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Doctors’ health & performance 

Doctors’ health & performance
Chapter:
Doctors’ health & performance
Author(s):

Andrew Baldwin

and Gil Myers

DOI:
10.1093/med/9780198827191.003.0015
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date: 24 July 2021

The 9th edition of this book claimed to be the first medical book to take the health of its readers seriously—on the grounds that the health of one person (a patient) must not be bought at the expense of another (their doctor). It is an unsettling paradox that when we study and practise medicine, our own health may be forgotten. This new chapter aims to support and resource you, and if needed, allow you to reclaim yourself.

Medicine is challenging and stressful. Healthcare environments are emotional places to work. Your every day is often a patient’s or relative’s worst ever day and this can take its toll. While the majority of doctors derive satisfaction from their work, it is important to recognize increasing burnout, stress, and dissatisfaction, which for some translates into mental illness, depression, or anxiety.1 If you are feeling drained, isolated, dehumanized or are experiencing hurt or insecurity, remember that your identity as a doctor does not take precedence over your identity as a human. Before we attempt to heal others we should, if needed, take care of our own healing. By concentrating on our physical, psychological, and emotional well-being, we can be more empowered and better capable of helping our patients.

You will have bad days, and at times medicine may not seem worthwhile, yet among the valleys there should also be peaks of satisfaction and fulfilment. Remember and cherish the mountaintop experiences, but also remember that very little grows on the summit. Finding out what can lead you through adversity is the art of living. We hope this chapter helps.

Fig 15.1 Throughout this book, at the start of each chapter, we have included inspiring stories of people or inventions that have changed and shaped healthcare. Our hope is that these stories can inspire you to achieve things that may at present seem beyond your perceived ability or possibility.
For this reason, at the start of this chapter, we include a mirror. Imagine a reflection of yourself. You are the inspiration: to your patients or colleagues, to family or friends. It may be because of who you are and how you treat others; it may be through advances that you bring—to your hospital, surgery, or specialty. Be the inspiration, and be encouraged.

Fig 15.1 Throughout this book, at the start of each chapter, we have included inspiring stories of people or inventions that have changed and shaped healthcare. Our hope is that these stories can inspire you to achieve things that may at present seem beyond your perceived ability or possibility.

For this reason, at the start of this chapter, we include a mirror. Imagine a reflection of yourself. You are the inspiration: to your patients or colleagues, to family or friends. It may be because of who you are and how you treat others; it may be through advances that you bring—to your hospital, surgery, or specialty. Be the inspiration, and be encouraged.

Artwork by Gillian Turner.

How to look after your own mental health

Quis custodiet ipsos custodes? (‘Who watches the watchmen?’) Juvenal

Doctors have a higher than average incidence of suicide and alcoholism, and we must all be prepared to face, and try to prevent, these and other health risks of our professional and private lives. Our own illnesses are invaluable in allowing us to understand our patients, what makes people go to the doctor (or avoid going to the doctor), and the barriers we may erect to resist advice.

If the time comes when our health seriously reduces our ability to work, we must be able to recognize this and take appropriate action. The following may indicate that this point is approaching:

  • Drinking alcohol before ward rounds, surgeries, or patient contact.

  • The minimizing of every contact with patients, so that the doctor does the bare minimum which will suffice.

  • Inability to concentrate on the matter in hand. Your thoughts are entirely taken up with the workload ahead or with other problems in your life.

  • Excessive irritability with those around you at work or outside work.

  • Inability to take time off without feeling guilty.

  • Feelings of excessive shame or anger when reviewing past debacles. Doctors’ health & performanceTo avoid mistakes it would be necessary for us all to give up medicine.

  • Emotional exhaustion—eg knowing that you should be feeling pleased or cross with yourself or others, but on consulting your heart you draw a blank.

  • Prospective studies suggest that introversion, masochism, and isolation are important risk factors for doctors’ impairment.

The first step in countering these unfavourable states of mind is to recognize that one is present. The next step is to confide in someone you trust (fig 15.2). Give your mind time to rejuvenate itself.

Fig 15.2 Hands-off! Don’t get too drawn into treating your own mental health without consulting a colleague.

Fig 15.2 Hands-off! Don’t get too drawn into treating your own mental health without consulting a colleague.

If these steps fail, various psychotherapeutic approaches may be relevant, eg cognitive behavioural therapy (p. [link]), or you might try prescribing the symptom. For example, if you are plagued by recurring thoughts about how poorly you treated a patient, set time aside to deliberately ruminate on the affair, avoiding distractions. This is the first step in gaining control. You initiate the thought, rather than the thought initiating itself. The next step is to interpose some neutral topic, once the ‘bad’ series of thoughts is under way. After repeated practice, the mind automatically flows into the neutral channel once the bad thoughts begin, and the cycle of shame and rumination is broken. Doctors’ health & performanceIn addition … learn from the experience!

