The Discussion Paper
"Like an essay, but one your supervisor will actually read β and maybe even enjoy discussing."
The Discussion Paper is one of the most misunderstood QIA types in GP training. Most trainees either avoid it entirely or write something that looks more like a school essay than a quality improvement activity. This page changes that β giving you a clear understanding of what it is, exactly how to write one, how it's marked, and how to make yours stand out.
Last updated: 25 April 2025
β‘ Jump to section
π Web Resources
A hand-picked mix of official guidance and real-world GP training resources. Because sometimes the best pearls are not hiding in the official documents.
Official RCGP guidance on what counts as a QIA, with real-world examples from GP registrars.
The QIP template, marking rubrics, and word pictures for supervisor feedback levels.
GMC guidance on the broader role of QIA throughout a doctor's career.
Courses, eLearning, and quality improvement tools for GPs and trainees.
The BVTS QI overview β covering QIP, QIA types, PDSA, common pitfalls and insider wisdom.
Detailed guide to audit as a QIA β useful to compare with a Discussion Paper approach.
How to run PDSA cycles properly β a key methodology to reference in many Discussion Papers.
Plain-language guide to what counts as QIA β useful for IMG trainees and newcomers.
Real QIA examples from Welsh GP trainees β useful to see what acceptable QIA looks like in practice.
Step-by-step advice on how to write up a QIA clearly, including what supervisors look for.
Tools, case studies, and QI frameworks from NHS England β great reference material for Discussion Papers.
How to reference properly β essential for a well-written, well-scored Discussion Paper.
π The Big Picture β Visual Overviews
Sometimes a picture really is worth a thousand words. Use these visuals to quickly see where a Discussion Paper fits in the world of QI.
Where Does a Discussion Paper Fit In GP Training?
Why QIAs Get Flagged at ARCP
Patterns seen repeatedly in ARCP panel feedback and supervisor assessments across UK deaneries.
Percentages are illustrative, based on patterns in deanery feedback across the UK.
The Quality Spectrum of a Discussion Paper
Which level does yours fall into? Most first attempts land in the middle β and that's fine. Aim higher next time.
The QI Chain β What RCGP Actually Wants to See
Every QIA β including a Discussion Paper β must show this chain. If any link is missing, the chain breaks and so does your QIA.
Step 3 β Action β is the one most often missing. You can write beautifully about steps 1, 2 and 5 but without a real action (step 3) and a real change (step 4), your Discussion Paper is just a very well-written essay. The RCGP will not accept it as a QIA.
π― If You Only Read One Thingβ¦
A structured written piece that critically explores a topic related to primary care quality, using evidence, analysis, and personal reflection β leading to proposed or actual improvements.
As one of your annual QIA requirements. Ideal for topics where you want to think deeply, argue a case, or explore evidence β rather than collect numerical data.
Typically 1,000β2,000 words. Clear, structured, and focused. Not a dissertation. Not a GP magazine article. Something in between.
Discussion alone is not QIA. You MUST show: topic β analysis β action β change (or planned change). Reflection without action = zero.
An audit compares practice against a measurable standard. A Discussion Paper argues a case β it explores complexity, weighs evidence, and proposes reasoned change.
Clear structure, referenced evidence, a personal hook (why YOU care about this), honest reflection, and a concrete action with outcome β even if small.
β What Is a Discussion Paper?
More interesting than it sounds β and harder to get right than people expect.
A Discussion Paper is a written QIA that takes a topic relevant to primary care, examines it using evidence and clinical reasoning, and argues for a change or improvement. Think of it as a cross between a literature review and a personal clinical argument β not just a summary of what the guidelines say, but an exploration of why it matters in your practice and what you (or your team) have done, or will do, about it.
β What it IS
- A structured written argument about a QI-relevant topic
- Evidence-based, referenced, and critical in tone
- Linked personally to your practice or experience
- Proposing or documenting actual change
- A QIA β so it must show action, not just thought
- An academic piece with a GP training context
β What it is NOT
- A clinical essay (this is not your A-levels)
- A case study (that's a separate QIA type)
- An SEA or LEA (those count separately)
- A literature review alone β you need action too
- A one-sided rant about what's wrong with the NHS
- A repeat of what NICE says without adding anything
Because it must include evidence of action. The RCGP requires all QIAs to show that data or evidence led to a finding, which led to an action, which led to a change (or a concrete plan to change). A well-written Discussion Paper demonstrates exactly this β using literature and analysis as the "data", and a documented change in practice as the outcome.
