A doctor who writes a reflection should quote and cross-reference the relevant passages of GMP, and refer to how it relates to their practice, and their learning. This is not something that can be rushed. It should also be done with great care. It should not be a short document, as short documents will suggest that the doctor has not given careful thought to the history.

The reflection should be supported by other evidence, if available, to demonstrate the authenticity and quality of the doctor’s learning, and of their developing insight. Discussions of professional values with other doctors or healthcare professionals can be helpful, too, to identify and discuss learning points.

A doctor who appears to minimise their responsibility for the things that have happened in the past risks a more servere outcome, than if they are able to demonstrate a full understanding of their failings or misbehaviour.

Showing full insight means accepting responsibility for the full history, showing recognition of how the conduct has impacted on colleagues, patients and others, and on the public’s confidence in the profession.

It should be be borne in mind that professional misconduct can be by way of act or omission, and the causes that led to the conduct of concern may need deep analysis to identify the relevant learning points. Deep analysis, remediation and reflection, is key to achieving full insight.

In some instances, a doctor might come too close to the subject-matter and not been able to see the bigger picture. This would be potentially be a boundary issue, and a course on boundaries may be helpful, before writing a reflection on preventing repetition in other situations in the future, by way of example.

In some circumstances, it may be appropriate to send patients or colleagues letters of apology. It is not always appropriate to send a formal apology, and so legal advice should be obtained on whether it is appropriate in a given set of circumstances. Nevertheless, in many cases it will be appropriate to make an apology within a reflective piece of writing submitted to the GMC/MPTS.

A doctor must be able demonstrate that there is a negligible or nil risk of repetition, where they can. In health cases, where there is an ongoing illness or risk of relapse, a doctor will also need to show that they have an action plan for when they become ill again, and have thought through and implemented strategies to remain well.

Even where a doctor does not admit a GMC allegation, they should still work through the same reflective process, in order to identify any steps or measures that they can take, to reassure others that there is a low or negligible risk of repetition in the future. This is an oft-misunderstood step that a doctor (who denies an allegation) needs to take, if they are to increase their overall prospects of success.

It may be useful to read the GMC’s guidance on undertakings, and GMC guidance on assessing insight in health cases, GMC guidance on assessing risk in health cases, GMC guidance for decision makers on assessing the impact of health in misconduct, conviction, caution and performance cases, which are written for those GMC staff, case examiners, or independent panellists, tasked with such responsibilities. These guides are a useful resource for doctors to read when considering how to respond to the GMC in writing.

A doctor may need to evidence the depth of their reflective thinking by completing courses (online, and face-to-face in a classroom, or with a personal tutor). A doctor needs to be able to demonstrate that they have fully explored: a) the duties and responsibilities of a doctor, b) the need for probity in all they do, c) the ethics of their past and future conduct, and d) the need to be fully up to date on changes in medicine. They also need to show that they do not have any deep-seated attitudinal problems that are incompatible with their ongoing practise of medicine.

Some examples of showing insight in specific situations:

A doctor who has had allegations of incompetence made against them will need to demonstrate not only that they have overcome their shortcomings, through remediation, they will also need to demonstrate how they will not fall into error in the future.

A doctor who has been dishonest will need to show that they have identified at root why their dishonesty occurred. They must explain the the changes made to their work or private life to prevent repetition, and show how they can ensure that the public and the profession can trust them again in the future. Evidence from others on the doctors probity will also be of value.

A doctor who has had allegations of sexual harassment or sexual touching made againt them by, say, colleagues or patients, needs to be able to demonstrate that they have reflected on their conduct, taken steps to work through any defective-thinking or beliefs that they once held, understand fully the impact of their past conduct on others, and to have taken steps to ensure that they do not transgress again. Even in situations where the sexual element of a situation is not proved, the general conduct of the doctor that led to a misunderstanding might still require insightful reflection and relevant remediation. See our article: ‘Sexually Inappropriate’ Doctors

The impact of a doctor’s conduct on patients or on the ‘victim‘ of an incident or other improper situation needs to be examined and understood. The impact on the doctor is of lesser concern to the regulators than the impact on others, including victims and members of the public who may lose confidence in the profession, the GMC, or the doctor.

The above guidance is not an exhaustive list. Each case turns on its own facts. And each doctor has their own unique history and outlook, which may mean that some struggle to understand why they are in difficulties. One or two doctors never gain full or any insight. For others it takes a long time to develop insight, and so they have what is often referred to in GMC cases as ’emerging insight’. Other doctors will have achived full insight. The less insight a doctor demonstrates the more likely that there will be an adverse outcome in their GMC case. Writing a good reflective piece is a key part of working through the issues and arriving at a state of full insight, in our view.

