Performance Appraisal Inside the Medical Club Part 2

Portfolio Based Performance Appraisal and Medicines New Professionalism

‘(Governance is) a form of activity aiming to shape, guide or affect the conduct of some person or persons’.

Gordon (1991:2).

Portfolios can be said to act as one of medicines key new ‘visible markers’ of trust within the contemporary governing context (Allsop 2006, Kuhlmann 2006b).It modernises how medical governance systems operate. The ‘fitness to practice’ of medical trainees and experienced ‘rank and file’ doctors is now more than ever before monitored in an open, transparent and accountable fashion, utilising ‘best evidenced’ minimum performance standards devised by medical elites themselves (Stacey 2000, Southgate 2001, Irvine 1997 2003 2006, Catto 2006 2007). As the ex-chairman of the GMC Sir Donald Irvine (2001: 1808) notes ‘the essence of the new professionalism is clear professional standards’.Certainly, at the centre of portfolio based performance appraisal lies an administrative rationalistic-bureaucratic process of standard setting and outcomes management (Harrison and Ahmed 2000, Grey and Harrison 2004). This relies upon the functional analysis of an occupational role in order to break it down into its constitutive parts and translate key competencies into specific measurable outcomes and minimum performance requirements (Searle 2000, Harrison 2004). Although their exact content may change depending upon the context of their application, portfolios tend to come with outcome-based performance standards and targets attached (Dean 1999, Searle 2000, Southgate 2001). For example, in the context of NHS Annual Appraisal, consultants and general practitioners must keep a portfolio of their continuing professional development which contains information relating to prescribing patterns, the outcomes of case note analysis, the results of clinical audit, as well as patient complaint case outcomes and even surgical operation success rates (Black 2002, Bruce 2007). Similarly, in the Foundation Programme for junior doctors, trainees must maintain a portfolio which contains evidence of their ability to perform key clinical skills within a range of medical and surgical specialties, as well as their ability to use clinical protocols and ‘best evidence’ practice guidelines when providing patient treatment and care (BMA 2005).


Portfolio based performance appraisal does possess a certain value as a ‘learning tool’ that must be recognised (Redman 1995, Gilbert 2001). In line with vocational and professional education in general, a portfolio is typically defined within medicine as a ‘dossier of evidence collected over time that demonstrate a doctor’s education and practice achievements (Wilkinson 2002: 371). It is argued by educationalists that portfolios help portfolio keepers to develop their study and critical thinking skills by requiring they ‘take charge’ of their learning and professional development in order achieve personal career aspirations. Portfolio keepers are encouraged to identify their own learning needs, set learning goals in light of these, and subsequently record activities and achievements for later peer review (Gilbert 2001). This is done under the guise of promoting ‘reflective practice’ (Long 1986) within the professional training context. (i.e. Snadden and Thomas 1998, Challis 1999, Wilkinson 2002). For here, ‘being reflective’ of one’s performance, and admitting mistakes and learning from them, is held to represent ‘good professionalism’. Not least of all because it is taken to signify willingness to place one’s client’s needs and interests above one’s own. This why portfolio based performance appraisal requires individuals to provide written statements concerning their learning needs and work performance in light of minimum performance standards governing an occupational task (Fletcher 1997, Southgate 2001, Wilkinson 2002). Yet recognising the educational value of portfolio based performance appraisal simply reinforces the need to focus on the political role portfolios play as governance tools. For their usefulness as educational tools reflects and reinforces their political value as an administrative and managerial tool that ultimately protects the principle of professional self-regulation. They may well act as a personalizable biographical career record containing information relating to a practitioner’s continued professional competence (Snadden and Thomas 1998). The adoption of clear standards governing the performance of work tasks certainly does allow individual practitioner’s competence to be judged and recorded. However, most importantly, in doing so they enable an organisations’ ability to monitor the achievement of these standards to in turn be assessed and verified by an independent third party. Consequently, whatever its educational value as a tool for ensuring an individual’s professional competence and professionalism, portfolio appraisal’s political value lies in its ability to function as an individually productive peer review exercise that also serves to protect professional autonomy at the institutional level in the form of the principle of professional self-regulation (Gilbert 2001). After all, who other than a professional’s peers possesses the necessary expertise to set the standards judging the quality of their work? This is an invaluable state of affairs if you happen to be a member of an organisation subject to overarching regulatory ‘watchdog bodies’. As medicine is with regards to the Council for the Regulation of The Health Care Professions.