π When Should You Choose a Discussion Paper?
It's not the right tool for every situation β but when it fits, it's genuinely enjoyable to write.
Not all QIA types suit all situations. The Discussion Paper is best suited for topics that are complex, contested, or genuinely interesting β where the journey of thinking through the evidence is the improvement activity. It works well when you have a strong personal interest or a clinical puzzlement you want to explore seriously.
| Situation | Best QIA type | Why |
|---|---|---|
| You want to review how your practice manages a condition against NICE | Clinical Audit | You need measurable data and a before/after comparison |
| Something went wrong and you want to learn from it | LEA or SEA | Those are designed specifically for learning event analysis |
| A topic genuinely interests you and you want to make a reasoned case for change | Discussion Paper β | You can explore the evidence, build an argument, and reflect on action taken |
| There's no clear standard to measure against, but you want to explore complexity | Discussion Paper β | Discussion Papers handle nuance and ambiguity well β audits do not |
| You want to propose a new policy or protocol in your practice | Discussion Paper β | Ideal format for arguing a case and documenting its impact |
| You've already implemented a service and want to write it up | New Service Implementation | That format is better suited to service-level change |
Discussion Papers are one of the few QIA types where your personal intellectual engagement actually shows in the writing. Supervisors can tell immediately if you're going through the motions. When trainees write about something they're genuinely curious about, the papers are more interesting to read β and consistently score higher.
π‘ Topic Ideas for a Discussion Paper
Choose a topic that genuinely interests you β but here's a generous list to spark ideas if you're stuck.
π©Ί Clinical Topics
- Polypharmacy and deprescribing in elderly patients
- Antibiotic stewardship β are we doing enough in primary care?
- Managing medically unexplained symptoms (MUS)
- Over-investigation in primary care β when less is more
- Shared decision-making: evidence vs reality in GP consultations
- The role of diet and lifestyle in chronic disease β and why we under-address it
- Diagnosing depression β are we over- or under-diagnosing?
- Frailty in primary care β are we managing it well enough?
- Valproate prescribing and the MHRA pregnancy prevention programme
- Early cancer diagnosis in primary care β barriers and opportunities
π₯ Systems & Access Topics
- Access to GP services β demand vs capacity in modern primary care
- NHS 111 and emergency department avoidance β does it work?
- The digital divide β are online consultations equitable for all patients?
- Social prescribing β evidence base and practical challenges
- Home visit decision-making β is there a consistent approach?
- The role of primary care in addressing health inequalities
- Long COVID management β what is the role of the GP?
- Primary care workforce crisis β causes, consequences, and responses
π€ Professional & Ethical Topics
- Burnout in GP training β how do we build resilience without ignoring the real causes?
- The ethics of prescribing for lifestyle conditions
- Informed consent in everyday GP β are we truly getting it?
- Confidentiality in primary care β where does it get complicated?
- Cultural competence and health inequality β what more can GPs do?
- The role of the GP in safeguarding β how effective are we, really?
- Communicating risk to patients β evidence on what works
π Prescribing & Pharmacology Topics
- Benzodiazepine and Z-drug prescribing β dependency and alternatives
- Opioid prescribing in chronic non-cancer pain β evidence and harm
- Over-the-counter (OTC) advice vs prescription β patient expectations vs evidence
- Repeat prescribing systems β are they safe enough?
- SGLT-2 inhibitors in heart failure β primary care uptake and barriers
- Deprescribing in care home residents β a practical challenge
The best-scoring Discussion Papers come from topics where there is genuine tension in the evidence β not topics with a clear-cut NICE answer. If NICE says "do X" and everyone does X, there's nothing to argue. Choose a topic where reasonable clinicians might disagree, where evidence is evolving, or where guideline recommendations conflict with real-world practice pressures. That's where your analysis can really shine.
π Structure of a Discussion Paper
There's no single mandated template β but this structure consistently gets good feedback from supervisors.
