Dr John Crippen
Hi John,
This is a thorny one. What is a good Doctor? Is it someone who keeps up to date and does his/her best for patients? Is it someone who toes the New Labour line? Is it someone who gives the patients what they want?
Most of the media link the matter of revalidation to Shipman but of course Shipman has nothing to do with it. I get asked by the PCT every year if I'm a mass murderer and I've answered no up to press!
Shipman is being used to try and coral a notoriously awkward profession who won't do as they are told.
I'm in favour of some sort of exam but it's not simply to do with the amount of knowledge one possesses. It's move to do with what one does with the knowledge one has. For instance Dermatology. I have a working knowledge of the subject and no interest in gaining any more. One of my partners has a diploma in it so if I have a problem, I ask him. I might fail the Dermatology part of my exam. So what! Does that make me a bad doctor?
As a profession, we must resist any attempt to use the revalidation issue as a means to control us.
Difficult one...particularly as I only have two years experience of keeping a (student) CPD portfolio...and have yet to experience KSF appraisal (although having spent 2 hours listening to a talk about it, it seems to be what we used to call supervision, just with more paperwork).
As far as knowledge of subjects go, could doctors go down the same route as AHPs?
We are required to meet all the standards of proficiency when we qualify...but afterwards some may be let lapse if they are not within your current scope of practice (would you expect an OT working in e.g. hand therapy to have the same level of skill in therapeutic moving and handling as an OT working in stroke rehab?)
It still probably wouldn't be perfect. Insofar as stopping the future Shipmans of this world goes, I have no answer - CRB certainly doesn't provide one...and I'm sure that people could manage to fill out any basic written psych. test with appropriate answers (as implied in your blog).
I don't think this issue is about exams, it's about power (and the potential harm of power in the wrong hands)
http://mmcmtas.blogspot.com/2007...s-
custodes.html
After I'd written my post, I saw the BMA's press release on the issue, which makes similar points - that the monopoly employer shouldn't be controlling revalidation, and that a lay panel might make mistakes because they don't understand or appreciate the nature of healthcare decisions.
I don't think I've ever written a letter to my GP to say what a good doctor she is. I say "thank you" at the end of every appointment and she says "you're welcome. Give my regards to your mother." Did I miss something? Am I supposed to be sending letters?
I'm a pathologist in the NHS. This continued suggestion that doctors qualify and then do nothing is seriously raising my blood presure.
As part of my job, I do CPD (continuing professional development)-I have to get at least 250 points over 5 years. 1 hour of training/education etc equals 1 point-and the local CPA person decides whether the course or meeting has sufficient educational quantity to qualify. I also do regular audits, attend national and international courses (at my own expense as the training budget was the first thing to be slashed), take part in regular external quality assurance schemes (that are exam like in that I'm given a bunch of cases and have to come up with a diagnosis)and generally collaborate with colleagues-a lot get learnt over a discussion about cases.
How much more do I have to do? I have to get the work done at some point.
I shared part of my undergraduate education with a biochemist who was obviously wrong in the head (technical term favoured by us science types, doc). 30 years later I saw him on the telly, being led from the trial where he'd been found guilty of the attempted murder of his wife. Dangerous johnnies, biochemists. I do hope that they are appraising away manfully.
Hi Dr, I like your site. I write a comedy blog, I wondered if you wanted to take part in an interview to highlight your site. My blog is http://mrjoeblogs.blogspot.com. The questions are as follows :
Name :
Age :
Location :
Vocation :
Philosophy :
Sum up what your blog is about.
Why are you doing your blog?
What’s the funniest entry on your site?
What is your writing style?
What do people commonly say about your site?
What would you be doing if you weren’t doing your blog?
Why should someone visit your site?
What did you learn from your first love?
Are there any blogs, you enjoy reading?
If you could invite anyone to a dinner party who would it be and why?
What one website would you recommend and why?
Tell us about a good deed you have done recently.
What’s the most valuable lesson you have learnt being a Doctor?
Tell us a random funny story that comes to mind.
What advice would you have given yourself 5 years ago?
Any interesting travel stories?
What’s the most incredible thing that ever happened to you?
Now it’s your turn! Ask me one question, anything you like.
Your Site Address :
Kind Regards
Joe Blogs
(please include any picture at all that you want to add to the interview)
That's simple, Dr. Crippen. Let the nurses do the evals! 
Great site Doc..keep it up 
www.iweightlossonline.com
Dr Crippen whats going to happen next year when (as was pointed out to me today) the unemplyment of doctors will mean cometition for jobs, reduced pay and eventually a conveyor belt of "relativley competent" "relevantly intelligent" cheap labour.