If no progress is made, the time has come to consult an expert, such as your gp or the Practitioner Health Programme (see p. [link]). If you think you need to consult a doctor, then do so, in privacy. Avoid ‘corridor consultations’ with colleagues. Other than for minor ailments, avoid self-diagnosis and management. Treat yourself as you would expect a patient with the same condition to be treated—and have a confidential consultation with a trusted health professional.

If you are the expert that another doctor has approached, do not be deceived by this honour into thinking that you must treat your new patient in any special way. Special treatment leads to special mistakes, and it is far better for doctor–patients to tread well-worn paths of referral, investigation, and treatment than to try illusory short cuts.

Managing stress

Every person’s experience with stress is different. What is common is that we all have stresses in our lives—whether it is money, relationships, work, or something else. Stress is something many of us find hard to talk about. Stress is generally assessed with the General Health Questionnaire (ghq). Higher scores imply likelihood of depression and anxiety difficulties. Burnout (p. [link]) is different than ‘simple stress’, with work-related instead of physical symptoms.

Engaging in reflection can help you manage stress. Acknowledge your emotions about difficult patients or challenging clinical scenarios—reflection is a valuable part of practice and is different from rumination (repetitively going over a thought or problem without completion). Consider joining a Balint group or engaging in Schwartz rounds.

While everyone has different ways to manage stress, here are 10 elements—5 things to do and 5 things not to do—to incorporate into your daily life in order to manage and reduce stress:

Do

  1. 1 Set (achievable) goals to feel more in control. Choose a realistic target but one that is important and map out how to achieve it. Positive steps forward help us feel more in charge and reduce stress.

  2. 2 Have a heathy diet with green vegetables (folate), oily fish (omega-3), whole grains (complex carbohydrates), and berries (vitamin c). All increase serotonin and boost mood.

  3. 3 Get a good night’s sleep. Aim for 7–9 hours most nights. We can get into an unhealthy cycle: stress reduces sleep and tiredness increases stress. Find what works for you to sleep better. But avoid too much sleep as that can have a similar negative impact.

  4. 4 Do something you enjoy which raises your heart rate. Physical activity releases endorphins which relieve tension.

  5. 5 Socialize with people who you love and who support you. Stress can make us isolate and shut down.

Do not

  1. 1 Do not touch your phone for a couple of nights or a whole day each week. Social media can be stressful—it’s easy to compare yourself unfavourably against a filtered version of someone else’s life. Switch screens off once you’re home or at least don’t check work emails. Avoid using screens before bed which disrupts sleep.

  2. 2 Do not asssociate with stressful people—reduce the amount of time you spend with them or end the relationship. You don’t have be friends with everyone you meet.

  3. 3 Do not use too much caffeine and sugar as mood boosters. Your blood sugar will soon come crashing down again, bringing your stress back with it.

  4. 4 Do not say ‘yes’ to everything. You can easily become overworked and stressed. Learn to say ‘no’, set healthy work limits, and delegate more by dividing jobs and sharing projects.

  5. 5 Do not ignore your feelings. It’s easy to accept stress as part of life. Chronic stress can be damaging, resulting in an increased risk of ihd, a weakened immune system, and faster ageing processes.

Resilience

Bouncebackability’ Iain Dowie, football manager.

Resilience

The quality of being able to recover quickly or easily from, or resist being affected by, stressful events. It is derived from the Latin verb ‘salire’ = to jump and the prefix ‘re-’ = ‘again’. Resilience is literally about jumping back. Resilient individuals demonstrate 6Cs:

  • Commitment: Persistence in adversity.

  • Composure: Low anxiety despite high-intensity situations.

  • Confidence: Trusting your own feelings, judgements, and decisions.

  • Challenges: The ability to manage challenges and make adversity meaningful.

  • Control: Recognition of your own limits of responsibilities and power.

  • Coordination: Predicting and planning for stress.

According to nhs England, a high level of resilience can be recognized in the following characteristics:

  • The ability to engage with and utilize others for your own support and development

  • The ability to manage negative emotions

  • The ability to assert influence but accept external controls

  • The ability to learn from past experience

  • The ability to seek and use supportive environmental factors

  • Practising the use of protective factors.

Being resilient maintains our health and well-being, increasing our compassion, empathy, and physical and mental health. It reduces burnout and helps us, as cynical doctors, to reconnect with the joy and purpose of our work. On a wider scale, staff resilience safeguards quality and sustainability of services. Where resilience is depleted, issues develop with slowing of work, sickness/absence, and ineffectual communication with teams and patients. Systemic issues within the nhs, such as understaffing, overworking, being under-resourced or poorly supported all contribute to burnout and it is important to acknowledge that even the most resilient of people may struggle when encountering issues they cannot directly address or control.