Typical word count (range 1,000β2,000 words)
Key structural sections to include
References expected for a well-evidenced paper
The TIRADE Framework
A memorable structure for Discussion Papers β each letter is a section
π T β Trigger & Background
What to write here: What prompted you to choose this topic? This is your personal hook. Was it a patient case? A gap you noticed? Something that surprised you in clinic? A conversation at an HDR? The best Discussion Papers start with a genuine moment of curiosity or concern.
Example opener: "During a routine consultation, I noticed that three patients in one week had stopped taking their statin without telling any of the clinical team. This prompted me to explore the evidence around medication adherence in primary care and consider what, if anything, our practice could do differently."
π I β Issue & Evidence Review
What to write here: What is the clinical or quality issue? What does the evidence say? This is your literature review mini-section. Summarise the key evidence concisely β this is not a full systematic review, but you should cite at least 4β6 references (NICE, peer-reviewed literature, NHS England guidance, RCGP statements).
- Describe the issue clearly and without jargon β a reader unfamiliar with the topic should understand it
- Cite specific evidence, not vague impressions
- Acknowledge complexity β show you can hold tension between different findings
- Use Harvard referencing throughout
π R β Reasoning & Analysis
What to write here: This is the "discussion" in your Discussion Paper. Don't just describe what the evidence says β analyse it. What do you make of it? Are there conflicting perspectives? What are the implications for your practice, your patients, or your patient population? This is where your critical thinking lives.
Most trainees summarise evidence well. Few analyse it confidently. Show that you can say "this study suggests X, but has limitations because Y, and in my practice context, the more applicable finding is Z." That's analytical β and that's what gets you above-expectation scores.
π A β Action Taken or Proposed
What to write here: What did you do, or what are you planning to do, as a result of this analysis? This is the most important section for QIA purposes. Without action, this is not a QIA β it's just an essay.
Actions can be:
- A change to your personal practice (e.g. always asking about adherence when reviewing a LTC)
- A discussion at a practice meeting (document it β date, attendees, what was agreed)
- A proposal for a new protocol or template, even if not yet implemented
- A plan to re-audit in 3 months β that's a concrete action
- A communication sent to the wider team sharing your findings
Vague future intention does NOT count as action. The RCGP is explicit: the QIA must show actual action or a concrete, documented plan. "I will consider" fails this test every time.
π D β Discussion of Impact
What to write here: What was the impact of the action you took or proposed? This doesn't need to be a full re-audit. Even a short comment on early signs of change β or an honest acknowledgement that the change hasn't happened yet and why β is valuable. Show that you're thinking about outcomes, not just process.
- Did anything change in how you or your team approaches this?
- How did patients or colleagues respond to the change?
- What were the unintended consequences, if any?
- Did you measure anything β even informally?
π E β Evaluation & Reflection
What to write here: This is your honest reflection on the whole process. What did you learn β about the topic, about the change process, and about yourself as a clinician? What would you do differently next time? What are the limitations of your Discussion Paper?
Supervisors love to see:
- Genuine acknowledgement of limitations (e.g. small scope, not yet measured)
- Personal learning β not just factual learning about the topic, but about how you think and work
- Connection to professional capabilities (e.g. maintaining performance, working with colleagues)
- A forward-looking statement β what will you do differently in future QI activities?
πͺ Writing Your Discussion Paper β Step by Step
From "I have an idea" to "uploaded and signed off" β a practical walkthrough.
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1Choose your topic β make it personal
Pick something that genuinely puzzled, bothered, or interested you in clinic. The personal connection is not just a nice touch β it's an RCGP requirement. Topics forced for the sake of filling the portfolio box consistently produce weaker papers. Ask yourself: "Is this something I'd still want to read about on a Tuesday evening after a full surgery?"
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2Discuss your topic idea with your trainer early
Before writing a single word, have a quick 10-minute conversation with your Educational Supervisor. This avoids the painful discovery at ARCP that your topic doesn't meet RCGP criteria. Your trainer can also point you towards relevant local data, team members to involve, or existing practice protocols relevant to your topic.
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3Do a proper (if brief) literature search
Use PubMed, NICE, BJGP, and the Cochrane Library. You don't need 40 references β 6 to 10 well-chosen, recent sources will do. Include at least one NICE guideline or CKS page if relevant. Avoid citing only patient-facing NHS website pages β these are not primary sources and will not impress.
