difficult-doctors or doctors-in-difficulty?

DIFFICULT-DOCTORS or DIFFICULT-DOCTORS or DOCTORS-IN-DIFFICULTY?DOCTORS-IN-DIFFICULTY?

ByDr. M Murphy

Dr. W Burn

Workshop outlineWorkshop outline• Overview of background

• Group work using vignettes

• Discussion

Why do you need to know Why do you need to know

aboutabout

this ? this ?• Understand factors influence performance

enhances training

• As Tutor/TPD etc will deal with trainees in difficulty

Performance and patient Performance and patient

safetysafetyVincent et al estimated 10% of hospital patients

experience some form of medical error

‘Why children die’- 2008- 23% preventable cause

BUT most of these relate to system issues and not

practioner issues HOWEVER need to look at practioner performance/safety.

Competence and performance?Competence and performance?

• Training initially mostly concerned with what the doctor knows how to do i.e competence.

• Performance is what the doctor usually does

• Poor performance is that which falls below standard for specialty and grade usually on-going

• In case of trainees also includes failure to progress ? when does slow progress constitute a performance problem

How common are serious How common are serious

performance problems?performance problems?

• Difficult to measure- Donaldson 1994 data from experience of medical directors estimated approx. 5%. of doctors. Similar to international estimates

• Approx 300 referrals GMC a year ( performance, health, conduct)

• Approx 650 referrals to NCAS each year• ?? Data on trainees ??

Performance problemsPerformance problems• Clinical capability/ competence

• Health

• Personal conduct- fraud, theft, repeated lateness, downloading pornography at work, assault on staff member.

• Professional misconduct- confidentiality breach, prescribing issues, improper certification

Analysis of first four years of NCAS Analysis of first four years of NCAS

referrals - Ireferrals - IMost recent publicly available data on profile of

performance problems. Obviously there will be ‘referral bias’.

• NCAS receives about 700 referrals a year (650 medical practioners) approx 10% assessed.

• 40% of referrals from GP/GDP sector- matches profile of medical workforce.

• 1 in 200 doctors referred (1 in 300 dentists).


referrals-IIreferrals-II

• Referral rates differ between specialities- psychiatry and obstetrics and gynaecology over-represented ? why

• Majority of referrals relate to senior doctors ? sit outside training structures

• Men more likely to be referred than women even after adjusting for other factors ? feminization of medicine

• Older doctors more likely to be referred. esp GPs


referrals-IIIreferrals-III• Concerns classified according to whether primarily

health, capability or behaviour or combination-

concerns about behaviour alone commoner men than women concerns about behaviour alone commoner younger

practioners

concerns clinical capability increased with age (46% in under 35 and

72% in over 65s) fits with literature on relationship between

experience and performance

health concerns independent of age but commoner amongst women


referrals- IVreferrals- IV

• 37% behaviour- greater than expected

• 21% clinical capability and behaviour

• 17% clinical capability- less than expected ? less technical specialty

• 10% health and behaviour

• 8% health, clinical capability and behaviour

Referral less likely to lead to assessment than in other specialities ?why

Psychiatrists

Analysis of first 50 cases Analysis of first 50 cases

assessed by NCASassessed by NCAS

• Clinical performance concerns 92%

• Health concerns 28% ( included cognitive problems).

• Communication colleagues sub-optimal 76%

• Training/CPD issues 48%.

Ethnicity and place of qualificationEthnicity and place of qualification• Data from GMC and NCAS points to an

over-representation of doctors who qualified overseas amongst those referred for performance concerns.

• Some work by GMC and NCAS on reasons for this but still in progress and no definite conclusions – BUT ? prep. working in NHS/UK

Key pointsKey points• Performance problems often not simply problem

with lack of clinical knowledge

• Need to understand why doctor isn’t doing what they know how to do or should be done

The performance triangleThe performance triangle

WORK CONTEX

T

CLINICAL CAPABILITY/

COMPETENCE

HEALTH BEHAVIOUR

Clinical capability / Clinical capability / knowledgeknowledge

• Spelt out in curriculum• Much of focus of training – knowledge tests,

WPBAs• Trainees need to work within limits of

competence / knowledge – may be apparent performance issue if stray outside this

Early warning signs

• The “disappearing act”: not answering bleeps; disappearing between clinics and frequent sick leave

• Low work rate: slowness in doing procedures, clerking patients, dictating letters, workload.

• “Ward rage”: bursts of temper; shouting matches; real or imagined slights.

• Rigidity: poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.

• “Bypass syndrome”: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.

• Career problems: difficulty with exams; uncertainty about career choice;

• Insight failure: rejection of constructive criticism; defensiveness; counter-challenge.

• Complaints ? How many/ what sort are significant ?

DOCTORS HEALTHDOCTORS HEALTH

Doctors health-IDoctors health-I• Good news is that better than average physical health.