Resilience itself is not a stable trait but rather a dynamic state that can change between situations and over the lifespan. It can be learnt, practised, and shared. By now you will likely be thinking, ‘How resilient am I?’ This online resource is a good place to start: resiliencyquiz.com.

How do we develop resilience?

Be agile:

Mental agility here hinges on the capacity to ‘decentre’ a stressor in order to efficiently handle it. This means responding to, rather than reacting to, a problematic event. ‘Decentring’ a stress doesn’t ignore our feelings of being stressed; it allows us to pause, observe the experience from a neutral standpoint, and problem-solve. By pivoting attention from what we are feeling (the narrative experience) to what we are seeing, we can shift perspective, protect ourselves against being overwhelmed, and generate options. Upset toddlers are told ‘use your words’, because stopping and labelling emotions activates cognitive, rather than emotional, responses which are necessary to reflect and act.

Be (temporarily) detached:

We have circadian (daily) rhythm and also ultradian (hourly) rhythms—times where our energy and productivity rises or falls. Mental focus cycles typically last 1–1.5 hours; outside these times, try to take a break just for a few minutes to ‘reset’ your motivation and regain drive. This can be tough, especially in a busy clinic or ward round, but even a brief time for detaching from an activity can promote increased energy and focus. This ultimately grows capacity for resilience throughout the course of the workday, preserving energy and preventing burnout over the longer term.

Be kind:

This means to others and to yourself. Effectivity and kindness are mutually exclusive. Being compassionate helps increase cooperation and collaboration; in individuals it generates positive emotions and improves relationships. Stanford University’s Centre for Compassion, Altruism and Research in Education (ccare) runs ‘Compassion training programs’ which have demonstrated that practising kindness increases well-being and decreases stress. Develop your skills in treating challenging situations or disagreements as an opportunity to learn and potentially build a deeper relationship.

Be mindful:

It is hard to describe ‘mindfulness’ in a medical textbook without it sounding fluffy and unscientific but there are clear evidence-based positive outcomes associated with using these techniques in clinical environments. At its root, mindfulness is simply focusing attention to the present moment—to your own thoughts and feelings, and to the world around you—to the exclusion of other thoughts, worries, or future planning. By reconnecting with our body and our sensations we can regain control over our thoughts. This feeling of control can boost resilience. Mindfulness needs to be practised but, once skilled up, it’s easy to incorporate into daily life.

Be selfish:

This means prioritizing your own health. Make sure your physical health is maintained: make sure you are engaging in the same high-quality preventive primary care that you would wish your own patients to receive. Check your mental health too, sometimes, withdrawing is protective. But it is also important to connect and give into personal relationships. We are more than technicians—take time each day to foster healthy relationships, with patients, colleagues, and friends.

Be regimented:

We can’t control the amount of information we receive—up to 11 million bits of information every second—but we can optimize how we process it. It may sound a little robotic, but try assigning tasks to different areas: work/family/relationships and then subdivide into activities—workplace-based activity eg ward tasks, research, etc. By compartmentalizing, it’s easier to switch between tasks, make quality decisions, and stop thinking about other parts when you don’t need to, increasing productivity. Even better, create dedicated times for specific activities (exclusively) as you would for a gym session or a favourite tv show. This is called ‘serial monotasking’. It may feel overly regimented for some but it’s worth a go.

Trainees in difficulty

A concern about a doctor’s practice can be said to have arisen where an incident causes, or has the potential to cause, harm to a patient, staff or the organisation; or where the doctor develops a pattern of repeating mistakes, or appears to behave persistently in a manner inconsistent with the standards described in Good Medical Practice.’ gmc, 2006

Any trainee can encounter difficulties during their education, for a variety of reasons: medicine is a highly pressured working environment with frequent job changes for junior doctors who may feel unsupported or socially isolated. For the majority, these difficulties are temporary blips which are usually resolved through supervision and support. As we move through training we are expected to take on more responsibility, which includes managing juniors. A good supervisor will support trainees and clearly identify the struggling minority so that they can receive additional support.

Performance problems are rarely straightforward. They often relate to interpersonal and personality difficulties which emerge during periods of stress. Poorly performing doctors and medical students often have problems in a range of different areas (known as ‘a persistent pattern of poor performance’), each falling short of a serious enough problem for direct action. These doctors underperform in all domains, rather than being deficient in particular domains. Poor performance indicators may include the following:

  • The ‘disappearing act’: Not answering bleeps; disappearing between clinic and ward; lateness.

  • Rigidity: Poor tolerance of ambiguity; inability to compromise; inappropriate ‘whistle blowing’.

