Understanding Doctors’ Performance

Description:

Understanding Doctors’ Performance addresses possible reasons why doctors under-perform, covering specific areas such as education and training, physical and mental health, workload, personality, organisational culture, drug and alcohol misuse, and cognitive impairment. It draws together evidence and describes the factors (apart from clinical competence) that adversely affect performance and how they can be prevented, identified, assessed and addressed. This practical and easy to read book is invaluable for NHS managers, medical directors, chief executives and board members, along with directors of human resources in healthcare and healthcare professionals interested in the assessment of performance or the management of underperformance.

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Introduction

Like other health professionals, most doctors work hard, strive to achieve high standards and provide excellent services for their patients. But there are more than 100 000 practising doctors in the UK and it is inevitable that some of them fail to meet reasonable standards.

Doctors’ professional performance has become the focus of unprecedented public scrutiny. Most people had assumed that their doctors were competent, but several highly publicised casesin the United Kingdomshowed howthattrustcould sometimes be misplaced. Failings of paediatric cardiac surgeons in Bristol led the British Medical Journal to conclude in an editorial: ‘All changed, changed utterly’ (Smith, 1998).

The medical profession had begun to address the problems of poor performance of doctors before these events made headline news, but public exposure of poor performance made it more urgent to find solutions.

By 1995 the General Medical Council (GMC), the body responsible for regulation of the medical profession, had obtained the necessary legislative framework to introduce ‘Performance Procedures’ which allow them to investigate and, if necessary, restrict the practice of doctors who may be putting their patients or the public at risk. The GMC developed methods to assess both competence (what the doctor can do) and performance (what the doctor does do) (Southgate et al., 2001) which have been sufficiently robust to withstand legal challenge. GMC performance assessments, quite properly since they are intended to protect the public, concentrate on description of the doctor’s clinical performance with reference to current standards. They are not designed to explain why the doctor’s performance is substandard. Furthermore, the GMC has tended to concentrate its work at the extreme end of the spectrum of poor performance, with procedures which are more disciplinary than developmental.

In 2001 the National Clinical Assessment Authority (now part of the National Patient Safety Agency) was created as a special Health Authority of the National Health Service (NHS) to advise the NHS about the management of poor performance. Its stated aim was ‘promoting confidence in doctors and dentists’ (NCAA, 2004a). Like the GMC, it undertakes assessments of performance but, unlike the GMC, its assessments are formative, intended to clarify concerns and to make recommendations to the doctor and the NHS body to whom the doctor is responsible. As well as assessing clinical performance, an assessment includes, as a matter of routine, psychometric testing, an interview with a behavioural psychologist and assessment by an occupational health physician. The thrust of these assessments – and the impetus for this book – is to try to explain the doctor’s practice as well as to describe it. Understanding more about the possible causes of a doctor’s practice helps to inform the most appropriate recommendations or remediation.

Regulators and other interested parties in other countries, particularly Australia, New Zealand, Canada and the USA are also working on the same problems. In general, there are three levels of assessment: screening whole populations of doctors (level 1), the targeting of ‘at risk’ groups (level 2) and assessing individual practitioners who may be performing poorly (level 3) (Finucane PM et al., 2003). Canadian provinces, for example, have a number of well-developed level 1 (screening) andlevel 2 (targeted assessment) programmes. Although level 3 performance assessments carried out in the UK are widely acknowledged as being the most highly developed in the world, so far we have no well-developed system for level 1 or level 2 assessments in the UK. They are likely to be introduced in the near future as part of the proposals for regular revalidation of doctors. The assessment of the factors described in this book would usually be part of a level 3 assessment but, of course, the causes of poor performance are the same however they are assessed.

One of the most significant changes to affect the medical profession in recent years is the recognition that being a good doctor is about more than just technical and clinical competence, skills or knowledge. The dissemination of the GMC document on the principles of Good Medical Practice (General Medical Council, 1998) has highlighted and embedded the importance of non-clinical attributes including team working, leadership, and communication. There is increasing evidence that complaints about doctors revolve largely around their behaviour (Sanger, 1998).