• Bad news is that evidence of increased risk ‘stress’, depression, substance misuse. Wall et al ’97 28% NHS staff above threshold GHQ compared with 18% UK workers, 30% unemployed. Women doctors and managers esp. at risk

• Firth-Cozens ’04 17 yr follow-up cohort of medical students, 30% above GHQ threshold and 17% depressed even higher first PRHO year.

• More bad news in that evidence doctors find it harder to accept/access services-more self-treatment, less use of primary care- esp amongst trainees

Doctors health-IIDoctors health-II• Many studies over years UK & US found

increased risk of alcohol/substance misuse.

• Evidence rates may be highest in psychiatry, anaesthetics, A&E.

• Pattern of substance misuse varies according to grade - alcohol in consultants, other drugs trainees .May also be differences across specialities in substances used.

Doctors health- IVDoctors health- IV• Doctors less likely present for treatment, variety

of potential reasons- ‘physician heal thyself culture’, stigma, fear of consequences, consequences for employment.

• Health professionals may be more difficult to treat.

• Debate about whether need specialist services- does seem doctors do better in specialist services substance misuse eg Sick Doctors’ Trust report very low relapse rate.

• Need to know what is available within Trust/Deanery including occupational health. Opportunities for prevention.

Doctors healthDoctors health• St4 trainee – frequently late for work, often appears tired

and distracted in meetings, MDT colleagues notice ‘ rushed decision’ making, frequent sick leave 1-2 days at a time , sudden uncertainty re career choice and complaint from in-patient unit about willingness to come in when needed on-call

• St3 trainee- very thin, appears lost weight recently, notice appears pale, often preoccupied, but very conscientious, often stays late. A parent mentions to the consultant on the adolescent unit that she is uncomfortable with Dr looking after her anorexic daughter because she appears to have anorexia nervosa and also has noticed old scars on her arms ? Nursing staff also mention to consultant that doctor appears unwell.

• St5 trainee previous episode of depression, arrested dangerous driving, police caution only, fellow trainee raises concern that X is hypomanic

BEHAVIOUR/BEHAVIOUR/ATTITUDEATTITUDE

Behaviour-IBehaviour-I• Complaints about performance often

relate to behaviour e.g trainee who is always late, trainee who is rude, poor communication skills.

• More serious complaints under category of personal/ professional misconduct e.g trainee who convicted of drunk driving, domestic violence, trainee who fails to turn up for on-call.

Behaviour-IIBehaviour-II• Considerable research in other industries on personality,

performance, career derailment less so in medicine

• Where personality traits/behaviour a problem not usually at level of ‘clinical’ personality disorder.

• Useful concept is that of a personality trait as an overplayed strength OR poor fit between person-context remember may need to find right niche

• Number of traits may show a U-shaped curve in relation to performance eg self-criticism, perfectionism, optimism.

Behaviour-IIIBehaviour-III• Interest in counterproductive work behaviours

(CWB) e.g poor punctuality, not following usual rules- as early warning signs - studies of US graduates show those disciplined later in career more likely than controls to have had conduct problems as medical students and be less likely to change.

Behaviour-IVBehaviour-IV• Evidence that can change behaviour.

• Must focus on behaviour which causes the problem

• Common issue in relation to poor performance is lack of insight- evidence most of us tend to overestimate our skills particularly in areas of weakness and that training actually causes us to become more aware of gaps , some evidence also applies to poor performers.

WORK CONTEXTWORK CONTEXT

Work context- IWork context- I• Seems obvious that work context will be linked to

performance but surprisingly little research in medicine

• Much of work on SUIs etc points to system issues

• Evidence that rates of stress as measured on GHQ differ between organizations even when control for other factors-key variables having a supportive manager, sense of control.

• Corrigan et al 2000- looked at leadership and patient outcome across 31 CMHTs found laissez-faire leadership poorer satisfaction and lower quality of life for patients. Leadership style accounted for 40% of variance.

Work context-IIWork context-II• May be issues within placement/system – trainee

is the ‘ canary in the coalmine’

• Have there been problems before ? is workload / task reasonable ?

• Trainer- trainee relationship may be problematic

SUMMARYSUMMARY• Given complexity of task and career on whole

doctors perform pretty well.

• Also evidence that performance problems result in most cases from an interaction of factors- not simply the doctor who is constitutionally difficult, recognising this opens way to remediation and prevention.

Framework for investigating Framework for investigating

performance problemsperformance problems

• Is there really a performance issue?• Are patients at risk?• Is it a fitness to practise issue?• Is it a training issue?• Should HR, Occupational Health or other Trust

policies be invoked?

Where does the problem lie ?Where does the problem lie ?

WORK CONTEX

T

CLINICAL CAPABILITY/

COMPETENCE

HEALTH BEHAVIOUR

Managing Managing performance problemsperformance problems• General principles.• Read and follow local guidelines• Tackle problems when they occur - do not leave it

all to the end of the job.• Find out the facts - there are at least two sides to

everything.• Involve others as needed e.g Tutor, TPD, Head of

School , Occupational Health etc• Document everything that you do

difficult-doctors or doctors-in-difficulty?

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