ECLIPPx: an innovativemodel for reflectiveportfolios in life-longlearningC. Ronny Cheung, Paediatric Specialist Registrar, Medical Education Fellow, Great OrmondStreet Hospital, London, UK

SUMMARYBackground: For healthcareprofessionals, the educationalportfolio is the most widely usedcomponent of lifelong learning – avital aspect of modern medicalpractice. When used effectively,portfolios provide evidence ofcontinuous learning and promotereflective practice. But traditionalportfolio models are in danger ofbecoming outmoded, in the face ofchanging expectations of health-care provider competences today.Context: Portfolios in health carehave generally focused on com-

petencies in clinical skills. How-ever, many other domains ofprofessional development, such asprofessionalism and leadershipskills, are increasingly importantfor doctors and health care pro-fessionals, and must be addressedin amassing evidence for trainingand revalidation. There is a needfor modern health care learningportfolios to reflect this seachange.Innovation: A new model forcategorising the health care port-folios of professionals is proposed.The ECLIPPx model is based on

personal practice, and divides theevidence of ongoing professionallearning into four categories:educational development; clinicalpractice; leadership, innovationand professionalism; and personalexperience.Implications: The ECLIPPx modeloffers a new approach for personalreflection and longitudinal learn-ing, one that gives flexibility tothe user whilst simultaneouslyencompassing the many relativelynew areas of competence andexpertise that are now required ofa modern doctor.

The ECLIPPxmodel offers anew approachfor personalreflection andlongitudinallearning

Life-longlearning

� Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 27–30 27

INTRODUCTION

Life-long learning is not onlydesirable but is a vitalcomponent of modern-day

medical practice, as emphasisedby the General Medical Council’ssupport of it as a pillar of ‘GoodMedical Practice’.1 It emphasisescontinuous, formative learning inall aspects of a doctor’s personaland professional life.

The most widely acceptedcomponent of training in healthcare is the portfolio, in whichevidence of life-long learning andreflective practice is recorded.Although e-portfolios have nowbeen introduced to postgraduatemedical training in many disci-plines, there is a criticism that thetemplate, designed to ensure abroad coverage of areas for whichevidence of learning should beprovided, is too prescriptive inwhat should be included, and doesnot allow the trainee to adapt itaccording to their individuallearning needs.2 Nor is the struc-ture of the e-portfolio for traineesrelevant for post training-gradehealth care professionals.

Furthermore, portfolios inhealth care have generallyfocused on competencies inclinical skills. However, initiativessuch as the Medical LeadershipCompetencies Framework illus-trate that many other domains ofprofessional development, such asprofessionalism and leadershipskills, are increasingly importantfor doctors and health care pro-fessionals, and must be addressedin amassing evidence for trainingand revalidation.3

PROPOSED MODEL

A new model for categorisingthe portfolios of health careprofessionals is proposed. TheECLIPPx model is based on per-sonal practice, and is adaptable toeach user’s personal and educa-tional needs. It divides the evi-dence of ongoing professional

learning into four categories:Educational development; Clinicalpractice; Leadership, Innovation& Professionalism; and PersonalExperience.

This model gives greaterflexibility, with wide umbrellaterms under which evidence ofprofessional development can bedisplayed, whilst giving enoughstructure to ensure broadcoverage of the essential areas,especially in light of the newareas of medical practice inwhich we need to demonstratecompetence.

The categories are illustratedby examples from my own practiceand portfolio, to demonstrate theflexibility and usefulness of themodel, with some ideas for howother professionals can make bestuse of this model in their ownportfolio use.

Educational developmentEducation and training (of self,colleagues, trainees and otherhealth professionals) is high onthe agenda for the modern healthcare professional, and this isreflected in its position in theECLIPPx model.

Suggestions for inclusion areformal courses attended, as wellas teaching experiences logged,with a short paragraph of self-evaluation as well as (where pos-sible) formal written evaluationfrom students, whether describingan ad hoc bedside session or aformal context, such as resusci-tation courses. Thus, this fulfilsone of Rogers’ tenets of adultlearning, the need for self-evaluation – complemented byfeedback from others.4

In order to further develop themanagement and organisationalaspects of education and training,involvement with educationalcommittees may give experiencesfrom which personal goals andreflective notes can be drawn andreviewed on a regular basis.

Clinical practiceThis section consists of recordsof continuous improvement inclinical procedural skills, ongoingevidence of clinical learning,evidence of specific identifica-tion of personal educationalneeds, and ongoing attempts toremedy those needs. The formerconsist of logbooks of procedures(both successful and unsuccess-ful) that are kept for proceduresappropriate to the level oftraining. These are not simplylists of self-evaluated proce-dures, however, as they alsoinclude comments from supervi-sors, so as to better informfuture learning. Formal work-place-based assessments such asdirectly observed proceduralskills (DOPS) and mini clinicalevaluation exercises (MiniCEX)provide further evidence.

