Central to personal development and demonstrating one's ability to learn from experience is the ability to reflect. Reflective practice or self-appraisal of learning notes present a standardised method of recording experience and personal reflections of what was learned and how this might inform personal development.
How to record reflective practice
Much like other parts of the portfolio, the recording and presenting of reflective practice should follow a standardised format that presents a summary of each aspect of reflective practice. Trainees and the ARCP panel need to understand the experience, learning and reference to any developmental needs. The actual form used is not important but trainees should ensure they record the following:
• a brief description of the experience, assessment or learning situation
• any feedback received (e.g. from a supervisor, a patient, a colleague)
• a summary of personal reflections – what was learned, what went well, what could have gone better as well as the emotional impact of the situation
• a note of any actions needed to take as a result of feedback and/or reflection (i.e. professional development).
It should be remembered that reflection or self-appraisal happens, or should happen, all the time and in many different contexts. Therefore, trainees should ensure they record reflective practice across a broad range of clinical and non-clinical domains. Examples include: ethical dilemmas, times when another team member dealt with a difficult situation well, when personal decision-making could have been better, when and why it was felt that a good protocol was vital in clinical audit, etc. An example of a reflective note completed in an informative and useful way is provided later in the chapter.
The difficult question of where to file reflective notes
Broadly speaking, trainees have three choices as to which section of the portfolio to file reflective notes in.
Method 1: A separate section titled ‘reflective practice’
Filing reflective notes in a dedicated section will result in a number of forms recording thoughts concerning a variety of experiences and learning situations. The key therefore would be to make this section orderly and logical so that the information does not become unmanageable, missed and even uninteresting. To avoid this pitfall, the section could begin with its own contents page, which categorises learning experiences in a logical way.
Management and leadership are two of the many duties of a doctor, and this is no less the case for the psychiatrist. Although more senior management experience is more relevant to trainees towards the end of their training, every trainee's portfolio should contain an element of management experience.
The portfolio is competency driven and although a list of experience shows that trainees are engaging in some level of management experience, it does not demonstrate performance. Leadership occurs in many situations, so time should be taken to think creatively, within reason, about what experience is sought and how it is presented.
What to communicate about management experience and skills
The training portfolio will benefit from a description of what actually occurred and what the developmental issues are. It may be helpful to consider the following questions in brief:
• What does the curriculum require in terms of management competencies?
• What was your role and who formed part of the team?
• What were the challenges or issues?
• What were the barriers to good team working?
• How were setbacks overcome?
• What skills were needed to be successful?
• What were the developmental needs following this experience?
• What type of feedback was given and what did it say?
Consider the following list of experience that a trainee might present.
Doctors in training representative for trainees CT1–3.
Observer at consultant meetings.
As experience all these are perfectly good examples but on their own they do not detail experience and development. Contrast this list with Box 10.1 and how the brief paragraph covers the prompts suggested. Presenting experience in this way and linking that to reflective notes and key learning points makes this part of the portfolio much more informative and developmental. Other methods of demonstrating leadership experience might include the following.
• A personal statement concerning the doctor's role as a manager, describing individual skills and how these have been integrated by reflective practice.
• It may be worthwhile adding a reflective note about each experience further capitalising on this part of skills and experience in a manner appropriate to the portfolio. This could be done in a similar way as suggested with WPBAs (see Chapter 5).
• The successful portfolio is a developmental tool that builds a collection of evidence of experience, assessments of competence, self-reflection and personal development planning over time.
• Trainees should ‘own’ the portfolio by managing their own learning, using the portfolio as an iterative tool.
• Portfolio evidence of competence must demonstrate trainees’ performance in reality rather than their factual knowledge or abilities in controlled examinations.
• Evidence of achievement of competencies occurs by combining different forms of evidence and assessments in various contexts and with multiple assessors.
• The more often the portfolio is used, the better, using formal points of appraisal as landmarks.
• True evidence in the portfolio is clear, transparent and demonstrable proof of competence.
• The evidence should not be overstretched.
• Attending a training course is not in itself evidence of competence.
• The portfolio supports the General Medical Council (GMC) revalidation process (General Medical Council, 2013).