Do you think the dumbing down of medicine is really the governments main concern?
As you yourself pointed out... just because an exam is stupid dosn't stop the hospital stopping all prescribing rights from the juniors due to the results.
An examination once every five years sounds like "the business" to me. In concert with the increased use of data mining to analyze prescribing habits each doctor could be sufficiently assessed. It also excellent news that the GMC will be used to gather data for presentation, and not to pass judgment. Doctors may feel that they can only be judged by a peer, but there are many smart people out there.
Why not be appraised independently, randomly and objectively using a well tried and trusted method used in retailer outlets.... the mystery shopper!
Of course in the NHS this would be much more difficult than just walking into a shop, the mystery patient would have to get an appointment first, no mean feat.
But wouldn't it be great if they used a really cantankerous old git with a hidden webcam, good objective assessment carried out... and even better... hours of endless amusement for us on YouTube.
One of my colleagues is soaking the labels off the bottles of whisky he gets from patients and sticking them in his appraisal folder.
Seems reasonable.
Seriously though, the BMA has been asking for at least 20 years for death certification to be tightened up, it was the govnmint that did not want to play.
I don't think this issue is about exams, it's about power (and the potential harm of power in the wrong hands)
http://mmcmtas.blogspot.com/2007...s- custodes.html
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Hi, HP, that is an excellent post - and i agree with you. This is INDEED about power and control and New Labour hatred of professional independence. I agree.
I feel strongly that the profession should continue to police itself. They are using the Shipman case as camofluage, as an excuse to take us over. You and I and most doctors know full well that no appraisal system will trap a Shipman.
But I wasn't looking so much at that (though I have many times in the past) as how we should approach revalidation. I think we have to accept that it is reasonable, and we also have to accept that the public demand it. I would like to see the Royal Colleges take it on. It is relatively easy to assess a surgeon, but I have not got a clue how you assess a physician or a GP.
When I talk of exams, I don't mean MRCP sort of stuff, I mean a practically orientated exam set so that any competent physician should be able to pass it.
I cannot think of any other way. The current appraisals GPs do are codswallop, and everyone knows it apart from the general public.
John
How about... mystery patients? :D
At my old GP surgery there was one doctor in particular who had a reputation as one who never examined you, sat you in the corner and barely looked at you while fiddling around with your notes. Indeed, when I was 16 and went to him to ask to be put on the pill (after a long time of building up my confidence) he enitrely dismissed me, made me out to be a dirty young girl etc! Luckily, I was even very determined back then and wouldn't leave without an adequate response, insisting "yes, this is the right decision for me thank you very much doctor".
How else can you judge how a doctor is in the confines of his little consultation room unless you experience it first hand?
I know it's not a perfect suggestion at all, but doctors with bad communication skills (which stretch to fobbing people off, generally) need to be pulled up. Medical students now have hours and hours and hours and hours (ad infinitum) of "communication" training. What about the grumpy old sods who sneer at patients? We can't just wait for them to die off!
If you want good revalidation then you need to tie it to validation i.e. the original qualifying examination.
Anything else produces bizarre consquences. You could easily imagine a system where a newly qualified GP would be unable to pass revalidation as the criteria were different. There must be a single criteria of competance.
Similarly there should be a single criteria of competance for doctors in general. It would be peculiar if doctors were removed from the register with greater knowledge and skills than those admited to the register.
Why not be appraised independently, randomly and objectively using a well tried and trusted method used in retailer outlets.... the mystery shopper!
********
Believe or not in the NHS we already have mystery patients. They have been used in the hospital where Dr Grumble works - though so far only on the receptionist and similar staff. It's probably only a matter of time before they send a mystery patient to see Dr Grumble.
I don't know what the solution is, but when it's found we should use it in nursing too!
Our system is known as PREP - basically, it means you have to do so many days of clinical practice (300?) and so many days of educational activity (5?) every three years in order to have your registration renewed. You are supposed to keep evidence of these activities in a portfolio, which may or may not be inspected when the time comes (Nursing Standard claimed sometime last year that some ridiculous number - half a dozen or something- had actually been checked). 'tis complete lunacy.
I quite like the idea of some kind of examination, but like the other respondents here I'm not sure how it could work: there is barely a standard set of criteria for entry to the register anymore (the NMC approves individual courses which supposedly provide for a set of learning outcomes to be met, but these outcomes are so wide thet different unis can, and have, interpreted them completely differently), so it is even harder to envisage how a post-reg "requalifying" exam could work, even if it was within individual specialities.
