Reflection on reflection

‘Our knowledge of the world is fraught with uncertainty, ignorance and indeterminacy, and influenced by emotion, biases and illusions, including the illusion of not having illusions.’¹

This summary of some of the challenges of being human¹ can give rise to cycles of action-reaction-reaction-reaction in various realms, including healthcare-related circles, where expectations of different invested parties are not met. Sometimes, crippling consequences ensue, such as bullying and medical complaints that are the subjects of three articles in this issue.^2–4

For a long time now, the importance of self-reflection in medical practice has been taught in undergraduate medical courses around the world in an effort to help future doctors acquire skills in critically analysing and learning from their individual cognitive, emotional, and behavioural responses to challenging clinical encounters. Rationally reflecting is a core lifetime activity for healthcare providers. This issue of the Journal has several examples of reflection, discussion of events that should prompt reflection, and ideas about the type of supports, such as restorative justice,² that might prompt reflection and help people resolve interpersonal challenges, including handling complaints² and responding to bullying.³

Most of the literature on workplace bullying takes the approach that the parties in a bullying event assume the roles of ‘bullied’ and ‘bullier’, victim and perpetrator. Wicks, Murton, and Lillis³ conducted qualitative research that deliberately avoided this assumption. They found that although bullying events clearly represent broken relationships, the distinction between participants in a bullying event is often complex and far more nuanced than may be generally appreciated. They present examples showing how reflection can defuse emotionally charged conflict. Wilkinson and Marshall further demonstrate in their research the damaging outcomes (to individuals, communities, and the country) that can arise from the current healthcare complaints processes.³ These authors recommend more widespread use of ‘restorative justice’ approaches that can be invaluable in assisting reflection among both patients and healthcare providers in a complaint. In the Guest Editorial, Cunningham⁴ refers to research about medical complaints to conclude (similarly to Wicks² and Wilkinson³) that current processes used in New Zealand do not work well. He suggests there is a case for professional organisations to provide pastoral support for their members facing these professionally challenging situations. The Royal New Zealand College of General Practitioners (RNZCGP; College) responds. In case College members are wondering about the under-recognition of the critical role of general practice in protecting the health of New Zealanders through these unusual times, the RNZCGP also provides an update of its Covid-19-related advocacy initiatives.⁵

With or without the benefit of university guidance on reflection, most people still do reflect on life at some stage. Occasionally, people share these thoughts. We are privileged to be able to publish one such reflection in this issue. Katelyn Costello shares with readers the experiences she and her siblings had in dealing with the deaths of both parents while still children.⁶ This is a poignant, colourful article that celebrates life.

Our other research articles address the usual wide variety of clinical topics. We have a report from the General Practice Pandemic Experience New Zealand (GPPENZ) study about changes in prescribing in general practice over the period of the first pandemic lockdown in 2020.⁷ This event prompted rapid change from in-person to electronic prescribing that was usually enthusiastically adopted by general practitioners. Largely problem-free, the biggest issue these researchers found was maintaining computer systems that can handle it, especially with respect to pharmacies’ receipt of electronic prescriptions. Our Cochrane Corner article summarises the evidence for Ivermectin use, showing there is no scientific evidence that Ivermectin protects against covid-19.⁸

Other New Zealand research in this issue is about patient transfers from rural hospitals in emergency situations,⁹ adult obesity,¹⁰ and employment of nurse practitioners.¹¹ All three articles have workforce inferences. The audit of emergency transfers from Thames Hospital for high acuity emergency care in tertiary hospitals draws attention to the inadequacy of staffing during many transfers.⁹ If these emergencies happen at night there is often only one doctor who is responsible for caring for all patients remaining in the hospital as well as preparing the emergency patient for transfer. Norman et al. found a very small body of research using interventions aiming to reduce the major health problem of obesity in New Zealand, suggesting that more is needed.¹⁰ There is a very small, but growing, pool of nurse practitioners working in New Zealand primary care. Mustafa et al. asked general practice managers why they employed these nurses, or not.¹¹ They found widespread ignorance about the nurse practitioner role and a perception that they were an expensive addition to general practice teams. Better information about this sector of the primary care workforce is needed, especially regarding the practical differences between practice nurses and nurse practitioners.

We have two articles that may be of most interest to academic and researcher readers.^12,13 Jiang et al. developed a measure of research impact and used it to remind us that it is very useful for general practice researchers to collaborate with people from other disciplines.¹² HealthPathways, a concept that originated in Canterbury to streamline health services across sectors, has been adopted in Australia and the UK. We have a review paper exploring how evaluations of HealthPathways are conducted.¹³ Lastly, we have a Case Report with a sobering message about the dangers of intrauterine contraceptive devises that are not regularly checked, especially if a woman assumes it to have been expelled, but cannot confirm seeing it.¹⁴

We hope you find much to think and reflect about in this issue.