  • Low work rate: Slowness in doing procedures; clerking patients; dictating letters; making decisions.

  • ‘Ward rage’: Bursts of temper; real or imagined slights.

  • ‘Bypass syndrome’: Colleagues or nurses find ways to avoid seeking the doctor’s opinion or help.

  • Career problems: Difficulty with exams; lack of expected progression; uncertainty about career choice; disillusionment with medicine.

  • Insight failure: Rejection of constructive criticism; defensiveness.

Trainees in difficulty often have a combination of the following factors:

  • Personality: Anxious; overconfident narcissist; perfectionist/obsessional.

  • Situation: Over-busy, under-supported; poor existing morale; weak team or poor team communication.

  • Personal: Drug/alcohol misuse; relationship problems; mental health difficulties; change in jobs; exam stress.

Above all else, the strongest predictor of poor performance is alexithymia: a psychological concept that refers to an inability to connect with or be aware of one’s own feelings or the feelings of others. Individuals may have alexithymia as a primary personality trait, or (more commonly) develop an induced alexithymia due to prolonged stress. Doctors’ health & performanceThis is burnout (see p. [link]).

Early recognition and appropriate intervention, coupled with effective feedback and appropriate support for trainees in difficulty (and their supervisors) are essential. A supervisor should:

  1. 1 Ensure a positive, safe learning environment.

  2. 2 Deal with problems when they arise.

  3. 3 Clearly identify what the problem behaviour is with specific examples; identifying ‘problem themes’.

  4. 4 Hear the trainee’s point of view and encourage reflection.

  5. 5 Resist the temptation to ‘pathologize’ (but not miss health problems).

The hardest part is resisting the temptation to leave it for someone else to deal with or stop the process due to worries about counterclaims. Because of this, the gmc advises that supervisors take advice and seek support.

bma guidance (2018). Social Media, Ethics and Professionalism and Social Media: Practical Guidance and Best Practice. London: bma.

Manipulative patients and boundary setting

We have all been manipulated by our patients, and it is wrong to encourage in ourselves such stiffness of character and inflexibility of mind that all attempts by our patients to manipulate us inevitably fail. Nevertheless, a patient’s manipulative behaviour is often counterproductive, and reinforces maladaptive behaviour. A small minority of patients are very manipulative, and take a disproportionate toll on your resources, and those of their family, friends, and colleagues. We are all familiar with these patients whom Madox Ford describes as being ‘like fireships on a crowded lagoon, causing conflagration in their wake’.15 After destroying their family and their home we watch these people cruise down the ward or into our surgeries with some trepidation. Can we stop them losing control, and causing meltdown of our own and our staff’s equanimity? The first thing to appreciate is that these people can be communicated with, and you can help them.

Setting limits

One way of avoiding becoming caught up in this web of maladaptive behaviour is to set limits, as soon as this behaviour starts. In a small minority of patients, the doctor may recognize that their needs for time, attention, sedation, and protection are, for all practical purposes, insatiable. Whatever a doctor gives, such patients come back for more and more, and yet in spite of all this ‘input’ they don’t get any better. The next step is to realize that if inappropriate demands are not met, the patient will not become sicker (there may be vociferous complaints!). This realization paves the way for setting limits to behaviour, specifying just what is and is not allowed.

Take, for example, the patient who demands sedation, threatening to ‘lose control’ if it is not given immediately, stating that he cannot bear living another day without sedation, and that the doctor will be responsible for any damage which ensues. If it is decided that drugs do not have a part to play in treatment, and that the long-term aim is for the patient to learn to be responsible for himself, then it can be simply stated to the patient that medication will not be given, and that he is free to engage in destructive acts, and that if he does so this is his responsibility.

The doctor explains that in demanding instant sedation he undermines her professional role, which is to decide these matters according to her own expert judgement, and that this is not beneficial to anyone. If there is serious risk of real harm, admission to hospital may be indicated, where further limits may be set. If necessary, he is told that if he insists on ‘going crazy’ he will be put in a seclusion room, to protect others. Every person is responsible for the decisions they make, and if necessary, security can be asked to escort a patient out of the hospital, in line with hospital policies on abusive behaviour.

Being a good doctor

Here is a list of some of the things pundits tell us we should be doing when we meet patients:16

  1. 1 Listen—no interrupting or taking control of the agenda (how often are we guilty of implying: ‘Don’t talk to me when I am interrupting you’?).

  2. 2 Examine the patient thoroughly (to establish the likelihood of competing diagnoses).

  3. 3 Arrange cost-effective incremental investigation.

  4. 4 Formulate a differential diagnosis in social, psychological, and physical terms.

  5. 5 Explain the diagnosis to the patient in simple terms (then re-explain it to relatives, and then try re-explaining it to the computer in terms it understands—ie searchable codes).