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4Draft using the TIRADE structure
Use the TIRADE framework above. Write each section in turn. Don't aim for perfection on the first draft β get it written first. The Analysis section will likely need the most redrafting; most trainees write a summary when they need an argument.
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5Make sure your Action section is concrete
Before submitting, re-read your Action section critically. Can you point to something specific that changed? Was there a meeting, a protocol update, a change to your personal practice, or a measurable outcome β even a small one? If not, your paper is at risk of being rejected as insufficiently QI-oriented.
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6Add references in Harvard format
The Bradford VTS referencing guide (linked above) shows exactly how to do this. Many trainees lose easy marks by using inconsistent referencing styles. Take the 20 minutes to do it properly β it signals academic rigour and your supervisor will notice.
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7Upload to your 14Fish ePortfolio as a QIA Learning Log entry
Remember: this does NOT go in the QIP section of FourteenFish. It goes in the QIA learning log. Log into your 14Fish account, create a new QIA learning log entry, attach your Discussion Paper as a document, and notify your Educational Supervisor for review.
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8Discuss with your supervisor β and update your reflection if needed
The discussion with your supervisor is not optional β it's part of the QIA process. Use it. Ask for specific feedback. If they suggest additions or clarifications, act on them before your ARCP panel reviews your portfolio.
Personal hook β discuss with trainer
6β10 sources, NICE, BJGP
~1,500 words, 6 sections
Concrete change documented?
QIA log β notify supervisor
With Educational Supervisor
π How Is It Marked?
Understanding the marking frame is half the battle β here's exactly what supervisors are looking for.
Supervisors rate your QIA as below expectation, meeting expectation, or above expectation across several domains. If you are consistently below expectation, you may be asked to redo it. But the bar is meeting expectation β you don't need to write a medical journal article.
| Marking Domain | Below Expectation | Meeting Expectation | Above Expectation |
|---|---|---|---|
| Personal Connection | No clear personal link to the work | Clear link to own clinical practice or experience | Compelling personal narrative that drives the paper |
| Evidence Base | Little or no reference to evidence; or only very old guidelines | Relevant evidence cited, mostly current; uses NICE/BJGP/peer-reviewed sources | Multiple up-to-date sources critically appraised; acknowledges conflicting evidence |
| Analysis & Reasoning | Mostly describes, not analyses; little critical thinking visible | Shows reasoning; makes a clear argument; considers alternative perspectives | Sophisticated analysis; holds complexity well; shows independent clinical thinking |
| Action Documented | No specific action described, or only vague intentions | Concrete action documented β change to practice, protocol, or team behaviour | Action taken AND impact evaluated; team involvement documented |
| Reflection | Superficial reflection; repeats facts without insight | Genuine reflection on personal learning; connects to professional development | Incisive personal reflection; identifies future QI learning needs; links to capabilities |
| Structure & Presentation | Disorganised; difficult to follow; not clearly structured | Well-structured; clear and readable; appropriately referenced | Professionally written; logically coherent; excellent references; well-presented |
The phrases and approaches that consistently impress supervisors: "I discussed this with the practice team at our next meeting and we agreed toβ¦" β "On reflection, my initial understanding of X was limited by Y" β "This led me to realise that my approach to Z had been influenced by assumption rather than evidence" β "I will re-visit this area in 6 months to assess whether the change has been sustained."
β οΈ Common Pitfalls β Don't Let These Trip You Up
Patterns that come up again and again in supervisor feedback and ARCP reviews.
A well-written, beautifully referenced exploration of a clinical topic that contains no action, no change, and no reflection. Interesting to read. Fails QIA criteria entirely.
Your supervisor knows NICE CKS exists. Restating what the guidelines say, without analysis or application to your practice, adds no value β and they will say so in feedback.
"Improving diabetes care" is not a topic β it's a department. A Discussion Paper needs a focused, manageable question. "Should all type 2 diabetics in our practice be offered structured education?" is a topic.
The QIA goes in the QIA Learning Log, NOT the QIP section. These are checked separately at ARCP. Getting this wrong means the panel may not find your entry β which creates unnecessary complications.
NHS.uk patient pages are not academic sources. Your Discussion Paper needs peer-reviewed literature, NICE guidance, RCGP resources, or equivalent. Citing only patient leaflets signals a superficial literature search.
