difficult-doctors or doctors-in-difficulty?

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  • 1. DIFFICULT-DOCTORS orDOCTORS-IN-DIFFICULTY? By Dr. M Murphy Dr. W Burn
  • 2. Workshop outline Overview of background Group work using vignettes Discussion
  • 3. Why do you need to know about this ? Understand factors influence performance enhances training As Tutor/TPD etc will deal with trainees in difficulty
  • 4. Performance and patient safetyVincent et al estimated 10% of hospital patients experience some form of medical errorWhy children die- 2008- 23% preventable causeBUT most of these relate to system issues and notpractioner issues HOWEVER need to look at practioner performance/safety.
  • 5. 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
  • 6. How common are serious 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 ??
  • 7. Performance 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
  • 8. Analysis of first four years of NCAS referrals - 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).
  • 9. Analysis of first four years of NCAS referrals-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
  • 10. Analysis of first four years of NCAS referrals-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
  • 11. Analysis of first four years of NCAS referrals- IV Psychiatrists 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 behaviourReferral less likely to lead to assessment than in other specialities ?why
  • 12. Analysis of first 50 cases assessed by NCAS Clinical performance concerns 92% Health concerns 28% ( included cognitive problems). Communication colleagues sub-optimal 76% Training/CPD issues 48%.
  • 13. Ethnicity 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
  • 14. Key points Performance problems often not simply problem with lack of clinical knowledge Need to understand why doctor isnt doing what they know how to do or should be done
  • 15. The performance triangle WORK CONTEXT CLINICAL CAPABILITY/ COMPETENCE HEALTH BEHAVIOUR
  • 16. Clinical capability / knowledge 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
  • 17. 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 doctors 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 ?
  • 18. DOCTORS HEALTH
  • 19. Doctors 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
  • 20. Doctors 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.
  • 21. Doctors 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.
  • 22. Doctors health St4 trainee frequently late for work, often appears tired and distracted in meetings, MDT colleagues notice rushed

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