  6. 6 Consider additional problems and risk factors for promoting health.

  7. 7 List all the treatment options, and seek out relevant guidelines etc. (evidence-based bedside medicine).

  8. 8 Incorporate the patient’s view on the balance of risks and benefits, harmonizing their view of priorities, with your own assessment of urgency.

  9. 9 Arrange follow-up and communicate with all of the healthcare team.

  10. 10 Arrange for purchase of all necessary care, weighing up cost implications for your other patients and the community, welcoming accountability for all acts and omissions, and for the efficient use of resources—with justifications based on explicit criteria, transparency, and principles of autonomy, non-maleficence, beneficence, and distributive justice.

The alternative

Do your best.

The synthesis

The alternative looks promising—even attractive, when compared with the 10 (im)possibilities just listed. But note that the alternative only looks attractive because it is vague. ‘Do your best’ is not very helpful advice—and once we start unpacking this ‘best’ we start to get a list like the 10 earlier points. ‘Professionalism’ sums up part of what being a good doctor entails—ie:

  • Self-regulation

  • Self-actuating and self-monitoring of standards of care

  • Altruism

  • Commitment to service

  • Specialist knowledge and technical skills reflecting but not determined by society’s values

  • Consistently working to high standards of probity and quality (no bribes, no favouritism, but a dynamic concern for distributive justice)

  • Self-determination—in relation to the range and pattern of the kinds of problems it is right to attempt to solve.

For a further discussion, see On Being a Doctor: Redefining medical professionalism for better patient care (King’s Fund, 2004) and fig 15.5.

Fig 15.5 How not to be a good doctor: Rowlandson’s Doctor Doubledose ‘Killing Two Birds with One Stone’ (1810). ‘With one podgy hand the physician takes the pulse of the cadaverous senseless invalid, while throwing an arm around the neck of the nubile girl. The “Composing Draught” and opium pillbox on the table suggest the physician may be giving his patient a helping hand out of this world, so as to switch his medical ministrations to her maid.’17 Georgian anti-medical satire was designed to deflate, lampoon, and expose pretension in the profession. The standing of early modern medics was precarious—disease and death held sway and doctors prescribed violent and painful procedures. Threats to one’s body were not just physical—Rowlandson’s other works depict doctors gawping at and groping their patients in a most un-Hippocratic manner.17 The 1841 Census estimated a third of all doctors were unqualified, with over 19 bodies regulating the medical profession—all using different tests for competence. There was no real way of saying who a doctor was until the gmc was established in 1858 allowing medical education and registration to be regulated.18 Since then self-regulation has been replaced with professional regulation, and consequently we see a high public trust in doctors—one that must not be taken for granted, and one that is up to us to maintain and protect.

Fig 15.5 How not to be a good doctor: Rowlandson’s Doctor Doubledose ‘Killing Two Birds with One Stone’ (1810). ‘With one podgy hand the physician takes the pulse of the cadaverous senseless invalid, while throwing an arm around the neck of the nubile girl. The “Composing Draught” and opium pillbox on the table suggest the physician may be giving his patient a helping hand out of this world, so as to switch his medical ministrations to her maid.17 Georgian anti-medical satire was designed to deflate, lampoon, and expose pretension in the profession. The standing of early modern medics was precarious—disease and death held sway and doctors prescribed violent and painful procedures. Threats to one’s body were not just physical—Rowlandson’s other works depict doctors gawping at and groping their patients in a most un-Hippocratic manner.17 The 1841 Census estimated a third of all doctors were unqualified, with over 19 bodies regulating the medical profession—all using different tests for competence. There was no real way of saying who a doctor was until the gmc was established in 1858 allowing medical education and registration to be regulated.18 Since then self-regulation has been replaced with professional regulation, and consequently we see a high public trust in doctors—one that must not be taken for granted, and one that is up to us to maintain and protect.

A lecherous doctor taking the pulse of an old woman while fondling a young one. Coloured etching by T. Rowlandson, 1810. Credit: Wellcome Collection. Distributed under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0). https://creativecommons.org/licenses/by/4.0/.

Authenticity

Trying to achieve authenticity is a meta-goal, and may be a better mast to nail your colours to than the 10 points listed earlier. Not because it is easier, but because paying attention to authenticity may make you a better doctor, whereas striving for all 10 of the points may make you perform less well (too many conflicting ideals). With inauthentic consultations you may be chasing remunerative activities, quality points, protocols, or simply be trying to clear the waiting room, at any cost, while the patient is trying to twist your arm into giving antibiotics or a medical certificate. Authentic consultations are those where there are no barriers; just two humans without status exploring and sharing hypotheses and beliefs and deciding what to do for the best (along the lines described in detail on pp. [link][link])—with no ulterior motives and no conflicts of interest. Authentic consultations know and tell the truth where possible, and where this is not possible, the truth is worked towards—diligently and fearlessly.