Doctors under Surveillance?

The political utility of portfolio based performance appraisal reinforces the need to answer several interrelated questions regarding their practical application within the medical club. Does portfolio based performance appraisal survey what it intends to survey and produce the effects that it intends to produce? Does it survey and record a medical trainee’s or doctor’s clinical performance and competence, including their self-monitoring inspections of their learning needs and professional practice achievements? Does it encourage its user to engage in self-inspection and practice self-discipline? Does it ensure organisational transparency and accountability through producing an accurate administrative account of professional competence and career development?

Taking to doctors indicates that they feel they are coming under greater collegiate surveillance and control. They are becoming more accountable for what they do educationally, in terms of how they supervise and assess the ‘fitness to practice’ of trainees, as well as how they maintain their own continued professional competence. Informants believed, first, that a key effect of recent reforms in medical education had been the introduction of more structured clinical placements for trainees, and second, that as part of this change the clinical performance of trainees was coming under greater formal surveillance and testing than previously had been the case. Both at medical school and during their ‘off site’ clinical placements. The follow comments from Dr Red (Surgeon) and Dr Yellow (Surgeon) illustrate these points.

‘Yes, I do think that we are placing students under more surveillance these days. As medical teachers, we have always been concerned with knowing how students perform. But I do think things have intensified as a result of recent reforms in the (undergraduate) curriculum..(and that) they are also being more intensively monitored in areas you weren’t so formally assessed in in my day, such as communication skills…There certainly was much more freedom to explore clinical areas when I was at medical school. You see, when they first come here they get a structured timetable and their attendance is monitored…they now have allotted teaching time in clinic as well as ward teaching sessions with me and my colleagues…before, well, things were much more flexible, you really just had to turn up for ward rounds, and you had a bit of clinical teaching here and there on top, and the rest of the time was yours to use as you wanted. And I think that approach did help me as a medical student as I could follow up areas that I wanted too explore further out ofpersonal interest, and I don’t think today’s students and juniors have that freedom, as everything is moving towards becoming much more regulated and structured in medical education these days.’

Dr Red

‘The introduction of the foundation programme does mean that juniors now have a much more structured training experience…they have a formal timetable of clinical teaching relating to different specialty areas… (and) they get a lot more formal testing of their ‘hands on’ ability to do the job…so yes, I would say that they definitely are under more surveillance, and certainly a lot more than we were as juniors I can tell you!’

Dr Yellow

Interviewees also held that the use of portfolio based performance appraisal was bound up with a more general increase in the surveillance of doctor’s clinical activities:

‘The portfolio is a tool for monitoring their competence to perform to minimum practice standards within a given clinical area. That is a given. But I do think that like many things these days in medicine it is also about keeping track of what you are doing and recording it to cover your arse, and the portfolio system introduces students to that fact of life early on’.

Dr Purple (Surgeon)

Interviewees also reported that its introduction in medical training had had some affect on how they personally went about supervising trainees during clinical placements:

‘If you look at the portfolio for final year (medical students) and the one for the foundation programme, well, they ask the same of you as a supervisor really, they both require you have a series of one on one meetings with a trainee, and the both ask you to fill in certain forms when you assess them.The upshot of all this change I think is that you really have to keep a closer eye on what you are doing as their supervisor.’

Dr Pink (Physician)