And of course, one would expect a nurse with 10 years experience to know more and be able to do more than one who had just qualified.
Suggestions on a postcard....
I wonder whether formally assessing the manual dexterity of thousands of surgeons is necessary in order to pick out the one who can't tie knots, or the one who mercilessly bullies his peers?
I'm envisaging a 360 degree feedback system where the feeder-back won't be punished for feeding back. It might not work for GPs who practice pretty much autonomously, but it could work well for hospital doctors, as it's unlikely someone with a serious problem would fail to be uncovered by confidential feedback from their contemporaries, their juniors, and their para-medical staff.
Then perhaps only the doctors with concerns would need to be revalidated.
But to make this work, 360 degree appraisal would have to be absolutely obligatory. And the Shipmans (Shipmen?) probably still wouldn't be found out.
Some sort of examination seems to be the theme. They have this in Australia and it helps to be a 'swimming pool socialist' who goes to the right symposiums ( in holiday resorts of course) and so knows the right answers.
Still it would be nice to actually judge the way a customer would - by results and courtesy.
At an ordinary level the control of mundane diseases like hypertension , obesity, depression - is , in general, far from admiral.
''I would not expect the overall mark to be published''quoth Crippen.
what planet are you going to ? this would be like expecting the PCT not to publish the QOF point scores, but they tried to make them into a league table available to the public, didn't they?
'Medical students now have hours and hours and hours and hours (ad infinitum) of "communication" training'. says missbliss
'Why is it that all technical support lines are full of fuckwitted numpties who seem to know fuck all about what they are talking about'.says missbliss
I bet they have all been trained in communication though. just like today's medical student. what you really need is knowledge pumped in during those hours and hours.
Dr Grumble - mystery patients - presumably these are real ill people? Do they get paid?
Being a member of the public rather than a doctor I think the idea of determining that a doctor is competent is a good one. As to how to do it, well I'm happy to leave it to people more qualified than in this subject than I am.
On the subject of Dr Shipman, correct me if I'm missing something but isn't catching mass murderers the job of the police force and not the medical profession?
Shipman was not caught by any clever system but because he got greedy and careless.
If they come up with something for GPs it will probably be applied to pharmacists as well. Which would be a good thing because I have seen some bloody awful pharmacists.
From what I've read about Shipman he would have sailed through any revalidation process. It may be possible to prevent another Shipman, but at what cost - I've already read that GPs are now reluctant to use opioids when needed, meaning people are in unnecesary pain. The one area that hasn't been looked at at all is signed orders, which is how another Shipman would get his supplies. (A signed order is basically a written note from a GP asking for say five amps of 10mg diamorphine injections for their bag.)
Apparently he managed to sweet-talk the pharmacist into supply vast amounts of diamorphine, and because he was so charming and seemed so honest, this was never questioned by said pharmacist, even when the amounts became ridiculous. I seem to remember there being some publicity of this fact (although it was somewhat overshadowed by the other aspects of the case), but I don't know if anything ever came of it.
As a medical student, I don't want to comment on such things (being that I'm more concerned with my own issues, like biochemistry), but I thought I'd post on what they do here in the colonies At least for internal medicine...
After your residency, you take the exam to become "Board Certified" in your specialty (in this case, IM), which must then be repeated every 10 years to maintain said certification. My sister just passed the exam, and a doctor in her group who has recert coming up next year is already studying for it.
Just cheer up!
If you really want to stop another shipman death certificates should be entered in a database and if a GP has more deaths than normal (and he had a LOT more than normal). An email is sent to the local police. It would be easy to do.
gorwell says "If you really want to stop another shipman death certificates should be entered in a database and if a GP has more deaths than normal"
That information was already there. The main reason why Shipman got away with it is that nowone believed it could happen. Even the police initially dismissed the concerns for this reason.
"An email is sent to the local police."
GPs with a lot of elderly patients of their lists will have a lot more deaths. It's not just simply a matter of numbers. I would humbly suggest that the police are not the first port of call!
Dr C - quick question (and forgive me if it has already been addressed in the comments) - do GP's have a CPD (continual professional development) requirement, like many other professions?
'What about the grumpy old sods who sneer at patients? We can't just wait for them to die off!'
Sadly these can often be the best, cetainly amongst the surgeons. When I have my operation I don't want a touchy feely experience, I want someone to cut the sodding tumour out. And be as brutal as necessary. GP probably different, however.
A quote from the Shipman deabacle.
