Sir Lame Donaldduck: Still only here for the beer?
Bad cases make bad law, and the case of Sir Liam Donaldson is becoming a very bad one indeed.
One of Sir Liam’s greatest concerns has been concern with issues of professional performance. So he will have welcomed Dame Janet Smith’s reports into Harold Shipman. The fact that Shipman is an entire one off, who actually performed very well as a GP is not noted. Shipman was not in any sense a representative of the profession when he carried out his murders. Shipman’s actions are his own, and he must carry the can for them. There is no reason that doctors should live their professional lives as an attempted expiation for Shipman’s crimes. Realism says shit happens, and that Shipman was shit. It does not say anything about anything else.
However the Shipman case is regularly trotted out by the bureaucrats and other twaterati as the justification for a nasty new affliction called PROBOPHILIA. This illness is characterised by the sufferer’s fundamental inability to believe that any professional can do his job if left alone. Professionals to these twats are irresponsible and reckless, and highly dangerous. They must be thoroughly inspected and regulated as without this they might actually get on and practise some real medicine.
Not if the twaterati and other probophiles have their way. No the goal must be “reflective practice” and evidence of “reflection in action” No case is complete when the patient leaves the room. It must be analysed, and reflected upon, and you should wonder if you could have done anything different, or whether the room was too hot or too cold. A reflective journal should be kept, and Personal Development Plans (PDP) drawn up as well as copious records of room temperature and anything else that might just be relevant. And it should all be reviewed with a supportive colleague in appraisal sessions. The fact that these are only once a year is bitterly to be regretted.
The fact that such reflection sets the twaterati’s pulses racing with excitement does not alter the fact that navel gazing is largely an abysmal use of time. Look long enough into the abyss and it starts to stare back into you.
And anyway there are other patients to see, and access targets to meet. So if I reflect sufficiently on my reflections I reach the conclusion that rumination does not get patients seen, staff home, or let me get to the end of the day in peace!
So we have a process that on reflection is time consuming to little purpose.
Now Sir Liam has been the driving force behind the introduction of appraisal into the NHS. At one level it makes sense. In its current form it takes about 6 hours preparation and about 2-3 hours for the appraisal interview. It’s currently a formative (supportive, peer to peer review) process and it is supposed to lead to reflection and some changes in practice. Evidence as to whether it achieves useful change in practice or not is very limited so far. It’s also taking about 12 hours of doctor time per appraisal. Applied over the 130000 doctors in the NHS it’s a large number of doctors taking a lot of time away from patient care. Are the patients getting a good deal from this NHS investment?
Well if it leads doctors to sort out their rough edges it may help. But if all it achieves is identification of the lacunae in medical systems (which there is no political will to acknowledge or fill in) then little action will follow from the appraisal. It doesn’t matter at present- an unachieved PDP goal is simply deferred or dropped next time around and some equally useless goal substituted for it. But reflection on why a goal was a noble failure is fascinating, but ultimately it’s intellectual cud chewing.
At least appraisal is up and running. It’s probably of some use to some doctors, and may help patients indirectly by keeping doctors saner and better supported.
However we now have the impending approach of three linked but separate policies of relicensing, revalidation and recertification
Relicensing comes from the work of Sir Donald Irvine who pointed out that doctors get their GMC licence for life and never have to prove they deserve this again. He may have a point here. The GMC has some idea of what it is asking for with relicensing. Relicensing is about the doctor as a doctor and maintaining his or her right to practice medicine signified by GMC registration.
There’s going to be a five yearly relicensing cycle, beautifully illustrated by this diagram which to most doctors looks like a circular saw into which poorly performing doctors will be fed as punishment. One colleague said it reminded him of a Masonic Pentagram.
Recertification is about the doctor as a specialist. It is supposed to answer the question “Is the doctor still fit to practice in his or her speciality?” (General practice is a speciality, just like cardiology or gastroenterology) It’s not clear how this differs from relicensing, or maybe relicensing is subsumed within it?
Potentially we could end up with a mess in which a doctor is recertified but not relicensed or relicensed but not recertified. Quite what would happen in such a scenario is currently unknown.
Recertification (the specialist part) is going to be the responsibility of the ever popular and deeply loved Medical Royal Colleges. Yes, Twaterati Towers will swing into action.
The problem the royal colleges face on recertification is that the process they use has to convince several masters. So it has to convince the GMC that it is valid. It has to convince ordinary doctors that it is fair, accurate and not too onerous. It has to convince the DH and the public that it is sufficiently onerous. And it cannot take too much time as there aren’t enough spare doctors to cover sessions missed whilst we go and revalidate ourselves. “The patients couldn’t be seen as the doctor was being revalidated” doesn’t make much sense really does it?