Organising the portfolio
• Organisation and reference to clearly indexed, triangulated evidence at the start of the portfolio sets the tone.
• Make it user-friendly; summarise evidence and clearly state the competency, giving clear and specific locations of evidence.
• How much is enough evidence? Two sources at least and three where possible.
• Plan your educational objectives early with reference to competencies.
• Remember that ‘if it is not documented, it did not happen’.
• Do not breach confidentiality within the portfolio. Never use patient-identifiable material. If letters about patients are included, remove all identifiers.
• Do not leave portions of the curriculum uncovered, especially if they are hard to evidence. Consider mapping the gaps.
Workplace-based assessments (WPBAs)
• The need to evidence a particular competence should drive which WPBA is chosen, not the other way round. Workplace-based assessment should occur regularly throughout a period in training. Do an Assessment of Clinical Expertise (ACE) early on as a benchmark.
• Present WPBAs in a logical sequence with a clear description of the experience and associated competencies.
• Link WPBA to reflective practice and show how this informs your professional development.
• Capitalise on opportunities in routine work – if you are discussing a case as a part of daily work, use it as a case-based discussion (CbD) WPBA.
• Patient feedback can be a powerful driver for learning.
Plans and reports
Some plans and appraisals are required as part of the portfolio and the completion of the ARCP. In a dedicated section, these reports should start with a contents page and include:
• initial planning meeting
• mid-point review
• educational supervisor's reports
• college tutor's structured report or training programme director's report
• completing the annual GMC survey is usually mandatory and evidence of its completion should be included in the portfolio
• some specialties in some deaneries may also require an annual survey to be completed for more specific feedback.
If individual deaneries do not have specific forms for these, they are available from the Royal College of Psychiatrists. Remember to make best use of these reports – they contain reference to competencies and should be signed; they therefore can contribute to evidence of competence.
Records of on-call work and educational supervision
Recording of previous placements, current placement and duties is required. Trainees should also record the nature of their current clinical activities and on-call/emergency work. Details of supervision with educational supervisors should also be recorded. This can be a very useful forum for discussion on issues pertaining to competencies that are harder to evidence; for example, a discussion about what happens in the event of a patient dying or working with the coroner. This is especially helpful if the supervisor has signed a formal record of supervision.
This book is a guide and not a set of rules – there will be alternative approaches to organising and populating a portfolio. Across the UK different programmes will use different portfolios, in paper or electronic versions, allowing varying amounts of freedom in terms of structure and presentation. Throughout this book there are repeated references to planning, assessment, reflective practice, development and evidence. This is intentional, reminding the reader of the guiding principles underlying the successful negotiation of the ARCP. There is an emphasis on using the portfolio as a tool that catalogues evidence and drives learning, and because the portfolio will change and improve over time, some educationalists refer to it as a living document. However, it is equally important that the portfolio is readable and well structured.
The first chapters of this book provide the reader with an insight into the background of the present approach to psychiatric training and how the portfolio fits into this. Included are lessons learned following the first years of specialty training and the ARCP process, which includes perspectives from training, administration and the ARCP panel. The book then looks at the individual sections of the psychiatric training portfolio in some detail. Each chapter, as far as possible, aims to follow the same structure such that trainees can translate its content into a method of using the portfolio to communicate evidence of competence effectively. Chapters begin with basic principles, often followed by bullet points in the form of prompts or questions. The methods suggested are then applied to specific examples, where possible comparing good and less successful practice. Because there is no ‘right’ way to produce the portfolio, the hope is to illustrate the issues early in each chapter by use of examples and not simply to spoon-feed directives. Trainees can apply the basic principles and prompts to see why the examples are informative, or uninformative, and then use this as a framework to structure their own work.
If this book helps trainees develop a conceptual framework as to how to plan their learning according to curriculum competencies and structure their portfolio to follow training, making each section logical and informative, then it has achieved its goal.
What is a portfolio?