"Dr Shipman was the nicest doctor my mother could have had. He was caring, available and gave her everything she needed.
Until he killed her'
Shipman would have sailed through Donaldson. 360 degree appraisal, when a whole load of numpties try to evaluate my medical practice about which they know fuck all, would have given him the highest score in the county.
Donaldson is NOTHING to do with Shipman. It is all to do lwith the Stalinist approach to heath care and the battering down of any percieved political power that doctors have. What most people don't realise is that political power is the ONLY weapon we have to protect our patients and the Health Service.
I know what I'm going to do. If all this comes in the way Donaldson wants it to and the lunatics finally take over the asylum
I'm going to retire.
I don't care if I do have a few years left to go. If I can't practice medicine the way I was taught and the way it should be done, then I'm going to open a book shop.
COI lost a patient yesterday, up till 5am, tired, pissed off, and wishing that wankers like Donaldson and Hewiit knew what life was really like in the NHS.
And I'm late for my sodding appraisal. Arse.
I was waiting for Dr C's comments on this and for what it is worth I throw in my own tuppence worth. I am GP trained, and work as a locum, most recently in psychiatry. It seems to me there are a lot of important issues here.
Starting assumptions:
(1) The detecting Shipman problem and the demonstrating competence problem are two totally separate problems. The former is about picking up very rare, very clever but very, very bad doctors, while the second problem is about routine monitoring of everyday professional competence. As has been noted many times, the latter will not pick up the former. But the government - disingenuously, to suit their own political purposes - have subsumed the one into the other. Their intention is to bring an unruly professional to heel on the back of a highly emotive criminal.
(2) We all want good doctors. As far as I (as a patient and as a doctor) am concerned a good doctor, to quote the first comment, is "someone who keeps up to date and does his/her best for patients". However the first bit isn't a requirement in its own right, it is only important in so far as it allows the doctor to achieve the second bit - do the best for his/her patient. And of course a doctor might be bang up to date, but a lousy doctor. Maybe people thought Dr Shipman was up to date; certainly many of his patients thought the world of him.
Detecting Shipmans
How we go about stopping the Shipmans of this world? The answer is we can’t - they are very rare (ie very small needles in very big haystacks), and very clever, and almost by definition, they are always - until caught - one step ahead of the rest of us. They will appear ordinary, even liked, and most likely be active themselves in any system intended to detect them (as in Shipman could have been an appraiser himself). No routine system can possibly hope to pick them up before they start to do harm. Indeed, they can only be picked up once they have started to do harm (you can’t pick up a harm that hasn’t been done).
The best we can hope to do is pick them up early, and to do so by constantly tweaking the system in the light of lessons learnt. In Shipman’s case, it is evident that both the (lack of) management of controlled drugs and the death certification system allowed him to get away with his crimes for as long as he did. So it is right and proper that we should build in additional safeguards. That is straightforward and easy enough to do, but we have to accept our Shipman radar will always be one step behind. All we can do, and should do, is make that radar as responsive as possible by constantly adjusting it so as to improve its detection rate.
Routine monitoring of everyday professional competence
It is all very well comparing airline pilots with doctors, but it is pointless, because they do very different jobs (OK they can both kill in large numbers - but in totally different ways). Perhaps we should ask ourselves - do we really need to demonstrate continuing professional competence anyway? And if we do, how can we do it (and if we can’t then should we be wasting time and money on an impossible task)?
We all want good doctors - but it doesn’t necessarily follow that we have to check up on them on a regular basis just to make sure that they are the good doctor we hope they are. Maybe regular checks are all part of the tick-box, pseudo-risk management culture that we live in today. All boxes ticked, all pigs fed and ready to fly. Bit like flying a plane, really.
The difficulty with the professions (compared to skills based jobs like flying planes) is that there is an awful lot more to doing a profession that carrying out skills. I might be very very up to date, astonishingly skilled and always get 10/10 in every exam - but still not be a good doctor.
Furthermore - as a patient - I am not even sure that I always want the most bang up to date doctor. Maybe that new drugs is not quite as good as they say it is. Maybe the older, wiser, more old-fashioned doctor - who isn’t so keen to rush into every new fad - is more to my liking. Or maybe the one who listens and talks to me, rather than rushing to check my BP and cholesterol, because that is what up-to-date modern state-sponsored GPs do. Or maybe the one who continues to see me for 20 minutes every week for a few weeks in the hospital psychiatry clinic even though I am not on any medication (so the managers would have a fit) because he knows that by prescribing the drug “doctor” he is doing me far more good than any antidepressant would ever do.