This phrase appears in far too many Discussion Papers. It doesn't count as action. What specifically changed? When? How will you know it's working? The RCGP needs to see data β finding β action β outcome.
Discussion Papers written under last-minute pressure reliably produce thin analysis. The intellectual work of genuinely engaging with evidence β reading critically, weighing perspectives, connecting to practice β takes more than an evening.
A Discussion Paper written as if it could have been written by anyone, about anything, in any practice, is not a QIA with personal connection. Make sure YOUR voice and YOUR practice context are visible throughout.
The Evaluation section. Most trainees write their Discussion Paper, describe what they did, and stop. They forget to step back and evaluate: did the action work? Was the paper itself a good piece of QI? What would they do differently? This section is short β but its absence costs marks every time.
π Insider Pearls & Real-World Wisdom
What nobody puts in the official guidance β distilled from real trainee experience across UK deaneries.
The single most reliable way to turn a good Discussion Paper into an excellent one is to present your findings to your clinical team. Even a 10-minute slot at a practice meeting β documented with a date, rough attendance record, and a note of what was agreed β instantly transforms your paper from "individual reflection" to "change leadership". Supervisors notice this immediately.
Many trainees write eight paragraphs of evidence review and then add a single sentence at the end: "As a result, I plan to change my prescribing." Your supervisor, who has read 40 portfolios this month, may not reach that sentence with the same enthusiasm they had at the start. Front-load your action. Make it visible. Refer back to it in your reflection.
Trainees who write Discussion Papers that confirm their existing views β and then reflect that their existing views were confirmed β miss the point of reflection entirely. The papers that genuinely impress supervisors are those where the trainee says: "I went into this assuming X. The evidence showed me Y. This has changed how I approach Z." That's intellectual honesty β and it's memorable.
This sounds cynical β but it isn't. Choosing a topic that your trainer finds intellectually interesting leads to better tutorials, richer feedback, and a more engaged supervision process. Ask your trainer what they've been thinking about clinically or professionally lately. The intersection between their curiosity and yours makes the best Discussion Paper topics.
Add a single paragraph explicitly linking your Discussion Paper to a relevant RCGP Professional Capability (e.g. "This connects to the Capability: Maintaining Performance, Learning and Teaching, specifically around identifying personal learning needs through evidence review"). Most trainees never do this β and it always impresses educational supervisors who are thinking about ARCP evidence.
A 3β4 sentence abstract at the top of your Discussion Paper (describing the topic, the key finding, the action, and the reflection) signals academic maturity and makes it much easier for a busy supervisor to understand what they're reading before diving in. No marking scheme explicitly requires it β but supervisors consistently respond positively to it.
π£ From the Trenches β Real Trainee Wisdom
These insights come from recurring patterns shared by UK GP registrars across training communities, deanery forums, and peer-to-peer advice networks. All checked against RCGP guidance.
The 10 Things Trainees Wish They'd Known Earlier
The most consistently impressive Discussion Papers involve the topic appearing in at least three different conversations: once with your trainer when choosing it, once with a colleague while doing the analysis, and once at a practice or team meeting when sharing findings. Three conversations = evidence of team engagement = consistently stronger outcomes.
A simple writing trick that forces good structure: every time you introduce a piece of evidence, challenge yourself to follow it with the word "therefore." "Evidence X shows Y β therefore, in my practice, I will do Z." If you cannot write "therefore" after a paragraph, you may be describing rather than arguing. That one word is a surprisingly good alarm bell.
A small but concrete action beats a large but vague intention every single time. "I updated the practice protocol for X on [date], emailed the team, and will review uptake in 3 months" is far stronger than "I hope to work with colleagues to improve this area." Small + specific + dated = credible.
Trainees sometimes pick an uncontroversial topic because they think it is easier to write. In fact, the opposite is true. A topic where "everyone agrees and NICE is clear" leaves nothing to analyse or argue. A Discussion Paper on a topic with genuine professional debate gives you something to work with β and something to demonstrate your thinking against.
Some trainees leave their QIA until their final year, thinking it will be easier when they are more experienced. In practice, the opposite happens: ST3 is the busiest year, with SCA preparation, ESR pressure, and ARCP looming. QIAs done in ST1 and ST2 are often more relaxed, more interesting, and better quality β because you had the time and headspace to do them properly.