Appraisal and revalidation

Appraisal

All uk doctors practising medicine undergo a yearly appraisal. It has moved from being an informal chat with a peer to a formal structured review on which revalidation (see later) is based. The supporting information that doctors use at their appraisal falls into 4 broad categories:

  1. 1 General information: Giving context about what you do in all aspects of work.

  2. 2 Keeping up to date: How you maintain and enhance the quality of your work.

  3. 3 Review of your practice: Evaluating the quality of your professional work.

  4. 4 Feedback on your practice: How others perceive the quality of your work.

There are 5 types of supporting information that you need to provide and discuss at your appraisal:

  1. 1 Continuing professional development (cpd): cpd is the process of tracking and documenting knowledge and experience gained both formally and informally as you work + how you apply this to your work. cpd should be relevant to the current and emerging knowledge and skills required for your roles. You also need to reflect and evaluate on what you have learnt and how this improves your performance. 50 hours of cpd are required each year.

  2. 2 Quality improvement activity: Eg completion of an audit cycle or a case review. Currently this is only required once every 5-year revalidation cycle.

  3. 3 Significant events: Record any incidents or events ± any investigation or analysis of these, lessons learnt, and action taken/changes implemented.

  4. 4 Feedback from colleagues and feedback from patients: These are collected once every 5-year cycle using standardized questionnaires.

  5. 5 Review of complaints and compliments.

Appraisal is a supportive developmental process, to reflect on your work and consider developmental needs. ‘By giving feedback on performance it provides the opportunity to identify any factors that adversely affect performance, and to consider how to minimize or eliminate their effects. It is an important building block in a clinical governance culture that ensures high standards and the best possible patient care.’Doctors’ health & performance19

There is a big question-mark over ‘ensures’. The effect of appraisal on patient care is unknown—but appraisal, it is hoped, can offer opportunities for interdependent support, self-education, self-motivation, and career development in the wider medical world. It may also be a catalyst for change and even a tonic against complacency.

Appraisal assumes doctors are professional, life-long learners (the ‘move-&-grow’ aspect of challenging appraisals). If this is not the case, the less cosy revalidation, performance management, assessment, and mediation will bite.

The Annual Review of Competence Progression (arcp) is the appraisal and revalidation process for all specialty trainees, including general practice trainees, where a panel from the Deanery meet to consider the evidence/documentation provided by the trainee and assess their suitability to progress.

Doctors’ health & performanceIf you decide not to work in a formal training programme (eg f3), you are responsible for organizing your appraisal and evidencing professional development in order to revalidate—this includes if you have been working overseas and wish to return to work in the uk.

Licence to practise

To practise medicine in the uk, all doctors are required to be registered with the gmc and hold a licence to practise. This gives a doctor the legal authority to undertake certain activities in the uk, eg prescribing, signing death or cremation certificates, and working as a doctor in the nhs. Re-licensing occurs every 5 years by the process of revalidation.

Revalidation

The process by which licensed doctors are required to demonstrate they are up to date and fit to practise. It is achieved by having annual appraisals and by providing the required ‘supporting information’ listed earlier. Revalidation occurs every 5 years but may be deferred if insufficient evidence is provided or there are unresolved concerns about a doctor’s performance.

Further reading

gmc (2019). Supporting Information for Revalidation and Appraisal. https://www.gmc-uk.org

gmc (2019). The Licence to Practise. www.gmc-uk.org/doctors/licensing.asp

Clinical governance

Clinical governance

The framework through which nhs organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish. It links continuing professional development, multidisciplinary learning, audit, risk management, and significant event reporting/analysis. It is about defining quality (eg standards set by nice, cqc, Quality and Outcomes Framework (qof)), assuring accountability, and improving quality (by monitoring standards).

Essential elements:

  • Risk avoidance—risk management; clear protocols; safe environment.

  • Infrastructure—access to evidence; time; training strategies; it support.

  • Clinical effectiveness—sharing good practice; significant event audit; evidence-based medicine.

  • Audit—regular review of practice against quality standards (see later).

  • Education/training—effective appraisal; performance feedback; targeted education.

  • Staff—training; leadership; communication; common goals/teamwork.

What does clinical governance entail?:

Individual doctors must consider their own professional development and educational needs. There must also be continuous review and appraisal of procedures and standards. Deficiencies in knowledge, skills, or experience must be acted upon through appropriate education and professional development. Resources should be provided to help develop clinical governance (eg protected time for audit, funding for courses and educational activities).

Significant event analysis

All hospitals and gp practices should have systems for reporting and investigating incidents which have or could cause harm to a patient. This should be done in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements.