The problem is that we are assuming that a proxy (being up to date) is a reliable guide to what we are really interested in (a good doctor). But the risk is that we mistake the finger pointing at the moon for the moon.
And even if the proxies (say, clinical knowledge, skills and attitude) were a reliable guide to what we really want to know (is this doctor a good doctor), can we devise a reliable, valid way (bearing in mind livelihoods are at stake) of measuring those proxies? We may be able to - but then the knowledge, skills and attitudes of an old wise and very good GP may be very different from those of a newly qualified GP - but they stand to be assessed in the same way. The outcome may not be what we expect - or want.
Which leads conveniently to my last point - who assesses the assessors? Who sets the standards, and on what basis? It is increasingly evident that Sir Fatto and his pals are ready to lie down and have their tummies tickled by Sir Don and his government goons - ie the standards and assessor assessors will be largely in the hands of the state. We already know that the government is more interested in votes (eg the pointless screening in general practice debacle) than a good medical practice. Once professional standards start being set by governments, we risk a rather sudden descent into overt Stalinism on a far greater scale than we already have. And before we know it, my professional questioning of government policy will be redefined as bad attitude. I will have to submit to “re-training” - of face a mental health assessment.
It will be a cold day in April and the clock will strike thirteen.
"Complementary letters"? - can they be distinguished by the smell of lavender?
Dr C - quick question (and forgive me if it has already been addressed in the comments) - do GP's have a CPD (continual professional development) requirement, like many other professions?
Katherine
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We used to have. Until New Labour started meddling, and introduced appraisals, we had a system of PGEA (post graduate education); you had to do 10 sessions of PGEA a year, and be signed off for it. If you did not, then your salary was reduced. 99% of GPs did it.
It has been abolished. PGEA courses have all but disappeared. Now you have to sit down with an appraiser and produce your Personal Development Plan (your PDP). It is usually a work of fiction. It is not worth the paper it is printed on. You can knock of a PDP in half an hour on Microsoft Word.
As a result, GPs are mostly not doing any formal post grad education at all.
It is one of the most retrograde changes that New Labour has introduced.
Try telling them that
John
Have a look at it all here. Download some of the documents. It is all a load of botty-wipe
http://www.dh.gov.uk/PolicyAndGu...2082&
chk=gXUb3K
I really enjoy your blog and generally agree with your comments but...
Appraisal - I am sorry you've had what you consider an inadequate appraisal but round here GP appraisals are 2.5hrs, with an appraiser chosen for you (not just a pal) and all appraisers are trained and have to undertake assessment before allowed to appraise. I find them very useful and the feedback received by the PCT suggests that most appraisees do. But I agree you cannot take a formative process (where are you weak, what do you think you need to get better at, how can you do that) and use it for summative (pass/fail). The two are different. I also agree wholeheartedly that Dr Shipman would have sailed through appraisals and I'm sure would have sailed through any revalidation process dreamt up by the government.
PGEA - 10 sessions and signed off for attendance - that was it. You didn't have to listen, take part or learn anything - you just had to turn up. It also didn't have to cover a topic you needed to learn about. You could just select a course that provided a nice lunch or that was convenient in time/location. At least appraisal should encourage you to think about what you need to develop, how you can develop it (personal study or internet learning may suit you better) and to do that.
In my world.....
Until this year we had a 'points win prizes' CPD scheme - 50 points/year with 1hr in the audience = 1 pt and more for being the presenter or for publishing etc.
Now, we have a much more 'touchy feely' scheme. Ultimately, we are assessed against the 'full' Knowledge and Skills Framework for our post, which you are expected to fulfil a couple of years before you reach the top of your band. At your annual appraisal, you agree learning outcomes, and then go off and achieve them, keeping records as you go.
The disadvantage with the former was that, as Skywalker says, bums on seats counted for a lot. But you couldn't collect all your points in one way - you had to publish, present, read etc too. The big advantage to it was that it could be used as a stick with which to beat the Trust, so that we could actually go to meetings.
The new version is fine in theory, and I'm sure that for many staff groups who have never really had a (professional) development culture it is great. But my KSF is a complete load of crap, quite frankly. I wrote it in a few hours, mostly by cutting and pasting from the person I sit next to. Anyhow, I won't go into how crap KSF as a concept is (could rant a lot). For my appraisal, I have to dream up ways to meet these random targets, which aren't going to help my job. Whereas, if there is a scientific meeting where I will learn about advances in a particular area which I am involved in developing for my Trust: tough, no money.
