EDITORIAL |
Measuring a doctor's performance: personality, health and well-being
Doctors, trusts and educational bodies have become increasingly accountable for their actions and a clear need has arisen to recognize underperformance earlier and in a structured and transparent manner [1–3]. Effective remediation also requires clarity and structure. Understanding the impact of underperformance in the broad context of organizational well-being is well-established in many settings outside the NHS. However, the assessment and subsequent management of underperformance in doctors are not so well researched or documented.There is a clear link between the health and well-being of both a doctor and the organization they work within [4]. This interaction is complex and as yet not well understood [5]. In the UK, following the Bristol and Shipman enquiries, the need to detect and understand the nature of underperformance in doctors has led to the development of performance assessments. Finucane et al. [6] reviewed the international literature and identified three levels of performance assessment. The first involves screening a population of doctors, the second the selective assessment of those doctors thought to be at risk and the third the targeted assessment of underperforming doctors. In the UK, the mechanisms for assessing at these three levels include appraisals, local trust-led performance procedures and referral to the National Clinical Assessment Service (NCAS) or General Medical Council (GMC), respectively.
Data from the review of the first 50 cases seen by the NCAS confirmed that the nature of underperformance is complex [7]. Factors associated with clinical care, behaviour and attitude, health and well-being as well as organizational issues were cited as reasons for referral. The assessment path followed by the NCAS reflects this diversity. Occupational health and occupational psychology assessments are performed alongside an assessment of organizational context. Clinical and communication skills assessments are also performed. The development of such processes to detect underperformance is an international phenomenon with reoccurring themes of health, personality and organizational factors being associated with underperformance [8].
Studies of physical and mental health disorders among doctors suggest that occupational health physicians have a key role in the assessment of underperformance. While only 1% of doctors referred to the (GMC) health committee had a physical health problem, mental health disorders predominated. Stress in health professionals is high, with 28% showing above threshold symptoms compared to 18% of workers as a whole in the UK. Between 10 and 20% of doctors in the UK become depressed at some time during their career and the risk of suicide is raised compared to the general population [9]. Evidence from Switzerland suggests that levels of burn out among doctors are high [10]. Alcoholism also affects a high proportion of doctors compared to other professional groups and along with drug dependency is an increasing problem [11].
Evidence about the relationship between personality and performance suggests that occupational psychology has a key role to play in understanding the patterns of behaviour associated with underperformance. Prior to the late 1980s, it was assumed that the relationship between personality and performance was tenuous at best. However, the emergence of the five-factor model of personality led to the acceptance of the view that personality can be reliably measured and is a valid predictor of performance of most jobs [12]. Evidence from >200 studies examining the personality–job performance link concluded that at the broadest level two traits (conscientiousness and low neuroticism) are positively related to job performance across the majority of jobs [13,14]. Paice [15] found behaviour patterns among poorly performing undergraduates that could be consistent with low conscientiousness and high neuroticism including ‘doing the disappearing act’, low work rate, ‘ward rage’, rigidity, unreliability, turning up late and ‘insight failure’.
If the individual is David, then the organization is Goliath. Factors such as high workload, shift systems, work patterns, poor leadership and team working, all have the potential to impact negatively on an individual's well-being and to distort patterns of behaviour and ability to perform. It is essential for occupational health physicians and occupational psychologists to work together to understand how each of the assessed elements of underperformance, whether they are health, behaviour or organizational, fits together for individual doctors.
Collaboration across institutions has brought insight into what constitutes effective and robust assessment. Much less is known about what constitutes effective remediation. Internationally, there is clear evidence of good practice developing [16–18]. In Wales, we have developed the Individual Support Programme [19] in which a multi-disciplinary team aims to understand underperformance through all grades from undergraduates to consultants. The service is led by an occupational health physician who by working with an occupational psychologist and a language specialist examines issues relating to motivation, personality and language in the context of the organization.
While progress with remediation models has been made, what seems to be lacking is a clear consensus about which remediation methods are appropriate in different circumstances. This problem is echoed by Leape and Fromson [16] who recently reviewed similar problems in the USA. The recognition that the causes are complex and multiple suggests that for remediation to be successful, it must address all factors. This is not a simple task and needs more than a prescription to attend anger- or time-management courses. This approach may be the sticking plaster to make both referrer and referee feel better but it is unlikely to last.
It is worthwhile standing back and taking a wider view of the problem of underperformance. Doctors are no different to the wider population where performance relates to well-being as well as to skills and knowledge. Taking a biomedical model to remediation is unwise. If we are to accept, that which is inferred by methods of assessment, that the biopsychosocial model [20,21] is more appropriate, then we need to learn from this. The biopsychosocial approach is now widely accepted as being successful in the Pathways to Work pilots [22] and Condition Management Programmes being rolled out across the UK. These programmes embrace health, social and psychological factors and provide a case-by-case approach to provide effective support for individuals on long-term incapacity benefits. Assessors are trained in the holistic management of cases and address motivation to change at the outset. We argue that the approach to remediation of doctors should follow the same model. Underperformance requires a holistic approach that also addresses motivation to change at the outset. Understanding an individual's motivation to change and engaging them in the process of change are well-established in behaviour change methods [23] and need careful consideration. Establishing a connection between assessment and provision of remediation is necessary. Health, well-being and personality are inextricably linked. Remediation must echo this and to achieve this end demands a closer working connection between occupational health physicians and occupational psychologists.
The aim overall must be to develop an evidence-based approach to remediation. If remediation is to evolve, we need to be able to learn from our collective experiences. The fragmentation of existing provision is not at present conducive to this. In our own data set, we are aware that there are many biopsychosocial markers and some of these might prove in the future to be valuable indicators for underperformance and remediability but a common larger data set is badly needed. Quality improvement in this context is about early detection and ultimately prevention. To be able to move towards this goal needs further effort. However, what must not be lost sight of is the stress and distress doctors experience when going through the process.
Director of The Individual Support Programme and Senior Medical Research Fellow, Cardiff University
Occupational Psychologist, Cardiff University
e-mail: cohenda{at}cardiff.ac.uk
References
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