Interviewees’ held that recent reforms in medical training had led to the academic and clinical performance of students and junior doctors being placed under greater surveillance than previously. They also argued that the growing use of portfolio based performance appraisal within medicine was bound up with the introduction of a more formal educational structure in clinical placements. They noted how this state of affairs contrasted to the traditional organisation of clinical placements for junior doctors and medical students. It is often held that the vast majority of clinical teaching and supervision within medicine has been undertaken traditionally in an opportunistic ‘ad hoc’ basis (Stacey 1992, Bridgens 2003). Until recently much of the clinical teaching that occurred at the bedside during ward rounds, as well as in hospital clinics, surgical theatre and GP surgeries for that matter, was undertaken at the personal behest and whim of the attending senior doctor (Atkinson 1995, Leinster 2003). The nature, quantity and standard of clinical teaching trainees receive was viewed by social scientists and medical educationalists to suffer from considerable variation in quality (i.e. Atkinson 1981, Sinclair 1997, Bligh 2001). That the quality of clinical education is inconsistent, and required greater direct medical school and postgraduate deanery intervention to ensure consistency, has been well known to sociologists since Becker (1961) first undertook his study of medical education in the late 1950s. Longitudinal studies of doctor’s careers throughout the latter part of the last century, as well as the early part of this one, have highlighted that senior doctors possess a high level of dissatisfaction with the organisation of the clinical training they received as medical students and junior doctors. In particular, they have concerns over the consistency of educational provision and general standard of clinical teaching offered to trainees (i.e. Allen 1995, Carvel 2002). This in itself may explain why the doctors interviewed were supportive of recent attempts to reform undergraduate and postgraduate medical education. However, the continued reliance of juniors on seniors for job references to enable career advancement has led to a certain amount of despotic patronage within the clinical training and practice context (Stacey 1992, Allsop 2002). This has helped inoculate it from calls for reform. That is until relatively recently, when medical elites have recognised that they have to reform medical training and regulation. Consequently, they initiated a process of change that will take time to take affect (Stacey 2000). Nevertheless, as the topic will discuss, in spite of positive attitudes concerning the need for change, interviewees reported educational practices congruent with a traditional view of the roles between clinical teacher and trainee (Bligh 2001). They also possessed attitudes towards the reporting of underperformance that were in line with the ‘patronage system’ medicine has operated traditionally under (Gladstone 2000). They reinforced the need for trainees ‘to keep their heads down’ and do as they are told, if they want to ‘get on’ and pass a clinical placement as well as get a good reference.

Interviewees’ accounts revealed that this move towards more structured clinical placements for trainees was linked with the introduction of different set of expectations of them as educational supervisors who were responsible for the assessment of a trainees’ clinical competence. They were quick to highlight that portfolio based performance appraisal required two key things from them. First, they should meet with trainees in a structured manner during clinical placements, agree a trainee’s learning goals in light of pre-defined clinical performance standards (at the beginning of a placement), monitor progress towards them (typically halfway through a placement), and assess their achievement (at the end of a placement). Second, they should provide a formal written record in the trainee’s portfolio of these meetings, their assessment of whether or not a trainee has met the minimum standard required of them, and include in this record the reasons for their decision. This would be reviewed by the medical school or postgraduate deanery staff. As Dr Orange (Physician) notes:

‘The portfolio the students use requires you undertake assessments of their progress. Now that of course used to happen but it is now much more directed by the medical school through the portfolio… It’s the same with the foundation programme portfolio too. What it all boils down to is the distribution of more and more pieces of paper to complete …and it is expected that I read them all, and use them when I make my own assessment of a student, before I tick and sign yet another piece of paper to say they are competent…the amount of paperwork involved makes it a very bureaucratic process really.’

Bureaucratic Accountability and the Restratification Thesis

Interviewee’s accounts of the use of portfolio based performance appraisal within the medical club indicated that ‘rank and file’ doctors involved in the supervision and assessment of trainees during clinical placements are being subject to greater collegiate surveillance and control. They were becoming more ‘bureaucratically accountable’ to medical elites (in this case to their local medical school and the postgraduate deanery) for how they supervise and assess medical students and junior doctors. The concept of ‘bureaucratic accountability’ was first developed by Harrison and Dowswell (2002), who undertook an analysis of doctor’s clinical autonomy. They looked at case record reporting and clinical guideline adherence by general practitioners with respect to angina and asthma patients. Their study highlighted that there was greater collegiate emphasis on individual doctors accepting the need to formally record their clinical decisions, alongside the reasoning behind them, in patient case notes. They found that there had been ‘a clear reduction in autonomy in the sense of GP’s ability to determine their own clinical practices and to evaluate their own performance without normally having to account to others’ (Harrison and Dowswell 2002: 221).