In case you hadn't twigged, I'm also quite narked that medics haven't had to go through the whole AfC / KSF / NOS thing. Trying to tick boxes that were written to try to cover every nurse, plumber, cook, therapist... has been hell. But then the rational part of me takes over, and realises that with MMC and stuff, it must be pretty rubbish for you too, and that you aren't the real enemy.
Bravo Scientist, I have seen grown men weep after exposure to KSF.
How can we take anything seriously that includes phrases like 'core dimensions' and 'level descriptors'.
More to the point, how can any objective standard be applied when assessors are expected to rate performance using such airy fairy concepts.
Don't worry scientist you are not the only one cutting and pasting - KSF is drivel, albeit very expensive and time consuming drivel.
Stripping the GMC of it's powers is good. It may not please those at the "coalface", "sharp-end" or "shopfloor", but there have been too many errors made to allow a self-policing medical profession. I know medicine is a "vocation" (?) peopled by the "top 1%"(?)of the population who are striving for "work-life balance", but you swim in the same water as the rest of us. Seeing as how we pay your wages "20p a day" (even though I haven't seen a doctor in years), we have the right to demand high standards.
By the Way- an excellent blog Dr Crippen
Haha! Airy fairy... botty wipe... I think I might have cracked my first smile of the day!
I really enjoy your blog and generally agree with your comments but...
Appraisal - I am sorry you've had what you consider an inadequate appraisal but round here GP appraisals are 2.5hrs, with an appraiser chosen for you (not just a pal) and all appraisers are trained and have to undertake assessment before allowed to appraise.
[Well, clearly a two hour appraisal is not going to be any good. But two and a half hours…that extra half hour makes all the difference.
I don’t believe that.
All the appraisers I know, including some in our practice, are in it for the money, and regard it as a joke. And who became appraisers? Some, like my partners, did it for the money. A fair number of them are the usual suspect, the arseholes with beards who got fed up with general practice years ago and prefer to spend there time telling other people how to do the job in which they have lost interest. In the meantime, whilst they “appraise” their patients are being seen by trainees, salaried doctors and nurse practitioner.
Yes, some of the young, inexperienced GPs take it seriously and earnestly produces folders full of letters from grateful patients and so on and so forth. Yuk!
All in all, the process is humiliating and serves little purpose.]
I find them very useful and the feedback received by the PCT suggests that most appraisees do.
[Each to his/her own. Of course the PCT gets good feedback. No one is going to clag off their appraiser. It’s a game. Some people play it earnestly, some people write in what they think the PCT wants to here. People interviewed in Zimbabwe always say nice thinks about that nice Mr Mugawbe]
But I agree you cannot take a formative process (where are you weak, what do you think you need to get better at, how can you do that) and use it for summative (pass/fail). The two are different. I also agree wholeheartedly that Dr Shipman would have sailed through appraisals and I'm sure would have sailed through any revalidation process dreamt up by the government.
[Ah…now we are getting to the REAL point. The government sells this crap as a way of preventing Shipmans (Shipmen?); read the findings of that dreadful female judge.]
PGEA - 10 sessions and signed off for attendance - that was it. You didn't have to listen, take part or learn anything - you just had to turn up.
[True. But most people who did turn up did listen. As for taking party, if you mean the ones that did “play school”…well, I avoided those.]
It also didn't have to cover a topic you needed to learn about. You could just select a course that provided a nice lunch or that was convenient in time/location.
[True]
At least appraisal should encourage you to think about what you need to develop, how you can develop it (personal study or internet learning may suit you better) and to do that.
[Maybe it SHOULD, but for most people it is just a humiliating chore to be got through as quickly as possible and then forgotten about for another year.]
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Appraisals are, in my opinion, a waste of time.
John
OK my last comment was far too long.
The key point is that by accepting the need for revalidation we are accepting a radical shift from a presumption of professional competence to a presumption of professional incompetence. You will be presumed incompetent unless and until you revalidate. Is this really a good way to go about things? Just think it through a bit.
Add to that the very considerable problems of how do you assess competence and the sinister implications of the control of regulation passing further and further away from the profession and closer and closer to government and I for one am beginning to wonder if the time has come to cancel my direct debit to the GMC.
what about 'mystery shoppers' - that would go down well with new labour
Does anyone remember the details of the public apparaisal of an education minister a few years back? The numpty (was it Bozo Byers?) was asked by an interviewer something like "what's 7 times 8?" and got it wrong.
oops, appraisal.
Appraisals is another idea borrowed from the private sector and misapplied. For an appraisal to have any value, the peson doing the appraising has to be your actual real boss and to have some actual real influence over what happens to your career next. (Even then, thye are often a bit of a waste of time).
