Intended for healthcare professionals

Views And Reviews Wounded Healer

Clare Gerada: What to do with appraisal

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2450 (Published 22 June 2020) Cite this as: BMJ 2020;369:m2450

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  1. Clare Gerada, GP partner
  1. Hurley Group, London
  1. clare.gerada{at}nhs.net

As we wait for the next phase of the pandemic, many of us are beginning to take stock of our experiences (good and bad) over the past tumultuous months. Despite the problems, there have been positive aspects to the changes in our working lives. For example, doctors have enjoyed the freedom of being able to determine their own learning needs—as adults should—for team working, clinical supervision, and a focus on psychological wellbeing.

They have welcomed new flexibilities in revalidation and appraisal. When appraisal became compulsory in 2004 it was introduced as a peer led, formative, and confidential process. It was intended to enable self-reflection and professional development.1 It has since morphed into a complex performance management process, instilling fear and trepidation in some and seen as a bothersome, time consuming, and largely pointless tickbox exercise by many others. Appraisal has been implicated as a major contributor to doctors’ wish to leave practice and to high levels of burnout.2

One legacy of covid-19 must be to review, refresh, and even discard old ways of working. We must create a working environment that is far safer psychologically than the unhealthy one that predominated before covid. This might mean abandoning appraisal in its current form and returning it to how it was intended, as a means of peer support rather than a tool for identifying poorly performing doctors or the next Shipman. It might mean bringing in better ways of supporting doctors, such as groups for reflection that give doctors time to stop and think about their work. Reflective practice makes educational sense, especially when clinicians discuss their cases, share their experiences, bring in relevant literature, and talk about ways to improve their practice. Unlike appraisal, reflection is a dialogical activity and a process of discovery with outcomes that might be unexpected, creative, and different for each participant.

Reflective practice, especially when done as a group activity with a skilled facilitator, is invaluable when dealing with the difficulties and uncertainties of day to day practice. New insights from colleagues adds depth to understanding. Group learning falls within the long and greatly respected tradition of the work of Michael Balint. A strong feature of Balint groups and other reflective practice groups is their professional cohesion and sense of shared purpose and identity. They also provide an ideal container for uncomfortable feelings or experiences.

Doctors deserve to be attended to, cared for, and treated as adults. Now is the time to think seriously about how to do this. I vote for abandoning the current system of appraisal and bringing in reflective practice groups for all doctors.

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