Where a doctor has to give evidence, they will find that their written, reflective writings will aid them in expressing themselves when they are asked difficult questions, under pressure. A doctor who does not answer well questions put to them may be found to have little or no insight. Such a finding would increase the risks of an adverse outcome, at a GMC or MPTS hearing.

In summary, a doctor must spend a considerable amount of time properly working through the issues in their case, if they are to develop and show full insight. MPTS panels and GMC prosecutors have a knack of asking questions that draw out the hollowness of a doctor’s assurances, that they have full insight. A doctor who does not have genuine insight is at risk of being seen as someone who is just saying things that they think others want to hear (i.e. just paying lip-service). The risk of a signicant sanction being imposed increases in such circumstances. Poor insight or no insight is very likely to  lead to erasure, in certain classes of cases. It should also be noted that in certain classes of serious cases, even full insight and full remediation will not lead to a doctor keeping their registration.

A doctor should produce more than one reflection. If there is a delay in the legal process taking place, it is important to keep revisiting the issue of reflection. Note, it is important to date all reflections, so that a tribunal can see the development of insight. Case studies, giving examples of good practice might also be of assistance. These should be written in a way that ensures that nobody could be identified from the writings. One needs to approach this type of written work with great sensitivity.

The Use of Language in Reflective Writing

A doctor needs to determine whether they have fallen into error, made a mistake, or whether their actions have different descriptive contours. This is important for the way that they address the concerns raised against them. See our article on Remediation for more details on this aspect.

A reflective piece of writing should be written with respect for others involved in the history of events, and be sincere. It should not merely give lip service to a subject matter. The greater the analysis and reflection, the more beneficial the total exercise is likely to be. The reflection is not merely about persuading others that the doctor has made changes to their practice, or their approach to the engagement with others, but to demonstrate a detailed personal journey of learning, which is embedded and which will stand up to scrutiny.

Quotations

Where a doctor quotes from documents, they must make it clear that they are quoting, and cite the source. A doctor should not copy pages of other documents and drop it into their reflective essay, as that could risk an allegation of plagiarism being made. It is therefore essential to use quotations and citations and then individually comment on how the doctor has interpreted the passage, how they have applied that to their analysis, and how it has influenced their judgment and practice, moving forward.

For example, if we take an allegation of inappropriate flirtation in the workplace as a discussion example: a doctor who is alleged to have inappropriately flirted with a colleague at work should read widely on sexual harassment and workplace boundaries, and go on courses on the same subject matter. They could then quote from some of the material that they have seen (as per the following (entirely fictitious) example):

1. I have read an article called ‘Inappropriate Touching in the Workplace’, by Gordon and Savage, published by William and Hakin University Press, (1989), pages 17 to 24. In that articles it is impressed upon the reader that people want to go to work without the pressure of undermining conduct of others. They wrote about a survey of clinicians in which:

‘In our survey of 1000 healthcare practitioners (undertaken in 1988), 98% indicated that they had been subjected to unwanted and inappropriate sexual or romantic overtures, or touch, from colleagues in the workplace, which had the impact of undermining their confidence generally, and which undermined their dignity in the workplace and which caused lasting harm. To go to work to be harassed was not something that many had anticipated would happen.’ (Gordon and Savage 1989)

2. Discussion: I was surprised about the high a figure that people were harassed at work. This has caused me to be much more aware of my own body language, my communication styles, and the subjects that I would speak about with colleagues. I was not self-aware enough at the time of my conduct, that my alleged conduct could be construed as unwanted or even harmful. I have reflected at length about what has occurred and I believe that I am in a much stronger place today to be able to avoid conduct that is unwanted. I must avoid such conduct altogether, and actively think about my communication style and body language. I steer clear of subjects that might be over-familiar. …….

[continued for another half page, before moving onto the next quote or course attended].

Bibliography

A bibliography of wider reading, with a summary of the contents, is also a helpful thing to include in a reflective statement, even where the article has been referenced elsewhere in the reflective document. There are many academic articles on subjects relevant to remediation and insight. A bibliography example might be written as follows:

Bibliography

1. 1. Dishonesty Among Student Doctors (1983) – Jones and Walker, Balmoral Accounts Press, pages 12-14
   2. Probity in Action (2017), in the UK Journal of Probity –  Billy Brown et al, Licorice Allsort Publishing

Providing quotes and citations from such articles would likely be helpful, but general reading can be cited in a bibliography. The above article citations are given by way of example and are fictitious. One needs to link remediation and insight to professional values. Use Google Scholar to find suitable articles on the subject relevant to the allegations: scholar.google.com

Read also our article on: Remediation and our article giving Further Guidance on Reflections in GMC Cases

Doctors Defence Service represents doctors who are going through the GMC investigations and FTP processes. For more information about taking steps to develop full insight, and writing reflective submissions for use at the GMC/MPTS, contact us in strict confidence on: 0800 10 88 739

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