How do I undertake a reflective conversation
with a trainee?
What is reflection?
Reflection is the capacity to think honestly about our spoken words and actions and the effect they have on
others, in order to make changes for improved future behaviour. It forms part of continuous learning in order
to discover ways to improve on surgical practice.
Why have reflective conversations with my trainee?
Discussion on the trainee’s words and actions may bring to the surface what the trainee is thinking about
their experience of surgical training (silent reflection). It may also bring to the surface what the trainee has
confided to other colleagues (oral reflection) or what the trainee has written in their reflective journal (written
reflection). If approached in the right way and in the right tone, the trainer will be able to elicit the trainee’s
thought processes, justifications for actions and the reasoning behind them. The trainer will then be able to
identify the trainee’s values and attitudes about their experience of surgery and working in the wider surgical
team. This can then allow the trainer to give some professional feedback in a non-judgemental way, with the
view of helping the trainee improve their surgical performance. This process can also help improve the
professional relationship between trainer and trainee.
Reflective practice is part of the surgical curriculum and as such, needs to be undertaken by trainees and be
supported by trainers. It is considered to be a necessary component of good surgical practice and is as
important as any other area that measures competence progression.
When should we have reflective conversations?
Ideally, at the conclusion of, or shortly after, any workplace based assessment (WBA) is a good time to talk
about the trainee’s surgical performance. Currently, reflective practice forms part of case-based discussions
(CBDs) and multi-source feedback (MSF). It can also be part of meetings with the Assigned Educational
Supervisor (AES) about the MSF feedback, as well as in any Learning Agreement (LA) meeting. A reflective
conversation, however, could potentially take place at any time when there is interaction between trainer and
trainee.
Where should we have reflective conversations?
Reflective conversations could take place anywhere where there is some level of privacy and a lack of
distractions. Ideally, this could be a place where both the trainee and trainer feel as relaxed as possible,
such as in familiar and or comfortable surroundings.
How do I begin a reflective conversation?
Body language is important, to give the feeling that you are working with the trainee and not judging them, so
gestures such as sitting at the same level, not too far apart, with good eye-contact, smiling and making sure
the trainee is physically comfortable, are important.
You could start by asking the trainee about their impressions of their performance of the WBA with a general
comment such as ‘Tell me your impressions about how that went.’ This puts the onus on the trainee to
initiate the discussion without any direct reference to their own performance initially, so you can listen for key
words to form some preliminary impressions. What the trainee does not say is just as telling so it is
important to listen out for that and take mental notes. It is also important in the first few questions to avoid
the use of ‘you’, such as ‘How do you think that went?’ This may have the effect of putting the trainee on
guard and therefore limiting information volunteered. Instead, an indirect approach such as ‘Tell me about
the surgical procedure’ may be better initially. It is important at this stage to discuss the things the trainee did
well during the interaction or WBA and be seen making a written note of that. Give credit freely where it is
due.
Focus on Self
Self-awareness/Insight
As you cultivate the impression that you are trying to help the trainee and not judge them, you can start to
ask more direct questions such as ‘How do you think your technical performance could be improved?’ or
‘Why did you approach the task in this way and not that way?’ or ‘What did you learn about yourself during
that encounter with the patient?’ or even ‘What went wrong, do you think?’ ‘If you could go back and do the
same task again, what would you do differently?’ This questioning process will have the effect of making the
trainee look at their own actions/behaviour and to verbalise to another person (trainer) those actions and
behaviours.
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Focus on Other
Empathy/sensitivity
After the trainee has gained some insight into their own actions through discussion and questioning, it is
helpful now to get the trainee to think about how their actions may have impacted on others. Empathy and
sensitivity are important values in surgery and are intrinsic to good reflection. You could try to cultivate these
virtues in your trainee by asking the trainee to talk about how they think others may see their actions. How
does the patient/consultant/colleague/nurse etc., experience the trainee’s own actions and interactions? For
example, you could ask the trainee ‘How do you think the patient felt after your history-taking session (as
part of the clinical evaluation exercise, (CEX)’ or ‘What messages do you think you are giving to the lead
surgeon?’ or ‘Tell me how you think the ward nurses would describe your behaviour that night’. It may be the
first time the trainee has ever thought about how their actions have impacted on others and how others might
describe their actions. By the use of your careful questioning, you can help to cultivate sensitivity in your
trainee by trying to change the mental focus of the trainee from self to others. This is a vital component of
reflection.
Improvement
Once the trainee has gained some insight, self-awareness and empathy, you can then begin to make some
suggestions for future improvement. If the trainee feels this is a joint task, it will be more effective, so try to
cultivate a ‘working together’ atmosphere, where you offer suggestions in a sympathetic way. For example,
you could say ‘If you get the team members to see that you are making efforts to control your impatience,
they will be able to focus more on your superior technical skills’ or ‘your ability to dissect in correct tissue
planes during that procedure was excellent, but how could you now improve the way the wound is closed
using more appropriate sutures?’
Conclusion: Reflection, A cyclical process
Reflection is a cyclical process whereby there is continual thinking about one’s own actions in an honest way
with a view to improving those actions. It involves trying to see how our actions impact on others. It also
involves how receptive we are to criticism from others. If we can accept those criticisms and change our
behaviour accordingly, we are surely going to improve our performance and competence in both a
professional and personal way.
Example of the cyclical process of reflection
Action: I spoke rudely to a junior colleague on a ward round yesterday. She was annoying me with her
constant questions and I told her impolitely to be quiet.
Reflection on Action: Thinking about the incident that night (silent reflection), I realised I had been
impatient and that I had acted unprofessionally (self-awareness, self-criticism, interpretation). I thought
about my thoughts and feelings at the time and if I needed to control my temper more (description, analysis,
self-awareness, self-criticism). Even though I felt she was being overly demanding, she was probably upset
about my response (empathy, sensitivity). I mentioned the incident to my work colleague and we discussed it
(oral reflection). The next day, I wrote down some action plans and ways to improve (written reflection). I
resolved to improve the way I speak to this junior colleague when I am pressured with work (silent reflection
including improvement element).
Improved Action: Next time I saw the junior colleague, I made a change (creativity). I answered her
questions for 5 minutes and then explained politely my commitments elsewhere. If she had other questions,
could she write them down and give them to the doctor on call (improvement element).
Reflection on Improved Action: I noted this interaction was much better and less stressful for me and the
junior colleague (analysis, sensitivity, empathy, self-awareness). I managed to keep to my schedule and the
junior colleague was satisfied (improvement). I felt more professional as well (creativity).
Exercise: You can apply this cyclical process with your trainee during reflective discussions, using relevant
actions that need to be discussed with your trainee.
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