Ongoing clinical learningrefers to the acquisition ofknowledge at work (throughdiscussion with colleagues andseniors). For trainees, this isepitomised by formative assess-ments such as case-based discus-sion (CbD) and also bysubscription to, and critical scru-tiny of, professional journals,including involvement in journalclubs. This is linked, of course, tothe identification of areas ofimprovement for the institutionas well as in personal practice (akey tenet of Tight’s life-longlearning theory).5

Active identification of learn-ing needs can be formalised, suchas during regular appraisals to setgoals for each clinical posting, orcan be personal and ad hoc. Frommy personal experience, short-

Education andtraining is highon the agenda

for the modernhealth care

professional

28 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 27–30

term goals can be set on a weeklybasis, records of which I keep in areflective case diary – theseinclude discussions with col-leagues or searching literature toanswer a particular clinical prob-lem, or written reflection on aparticularly difficult case.Medium-term goals are oftendiscussed in appraisals, but willinvolve recognising particularlearning needs and settingstrategies to overcome them,either in respect of knowledge(Box 1) or professional skills(Box 2).

Leadership, innovation andprofessionalismThis section is closely related tocareer development, involvingareas not specifically to do withdirect patient contact and medi-cal knowledge, but rather withdeveloping skills around thelarger picture of becoming amodern-day health care practi-tioner. Although the coreconcepts of life-long learning –identification of learning needsthrough experience (of self orothers), and planning to addressthose needs – are still key to thissection, the areas considered areslightly different, and includemanagement and leadershipskills, dealing with complaints,professionalism and clinicalgovernance (Box 3).

Personal experienceFinally, there are occasions whenpersonal experiences may havepositive learning potential forprofessional life. This may be inthe form of reflective notes on howpersonal interaction with patientsand relatives influence one’s pro-fessional interaction with them, aswell as records of patient com-ments and letters. Personal reflec-tion humanises our work andprofessional development, and theinclusion of this area in a portfolioalongside the more traditionalareas of development reflects itsimportance in this model (Box 4).

DISCUSSION

Health care has been relativelyslow in embracing portfolios as aformal technique for learning, andmedicine has been slower still –nurses have used, and researched,portfolios in their training formany years. Indeed, even thoughthey have been used informallyby many doctors for the pastdecade or two, compulsorilyincorporating portfolios intotraining was only introduced withthe establishment of FoundationYear training, and competency-based assessments in ModernisingMedical Careers.6

The use of portfolios hascoincided with the shift from

traditional, examination-basedsummative assessments to theformative evaluation of compe-tencies, based on work-basedexperiences and formal assess-ments. Keeping a portfolio allowsthe learner to demonstrate lon-gitudinal learning and progress,as well as allowing for the reviewof evidence of previous know-ledge gaps gradually filled bydeliberate, self-directed learn-ing.7 This, of course, relies onevidence of practice that caststhe learner in both positive ornegative light being included inthe portfolio, which consequentlymust be used in a non-threaten-ing, non-punitive way to fulfilRogers’ humanistic principles ofadult learning.4 In addition, theyshould include reflections on theprocess of learning, rather thanjust a record of achievements, inaccordance with Kolb’s learningcycle.8

Most important perhaps is thesheer breadth of evidence thatcan be shown by the assessmentscontained within portfolios. Notonly can different levels ofknowledge acquisition (factualknowledge, processes and proce-dures, and higher cognition anddecision making) be demon-

Box 1. An example of the identification of learningneeds

In a recent appraisal I identified (from reflective cases in a previous job) anarea of weakness in the management of patients with epilepsy, whichencouraged my enrolment on a paediatric epilepsy training (PET) course onepilepsy management. The performance review at the end of the 6-monthplacement confirmed that my knowledge gap had improved significantly,and enabled me to set appropriate goals for further input over the following6 months.

Box 2. Using video to aid reflection

The use of video to reflect on my clinic appointments (in discussion with asupervisor) identified the root cause of the problem of overrunning clinics,leading to an opportunity to review my practice, followed by self-auditingmy subsequent clinic appointment times. This meant I was able to improvemy clinical performance and waiting times, to the benefit of patients andclinical service provision.

Box 3. Suggestions foractivities or experiencesfor inclusion in theleadership, innovationand professionalismcategory

Dealing with complaints

Mentoring ⁄ supervision

Critical incident review

Guidelines and integrated carepathways

Chair ⁄ membership of committees

Clinical leadership roles

Service change and evaluation

Critical appraisal in clinicalproblem solving

Research and ethics

Keeping aportfolio allowsthe learner todemonstratelongitudinallearning andprogress

� Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 27–30 29

strated, all of these can be laidout longitudinally to displayprofessional development in avirtual ‘timeline’ of learning, todemonstrate continuous learningand assessment. They also dem-onstrate continued excellence inparticular skills, not just a ‘cross-sectional’ view of competence.When mapped to a curriculum,learners can identify individualneeds, based on both gaps inexperience and poor performancein assessments.

