Appraisal and the Elitist Nature of the Medical Club
It also shows how there is a propensity for doctors to hide such attitudes behind the ‘service ideal’ of their professionalism (i.e. that it is in the best interests of patients that they be left alone to manage their own affairs) (Gladstone 2000). Critical social commentators have argued that such attitudes have been a pervasive feature of the occupational culture of the medical profession since the 1858 Medical Act established the
GMC and institutionalised the principle of professional self-regulation under the banner of serving ‘the public interest’ (i.e. Stacey 1992, Allsop and Saks 2002, Davies 2004, Slater 2007). Whether they viewed appraisal positively or negatively, interviewees comments showed that they possessed exclusory ‘closed shop’ attitudes concerning Annual Appraisal. The following extract from Dr Black’s (Physician) interview is typical in this regard:
‘What worries me is the question of if a ball has started rolling that will eventually roll in the direction of including non-medical staff and even patients in the appraisal interview…I would argue that your appraisal should be managed by your colleagues. As they are the only ones who can really judge if you are performing satisfactorily. There is no way I would be happy doing it if somebody other than medical members of staff were actively involved’.
Interviewees’ accounts may pay ‘lip service’ to the contemporary requirement that medical governance be open and accountable to the public. However, there accounts were nevertheless replete with paternalistic, elitist and exclusory attitudes concerning performance appraisal and professional accountability:
‘Talk of transparency and accountability is all well and good. You certainly find a lot of it in today’s NHS with its obsession with meeting targets and reducing waiting lists. But at the end of the day you don’t ask the airplane passengers to judge the quality of a pilots landing past a very basic level. It is the same with doctors and clinical work. And I think that fact needs to be acknowledged, and we need to be left alone to get on with the job ourselves’.
Dr Silver (General Practitioner)
Along with this antagonism towards attempts by the state to ‘open up’ medical governance, of which Annual Appraisal is one example, was the belief that as its stands appraisal ‘is a paper exercise and doesn’t really change a thing’ (Dr Green General Practitioner). Indeed, interviewee’s who were positive about appraisal said they were positive despite a frequent lack of ‘follow up’ on the outcomes of appraisal. Dr Purple (Surgeon) and Dr Lime (Physician) highlight this point:
‘It does give you an opportunity to step back and look at the work you do and what problems you face doing your job on a day to day basis. Like in terms of its management; in terms of organising things like clinical and secretarial support in order to operate effectively. But the problem is that when things are highlighted, and it is agreed that changes need to be made. For instance, it was agreed in my last appraisal that we needed another medical secretary in the department. But here we are still waiting for that to happen eight months later’.
Dr Purple
‘I can see that you could argue that appraisal is a positive thing as it can encourage a consultant to take study leave for developmental and career reasons. The fact remains that such things need financial resources behind them and staff to cover absences. And that can be a major problem.’
Dr Lime
Dr Lime’s comments illustrate how interviewees believed that the appraisal process lacked ‘follow through’ and that this was due to financial and human resource factors. Furthermore, it was this criticism of appraisal that interviewees frequently used to justify a cynical attitude toward the argument, put forward by the state and NHS management, that Annual Appraisal improves the performance and working conditions of doctors and the quality of NHS service provision (i.e. Department of Health 2001). They felt that appraisal had been unnecessarily forced upon the profession for political reasons, and without adequate consideration of its resource implications. For them it was essentially a ‘knee jerk’ response to recent high profile medical malpractice cases, such as the Harold Shipman case. As Dr Indigo (Physician) argues:
‘Appraisal does not make a blind bit of difference to your average doctor who performing well. And you need to remember that 95% of doctors are doing a very good job. Of the remaining 5%, well, I think they would have been picked up anyway by their colleagues. And I also think that you can say without a doubt that Shipman would not have been picked up by Appraisal. He was a one off, a killer, and he knew how to cover his tracks. You know don’t you that he always got good feedback on his performance from patients? He was well liked by them you see, which is ironic really (laughs). So the question is why was appraisal introduced? So the politicians could appear to be doing something; that is why! You can talk about Shipman and Bristol and the need for good clinical governance, everyone does these days, but at the end of the day it’s about appearing to doing something for political reasons’.
Like Dr Indigo above, it was generally held by interviewees that poor performance would be detected by clinical colleagues ‘at the day to day level on the ward, not in an appraisal meeting’ and furthermore would be dealt with "outside of the appraisal system " (Dr Purple Surgeon). Interviewee’s accounts highlighted that the traditional ‘informal processes’ of the medical club, such as ‘having a quiet word’, were being collegially relied upon to deal with underperformance (Stacey 1992). They were also preferred to more formal approaches such as appraisal. The following comments from Dr Silver (General Practitioner) reinforce this point:
‘I would say that it is pretty much self-evident if you aren’t doing your job properly. And that my colleagues here will quickly say something to me if I don’t do my job right. Because that is what has happened in the past in medicine and it is how we still do things now. Somebody has a quiet word with you and you sort yourself out. And if the problem continues, well, then things may get more formal. But most of the time there is no need’.
