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:m2450Read our latest coverage of the coronavirus pandemic
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Clare Gerada’s call for peer group case discussion in professional development is timely. She writes: “Reflection .. is a process of discovery with outcomes that might be unexpected, creative and different for each participant”.
Echoing military experience, the current crisis has highlighted the ‘front line’ where - even without a pandemic - there is no doubting the stress of clinical work (1). It was during the second world war that social scientists, appointed by the British army to select future officers (2), made new discoveries about how small groups can enhance mutual respect, and how easily that can be crushed. Consider the contrast between a traditional ward round with its steep hierarchy of expertise – where the fear of humiliation is never quite banished – and a discussion group whose collective commitment is to ensure each contribution is equally valued, however inarticulate or disagreeable it may be. If individual differences in perspective are regarded as a necessary condition of learning, then each will gain from others.
Most of us can tell clinical stories without difficulty. The work discussion facilitator has to resist any temptation to supervise but instead encourage others to be curious, and not criticize. “It soon becomes clear that what is most helpful for group learning is courage rather than correctness, honesty rather than knowledge” (3). Not all colleagues want to engage in countercultural dialogue, yet at every level of skill I have over the years noted the liberating pleasure to be gained from a different kind of conversation, and the confidence that follows. This is more ethics than scholarship. In place of deference to a leader’s superior knowledge, each member’s personal authority is enlisted in the task of professional development.
Such groups may be more widespread than we know. Being confidential and unminuted, this work is rarely written up in detail, but there is a disparate literature (e.g. 4, 5, 6, 7) and a number of organisations promoting it. The war time social scientists later became the Tavistock Clinic (8) and Institute (9), both of whom continue to provide consultancy services. Balint groups are relatively well known (10). APPCIOS (11) provides registration and support for group facilitators. While some form of appraisal is mandatory, work discussion generates no record and should be voluntary, but available everywhere. The BMJ could help by calling for contributions to a round table on this topic.
1. Jones GAL, Colville GA, Ramnarayan P, et al. (2020). Psychological impact of working in paediatric intensive care: A UK-wide prevalence study. Archives of Disease in Childhood,105:470-475.
2. Bion WR. (1946). The leaderless group project. Bulletin of the Menninger Clinic, 10, 77–81.
3. Kraemer S. (2018). Stop running and start thinking. Child and Adolescent Mental Health 23(4):381–383 (p. 381) http://bit.ly/2JgTdy4
4. Launer J. (2015). Collaborative learning groups. Postgraduate Medical Journal, 91:473-474.
5. D’Urso A, O’Curry S, Mitchell L, Casey S, D'Amore A, King M, Broster S. (2019). Staff matter too: pilot staff support intervention to reduce stress and burn-out on a neonatal intensive care unit. Archives of Disease in Childhood - Fetal and Neonatal Edition,104:F341.
6. Hartley P, Kennard D. (2009). Staff Support Groups in the Helping Professions. London: Routledge.
7. O'Neill L, Johnson J, Mandela R. (2019). Reflective practice groups: Are they useful for liaison psychiatry nurses working within the Emergency Department? Archives of Psychiatric Nursing, 33(1): 85 – 92.
8. https://tavistockandportman.nhs.uk/
9. https://www.tavinstitute.org/
10. Yakeley J, Schoenberg P, Morris R, Sturgeon D, Majid S. (2011). Psychodynamic approaches to teaching medical students about the doctor-patient relationship: randomised controlled trial. The Psychiatrist, 135: 308-313.
Competing interests: No competing interests
Dear Editor
I support Clare Gerada's comments about the overblown appraisal and revalidation system. Having been suddenly thrust into the twilight of my career due to my age and the pandemic I was relieved that the demands of the system were put aside, but I am still haunted by long habits such as keeping a check on how many CPD points I had accumulated, collecting data for the next appraisal and other tick-box activities. I hope we will see a much simpler system in the future.
Hugh O'Neal
BMA membership no. 6540413
Competing interests: No competing interests
Dear Editor
It would strike chord with many that the current appraisal process is unlikely to detect the “the next Shipman”[1] particularly as such mandatory process followed Shipman’s murders. Whether the GMC genuinely intended to catch another Shipman through such process, or it was merely another reactive process designed to reassure politicians and the public, we shall never know.
Gerada’s robust proposal to abandon the current system may not be music to the ears of those who have financially benefited from this system including those who developed online tools which were slavishly purchased by some NHS Trusts to replace the perfectly workable format that was free from the NHS; it is also a fact, serial appraisal have generated handsome additional fee-incomes for some.
The objective evidence that Gerada points to [1] confirms the degree of disquiet about the current system. Indeed, there is no shortage of anecdotal evidence to demonstrate how cumbersome this process could be for some rather than being a supportive exercise [2]. I believe, there is also a strong case to reduce the frequency of mandatory appraisals, and it is concern as to how much of taxpayers’ funds are spent on continuing professional development and PDPs [3].
References
[1] BMJ 2020;369:m2450
[2] https://www.bmj.com/content/358/bmj.j4215/rapid-responses
[3] https://www.bmj.com/content/358/bmj.j4215/rr-1
Competing interests: No competing interests
Dear Editor
Dr Gerada states that doctors cannot choose their own learning needs, and unable to focus on psychological well being. In fact developing our own learning needs is a fundamental part of appraisals, the only format that is compulsory is Multi source Feedback and Patient satisfaction questionnaires that are done once every five years. Where is the complex management process she refers to? Appraisers are encouraged to support doctors, and provide direction for those who need additional support, LMC mentors or GP tutors are examples.