IF challenged legally, the revalidation process has to be robust enough to demonstrate its reliability as a process, and the process is likely to be challenged legally either by a disgruntled doctor wanting his certificate back, or by an aggrieved relative saying, “You recertified this doctor last year and this year he’s gone and killed my old mother. Why didn’t you anticipate this problem sooner?”
The colleges are going to have great fun finding a way past all these potential problems. They also don’t want to do revalidation by means of an exam, although there will be “explicit standards” and “pass-fail criteria” Any test of my performance against a pass/fail criterion is an exam- no matter what you call it. They’ll need the medical equivalent of a flight simulator for pilots, but no-one seems to have come up with one yet.
And collecting a big girly folder of appraisal evidence and personal development plans is useless. I write well enough to fill several such folders…but it would give anyone reading it little real idea of how well I did or did not treat patients in practice. And anyway there isn’t enough time in the world to read all the guff doctors would produce if necessary. Just who will the time to read it and assess it thoroughly? And if anyone has the time to do this why aren’t they doing something more important?
However the circles are squared eventually, and at present the concept that the profession is going to be revalidated by means of relicensing, recertification, re this, re that and re the other, is faintly ridiculous. The confusion around these issues (which has been present ever since they were mooted over 10 years ago) is still present, and the initiative is at risk of “slippage.” I wonder if it will slip away before or after Sir Liam’s departure?
(P.S. Apparently a similar re-accreditation scheme was suggested for barristers some years ago. For some reason it got dropped).
Dr Rant
Dr Cardigan
Dr Blue
Dr Brown
Rev Dr Green
Dr Mustard
Mr Orange
Dr Pink
Dr Purple
Mr Salmon
Dr White
Mr Beige
Ms Scarlet
Dr Informed
Posts
14 comments:
The Rant team will be horrified to learn that A&E C/N has a little sideline.........he takes a group of first year medical students for PDS [personal development spine].
We meet each week to discuss the universe and everything that surrounds it.
I can't tell you how suprised I was to discover that these young pups are being exposed to Schon [or which ever other theorisits/proponent of "reflective practice" comes to mind, for their names are legion].
Hang on, I found myself thinking, isn't reflective practice the sort of guff that nurses have been saddled with for years; the sort of twaddle that none of us has ever found valuable........ever ?
In fact, rates of bed sores, HAIs and malnutrition have all increased since reflective practice became endemic, because nurses now have to spend most of their time filling in portfolios rather looking after patients.
Doctors, get a fucking grip, reflective practice has not improved nursing standards, so why should it work for you ?
Stick to passing your science exams and developing borderline autistic personalities then we all know where we are, eh ;o)
I've always found the idea of "reflective practice" a bit like nailing wheels to a satsuma - yes you can do it, but why the hell would you want to?.
If you're the sort of person who needs to be *told* to sit down and reflect on how the last episode of whatever went and how you could have improved it, then you're terminally fucking thick and probably shouldn't be doing your job in the first place! Surely as a professional you are constantly reflecting on your performance - if not, then you lack insight and you are doomed to always maintain the same level of performance that you have at the moment - this applies to medicine, flying planes, selling mortgages or whatever.
The sadly entrenched view that unless you have a folder full of guff and spend at least one session a week navel gazing is pathetic pseudo-intellectual snobbery.
As A&ECN has said, it has done fuck all to improve modern nursing so how it's going to change the face of modern medicine is a bit of a mystery.
Hee, hee hee,
We're proud to be heretics on here. Mind you we could always pass this blog off as reflective writing.
Now how would you all feel about that?
Not directly relevant to your latest post, but lots of people are very concerned about a recent comment on Dr Crippen's blog. Are you able to shed any light on it? Is it just a very bad joke?
The Devil has some news about Dr Crippen:
click here.
I feel that the comment on his blog about him being killed was either a sick joke, or a desperate attempt to get him to break cover.
Dr Grumble has news to the same effect. But DK is horse's mouth, so, thank you.
either dr blue is censoring me or I'm asleep (OK, I'm asleep). Tc I agree. The theories of reflective practice aren't necessarily vacuous and anyway some people who have to be employed also need to be told the bleeding obvious... but integrating the theories into nursing degrees etc. is crazy. It's a by-product, in the case of nurses, of the move to an all-graduate profession combined with an insistence that the degree be 'nursing studies', but it is not a necessary by-product, and I assume the courses are being taught by people who, to put it bluntly, need customers.