My only suggestion for an alternative to exams (or in addition to) is audit. An audit done by an experienced level-headed properly-qualified auditor, working within a structure but not required to tick boxes blindly, can be very useful. But as in this case "properly-qualified" would mean medically-qualified, it might be hard to recruit enough of them. But you would have a similar problem in marking the exam, unless it was multiple-choice.
Appraisals is another idea borrowed from the private sector and misapplied. For an appraisal to have any value, the person doing the appraising has to be your actual real boss and to have some actual real influence over what happens to your career next. (Even then, they are often a bit of a waste of time).
My only suggestion for an alternative to exams (or in addition to) is audit. An audit done by an experienced level-headed properly-qualified auditor, working within a structure but not required to tick boxes blindly, can be very useful. But as in this case "properly-qualified" would mean medically-qualified, it might be hard to recruit enough of them. But you would have a similar problem in marking the exam, unless it was multiple-choice.
potentilla
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Yes, I agree.
Appraisals have some validity in a hierarchy. But senior doctors are not in a hierarchy. Maybe they should be, but they are not.
GP appraisals are transactionally inappropriate. They are embarrassing for the appraiser and humiliating for the appraisee
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Audits.
Well, OK in theory, but what do you measure?
How do you compare the brilliant paediatric cardiac surgeon who takes on the complex cases - he saves 50% but 50% die - with the surgeon who does nothing adventurous?
How do you audit what a GP does? Remember, this is what the government is doing to us now. We are deemed tobe good (and are paid more) for hitting predetermined targets. The year end approaches; GP are currently reducing time available for patients to tick boxes for the government. Most will deny it, but that is what they are doing.
All sensible doctors accept without reserveation that it is right and proper that their competance should be assessed at intervals. And any who don't should retire now.
I am not trying to be difficult. Tell me how it should be done, and I will do it gladly.
But find a system that is genuinely discriminating without being humiliating.
And PLEASE can we stop talking about SHIPMAN? I cannot tell you how much offence and upset we all feel being compared to this lunatic.
No one suggested after 9/11 that all American airline pilots might be terrorists? Why why why do people think that GPs might be homicidal maniacs?
We should just be grateful that Shipman was a doctor and NOT an airline pilot!
John
re "I feel strongly that the profession should continue to police itself" no way no how, how can you defend a system as bad as the current one, any of you docs sheltered in your nice little middle class surgerys thinking all is rosey i suggest you get off your bums and go see how substandard the average inner city GP is, I'm no medic but I have witnessed half a dozen this year that fail very short of the basics of decent health professionals
still think GP's are wide open to a TV under cover expose, if I'd had a hidden camera on while watching some of the crap GP's in action I'm sure it would make good telly
I'm sorry to say the service the public get is crap, this to some degree is down to piss poor doctors, the profession itself has done not enough to ramp up quality, it is inevitable the public or their representatives will fight back
Well, clearly a two hour appraisal is not going to be any good. But two and a half hours…that extra half hour makes all the difference.
>>In your April 06 blog you say you and your mate had a chat for an hour over lunch and spent £1000 - did you both do each other in one hour?
All the appraisers I know, including some in our practice, are in it for the money.
>>I will not disagree - the money is good but the appraisers round here do need to go on a course to learn how to appraise (where they have to "take part") and then have to be assessed to show they can manage an appraisal (or the appraisee?), ask questions in a useful way, challenge, suggest, (not "telling people how to do the job")
People interviewed in Zimbabwe always say nice thinks about that nice Mr Mugawbe.
>>Sorry if I wasn't clear - anonymous feedback to the GP tutor...
Maybe it SHOULD, but for most people it is just a humiliating chore to be got through as quickly as possible and then forgotten about for another year.
>>I think that's the problem, isn't it? I will agree with you that it does sound as if appraisals are, in your neck of the wood, a waste of time.
for most people it is just a humiliating chore to be got through as quickly as possible and then forgotten about for another year.
>"Most people" - really, you know that? Again maybe in your area the way your PCT runs it?
For an appraisal to have any value, the peson doing the appraising has to be your actual real boss and to have some actual real influence over what happens to your career next.
>>words, eh? Can't trust 'em. That sounds like perfomance review - which I agree is very different from developmental appraisal. Assessment, performance review, appraisal and revalidation are all different and used differently. What exactly do we want?
>>Agree Shipman is irrelevant to this discussion (or should be..)
All sensible doctors accept without reservation that it is right and proper that their competance should be assessed at intervals. And any who don't should retire now.