When this issue of the preference for ‘informal processes’ by doctors was explored in more detail, it was apparent that in spite of being dismissive of appraisal interviewees recognised that a key outcome of the appraisal process was a formal, individualised, ‘career record’. In short, if a complaint is made, it becomes a matter of ‘appraisal record’. This has negative connotations in terms of career progression. A fact that seemed to reinforce to interviewees’ the need to advocate the use of ‘informal processes’, which are a known feature of the medical club, such as ‘having a quite word’ (Stacey 1992 2000, Allsop 2006). As Dr Burgundy (Surgeon) argues:
‘I think you do have to say you have concerns with a colleague’s ability to do the job if you have them. I just don’t think you should ‘jump the gun’ and do it in such a way that it leaves a ‘black mark’ against their name for the rest of their career. Which is essentially what appraisal can do if, say, you were reported to your clinical director but nothing came of it; well even then it would have to go in your portfolio, and so would be part of your appraisal discussion. So it would be recorded and ‘out there’ for people to see. And I think that is unfair. We all have out bad days, even the best of us, and mistakes and accidents do happen because we deal in risk everyday. You don’t have to be a bad doctor for something adverse to happen and patients to complain’.
Whatever the truth of Dr Burgundy’s assertions regarding the ‘risk laden’ nature of medical work, his argument that a doctor’s failings should not be ‘out there’ as a matter of public record, belie the inherently ‘protectionist’ nature of the medical club (Gladstone 2000).This is because it is undertaken under ‘closed shop’ collegiate conditions. She is concerned that a culture of ‘mutual protectionism’ lingers on within the medical club. Despite protestations by medical elites that things have changed (i.e. Irvine 2003, Catto 2007).
Certainly, the doctors interviewed possessed elitist and exclusory attitudes about doctor appraisal. They shared a propensity to argue that the monitoring of a doctor’s performance was something that should remain within the medical fraternity. Interviewees argued that ‘your appraisal very much depends upon your relationship with your clinical director, if that’s generally good on a day to day level then your actual appraisal meeting usually lasts for as long as it needs to complete and sign all the forms’ (Dr Brown General Practitioner). What is more, they also reported that their appraisers approached the appraisal process as a ‘paper exercise’. They were not concerned with identifying areas of poor performance, but with ‘ensuring I had done all the necessary paperwork so we could get it over with as quickly as possible’ (Dr Pink Physician)
Statements such as Dr Brown’s and Dr Pink’s above, about how their peers approached the appraisal process, support Dame Smith’s arguments that the medical club remains inherently ‘protectionist’ and appraisal fails to protect the general public from underperforming doctors. Furthermore, they reinforce the need for a system of ‘checks and balances’ to collegiate control over medical training and regulation (Slater 2000 2003).
It does seem logical to argue that if poor performance is identified and dealt with; it will be recognised and addressed at an informal level outside of the formal Annual Appraisal process. If a doctor fails to perform in an operating theatre or an outpatient’s clinic, then one can hardly imagine such matters would be ‘put on hold’ by clinical colleagues until they can be addressed at a later point in an appraisal interview. As Dr Orange (Physician) notes:
‘If there is a problem it’s going to be handled immediately and quite informally at first too. Nine times out of ten that will solve it I think’.
Yet it is difficult to imagine that the parents of the children involved in Bristol and Alder Hay, or the family of the victims of Dr Shipman, would agree with interviewees that ‘having a quite word’ ‘off record’ is a satisfactory response when underperformance is identified. They would more than likely argue that such methods have persistently proved to be ineffective in ensuring the public is protected from ‘failing doctors’ (Gladstone 2000, Llyod-Bostock and Hutter 2008). Furthermore, their arguments may appear logical to members of the medical club, but to an outsider it is somewhat surprising to that interviewees argued on one hand that appraisal would not pick up ‘another Shipman’, while on the other hand maintaining that a ‘closed shop’ collegiate approach is the most appropriate regulatory model.This makes it difficult for a member to confront a colleague who is performing poorly (Smith 1995, Irvine 2003 2006). It also goes some way to explaining why ‘informal processes’ were preferred by interviewees, and ‘formal processes’ such as appraisal treated with some caution.