GP trainers and TPDs consistently say the same things when they describe an above-expectation Discussion Paper: it reads like the trainee is genuinely wrestling with the evidence. It is honest about limitations. The action is specific and dated. The reflection shows the trainee knows more now than they did at the start β not just about the topic, but about how they think and work.
β± The Ideal Timeline β Writing Your Discussion Paper
Spread the work over 4β6 weeks. This is not procrastination β it is how good writing actually works.
π³ Topic Picker β Is Your Topic Right for a Discussion Paper?
Not sure if your idea will work? Walk through this quick decision tree before you start writing.
π¬ Voices From Training β What GP Registrars Say
Patterns drawn from UK GP training forums, deanery peer-learning groups, and registrar accounts. All consistent with RCGP guidance.
Nobody explained to me that a Discussion Paper needed an action. I thought it was just about making a good argument. I submitted a beautifully written piece and my supervisor said it couldn't count as my QIA. I had to add an action section and resubmit.
β Recurring theme across UK deanery registrar feedback groups
I was so worried about making it academic enough that I forgot to make it personal. My second Discussion Paper β where I actually wrote in first person about a real clinical puzzlement β was twice as easy to write and scored much better.
β Advice widely shared in GP training peer groups across the UK
My trainer said: "A Discussion Paper should make me think differently about something, or make you think differently β or ideally both." That helped me understand what I was aiming for. Not information. Not a summary. A shift in thinking.
β Trainer advice echoed across multiple UK GP educational supervision forums
I wish I had used a clear subheading structure from the start. I wrote mine in flowing prose with no headings and my supervisor said it was hard to find the key parts. Subheadings are not just for clarity β they show you have a plan.
β Practical advice from GP trainer feedback sessions, widely replicated
The biggest surprise was that my supervisor was actually interested in what I wrote. I expected them to just check a box. Instead we had a really good 30-minute conversation about my topic. Write something you would actually want to talk about.
β Common positive experience reported by trainees in GP training communities
I kept my QIA for last because I thought I could do it quickly. I ended up writing it in a weekend before my ARCP. My reflection was thin, my action was vague, and I could see my supervisor's disappointment. Don't be me.
β Cautionary pattern reported across multiple UK deanery ARCP accounts
β Pre-Submission Checklist β Run Through This Before You Upload
Tick each one honestly. If any are blank, fix them before uploading. (Your ARCP panel will notice what you missed.)
π For Trainers & Supervisors
Teaching Discussion Papers well takes a little thought β here's how to make tutorials on this topic genuinely useful.
Common Trainee Blind Spots (Teach to These)
- Not understanding the difference between a Discussion Paper and a literature review β they think describing evidence IS the QIA
- Forgetting that action and reflection are what make it QIA β not the quality of the analysis alone
- Choosing topics too broad for a document of 1,500 words
- Writing in a passive, impersonal academic tone that strips out all personal connection
- Failing to see the Discussion Paper as an opportunity for genuine intellectual growth β treating it as box-ticking
- Not presenting findings to the team β missing the easiest way to demonstrate team involvement
Tutorial Ideas & Discussion Prompts
- "What clinical question genuinely puzzles you right now?" β start with curiosity, not compliance
- Ask the trainee to summarise a relevant NICE guideline in 3 bullets β then ask "but what's the problem with that guideline in your specific patient population?" This models the difference between describing and analysing evidence.
- Show the trainee the RCGP marking domains and ask them to self-assess a draft against each one before submission
- Explore: "Tell me about a patient who made you question how you practice in this area." The story behind the paper matters as much as the paper itself.
- Ask: "What would need to be different in 6 months for you to say this paper had made a real difference?" β this crystallises the action section
- Use the Bradford VTS downloads (sample Discussion Papers) as teaching material β read one together and critique it against the marking domains
When reviewing a trainee's Discussion Paper, read the action section first and the reflection last. The action section tells you whether this genuinely qualifies as QIA. The reflection tells you whether the trainee has learned. If the reflection is richer than the action section, it usually means the trainee understood QI intellectually but hasn't quite translated that into practice yet β a specific and productive conversation to have in the tutorial.
π FAQ
The questions that come up every single year β answered clearly.
β Final Take-Home Points
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