There are, however, disadvan-tages to implementing the wide-spread use of portfolios,especially on a compulsory basis.The most common criticism is thesheer effort and time that isrequired to collate evidence for awell-constructed portfolio.Indeed, it is the most commonlyquoted reason for the dramaticdrop-off in use of portfolios wheretheir use is not compulsory – afact we often see anecdotally aswell as in the evidence.2,9,10

As a formative tool, it hasmany benefits, and the inclusionof both failures and successes in abid to demonstrate an individual’slearning curve is invaluable.However, when used in both asummative and formative way,learners naturally tend to be morewary of the content they choose

to include, and there is a shiftthen from portfolios being used tohighlight learning needs to a‘logbook’-style document thatmerely demonstrates competen-cies in certain areas without anyreflection or targets for improve-ment.10 Its use as a summativeassessment tool in the AnnualReview of CompetenceProgression further stifles theself-directed learning aspect ofportfolio use, by reinforcing theneed to adhere to a rigid frame-work for fear of being penalised.6

There is also a wider agenda fordoctors and health care workersto move their focus fromdeveloping clinical skills to otherprofessional aspects of the job,such as education, leadership,professionalism and medicalhumanities.1

The changing nature of train-ing, revalidation and education inhealth care means that a newmodel for personal reflection andlongitudinal learning is required,one that gives flexibility to theuser whilst simultaneouslyencompassing the many relativelynew areas of competence andexpertise that are now required of amodern doctor. The ECLIPPx modeloffers one such approach, andhighlights the need for furtherdevelopment in this exciting areaof modern medical education.

REFERENCES

1. General Medical Council. Good Medi-

cal Practice. GMC 2009. Available at

http://www.gmc-uk.org/guidance/

good_medical_practice.asp.

Accessed on 2 June 2010.

2. Buckley S, Coleman J, Davison I,

Khan K, Zamora J, Malick S, Morely

D, Pollard D, Ashcroft T, Popovic C,

Sayers J. The educational effects of

portfolios on undergraduate student

learning: a Best Evidence Medical

Education (BEME) systematic review.

BEME Guide No. 11. Med Teach

2009;31:282–298.

3. NHS Institute for Innovation and

Improvement. Medical Leadership

Competency Framework. 2009. Avail-

able at http://www.institute.

nhs.uk/images/documents/Build-

ingCapability/Medical_Leadership/

Medical%20Leadership%20Compe-

tency%20Framework%202nd%20ed.

pdf. Accessed on 2 June 2010.

4. Rogers C. Freedom to Learn. Colum-

bus, Ohio: Charles E. Merill, 1969.

5. Tight M. Life-long learning: oppor-

tunity or compulsion? British Journal

of Educational Studies. 1998; 46:

251–263.

6. MMC. Modernising Medical Careers.

2009. Available at http://

www.mmc.nhs.uk. Accessed on

2 June 2010.

7. Wilkinson TJ, Challis M, Hobma SO,

Newble DI, Parboosingh JT, Sibbald

RG, Wakeford R. The use of portfolios

for assessment of the competence

and performance of doctors in prac-

tice. Med Educ 2002;36:918–924.

8. Kolb DA. Experiential learning: expe-

rience as the source of learning and

development. London: Prentice Hall,

1984, xiii, pp. 256.

9. Dornan T, Carroll C, Parboosingh J.

An electronic portfolio for reflective

continuing professional develop-

ment. Med Educ 2002;36:767–769.

10. Driessen E, van Tartwijk J, van der

Vleuten C, Waas V. Portfolios in

medical education: why do they

meet with mixed success? A

systematic review Med Educ

2007;41:1224–1233.

Corresponding author’s contact details: C. Ronny Cheung, 25 Lichfield Court, Sheen Road, Richmond, Surrey TW9 1AU, UK. E-mail: ronny.cheung@doctors.org.uk

Funding: None.

Conflict of interest: None.

Ethical approval: This study does not describe research on human subjects and therefore ethical approval was not necessary.

Box 4. Personal experience

In the past year I have become a parent to a young infant with Hirsch-sprung’s disease, which has given me the patient’s viewpoint for the firsttime since my career in paediatrics began. I have many notes and records ofmy personal experiences of the UK’s National Health Service and paediatricsfrom a parent’s perspective, all of which I have included in my portfolio toinform my own practice from the opposite side of the interaction. Thisexperience has been invaluable to my professional learning, and demon-strates perfectly how life-long learning is not confined merely to ‘work time’,but is instead a pervasive process that should be informed by every aspect ofone’s life.

A new model forpersonal

reflection andlongitudinal

learning isrequired

30 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 27–30