It needs to be noted at this point that doctor’s accounts of Annual Appraisal are just that, accounts. It was not possible to confirm if what interviewees said happened did in fact happen. Additionally, no interviewees admitted to underperforming or knowing of particular instances where underperformance had been addressed within the appraisal process (although they were well aware of instances were underperformance had been dealt with informally). This means that it was not possible to identify rigorously if Annual Appraisal does:
• "Lack depth’, in the context of if it does indeed operate under the cloak of ‘mutual protectionism’ traditionally found in the medical club when problems are identified and have to be addressed by a doctors peers (Waring 2005).
• ‘Lack teeth’, in the context of actually being able to identify underperforming doctors in the first place (Smith 2005).
• ‘Lack follow up’, in the context of the general financial and human resource backing necessarily to ensure appraisal outcomes have a positive impact upon service delivery and doctor performance (Slater 2007).
Investigating such matters would require direct observation of actual appraisal ‘events’, alongside a thorough longitudinal investigation of the concrete effects of the outcomes of appraisal on doctors performance and working conditions. Although the fact is that 46 doctors from different hospitals and general practice surgeries possessed the same experiences and perceptions concerning Annual Appraisal. Which does lend substantial weight to the validity and reliability of this studies finding that, as it currently stands, appraisal does not operate as a thorough evaluation of a doctor’s ‘fitness to practice’ (Smith 2005).
The Appraisal Ritual Outside of the Medical Club
Relevant literature in the public sector, higher education and industry contexts frequently report similar findings to that found by this research (Bruijn 2001, Armstrong 2005). Academic research on the implementation of performance appraisal has long highlighted that ‘for the majority of employees. (the appraisal) interview either did not take place or was of little consequence’ (Pym 1973: 232). For instance, Hill’s (1992) study of academic appraisal found that just 15.3% of respondents agreed that post-appraisal follow-up action had been undertaken. The value of appraisal for individuals and organisations has been questioned due to the fact that there is meagre evidence to support the assertion that staff appraisal improves individual and organisational effectiveness (Meyer 1991, Bruijn 2001). Additionally, it is often argued that for managerial staff performance appraisal is an onerous and time consuming process, which does not deliver what it promises, in terms of productivity, efficiency or accountability (Armstrong 2005). This is frequently due to its human resource and financial implications (Fletcher 1997). Often it is up to individuals to extract what personal benefit they can from the appraisal process. This usually results in their reporting, similar to my interviewees, that it is the fact that they personally took time to prepare for their appraisal, rather than the appraisal interview itself, which helped identify how they are doing in their job, as well as decide what the ‘next steps’ in their career should be (Bruijn 2001). Consequently, it has been argued, ‘if appraisals fail to meet their manifest purpose, they succeed rather as rituals of employment’ (Pym 1973: 233). In the sense that they may appear to be occur ‘on paper’, but in reality a mixture of human resource and financial pressures mean they frequently fail to achieve their manifest purpose of improving individual and organisational effectiveness (Fletcher 1997, Armstrong 2005). The contribution of an organisations ‘working culture’ to this state of affairs also must be recognised. The accounts collected by this research suggest that Annual Appraisal for doctors has been implemented because of a shift in the governing conditions under which ‘medical collegitism’ is practiced (Catto 2006 2007). Yet they also reinforce that it possesses a real propensity to become a ‘ritual of employment’ (Pym 1973). This may be in part due to justifiable doubts concerning its ability to identify underperformance and support change. Clearly human and financial resource factors do impact upon the implementation of Annual Appraisal. However, as the previous section discussed, the ‘exclusory’ and ‘elitist’ nature of organisational culture of the medical club also seemed to stop the appraisal process initially identifying, formally recording and subsequently addressing, underperforming doctors (Smith 2005).
‘Paperwork Compliance’: A Definition
It may appear that doctors are becoming more ‘bureaucratically accountable’ for what they do to their peers, for they must now formally record their decisions and the reasons for them (Harrison and Dowswell 2002). Nevertheless, the data collected shows that this accountability possesses ‘a ritual quality’. In the sense it exists ‘for the sake of appearances’ (Pym 1973, Slater 2002). This can be seen in the adoption of a stance by interviewees toward the completion of portfolio based performance appraisal, defined as ‘paperwork compliance’.
The concept of ‘paperwork compliance’ was generated from interviewees’ accounts of how portfolio based performance appraisal was undertaken, especially how they approach trainee supervision and assessment during clinical placements. Interviewee’s accounts of their own appraisal experiences highlighted the ritual nature of the conduct of portfolio based performance appraisal within the medical club. Consequently, they did play a significant part in the development of this construct. Certainly, doctor’s accounts of how their appraisers approached Annual Appraisal in a ‘paper filling’ ‘tick box’ manner means that ‘paperwork compliance’ may be present in the Annual Appraisal context too. However, verification of this fact would require that the doctors involved as appraisers in Annual Appraisal were interviewed to identify if they adopt this stance when conducting appraisals. This task was outside of the aims of this research, which investigated ‘rank and file’ practitioner’s experiences of portfolio based performance appraisal.
