'I feel many of my reflections are forced': a mixed methods qualitative study of international medical graduates' perspectives on reflection in UK general practice training.

Background: UK general practice training requires trainees to evidence clinical competencies through reflective writing entries in online portfolios. Trainees who complete their medical degree in the UK experience reflection as an undergraduate, whereas 80% of international medical graduates (IMGs) have no previous experience of reflection.

Aim: To explore international graduates' perspectives on the positive and negative aspects of reflection in the context of postgraduate GP training.

Design & setting: Qualitative 'free text' survey data obtained in 2021 was analysed with themes further explored by semi-structured interviews conducted 2022-2023.

Method: Participants were IMGs with experience of the UK GP training scheme. Verbatim open question survey data underwent content analysis. Broad themes identified were used to develop the interview topic guide. A geographically dispersed, purposive sample of participants were recruited for semi structured interviews. Interview and survey data were then analysed thematically.

Results: 433 participants data sets are included: 422 of 485 responses to a UK wide survey including open questions and 11 interview transcripts. IMGs considered reflection to provide an effective approach for learning, an opportunity for self-assessment and professional development and a means of developing self-awareness. Concerns were expressed about how time-consuming recording reflection is, how its mandated aspect makes it forced, and fears regarding the medico-legal consequences of reflective writing.

Conclusion: Despite a lack of previous experience in reflection, most international graduates showed an understanding of the benefits of reflection in GP training. However, the challenges of reflection must be addressed, to avoid devaluing reflection for clinical learning.