Harrison and Dowswell (2002) argue that their findings demonstrate the contingent nature of individual ‘rank and file’ doctor’s day to day clinical autonomy, and in doing so provide further evidence for the restratification thesis. Similarly, the increased emphasis placed by portfolio based performance appraisal upon doctor’s formally recording their decisions about student performance, and the reasons for them, does seem to indicate that they are becoming more ‘bureaucratically accountable’ to medical elites. The accounts provided by consultants and general practitioners concerning the introduction of portfolio based performance appraisal for trainees certainly revealed that appraisal is placing them under a greater degree of collegiate surveillance and control as educational supervisors. Not least of all because they were responsible for coordinating and undertaking the assessment of trainees during clinical training placements, planning and recording assessment events within a trainees portfolio, as well as ‘signing them off’ as ‘fit to practice’. Nevertheless, as the topic will discuss, further investigation revealed that doctor’s ‘bureaucratic accountability’ to medical elites within the clinical education context currently possesses a ‘ritual quality’ (Pym 1973). Portfolio appraisal was viewed as something of a ‘paper chasing’ and ‘form filling’ exercise by the doctors interviewed, such as Dr Green (General Practitioner):

‘In medicine in general they are more pieces of paper flying around these days. So you would expect that medical education would be the same. But I think there is a general kind of automation to filling in forms, on behalf of both trainees and supervisors. You see, you are going in, doing this and doing that, filling out this and filling out that; and not because you want to but because you have to. So I am not sure how much is actually being done properly as our medical education masters require’.

This tendency to view portfolio based performance appraisal as a paper-chasing exercise was due to a mixture of ‘structural’ and ‘ideological’ factors. These will be defined and discussed in detail later in the topic. First, the ‘ritual nature’ of doctor’s ‘bureaucratic accountability’ must be discussed in greater detail. A good place to begin is Annual Appraisal.

Annual Appraisal and the Shipman Affect

‘You do realise, don’t you, that this is all because of Shipman?’

Dr Violet (Physician)

When I discussed the introduction and affects of portfolio based performance appraisal interviewees, I found that they recognised the system of medical training had undergone extensive change in the last decade. Furthermore, it had moved towards emphasising a structured competency focused, outcomes based, approach to training and career progression by means of formal appraisal (Bruce 2007). The introduction of Annual Appraisal for general practitioners and consultants and recent modernisation of junior doctor and later specialist training are bound up with this process (BMA 2005, Slater 2007).As the following extract from a key Department of Health document relating to the implementation of appraisal for doctors notes:

‘Appraisal should include data on clinical performance, training and education, audit, concerns raised and serious clinical complaints, application of relevant clinical guidelines, relationships with patients and colleagues, teaching and research activities, and personal and organisational effectiveness’.

(Department of Health 2001: 34)

These had led to calls for an end to medical self-regulation, or at least, the introduction of greater non-medical input into the regulation and monitoring of doctor’s fitness to practice (Stacey 2000, Slater 2003, Davies 2004). Interviewees such as Dr Yellow (Surgeon) recognised that appraisal had not been initiated by elites within the medical profession:

‘I don’t think you can honestly say that we as a profession wanted appraisal. It is a government thing, because of the events at Bristol, and because of Shipman of course…I think Tony Blair and his mates wanted to bring us doctors inline and make us more accountable, at least on paper, and the (royal) colleges and the BMA and GMC knew that the tide was against them, so they had no choice but to get on board’.

Dr Yellow’s comments reinforce that appraisal met with a mixed press within medicine when it was first proposed, not least of all because it could lead to a doctor being referred to their employer and the GMC for underperformance (Graham 2002). It is therefore perhaps not surprise to learn that although open to NHS managerial input, because of intensive lobbying from the Royal Colleges, the GMC and the BMA, Annual Appraisal was introduced firmly under collegiate control (Irvine 2003). It was successfully argued by the professional elites that this was the only valid and acceptable method by which Annual Appraisal could be undertaken (Slater 2002).

Appraisal is completed by a consultants’ Clinical Director in the hospital context, or a Primary Care Trust registered GP trainer in the general practice setting. Both have undergone training in their role by the Royal Colleges (Black 2002). Appraisal essentially involves a review of a doctor’s achievements to identify their developmental needs (Rughani 2000). Appraisers may occasionally report to their NHS employer and the GMC that a particular doctor’s professional performance is unacceptably poor. However, for most doctors, appraisal is said to be a positive process, focused upon maintaining and recognising good standards of clinical care (Department of Health 1999). In principle, it can lead to promotion, managerial and administrative duties being contractually recognised, an increase in secretarial or clinical support, or even a Royal College merit award (Black 2002).

