Career Focus

Appraising doctors and dentists in training

BMJ 1997; 315 doi: (Published 01 November 1997) Cite this as: BMJ 1997;315:S2-7116
  1. Jolyon Oxley, Secretary
  1. Standing Committee on Postgraduate Medical Education,1 Park Square West,London, NW1 4LJ.

    Appraisal is a vital element in improving postgraduate education and training. Here, Jolyon Oxley defines the terms and outlines a checklist for action

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    All doctors are very familiar with assessments - a variety of processes designed to measure knowledge and skills - usually with a view to achieving the next step in a career. Informal day to day feedback is commonplace but increasingly doctors also experience systematic appraisal which has aims that are complementary to, but different from, assessment. Appraisal is now recommended for specialist registrars1 and pre-registration house officers.2 There is little doubt that senior house officers would benefit from it too.

    Clarifying the terminology

    Appraisal has been adopted in many fields of employment outside of medicine where it has a wide variety of purposes and applications. It is relatively new in medicine in the NHS, though it has been established in the academic sector for some years. It was obvious at the start of the enquiry into appraisal conducted by the Standing Committee on Postgraduate Medical Education (SCOPME) that little progress could be made until there was greater clarity and agreement about terminology. Appraisal, formative and summative assessment, and individual performance review are all widely used terms that have different meanings to different people, sometimes being used almost interchangeably. Formative (or educational) assessment and summative (or regulatory) assessment are terms well established in general practice where they have been found to be very helpful.

    Criteria for effective appraisal

    Appraisal will be most effective when
    • its main purpose is to identify the educational and developmental needs of the individual doctor in training

    • it is confidential to the appraiser and the doctor in training

    • it is part of and not a substitute for an ongoing dialogue between individual consultants and doctors in training

    • it takes place in a working environment that engenders trust, mutual respect, and support for the individual doctor in training

    • the appraiser has been trained in appraisal

    • enough resources - particularly time - are provided to support appraisal training, to launch, implement, and support the appraisal process and to monitor participation

    After much discussion, the committee decided that the best way forward would be to use the term appraisal to describe a process that is confidential (except in defined circumstances), primarily educational and developmental, and designed to help the individual to progress; assessment to describe processes that are open and objective, subject to appeal, and designed to inform decisions about career progress; and performance review to describe processes that are employment related and designed to measure achievement against the individual's job plan, local business plan, and agreed targets.

    It should be emphasised that both assessment and appraisal are important parts of the educational process, but they have different characteristics which require different skills and approaches. For doctors and dentists in training, whose educational progress is of equal priority to their contribution to the clinical service, we consider that both appraisal and assessment are needed. As both have elements of performance review, it should not be necessary for this to be a separate process.

    On educational grounds appraisal has many strengths. It should help doctors and dentists in training identify educational needs as early as possible, assist them to develop the skills of self-appraisal and reflection that they will need throughout their careers, allow relevant learning opportunities to be identified and provided quickly, and provide a mechanism for reviewing progress and for taking action. It should also provide a mechanism for giving feedback on the quality of the training provided with the aim of making the training more effective and efficient.

    In advocating systematic appraisal as an important part of the educational process, we stress that it should complement and not replace the informal supportive working and learning relationship between trainers and trainees which should provide immediate and constructive feedback about performance and progress. Appraisal should help ensure smooth educational progress and the attainment of career goals and could become an important part of risk management.

    Appraisal provides a unique opportunity for the trainer and the doctor in training to step back regularly from day to day work, review progress and plan appropriate action.

    Implementing appraisal in NHS trusts

    There is no doubt that appraisal should be introduced for all doctors and dentists in training but there are practical difficulties in achieving this in NHS trusts. Respondents to the committee's consultation endorsed our view that there are barriers to implementation. The chief barriers are lack of time, a lack of understanding of its purpose, and a lack of appraisal skills in trainers.

    Appraisal checklists

    Questions which judge discussion quality
    • Are the appraisal discussions conducted in an atmosphere of trust?

    • Are they held sufficiently often to meet trainees' needs and according to an agreed plan?

    • Are they informed by a variety of assessments and other inputs?

    • Are they conducted without interruption?

    • Are they undertaken by an appraiser who works with the trainee, has been trained in appraisal, and is monitored in this role?

    • Is there opportunity for self appraisal by the trainee?

    • Is there sufficient opportunity to review educational and personal matters, together with career ambitions?

    • Are the interviews confidential to the appraiser and the trainee?

    • Do they result in an agreed learning action plan and further learning opportunities as necessary?

    • Is the learning reviewed regularly?

    Questions which judge scheme quality
    • Is your appraisal system designed to identify educational and developmental needs of the trainee?

    • Is it part of, and not a substitute for, day to day supervision, support, and feedback about performance?

    • Were trainees and trainers involved in devising, launching, implementing, and reviewing your system?

    • Is it recognised as separate from assessments conducted for regulatory purposes?

    • Are the aims fully understood by all concerned?

    • Are the processes fully understood by all concerned?

    • Is the system properly resourced?

    • Do you have a mechanism for monitoring participation in appraisal?

    • Do you have a mechanism for encouraging and collecting feedback about how well the system is working?

    • Do you have a mechanism for reviewing your system and re-launching it as necessary?

    There is no easy solution to the question of available time and this will have to be addressed at trust level through negotiations over job plans. Many trusts run appraisal schemes for other staff and chief executives, and human resource managers are already familiar with the benefits of appraisal. Proper training and support for appraisers should ensure that whatever time can be made available is well spent.

    Another much discussed issue has been the confidential nature of what takes place during an appraisal. This is clearly a difficult concept for some. With posts of short duration it has been said that there will have to be some kind of handover of information from one appraiser to another, particularly if the trainee has been having problems. Appraisers may also want to disclose information about the doctor in training to get the best educational opportunities. Certainly anything that arises during appraisal should only be disclosed with the trainee's knowledge and in almost every case, with the trainee's agreement. The only envisaged exception would be if the trainee's clinical work was endangering patients but it is unlikely that appraisal would be the only source of this information. Our committee believes that trainees should be responsible for passing on relevant information arising out of appraisal, such as an agreed educational plan. The only information which should be passed to others is that appraisal is taking place.

    A template for appraisal

    One of the lessons to be learned from appraisal in industry and commerce is that appraisal schemes are organic in that they grow and develop, flourish and sometimes wither. They need local ‘champions' to launch and sustain them and they often have to be revised and re-launched to meet changing needs. We wish to see clinicians and other staff at trust level take responsibility for developing locally owned appraisal schemes, so the committee has not produced an appraisal blueprint. There is a need for a reasonable degree of consistency in the overall purpose and style of schemes throughout the country, however, and the checklists outlined in the boxes may serve as a template to guide the administration of schemes. The organisers will have to tackle and solve some of the practical difficulties which have been highlighted - and decide who are the people best suited to be appraisers. Experience will also be needed in how appraisal and assessment can be kept separate: the same consultants could be involved in both the assessment and appraisal of the doctors in training they work with.


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