Reflection is already part of appraisals, and doctors are free to develop reflection in any way they choose. Group reflection Dr Gerada refers to is fine for those doctors who find this approach useful, but to be prescriptive about reflection groups would likely send many doctors running for cover.
The GMC and NHS has already put together a reflective document, one page of A4, for doctors for appraisals in the next 6 months once appraisal system starts again, currently in pilot, which I was involved in and took 45 minutes to complete.
I disagree that the appraisal system or revalidation was ever trying to find poorly performing doctors. The vast majority of poorly performing doctors are identified in other ways, often from other doctors they work with or complaints. The whole training and focus of appraisal is a supportive and for professional development. As for detecting Shipman, changes in death certification coming in soon are more likely than revalidaton to detect criminal activity such as Shipman.
This is an opportunity to review and develop appraisal and revalidation, but to suggest that reflective groups alone as an option is the answer is rather limited.
Competing interests: No competing interests
An idea for a more creative appraisal
Dear Editor
Clare Gerada’s critique of the current doctors’ appraisal process and her reflections on how the COVID-19 crisis has exposed it as the emperor’s new clothes, are timely and highly relevant. She advocates the use of reflective groups run by skilled facilitators alongside the Balint model as a more creative process with unexpected positive outcomes.
To add to this innovative line of thinking, we will present here the appraisal model that our multidisciplinary team in Southampton, including child psychiatrists, mental health nurses, psychotherapists, family therapists and administrators, has been using in the past three years to assess our teaching activity to fourth-year medical students in the module “Psychiatry”. Indeed, we have been astounded by the positive changes that this process has brought to us as individual educators/clinicians as well as to the team as whole.
Some of the principles of the process, like a yearly review with a focus on performance and developmental needs, are similar to what most medical doctors experience in their usual appraisal. However, we have introduced three elements that we think contribute to the success of the model. First, performance and need to change are situated within a specific team; second, the direct and explicit link of each individual’s appraisal to those of other individuals and the team as a group, and third is the, collaborative and non-hierarchical nature of the process that, unlike Balint groups, does not rely on outside experts with a containment function.
Equally, some of the methods we use like self-reflection, written reflection, and compilation of lists of challenges and successes are familiar to most doctors. But alongside those, we have benefitted from interview strategies and group activities frequently used in systemic family therapy such as circular questioning and reflective group conversations.
Circular questions are those in which, in order to answer a question, the individual is encouraged to take a perspective different to the one they hold at that time. For instance, for a direct question such as “do you think this was a good performance?”, a circular question would be “do you think your supervisor thinks this was a good performance?” or “Do you think you would have thought this was a good performance last year?”. Circular questions invite curiosity between the different perspectives and call for follow up questions. [1]
Reflective group conversations are conversations had in a group about an individual or a group of individuals who are present but remain in the observer role, without taking part in the conversation about them. They often sit outside the circle where the conversation is being had. Reflective group conversations allow individuals to see themselves from other perspectives. [2]
In our appraisal model, every summer, coinciding with the end of the teaching programme, the team administrator books a 60-minute meeting for each member. Each meeting includes a sequence of group and individual conversations, as follows:
1. Interview. During this time, an “appraiser” will interview the appraisee using three circular questions and some follow up ones. The rest of the team listens to this interview without interrupting. They may take notes. The questions are:
• What are you particularly proud to have achieved this year?
• Imagine that next year has passed and it all has gone very well, what did you achieve and how (“the magic questions”)
• What do you think could stop all that from happening (“challenges”)?
2. Reflecting conversation. The team proceeds to have a reflective group conversation about the interview they have just observed. In this reflective conversation, both appraiser and appraisee sit aside, listen to the comments made about them, and take notes if they wish to. The conversation is focused on strengths, curiosity, and relationships. Criticism is discouraged.
3. Personal Reflection. Once the reflective conversation ends, the appraisee is invited to reflect aloud about what the team has said about them and what goals they intend to pursue the following year. During this time, the team will take notes that are then handed back to the appraisee.
4. Team Reflection. The whole team reflects on the appraisee’s thoughts with a focus of how the team can help them achieve those goals.
5. Objectives review. Finally, the appraisee collects all relevant notes and writes a personal reflective account of the process including personal goals. The team updates the Team’s strategic and operational goals in light of the appraisal conversations.
During the appraisal process, each member of the team will take the appraisee and the appraiser role once and all members of the team will sit as part of the reflecting team for everybody else. This is time intensive. There are six members of the team and we dedicate three two-hour meetings to the process. However, we are confident in stating that our initial scepticism about the time investment and complicated process has been eroded and we have become enthusiastic advocates of the model. In fact, team members gain very useful insights and draw motivation from the kindness, curiosity, and different perspectives that other members bring. They also experience a sense of connection to other members and belonging to a team that is seldom experienced in current NHS practices. The sense of connectedness and common purpose goes well beyond team away days or structured 360 degree feedback surveys. But the most striking gain is that we achieve an appraisal of the team. By the time all individuals appraisals have been completed, the strategic plan has been reviewed six times, and there is a commitment and a sense of ownership that has yielded demonstrable returns to the performance of the team that were difficult to imagine three years ago.
Overall, we believe the appraisal model that we have described here may offer valuable insights to medical doctors who are looking for creative alternatives to the more standard top down managerial models of appraisal currently implemented in most NHS Trusts across the UK.
References
1 Anderson T. The Reflecting Team: Dialogue and Meta-Dialogue in Clinical Work. Family Process 1987;26: 415–428.
2. Tomm K. Interactive Interviewing: Part III. Intending to Ask Lineal, Circular, Stategic, or Reflexive Questions Fam Proc 1988;27:1-15.
Competing interests: No competing interests