Insights into international medical graduates’ experiences of reflection in UK general practice training: A qualitative study integrating verbatim survey and in-depth- interview data

Problem

International medical graduates (IMGs) have less experience of reflection than their UK based colleagues, as more didactic methods of education are often favoured in international medical schools. This lack of experience in reflective writing can be problematic in General Practice (GP) training where reflection is used to evidence curriculum competencies, achievement of which is required for progression to completion of training. The aim of this study was to gain insight into IMG experiences of reflection in UK GP training, specifically views on the purpose of reflection and best and worst things about reflection.

Approach

This qualitative study had 2 phases. Phase 1 involved analysis of open question verbatim data from a national cross-sectional survey conducted in March-April 2021. The survey was circulated to IMG trainees working in 12 of the 14 UK training regions. All 485 survey respondents completed at least one of the open questions. The survey had a 14% overall response rate and demographics were representative of UK IMGs. Preliminary analysis of verbatim data regarding the purpose of reflection and the best and worst thing about reflection were used to generate questions for Phase 2; semi-structured interviews. Interviews continued to data saturation in a purposive maximum variety sample of 11 IMGs. Both survey and interview datasets were analysed thematically.

Findings

Most IMGs articulated a good understanding of the purpose of reflection in both their survey responses and in-depth interviews. Themes identified in IMG responses to the question ‘what is the purpose of reflection?’ were consistent with at least one component of the Academy of Medical Royal Colleges (AoMRC) definition of reflection; analytical thinking, gaining insight, lessons learned and maintain/improve practice. Similar themes were identified in responses to the question ‘what is the best thing about reflection?’: reflection provided an effective approach for learning, opportunities for self-assessment and professional development, and was a means of developing self-awareness. Answers to the question ‘what is the worst thing about reflection?’ revealed concerns about how time consuming reflection is, that it is mandated and can feel forced, and the fear of medico-legal consequences. The interview topic guide included these open survey questions but also allowed rich contextual exploration of how reflection encompasses more than the education and assessment objectives.

Consequences

There are a wide variety of educational interventions to assist IMGs in adapting to the NHS and the requirements of UK GP training, but few have educational research exploring the lived experiences of IMGs at the core. The results of this study offer an opportunity to look at how we use reflection in GP training through the lens of IMGs and co-design interventions to assist the development of this valuable skill.