Audit

The systematic critical analysis of quality of healthcare. Its purpose is to appraise current practice (What is happening?) by measuring it against preselected standards (What should be happening?) to identify and implement areas for change (What changes are needed?) and thus improve performance. Audit is a continual process and an integral part of clinical governance.

Criterion-based audit—the audit cycle

The process of identifying areas of care to be audited, implementing necessary changes, and periodically reviewing the same issues is known as the audit cycle.

  1. 1 Identify the issue. This can be any practice matter—clinical or administrative. Make sure the topic is important, manageable, clearly defined, and data are available to assess the criteria chosen. Good starting points are significant events, qof targets, complaints, clinical guidelines, or personal observations.

  2. 2 Agree criteria. These are specific statements of what should be happening.

  3. 3 Setting standards. These are the minimum levels of acceptable performance for a criterion (100% achievement is unusual). Set realistic standards. These can be based on previous audit, comparison with other trusts/practices, or guidelines (eg ‘90% of patients with iron deficiency anaemia should be screened for coeliac disease; British Society of Gastroenterologists 2005’).

  4. 4 Planning and preparation. What data will you use? How will you search for it? What literature has been consulted?

  5. 5 First data collection. What is current practice (compared to standards set)? What changes are needed?

  6. 6 Implement changes.

  7. 7 Second data collection. Monitor the effects of change and compare data with the first round of data collection and against standards set.

  8. 8 Summary of findings.

Managing uncertainty and risk

Medicine is the art of managing uncertainty. Many patients present with problems or symptoms that are undifferentiated and unorganized and do not have an obvious diagnosis at presentation. Many symptoms are also medically unexplained (see p. [link]). Almost any symptom can be made to seem fatal (‘Is this lethargy due to cancer?’), even seemingly trivial problems (‘This pain in my toe …’—could it be due to an embous or osteomyelitis?). Medicine is for gamblers (see later) and in order to survive we must learn to manage uncertainty and avoid lying awake at night worrying about the meaning of our patients’ symptoms. (See also p. [link].)

Tips for dealing with uncertainty

Consider the differential diagnosis:

A careful history and examination will allow you to consider the differential diagnosis. Making decisions when there is uncertainty and risk is difficult. Decisions are based not just on risk but also on possible outcome. High-risk problems should have a lower threshold for action (eg for possible mi or appendicitis).

Time as a tool:

The skilful use of time (by reviewing a patient over a number of consultations across a period of time) can obviate the need for extensive investigation, or allow for incremental investigations as symptoms develop, or the results of initial investigations emerge.

Evidence-based medicine:

When deciding on an investigation or treatment, consider what evidence exists for its use, how valid the evidence is, and if it is applicable to the patient you are seeing. No treatment is completely safe, entirely effective, or without side effects.

Sharing uncertainty:

Sharing uncertainty with patients may increase trust and avoids deception. We can also share uncertainty with colleagues (eg discussing symptoms with another doctor or referring to a specialist—this is also useful if you think the source of your uncertainty might be a gap in your own knowledge).

Safety netting:

Discuss a contingency plan with the patient by informing them what to do if things don’t go to plan (eg seeking urgent review if red flags develop with back pain, or educating a parent about the signs to look for that should prompt review of a febrile child).

Gamble safely:

Making decisions under conditions of uncertainty is a form of gambling. We cannot refer and investigate every problem, yet we still need to make decisions. Some of these decisions will be scientific and rational. Some will be based on subtle clues or feelings. Make sure you assemble sufficient evidence to maximize your chances of being lucky.

Clinical governance:

No matter how carefully we practise, adverse events will occur. It is important to discuss, reflect, and learn from any errors and improve systems to try and prevent similar events (see pp. [link][link]).

Organizations that can help

All uk doctors should be registered with a general practitioner—your own gp can be a fantastic source of support and advice. There are few perks to working in the nhs and in general, doctors are keen to support and help their colleagues.

Doctors’ Support Network is a confidential peer support network for doctors and medical students with concerns about their mental health: www.dsn.org.uk

DocHealth is a confidential, not–for–profit service giving doctors an opportunity to explore difficulties, both professional and personal, with senior clinicians. Self-referring doctors can access up to six face–to–face sessions. A fee structure is based on grade/circumstances. www.dochealth.org.uk

The nhs Practitioner Health Programme is an award-winning, free, and confidential service for doctors and dentists with issues relating to mental or physical health or addictions, in particular where these might affect their work. Any doctor in England can request a referral via their gp: www.php.nhs.uk

gp Health Service is a confidential nhs service for gps and gp trainees in England. It aims to help doctors with issues relating to a mental health concern, including stress or depression, or an addiction problem, in particular where these might affect work: www.gphealth.nhs.uk

rcpsych Psychiatrists’ Support Service is a free, confidential support and advice service for psychiatrists at all stages of their career who find themselves in difficulty or in need of support: 020 7245 0412; pss@rcpsych.ac.uk