A & e charge nurse, I hope 'sideline' means you get paid for the Personal Development Spine (!!) teaching. (Schon isn't bad, I do though still remember drifting off to sleep as he Reith-lectured, perhaps he should be prescribed on the NHS?)
we could always pass this blog off as reflective writing
no comment.
What you have here is the human resources industry busy expanding it’s empire. Looks like they are moving into GP land, they probably already have the hospitals by the scrotum. You can plot their progress with certain milestones e.g. appraisals.
When I first started working for a sizeable engineering company the personnel department consisted of a few clerks who updated employee’s records with such things as qualifications, sick notes and appraisals. The appraisals were for staff members only the workforce’s annual remuneration rise was negotiated by the appropriate trade union. In those days an annual appraisal would be a sentence or two. Something like “Smith is NBG (50s terminology for a wanker) and should not considered for the annual cost of living rise”. Notes like this would be filed in the employees’ files. Today an appraisal is agreed with the employee, takes hours to prepare and agree and is probably pretty meaningless in the pay and promotion round.
In my youth the only other nod in direction of personnel was the Welfare Officer, in my firm a doleful character who broke bad news to families (like the explosion in the foundry that killed a man) and generally helped employees and their families who were sick and needed help with the paper work. His boss was the works manager.
Many years later when I moved office in the late 90s to outside the UK, Human Resources (HR) had an iron grip on the business world in general. They had responsibility for “managing hireings and firings, appraisals (now extended to everyone, there are now only “professionals”), safety, quality management, professional development and training in general. They ran audits (not the financial sort), employed management consultants and did lots more. One day, in connection with my move to foreign shores, I visited the HR expat bloke. I wasn’t surprised to find there was a whole floor of them accompanied by various HR mangers in glass fronted offices around an open plan office. My chap basically said “bon voyage I’ll be doing a tour round soon just to see everything is OK”. So, he was getting in some foreign travel without the worry of actually having to do anything that might generate some revenue for the company.
One interesting thing is, although the welfare responsibility had long ago been absorbed into HR, in the case of a fatal accident, the job of informing the next of kin fell to the victim’s line manager. Who had, of course, been on a training course organised by HR.It happened to a colleague.
My heart rose at the thought of the Ginger Limpet's 'legacy'. Surely he must be gone then? Rid of him at last? Then, sadly a mention that maybe he hasn't yet.
He could be advised to do so for everybody's benefit, before he's forced to cotton on to the strange idea in the management consultancy fad business of the inverse appraisal, where bosses are appraised by their JUNIORS!!!!
His marks there would be unlikely to remind one of another bit of management consultant speak, that the main part of 'appraisal' is 'praise'.
Show him the door, and apply the boot in the right place for all our sakes!
I like the 360 degree appraisal!
You get a lod of people who you don't work directly with...and who probably only know you to say hello in the morning to write a report on how you interact with patients (even though they have never seen you do this), how competent you are ( i love ward clerk deciding on my prescribing skills), and how well you work with others.
I now am a better person and work much better with others.
Oh and being told i am competent to be a doctor by the HCA who was on my ward for an 8 hour shift makes me much more confident about my future.
Dr Cox is as perceptive as his namesake on Scrubs.
Long ago I worked in a galaxy which stretched from Westminster to the Old Kent Road. The prevalence of confidence in the top management of one particular "Group" was a princely 16% according to the annual staff survey.
I now realise that the then head of that group spent many hours reflecting - just like Narcissus.
Amen, A+E C/N. Amazing how the faux-academic drivel seems to go hand-in-hand with ever greater chaos on the frontline.
Has anyone, to anybody's knowledge, ever tried to claim their blog constitutes their "required reflective writing"?
Quite a few of the MedBlogs are (at least occasionally) reflective... e.g. The Lowly Worm, or the currently-off-the-air Hospital Phoenix. Or the currently sadly missed (though seemingly still extant) Dr Crippen.
I would say a good bit of reflective writing on a blog should score many more points (in a rational system) then some hurried piece of crap that was only written to stuff it in a file and prove you'd done it. But then I did say in a rational system.
Not sure if Dr Rant would qualify as reflective, though. You couldn't see the reflection as the water would be boiling with rage. Or if mirror, steamed up from the shouting.
And yes, where I work too the 1st year medical students all have "portfolios" that they are encouraged to fill with "reflective writing", and portfolio tutors (in academia, usually bought-back people who have been eased into early retirement on the grounds of general ineffectualness}.
So A&E CN's students are probably getting rather a good deal as these things go.
Pharmacists got the Shipman blow the hardest. Now we have very complex CD registers, and have to ask ID to everyone that collects them... What for? Who carries ID in this country?
And yes, we also have continuous professional education and reflexive practice.
Post a Comment