Appraisal requires that doctors maintain a portfolio of evidence relating to their practice achievements, just as medical students and junior doctors must maintain a personal portfolio. The Annual Appraisal portfolio is themed into sections relating to the GMCs Good Medical Practice (1995): Good Medical Care, Maintaining Good Medical Practice, Working Relationships with Colleagues, Relations with Patients, Teaching and Training, Probity, Health, Management Activity and Research. The appraisal interview revolves around discussing the evidence doctors provide in each section to prove they are maintaining basic professional standards. For example, the results of clinical audit and information relating to clinical caseload should be recorded under Good Medical Care. Evidence of continuing medical education in the form of conference attendance and training programs completed should be included under Maintaining Good Medical Practice. The results of peer reviews of a doctor’s clinical practice should be included under Working Relationships with Colleagues. Examples of good practice relating to gaining informed consent and general interaction with patients should be included in Relations with Patients. A summary of formal teaching activity and any feedback on its quality should be included under Teaching and Training. Relevant critical incidents and issues should be included in the Probity and Health sections. Administrative and managerial commitments should be placed under Management Activity. Information relating to research activity, such as ethical approval applications and research publications should be held under the section entitled Research (Black 2002). Finally, each portfolio includes a professional development plan that summarises actions agreed because of the appraisal interview (Rughani 2000). For example, it may be decided that targeted training in a specific surgical technique is necessary. This plan will subsequently include an account by the doctor of how they went about meeting agreed goals (and the reasons why they did not achieve them if they did not) (Gentleman 2001). This shows that Annual Appraisal is a further example of how rank and file doctors are becoming more ‘bureaucratically accountable’ for their activities to medical elites, in terms of having to formally document what they do, and provide reasons for doing it, for subsequent review by their peers (Harrison and Dowswell 2002).

Given the politicised background to the introduction of Annual Appraisal, it was anticipated that interviewees would possess a range of positive and negative views. The forty-six doctors interviewed were split into two opposing camps, with eighteen viewing appraisal positively:

‘There is a lot of paperwork involved in appraisal, which can be quite a pain, and I know a few colleagues who are really negative about it. But I have to say that I found it a very useful exercise. At least for establishing in my own mind where I am career wise and what I want to be doing in a years time’.

Dr Purple (Surgeon)

As Dr Purple’s comments illustrate, interviewees who viewed appraisal positively tended to emphasise how it helped them ‘keep track of how I am getting on’ (Dr Brown General Practitioner). This contrasted to the twenty-eight interviewees who viewed appraisal negatively, and tended to regard it as a ‘waste of energy and time, nothing more than a paper exercise’ (Dr Blue Surgeon).

The following comments from Dr Violet’s (Physician) are typical:

‘Appraisal is a waste of time. I get nothing from it at all. It’s just another thing I have to do because ‘the powers that be’ require it be done for their own purposes. I mean, do you think if I did have a problem it would help solve it? No, it’s just a superficial exercise that achieves nothing concrete, and it takes up time that could be better spent doing other things’.

While some interviewees held that they found appraisal a personally meaningful exercise, many found it an onerous task. All reported that Annual Appraisal involved a lot of ‘paper chasing’ and ‘form filling’ (just as they did when discussing portfolio appraisal for trainees). They said that maintaining their portfolio took a considerable amount of time and effort. A key difference between the two ‘camps’ was that those who viewed appraisal negatively tended to stress how it interfered with their clinical workloads. More often than not, they would be highly dismissive of appraisal and argued that it was formalising something that medical practitioners did anyway as a matter of professionalism:

‘These days it is all about accountability, and that is fine, but I do think it needs to be remembered by the government and management that they are dealing with professional people, not with the cleaning or canteen staff, and to my mind being a professional means that you have high standards and make sure you achieve them, and keeping up to date forms a necessary part of that professionalism .Without having to complete some form or other so that management can double check to make sure you are doing what you are supposed to be doing.’

Dr Scarlet (Physician)

In contrast, those who viewed appraisal positively acknowledged that appraisal took time and effort. Furthermore, they often also held that it was indeed something that a doctor’s professionalism had always required them to do anyway. Nevertheless, they said they had found it a personally rewarding exercise:

‘It takes up a lot of time… (but) you get out a lot out of preparing your portfolio. It certainly makes you sit down and think about what you need to do to improve as a doctor’.

Dr Red (Surgeon)

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