1. DIFFICULT-DOCTORS or
DOCTORS-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 safety
Vincent et al estimated 10% of hospital patients
experience some form of medical error
‘Why children die’- 2008- 23% preventable cause
BUT most of these relate to system issues and not
practioner 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 - I
Most 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 behaviour
Referral 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 isn’t 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
doctor’s 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
decision’ making, frequent sick leave 1-2 days at a time ,
sudden uncertainty re career choice and complaint from in-
patient unit about willingness to come in when needed on-
call
• St3 trainee- very thin, appears lost weight recently, notice
appears pale, often preoccupied, but very conscientious,
often stays late. A parent mentions to the consultant on the
adolescent unit that she is uncomfortable with Dr looking after
her anorexic daughter because she appears to have
anorexia nervosa and also has noticed old scars on her arms ?
Nursing staff also mention to consultant that doctor appears
unwell.
• St5 trainee previous episode of depression, arrested
dangerous driving, police caution only, fellow trainee raises
concern that X is hypomanic

23. BEHAVIOUR/ATTITUDE

24. Behaviour-I
• Complaints about performance often
relate to behaviour e.g trainee who is
always late, trainee who is rude, poor
communication skills.
• More serious complaints under category of
personal/ professional misconduct e.g
trainee who convicted of drunk driving,
domestic violence, trainee who fails to turn
up for on-call.

25. Behaviour-II
• Considerable research in other industries on personality,
performance, career derailment less so in medicine
• Where personality traits/behaviour a problem not usually at
level of ‘clinical’ personality disorder.
• Useful concept is that of a personality trait as an overplayed
strength OR poor fit between person-context remember may
need to find right niche
• Number of traits may show a U-shaped curve in relation to
performance eg self-criticism, perfectionism, optimism.

26. Behaviour-III
• Interest in counterproductive work behaviours
(CWB) e.g poor punctuality, not following usual
rules- as early warning signs - studies of US
graduates show those disciplined later in career
more likely than controls to have had conduct
problems as medical students and be less likely to
change.

27. Behaviour-IV
• Evidence that can change behaviour.
• Must focus on behaviour which causes the problem
• Common issue in relation to poor performance is
lack of insight- evidence most of us tend to
overestimate our skills particularly in areas of
weakness and that training actually causes us to
become more aware of gaps , some evidence also
applies to poor performers.

28. WORK CONTEXT

29. Work context- I
• Seems obvious that work context will be linked to
performance but surprisingly little research in
medicine
• Much of work on SUIs etc points to system issues
• Evidence that rates of stress as measured on GHQ
differ between organizations even when control for
other factors-key variables having a supportive
manager, sense of control.
• Corrigan et al 2000- looked at leadership and patient
outcome across 31 CMHTs found laissez-faire
leadership poorer satisfaction and lower quality of life
for patients. Leadership style accounted for 40% of
variance.

30. Work context-II
• May be issues within placement/system – trainee is
the ‘ canary in the coalmine’
• Have there been problems before ? is workload /
task reasonable ?
• Trainer- trainee relationship may be problematic

31. SUMMARY
• Given complexity of task and career on whole
doctors perform pretty well.
• Also evidence that performance problems result in
most cases from an interaction of factors- not simply
the doctor who is constitutionally difficult,
recognising this opens way to remediation and
prevention.

33. Framework for investigating
performance problems
• Is there really a performance issue?
• Are patients at risk?
• Is it a fitness to practise issue?
• Is it a training issue?
• Should HR, Occupational Health or other Trust
policies be invoked?

34. Where does the problem lie ?
WORK
CONTEXT
CLINICAL
CAPABILITY/
COMPETENCE
HEALTH BEHAVIOUR

35. Managing performance
problems
• General principles.
• Read and follow local guidelines
• Tackle problems when they occur - do not leave it
all to the end of the job.
• Find out the facts - there are at least two sides to
everything.
• Involve others as needed e.g Tutor, TPD, Head of
School , Occupational Health etc
• Document everything that you do