The concept of what a portfolio actually is has evolved over time (McMullan et al, 2003). Earlier definitions described the portfolio in more simple terms of a record of what someone has done (Redman, 1994). The definition has been extended to include giving regard to the dynamic process of learning, including a collection of different types of work that demonstrate achievement, learning and progress over time (Wenzel et al, 1998; Karlowicz, 2000). The portfolio can therefore be seen as a means of both assessment and recognition of learning (Knapp, 1975). Contemporary learning theory extends the portfolio's role as not only a document providing evidence of an individual's competence but also the record of professional development and how this has been achieved (Price, 1994). The developmental portfolio can therefore be seen as:
‘A private collection of evidence, which demonstrates the continuing acquisition of skills, knowledge, attitudes, understanding and achievements. It is both retrospective and prospective, as well as reflecting the current stage of development and activity of the individual.’ (Brown, 1995)
The portfolio should contain evidence from a number of sources chosen at the discretion of trainees, which should demonstrate particular competencies in different ways as well as recording personal reflections on the learning process and developmental needs. Put another way, the portfolio collects evidence by recording the process of development through experience, assessment and critical self-analysis or reflection.
The approach to the developmental portfolio
The theoretical approach to the developmental portfolio assumes that the individual is able to develop as an adult learner. As a part of this assumption trainees should (Knowles, 1975):
• be able to be self-directed
• have previous experience from which to learn
• be ready to learn, developing from experience
• be curious and motivated to develop.
Therefore, portfolio-based development is not passive learning facilitated and led by an expert but is informed by the process of reflecting on experience, so-called experiential learning. The dynamic interaction between theory, practice and experience is continuous and is demonstrated in Kolb's experiential learning cycle (Fig. 2.1).
In this way, Kolb's learning cycle is an attractive model for understanding the process of development as it explains the relationship between theory, such as concepts, and reflection on practice, such as experience and the testing of concepts.
Psychotherapeutic skills and experience within different schools of therapy remain an important part of training. The portfolio should therefore not simply record the fact of courses, training and experience in a certain area, but should also detail knowledge, skills and attitudes in this respect and how they have been integrated into competent practice.
Recording activity and competence
Over the course of 3 years’ basic training, trainees should build up a catalogue of experience. Presenting an account of this is part of demonstrating development and will usually include:
• previous Balint group involvement
• interview skills training
• specific forms of therapy, including cognitive–behavioural therapy, cognitive analytic therapy and psychodynamic therapy with associated feedback
• training days or courses
• other specific experience.
During the years of core training, trainees need to demonstrate a level of general psychological competence. This essentially entails being able to account for clinical phenomena in psychological terms, demonstrating advanced communication skills and advanced emotional intelligence in dealings with patients and colleagues. At later stages, this will more specifically involve demonstrating appropriate referral for formal psychotherapies, jointly managing patients receiving psychotherapy and delivering basic psychotherapeutic treatments and strategies where appropriate.
At the time of writing the minimum requirements for demonstrating acquisition of the competencies at CT3 level are:
Attend a minimum of 30 CbD groups over the first 12–18 months of core training and provide evidence of the attainment of appropriate competencies through the use of the CbD tool.
Undertake two psychotherapy cases in two modalities and over two different durations between years CT1 and CT3. (Trainees must achieve the competencies in the CbD groups, usually by the end of CT1, before proceeding to undertaking psychotherapy cases under supervision.)
Complete a psychotherapy ACE for each of the different modalities of psychotherapy undertaken.
More detailed and up-to-date information on psychotherapy competencies and training requirements can be found on the Royal College of Psychiatrists’ website: www.rcpsych.ac.uk/specialties/faculties/ psychotherapy/training.aspx.
It is helpful to provide details of what psychotherapy experience has involved. This could potentially become very long-winded but the record itself should be orderly and informative. It might be helpful to follow the ‘Who? Where? Why? When? and What?’ format of questioning to complete this.
Teaching forms a large part of the competencies trainees need to demonstrate – especially as trainees become more senior – and is yet another role that the psychiatrist can reasonably be expected to fulfil.
Teaching can occur in a variety of situations, indirectly (e.g. shadowing by a medical student) or directly (e.g. giving a formal teaching session on the mental state examination to foundation doctors). There are therefore many opportunities in which a trainee can act as a teacher, record experience, be assessed and thus demonstrate competency. There are also courses which a trainee can attend, such as to become a communication skills tutor or to become an examiner. Examining and assessing is another important skill to develop. When planning teaching, trainees should always refer to the curriculum to ensure that this will enable development and evidence of the relevant competencies. It is valuable to plan how evidence of competency will be recorded, for example by recording topics or the use of WPBAs such as Journal Club Presentation, Case Presentation or Assessment of Teaching.
