Malu Mohan has described the distress faced by the researcher who attempted to study the practice preparedness of recent graduates of a stream of clinical practice through critically reflective diary entries (1). The graduates realised that they were grossly underprepared for competent and independent clinical practice. The researcher’s distress arises from the dilemma as to whether she has precipitated a sense of “incompetence” and “hopelessness” among the fresh graduates, causing unintended harm. It is commendable that the researcher has introspected seriously on the consequences of her study. I would like to comment on the specific ethical conflict faced by the researcher in this case and the possible mitigative measures that could have been undertaken. I will also try to derive broader inferences for the use of critical reflection in public health research.

This study has been conducted against the background of intense commercialisation of medical education and a burgeoning of graduates and private practices in the field. It is well known that in private medical institutions, patient numbers are much lower than in public institutions, providing fewer opportunities to learn skills and procedures. So, the researcher as well as the ethics committee reviewing this research proposal must have considered that at least some of the recent graduates are likely to find themselves ill-equipped for independent practice. The researcher has embarked on the study with the specific objective of probing this aspect. Given the intense competition in the market, it is also natural to expect those graduates who perceive themselves as underprepared to experience substantial distress.

The benefit-risk assessment in qualitative research studies is often ignored or performed in a perfunctory manner. It is not uncommon to find the statement, “this qualitative study lacks any major risks for the participant” in many qualitative research proposals. Some of the benefits of qualitative research are, enhanced understanding of the self through reflection, self-expression and sharing of one’s opinions, and acquisition of new knowledge and skills through participation in the study. Some of the common risks of qualitative research are, breach of confidentiality, emotional and social distress because of reliving some sensitive or traumatic experiences, risk of misunderstandings and misinterpretations (2, 3, 4, 5). Therefore, a more thorough ethical reflection on the proposed research could have helped the researcher as well as the ethics committee identify and anticipate this important ethical conflict.

Once identified, the researcher could have instituted mitigative measures against the distress that the reflective diary elicited in the participants. She could have involved a career counsellor, a senior practitioner-mentor in the field, or a psychologist, to provide emotional and psychological support for the participants. She could have read early signs of such distress in the reflective diaries and encouraged the participants to seek help. Moreover, she could have channelised this distress among the young graduates into a motivation to enrol in clinical training or capacity building courses to improve their skills.

Another important ethical dimension of this type of research is identifying whether such a critical reflection exercise is a research or non-research educational activity. Reflective practice of medicine is defined as the process where the practitioner studies and reflects on their own experiences to learn from them and to improve their responses to specific situations. In the medical profession, where there is a need for constant reflection in order to be a life-long learner, reflective practice is essential (6). In fact, the Attitudes Ethics and Communication (AETCOM) module, introduced by the Medical Council of India into the medical curriculum from 2019, lays a lot of emphasis on reflective writing by medical students in the area of medical ethics and professionalism (7). Therefore, one could view this research as being on the interface of research and practice. In such situations, it is important to provide opportunities to research participants to complete their learning cycle using the reflective writing exercise.

One more ethical conflict which the researcher is facing here arises from her intimate knowledge of low preparedness and professional insecurity among some of the practitioners. The researcher must also think about what her role in this situation is. Should she let these under-prepared young graduates be, or should she organise a refresher course for them with more hands-on training? Does this researcher have a responsibility to the community which is served by the under-prepared practitioners? Such a reflection should have taken place at the stages of designing the study and of ethics review. The researcher should have put in place follow-up action for participants who find themselves unprepared. On a related note, the researcher may also incidentally find lack of competence among the practitioners, outside of the purview of her research. In other words, rather than from self-reflection in the diary, the knowledge of poor competence may emerge from some other observation, or casual discussion. Such a finding is referred to as an ancillary finding. What is the responsibility of the researcher in such a situation? All these ideas should be discussed in detail before beginning a study.

I think the idea that the researcher must stop the respondent-practitioners from performing any further reflection is unhealthy. Rather than stopping them from proceeding with the reflection, she must now involve a professional career counsellor or senior mentor as mentioned earlier and help those whom she thinks are in imminent danger of quitting the profession. Though in this case, the distress caused by the self-reflection is research-induced harm, it is important to remember that while reflective practice can be distressing, that distress is the first step in changing oneself for the better. The only problem in this research study was that this reflection-induced distress was not anticipated and supports were not put in place. If proper supports are in place, such a reflection will result in positive outcomes for the participants.

Critical reflection has been used for improvement of the quality of work of healthcare professionals, including community health workers and other healthcare providers. Reflective writing has been used as an integral part of qualitative research. It is sometimes used as a primary data source when participants write reflective journals, as in this case study. At other times, the researchers themselves maintain reflective journals of their experiences of conducting a study (8). It is likely that such reflective writing could induce similar emotional responses in the writer. Therefore, before embarking on any qualitative research that employs reflective writing, one must keep in mind the risk of causing emotional distress in the writer and proper mitigative measures must be put in place.