Health for Health Professionals Wales is a face-to-face counselling service for all doctors in Wales: 0800 058 2738.

bma Counselling has a 24/7 telephone line and offers up to 6 structured telephone counselling sessions: 0330 123 1245.

bma Doctor Advisor Service runs alongside bma Counselling, giving doctors and medical students in distress or difficulty the choice of speaking in confidence to another doctor: 0330 123 1245.

bma Doctor Support Service is for any doctor (you do not have to be a bma member) who is facing a gmc investigation or licence withdrawal. Being subject to a gmc complaint can be uniquely and deeply stressful and this service offers emotional help from fellow doctors and functions independently of the gmc: www.bma.org.uk/advice/work-life-support/your-wellbeing

The Doctors Support Group aims to provide support and assistance to any medical professional or dentist facing suspension, exclusion, investigation of complaints, and/or allegations of professional misconduct: www.doctorssupportgroup.com

British Doctors and Dentists Group is a recovery group for doctors and dentists addicted to alcohol and/or drugs: www.bddg.org

The Sick Doctors Trust supports and helps doctors, dentists, and medical students who are concerned about their use of drugs or alcohol. 24/7 Helpline: 0370 444 5163. www.sick-doctors-trust.co.uk

Useful apps

The apps and websites listed here were suggested by the contributing authors and are commonly used by doctors in the uk. Please note: oup is not responsible for the content of external apps or websites.

  • The bnf/bnfc app contains all the content from the bnf and the bnfc in one place, providing up-to-date information about the use of medicines and drug interactions for free. Essential!

  • Microguide allows you to download your hospital’s antimicrobial guidance, with easy-to-search first-line/alternative antibiotics listed by bodily system. Updated guidelines are automatically downloaded and the app works offline.

  • MDCalc (other medical calculators are available!) contains all the widely used clinical calculators that help support decision-making and evidence-based care, from Apgar to vbac (and many, many others in between).

  • Toxbase is the clinical toxicology database of the uk National Poisons Information Service, providing advice on the features and management of poisoning/overdose. It is free if you sign up using an nhs.email address.

  • Developed by nhs Blood and Transplant, the Blood Components app summarizes relevant national guidelines to act as a prompt to facilitate appropriate use of blood products. It is based on the National Blood Transfusion Committee Indication codes.

  • The Induction app allows you to avoid dialling switchboard by viewing and dialling hospital extensions from your phone. You can also search who is paging you by entering the extension.

Other useful selected apps and websites

NHS Apps website:

An updating list of nhs-approved apps for patients across a variety of specialties: www.nhs.uk/apps-library/

O&G:

The rcog Green-top Guidelines are aids to good clinical practice and are available to browse: www.rcog.org.uk/guidelines

Paediatrics:

  • NeoMate is a free app for nicu staff and includes drug and fluid calculations, guides, and checklists for care.

  • BiliApp helps you interpret and guide management of newborn jaundice based on nice guidance.

  • uk Growth Charts are available at www.rcpch.ac.uk/resources/growth-charts

  • Paediatric Care Online (www.pcouk.org) is a decision-support tool on child health and safeguarding.

Dermatology:

  • DermNet nz (www.dermnetnz.org) is an a–z of skin diseases and treatment with an excellent image library.

  • The British Association of Dermatologists (www.bad.org.uk) also has a wealth of clinical information/patient leaflets.

ENT:

  • www.ent.org.uk (British Association of Otolaryngology) has published guidelines and patient leaflets.

  • Mimi Hearing Test is an ios app calibrated for EarPods® and AirPods®.

Emergency medicine:

Mersey Burns calculates burn area percentages.

Trauma & orthopaedics:

OrthoFlow is a purchased app which helps you diagnose and manage orthopaedic trauma.

General practice:

  • nice Clinical Knowledge Summaries provide >300 summaries of current evidence and guidance on best practice for common/significant primary care presentations: https://cks.nice.org.uk

  • Patient.co.uk and the nhs website (www.nhs.uk) have excellent information for patients on various illnesses and diseases.

Notes:

With many thanks to our junior readers Grace Castronovo and Eliot Hurn for their contribution to this chapter.

1 gmc (2012). Raising and Acting on Concerns about Patient Safety, p5. London: gmc.

2 See Good doctor, bad doctor—a psychodynamic approach. bmj 2002;325:722 by Jeremy Holmes (whom we thank for permission to quote from his excellent article).

4 This material was originally published in the Oxford Handbook of Clinical Medicine 9th edition by Longmore et al., and has been reproduced by permission of Oxford University Press.