As with other areas of the portfolio, this section should record exactly what teaching has been undertaken and what skills are involved. This should follow the format:
• a clear explanation of the task and topic
• the skills required and the application of any previous training
• a reference to content
• assessments, feedback and reflection.
Reflecting on what went well and what could be done better is always valuable, especially if it adds to your professional development. Trainees may therefore wish to link the assessment or experience to a reflective note. Box 8.1 is an example of how a trainee might present their work.
The intention of this chapter is to capture the common questions and concerns raised by psychiatric trainees about portfolio-based learning in psychiatric training. Because of the often subtle answers to such questions, a structured, real question-and-answer format has been adopted. What follows is a transcript of a discussion about portfolio-based learning in psychiatric training, with Dr Samuel Dearman (S.D.) leading with questions from his position as a senior psychiatric trainee, Dr Damien Longson (D.L.) as an ARCP panel chair and Mrs Samantha Abbott (S.A.) as the head administrator of a medical education department. By reading this transcript, you should get a better understanding of why a portfolio is used, how to use it and how much to put in it, how the ARCP panel will judge your portfolio, as well as gaining improved understanding of the use of WPBAs, reflection, and meeting management and research competencies.
The developmental portfolio
S.D.: If we look at the portfolio itself as a place to start with, could you briefly describe what you think the portfolio needs to be from the position of the school of psychiatry, from an ARCP panel but also speaking as a trainer?
D.L.: It is a document owned by trainees, one of many they will have through their professional careers. What the panel really are trying to see is not whether trainees are developing habits that are going to become lifelong, but the way they learn, reflect and document things, and the way they drive their own personal development. It is a tool for the ARCP to use to make sure the individual develops properly. What the ARCP panel looks for is demonstration of that style of thinking. If there are serious deficiencies in terms of learning outcomes or things just have not been done at all, then clearly that's an issue and at the end of the day the curriculum requirements have to be met. We would be a lot more comfortable knowing that somebody is going to be a safe doctor for the next 20 or 30 years if their portfolio demonstrates the learning cycle. If the portfolio just demonstrates log book functions and no reflective processing, then we would be worried and would scrutinise more closely. But if overall it is a well-developed portfolio – well triangulated, well reflected – we will think, ‘This is an adult learner, we are happy’.
Workplace-based assessments have become a common formative assessment tool in all areas of postgraduate medical education. There is no pass/fail, so WPBAs should provide feedback to trainees about developing skills required to carry out their work competently. Workplace-based assessments may also highlight areas that require more attention and so can inform future PDPs. They have become an important part of postgraduate medical training as they are considered to demonstrate effective and frequent review and appraisal of trainee doctors. They test an individual's skills, knowledge and behaviour against GMC-approved curricula (General Medical Council, 2010) in a wide variety of clinical contexts and allow trainees to demonstrate progress in their skills in their workplace. Workplace-based assessments also have the opportunity to identify trainees who are struggling, as mandatory WPBAs oblige closer supervision than would otherwise exist without them. Assessment of competence in this way can be argued to be an obligation of professionalism and professional duty, given that the public has expressed a desire for improvements in self-regulation (Cruess & Cruess, 2006).
Workplace-based assessments have their limitations too, such as not being reliable as the only source of assessment for trainees and being completed to ‘get the numbers’, rather than using a WPBA as a valuable educational experience for which it is intended. Many WPBAs require assessors to rate trainees on a number of different scales. Low scores can leave trainees feeling like they have failed, despite the formative nature of WPBAs. Senior clinical staff and educational supervisors can often struggle to find the time to complete WPBAs, so a supervisor must be prepared to make time to observe and provide feedback. Finally, standardising judgement can be difficult (General Medical Council, 2010) and so WPBAs may not be as reliable as summative assessments.