>>Makes sense to me. This obviously isn't what appraisal is all about. I would suggest a system that had an assessment part to check competence and then some form of developmental appraisal separately to aid development. Of course any assessment system would probably need to be clinical to be reliable and valuable - and would be very expensive and time-consuming. Who would pay?
Hi Skywalker
I think we are going to have to agree to differ.
Maybe I am surrounded by cynical doctors, and you are surrounded by...well, I don't know what...but we will not agree on this.
Who are the appriasers? As I said before, all the usual suspects.
But one very scary comment.
You say
"Sorry if I wasn't clear - anonymous feedback to the GP tutor..."
Are you suggesting that appraisers leak confidential information about appraisals to the local GP tutor?
John
Hello Everybody Out There !!! Very Many Thanks for kindly signing (and globally circulating) this New Downing Street Petition at http://petitions.pm.gov.uk/AbolishGMC
Who are the appraisers? Mainly local principals (many GP trainers), beginning to have more non-principals. Two full-day course (with taking part). Then two separate assessed appraisals with real and willing appraisees. Assessed by an experienced appraiser who has been trained in assessment against a set of criteria (so a proper "assessment"). If these appraisals are both satisfactory, the appraiser is approved and can appraise solo provided he/she continues to attend a number of refresher courses a year.
I really enjoy the clarity of your writing and am sorry I can't compete. What I meant was that the appraisees complete a feedback form after the appraisal, unseen by the appraiser and sent without name to the GP tutor. The GP tutor reviews, collates, summarises these feedback forms - the majority of local GPs say they find appraisal a useful process. As you would expect, confidentiality is preserved.
I am truly sorry you seem to have had short, unsatisfactory appraisals. I understand they don't suit everyone. I'm sure if we moved to exams we'd have a large group of doctors who felt those were not fit for purpose. I know appraisals are not "the" answer. But until "the" answer arrives I think they are better than nothing and better than PGEA. Whether the fact that appraisal isn't working for you is because of your local set-up or you, I leave to your judgement.
I guess we won't agree because of our very different experiences. I tend to lurk and agree with almost everything else you write about the state we are in but I didn't want everyone to believe your experience was universal. Our difference will not spoil my enjoyment of your blog!
beginning to have more non-principals.
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Wow! Non principals appraising.
That's like the monkey appraising the organ grinder
Crazy
John
"All sensible doctors accept without reservation that it is right and proper that their competance should be assessed at intervals. And any who don't should retire now."
What is the evidence for this outrageous statement? Have you spoken to "all sensible doctors"? If not, how do you know their views? Rather presumptious of you, to say the least. And then to pronounce anyone who disagrees with your views should "retire now". Oh really?
Your blog lists the day in day out awfulness of the NHS. You make it very clear you don't think appraisal can work. Audit isn't really workable either - things like differing case-mix bias results - and livlihoods are at stake. Why on earth do you automatically assume that it is a good thing to assess our competence visibly and formally on a regular basis in? All the professions have managed without this regular formal competence assessment since the beginning of time. Why is it suddenly such a sensible idea now? If it was such a obviously good idea, why didn't they bring it in years (centuries) ago?
I also sense you have an anti-locum bias. Now let me tell you, as a locum I get to see lots of other doctor's work. Some are very good (and are on my Desert Island Doctors list). But many are just plain awful. GP partners like you. I alluded to the fact I do some psychiatry. So I get to see GP referrals in a wide range of places. And you would not believe some of the comedy referrals your esteemed co-partners send in. Things like:
- patient thinks they may have married the wrong person; please see and advise
- patient wants to carry on taking dope; can you recommend a suitable anti-psychotic
- Miss X is feeling a bit down so I started her on 10mg of citalopram today; please see her URGENTLY
and so on.
All from established partners like you.
So don't give me the all partners are wonderful all non-proncipals are lousy crap.
Principals and non-principals are just like any other group. Some are good and some are not so good.
Dr No
speaking as one of the gps who actually first suspected that shipman was killing his patients, i agree with several of the points, how come when i was the only female gp in hyde out of 15 or so gps the pct (or whatever it was called then), could spot that i prescribed more hrt than any of my male colleagues but couldn't spot that shipman was prescribing far more diamorphine than anyone else; how come it took our practice to count the number of part 2 crem forms we were being asked to do for shipman, and that was just the cremations, surely the registrar should have been counting the total number of deaths; and shipman would easily have jumped through the hoops of QOF, appraisal and revalidation and would i agree have probably been an appraisor
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