‘Paperwork compliance’ exists when the paperwork completion requirements of appraisal are fulfilled, with relevant sections of a portfolio completed and an appraisee ‘signed off’ by their appraiser as either having meet minimum performance criteria or not. However, though the paperwork has been completed, the technical aspects of the appraisal procedures have not been adhered to by the appraiser, that is past a highly superficial ‘tick box’, ‘paper filling’, level. The following comments from Dr Lime (Physician) encapsulate ‘paperwork compliance’ succinctly:
‘Its like this, you fill in the forms in a workmanlike ‘doting the I’s and crossing the T’s', fashion. But its all for the look of the thing. It doesn’t mean that you actually have done what you are meant to have done, or for that matter believe in what you have written past a very superficial level. You see, you tend to ‘bend’ the paperwork because you have checked out that everything is OK your own way. So you are just complying with the bureaucratic need to get the paperwork done, and that’s all really’.
Stated in formal terms, ‘paperwork compliance’ gives the impression that an appraisee has been appraised using collegially agreed minimum performance standards. These have been predefined with regards to occupational specific knowledge, skills and attitudinal ‘competency domains’. Yet, in reality these have played a superficial role in helping an appraiser form an opinion in regards to: a) Which tasks an appraisee should undertake and be assessed in to be defined as ‘competent’ at a level appropriate to their career level (i.e. compare a final year medical student and a senior house officer). b) The level of proficiency possessed by an appraisee about these tasks. As this section of the topic will now discuss, this is because medicine possesses a high level of ‘indetermination’ within the indetermination/technicality ratio, which forms the basis of its expertise (Jamous and Peloille 1970).
Sociologists have argued that as a profession, medicine possesses a particularly high ratio of indetermination/technicality (Turner 1995).This refers to publicly available ‘techniques and procedures’ and private and personal ‘rules of thumb’. The explicit ‘technical mode of knowledge’ can be expressed as a precise list of unambiguous specifications. This is unlike the implicit ‘indeterminate mode of knowledge’, which remains imprecise, ineffable and only graspable through the acquisition of personal insight. It is always therefore bound up with the personal career biography of a practitioner. The ‘technicality’ and ‘indeterminate’ elements of occupational expertise share in common that a trainee acquires them by observing and following ‘the example’ of a more experienced practitioner. But in the final analysis, the ‘indeterminate’ elements can only be ‘picked up’ by a trainee through the acquisition of direct personal experience (Bosk 1979). In Jamous and Peloille’s (1970) terminology, indeterminate knowledge is located in personal attributes (or ‘virtualities’ as they call them) of its producer herself. The producer is the ‘owner’ of their means of production and reproduction, rather than simply a user of them This is why sociological accounts of medical education highlight how practitioners reinforce trainees need to maximize ‘exposure’ and gain as much clinical experience as possible during clinical placements (Sinclair 1997). Furthermore, these accounts highlight that an experienced doctor’s ‘clinical acumen’ is used to ‘trump’ formal academic knowledge and ‘best evidenced’ clinical guidelines (Bosk 1979, Harrison 2004). In effect, this ‘trumping’ happens within the portfolio appraisal process, causing ‘paperwork compliance’.Armstrong found that the GPs he interviewed asserted the need to exercise personal judgment during doctor-patient encounters due to the ‘indeterminate’ aspects of their expertise, and furthermore, they did so in the face of the ‘technicality’ being promoted by medical elites operating in ‘the guideline industry’ and producing clinical protocols and evidenced based guidelines.
In summary, ‘paperwork compliance’ occurs the doctor as appraiser ‘trumps’ with their personal ‘clinical acumen’ the formal ‘technicality’ bound up with portfolio based performance appraisal. As the topic will demonstrate, she succeeds in doing so because of structural factors within the clinical training context and a cultural tendency within the medical club to reinforce, first, the need for a clinician to rely upon her ‘gut feeling’ when making a professional judgment, and second, the need for one club member to respect another’s clinical expertise and right to independent practice, as long as this remains within acceptable ‘club limits’ (Freidson 1970, Stacey 2000). As Watkins (1987: 21) rightly notes ‘the medical profession is organised along the principle that once you have ensured that people conform loyally to the right ideas you can allow them a considerable degree of independence of action’.
The concept of ‘paperwork compliance’ was prevalent within interviewee’s accounts of portfolio based performance appraisal for medical students and junior doctors. The next section of the topic will discuss this issue.
