The false god of medical appraisal

Dr Margaret McCartney has written of how doctors and patients suffer because of the false god of appraisal.  Click through to the BMJ to read the piece.  The demands are enough to drive anyone to be another Shipman!  Don’t miss the glimmer of light – a company that has dispensed with the counter-productiveness of personal appraisal.

Don’t appraise any staff unless they ask for it.

Let the market sort them out!

Margaret McCartney: The false god of appraisal

BMJ2015; 351 doi: (Published 21 September 2015) Cite this as: BMJ 2015;351:h4982

Margaret McCartney, general practitioner, Glasgow

Twenty three minutes on a train. Until a couple of years ago I used the time spent on this regular journey thinking about things I’d like to write about, or the best birthday presents for friends, the colour of the trees rushing by, the enticing smell of other people’s fish and chips. That time was mine. It was aimless but gloriously, fruitfully productive.

This has stopped. Appraisal now means that I use those 23 minutes writing down my “learning activities” from the week before. Appraisal means that I must keep collecting evidence of professional development. It is a sacrifice to the god of revalidation—because only when written down is something proved to have happened.

Like everyone else, I look up things I don’t know about during the course of the day—diagnoses I’m unsure of, drug interactions I’ve forgotten, treatments that are new to me. But I don’t write it down as I go because, despite coming to work earlier and leaving later, minutes spent on myself mean fewer spent on patients.

Appraisal is a false god. It is a waste of time and a misuse of resources. It was never going to “stop another Shipman.” Of course, it’s nice to have a conversation with a fellow GP about the work we do and the hazards we face—but if it takes appraisal for this to happen once a year, it’s the working conditions that are the problem, and appraisal is not the solution.

What are your strengths and weaknesses? What are your reflections on learning? What have you learnt from this activity? What changes have you made? The questions invite answers by rote from a numb mind.

Appraisal now includes “360 degree feedback,” which means that each of the United Kingdom’s 43 000 GPs sends an appraisal every five years to 15 peer raters. If the 10 minutes it takes me to fill one in is the average, then health professionals spend 21 500 hours a year ticking boxes rating colleagues. Where is the evidence of value? What work—or what life enhancing, burnout reducing, play away from work—is not getting done instead? Look to business: the financial services company Accenture has just got rid of annual appraisals for employees. Bravo!

What of the harms? I know of several doctors who have had vile slurs written on feedback documents. How many others have retired early because of stress brought on by appraisal? Complaints against doctors are rising, not falling—any hopes that the process would help are unfounded.

Yet our colleges have signed up to this time wasting, navel gazing, and expensive process without properly considering either the opportunity costs or whether the endeavour is evidence based.

This is how John Seddon explained it previously:

Toyota’s basic idea is expressed by the axiom ‘bad news first’. Both managers and workers are psychologically safe in the knowledge that it is the system – not the worker – that is the primary influence on performance. It is management’s responsibility to ensure that the workers operate in a system that enables them to perform.

Performance appraisal, on the other hand, sprang from a different managerial assumption. To judge achievement, managers use data about an individual’s activity, not the process or system’s achievement of purpose. The result is that performance appraisal is judgment of one over another, ignoring the true influences on performance. Thus the appraisal experience becomes one of pleasing the boss, psychologically unsafe and socially driven, determining who is ‘in’ and ‘out’.



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