So what are the factors that cause a doctor who can practise safely not to do so? Why do some doctors successfully address their difficulties while others fail to do so? What is the impact of such factors as physical and psychological health, cognitive deterioration, personality, attitudes, values, beliefs, workload, sleep loss, shift patterns, organisational culture, teamwork, leadership and life events and so on?

Early experience of including behavioural assessment as part of performance assessment has provided some insights, as has the work of regulatory bodies in other countries such as Canada, Australia and New Zealand. For example, Canadian experience indicates that cognitive impairment may affect up to a third of poorly performing physicians assessed in Ontario (Ferguson B, personal communication). Similarly, although numbers are too small to generalise with confidence, a review of the first 50 assessments carried out by the National Clinical Assessment Authority revealed that two doctors (4%) were affected by cognitive impairment.

How widespread is poor performance amongst doctors? The international literature has shown consistently for more than a decade that in the hospital workforce there are around 6% of doctors with serious performance problems (Donaldson, 1994). Of those whose performance has been assessed by one of the national bodies, only a small minority are simply incompetent.
The themes of this book were first presented as a report for the NHS (NCAA, 2004b). We believe that this is the first time anyone has attempted to bring together existing knowledge about the factors influencing a doctor’s performance. Our aim is to provide practical, evidence-based guidance to assist individuals, employers and regulatory, educational and professional agencies that are faced with the challenge of managing concerns about the performance of doctors. Although the primary focus is on doctors, many of the issues are equally applicable to other health professionals, including dentists.

Our initial literature search revealed a complex array of issues that can impact on a doctor’s performance. Some clear themes emerged and these provide the basis for our chapter headings. Some themes, whilst crucially important, proved difficult to cover satisfactorily in a single chapter – in particular, issues concerning ethnicity, equality and diversity. These cut across many different topic areas. Rather than risk oversimplifying issues of such sensitivity and significance we chose to address them, as appropriate, as part of a number of chapters. There is a substantial and broadranging international literature on the impact of ethnicity and diversity on human performance and, to a lesser extent, on the performance of healthcare staff. Much of  literature concludes that inequalities that impact on minority groups exist around the world, in the whole field of human endeavour.

Similarly, there is an extensive literature on safety and quality issues in healthcare which lies beyond the scope of this book but which we recognise is central to the issues relating to poor performance in doctors. Finally, although some high-profile cases concern criminal or unethical activities, we have not addressed them in this book. Procedures for dealing with them do not normally include performance assessment.

Chapters in the book were commissioned from experts who were asked to review and analyse the relevant literature and address specific questions to develop our understanding of the significance, assessment and possible remediation of factors that affect performance. Each contribution was further refined by discussion and editing by the working group.

We aimed to answer some important practical questions about each of the factors identified:
• What are the factors that influence a doctor’s performance?
• Why do the factors arise?
• To what extent does each factor affect performance?
• What are the most effective methods for assessing each factor and its impact on the performance of a doctor?
• To what extent does each factor affect the remediability of poor performance?
• For which factors has intervention been effective?
• How sustainable are changes which result from interventions likely to be?
• What are the questions for further research?

We are aware of many of the limitations of this exercise (and, no doubt, ignorant of others). Nevertheless, we hope that this work will be a useful contribution to the world literature on performance assessment and be of interest to regulators and professions other than medicine in the UK and abroad. In the longer term we hope that the insights gained from this work will help us to promote and restore confidence in our doctors.

Table of contents :

Cover
Title Page
Copyright Page
Table of Contents
About the Editors
List of Contributors
Acknowledgements
Introduction
1 The Impact of Health on Performance
2 A Perspective on Stress and Depression
3 Misuse of Drugs and Alcohol
4 Cognitive Impairment and Performance
5 Are Psychological Factors Linked to Performance?
6 The Role of Education and Training
7 The Impact of Culture and Climate in Healthcare Organisations
8 The Influence of Team Working
9 Leadership and the Quality of Healthcare
10 Workload, Sleep Loss and Shift Work
Conclusions
Index