The WPBA is one of the cornerstones of assessment structure. The requirements in terms of numbers per training post are actually relatively small when one takes time to reflect on the number of competencies a trainee is expected to demonstrate each year. When used well the WPBA is very helpful and can cover a wide range of competencies. Workplace-based assessments cover a variety of skills and information, and the upshot of this is that they convey a great deal about a trainee's skills.
An additional, perhaps miscellaneous section, can be useful for experiences, documents or achievements that simply do not fit elsewhere in the portfolio but are of use in contributing towards evidence. The guiding principle here should be why is this in the portfolio and what competency does this relate to? This is an important point and needs emphasis. A degree certificate is certainly an achievement but alone it is not evidence of competence. The list of what could conceivably be included in this section is endless and the following examples are intended as a guide to illustrate how various documents can be used.
• Original degree
• Other degree certificates
• GMC certificate
• Disclosure and Barring Service clearance
• Intermediate and basic life support
• Breakaway techniques certificate
• MRCPsych exams (some people give number of attempts)
Although these may not relate directly to specific competencies, they do say something about level of seniority and staying up to date. If any of these are related to competency, a word about their content should be given. For example, if it is a certificate concerning an examined course, a brief note about the content of the course, the skills involved, key learning points, reflective notes and the fact of the examination should be added. This should then be indexed in the summary of evidence section, especially if it involves any directly observed skills in practice. As most training schemes and NHS trusts require annual breakaway and cardiopulmonary resuscitation training, why not also use these to complete a DOPS (Direct Observation of Procedural Skills) WPBA?
Your curriculum vitae
The curriculum vitae (CV) may appear slightly outdated now with the electronic application system for jobs and the existence of the portfolio itself. The CV can be useful if it can be structured with competencies in mind. It can further be used as a bank for achievements you may have that do not fit well into the portfolio. It should be remembered that the portfolio contains evidence of competence, so unsubstantiated claims are not helpful. Therefore, and for example, a section of the CV concerning awards with a list of prizes for clinical excellence only becomes evidence when accompanied with the supporting documentation.
In all likelihood, portfolios are here to stay. They provide a system to demonstrate competency and therefore public accountability. With the introduction of revalidation by the GMC, all doctors at all levels need to be appraised and portfolios are required for this (General Medical Council, 2013). Trainees’ appraisal for revalidation will take place at the ARCP panel. It is most likely that all organisations (deaneries (LETBs as of April 2013 in England), NHS trusts and private healthcare providers) will move to e-portfolios, as there are pedagogical gains as well as being easier to administrate (Strivens et al, 2009). The case is put forward that a wellmaintained portfolio will ensure public accountability (Ingrassia, 2013).
Keeping a portfolio may help doctors identify areas of interest and keep a ‘portfolio career’. This may increase job satisfaction and reduce burnout if doctors take on interests such as management, medical education, research, medico-legal work or even media, business, humanitarian aid or health policy. This will also reduce absence through sickness and increase productivity (Pathiraja & Wilson, 2011).
Medical Royal Colleges, deaneries or schools (i.e. specialties) within deaneries may have designed a portfolio which is being used. Some trainees may get frustrated with it, or identify ways to improve it without necessarily being able to influence change. There is no consistency, either between portfolios or deaneries/LETBs, so expectations can be different. The future may be a standardised portfolio (which would make writing guides such as this easier) or even a fluid, ever-evolving portfolio which is an open source so that trainees and educationalists in deaneries can modify it. This has the benefit of the potential for majority rule. An open-source portfolio has been proposed and is in its embryonic stages at the time of writing (see http://oportfol.io).
The BMJ have made a portfolio app, which allows the user to document clinical encounters and e-learning. However, it does not yet integrate with the portfolio which this book describes in detail. Integration of e-portofolios with apps is beginning to take place in non-medical areas, for example: https://sites.google.com/site/eportfolioapps/.
Twitter is being used as a platform for collaborating and troubleshooting the foundation doctor e-portofolio. This allows the flow of ideas and the potential to gain national consensus to drive up consistency and standards (e.g. https://twitter.com/NESePortfolio). There is an app available for use with this portfolio (https://app.nhseportfolios.org/app), but access requires a password so we could not assess its functionality.
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