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BMJ No 7108 Volume 315 Personal view Saturday 6 September 1997 Dodgy doctors: your time is up This year the General Medical Council will introduce its new performance procedures, the greatest extension to its powers since 1858. Their purpose is to protect patients from "dodgy doctors"-doctors whose performance is seriously deficient. Failure to comply with the performance procedures may result in restricted registration or suspension. The process begins with a preliminary review of the doctor's professional attitudes and approach to practice. If this raises concerns a more detailed appraisal will ensue, involving a visit to the workplace by an assessment team. The visit is agreed beforehand, but advanced notice is insufficient to remedy bad practice. The assessors provide a profile of the doctor's performance and make recommendations to the GMC. I recently volunteered to take part in a national experimental assessment in obstetrics and gynaecology-luckily my own specialty. The purpose was not to determine my competence, but to enable the GMC to evaluate the feasibility and effectiveness of its assessment programme. Before the visit I completed a portfolio and competence lists for communication and clinical skills to help the team understand my background and current professional responsibilities. It included details of recent operations, obstetric interventions, and outpatient clinics. It took several hours to check theatre lists and labour ward records, and to complete the various forms. Two weeks later the team arrived: two consultants, an independent educationalist, and a GMC observer. Having met them, I was escorted away for a written examination lasting an hour and testing my knowledge of clinical scenarios, from the management of gynaecological cancer to resuscitating a collapsed woman. To compare my knowledge with that of my peers two colleagues sat the exam-a senior registrar and specialist registrar who was at the peak of his learning, having just sat part 2 of the membership examination of the Royal College of Obstetricians and Gynaecologists. I thought that this was tough competition. Next came the guided tour of the hospital, illustrating the positive and negative attributes of my current place of work. This culminated in a visit to the outpatient department, where a gynaecological clinic was in full flow. I had arranged to see some patients, observed by the two consultants. I could not remember the last time that anyone had listened to me take a history; it was probably at medical school. The management consultation was witnessed, then discussed after the patient had left. This was less intimidating than a postgraduate viva, but still an uneasy experience. I think I am thorough with my patients, but I imagine that this process could be stressful for doctors who are not. The performance was then recreated in an antenatal clinic, before the curtains closed on Act 1. Act 2 started the following morning. The refreshed team was ready for action. I was exhausted after a night on call. The morning session involved structured interviews with my colleagues, including midwives, nurses, theatre staff, a paediatrician, and fellow obstetricians. My colleagues found the interviews arduous; they were asked to criticise any aspect of my practice. Does the fact that I don't wear a white coat or that I introduce myself to my patients by my Christian name really matter to my performance? Some may think so. In reality, would my colleagues be willing to criticise me behind closed doors? Nurses have been assessing each other for years, doctors are only just beginning to. Team observations now form part of our annual assessment. The idea that a midwife or a nurse can criticise (constructively or destructively) a trainee in obstetrics and gynaecology has raised more consternation among my peers than any other part of our assessment package. For the majority of fellow trainees it might be a useful and rewarding exercise, often allowing praise to be expressed for the first time. The final part of the assessment involved the team and me. I was allowed to nominate a friend or colleague to be with me during this time as a supporter. As my mother was busy, I sat there alone, the four of them versus me. Had it been authentic, I think a solicitor may have cowered with me. They began by reviewing my note keeping. I pictured myself before a wise old man with a black gown and grey wig, explaining that the swabs, needles, and instruments were obviously correct because they always were even though I had not documented it. I was concerned that when I had gone round with my senior house officer my instructions had not been recorded. It was difficult to prove the date of removal of a suprapubic catheter and a particular patient from the ward. I certainly could not remember seeing her that morning either with or without a catheter. My case management was scrutinised. With gloves held high I deflected some blows but also took some. I realised that part of my practice was dictated by the preferred management of my consultant, sometimes disagreeing with that of team members. But does it mean that it is wrong? My operation notes may have been well written but does that reflect my surgical abilities? The interview concluded, I passed the examination and, as a result of the team's observations, it was decided that I would not need any remedial training. I left the room stressed and exhausted and headed off to talk to my senior house officer. For the next few days I spent many hours explaining to colleagues that it was only an exercise and that I was not going to be struck off. Overall, I felt that the process had been useful, pointing to some deficiencies in my work, which have now been rectified. In the future these assessments may become more frequent, involving all of us for reaccreditation. I am concerned about who the assessors will be. I hope that they are down to earth and perhaps not the leading academics or college members who always get involved. Perhaps they will be trainees either assessing other trainees or even the trainers. I pray that I will never be considered a dodgy doctor, either by my colleagues or by my patients. I say this not only to protect my fragile ego, but in the hope that I never have to undergo the microscopic scrutiny of a GMC assessment panel. Andrew Pickersgill, lecturer in obstetrics and gynaecology, Salford Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline