Underperformance of Doctors - Dr Graham Emblen

​So you have been asked to see someone who you believe (or someone else believes) is not up to scratch in the way they are functioning as a doctor. How do you approach this situation?
 
It can be one of the hardest parts of being a medical educator, and also one of the most rewarding. To be able to be effective in this area, there are a couple of things I believe you need. They are

1. A diagnostic framework. That is a way of deciding where the problem lies in this doctors performance.
2. A sense of curiosity.
3. An approach with compassion.
4. Recognition of the importance of the work you need to do.

I am going to discuss these in the reverse order as if we forget 2-4 we can significantly reduce our effectiveness.
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Recognition of the importance of the work you need to do.
A doctor who is underperforming is one that can have significant impact on many people’s lives. Everyone they see is someone else’s mother/ father/ sister/ brother/child. They are all part of our community who deserve the best in health care. They deserve the best in health care they can receive. Failing to identify and support the doctor in improving means we are potentially committing that doctor’s patients to substandard care for the rest of that doctors career.
An approach of Compassion.
I believe that very few people get up in the morning and say “I am going to do a bad job today”. Most people approach their work with at least an intention to do things well. Most doctors who are underperforming want to do better. They may be unaware of what they are doing or aware but not sure how to change.
This does not mean that we do not confront the person about their underperformance. An approach I have learnt to use over many years uses a term coined in a book by an American Paediatric Oncologist called “The anatomy of a lie” She used the word “carefrontation”- which is confrontation with care. You are challenging this doctor because you care about them and their patients, and so it is done with the intention to help.
A sense of Curiosity
We have heard the term “premature closure” in consultations. We can do the same when considering underperforming doctors. We have identified our pet problem doctors have, so that is the only problem they may have. Or this is the only thing we know how to fix, so that is the problem we will tackle. If you only have a hammer, then everything is a nail.
Approaching the problem with curiosity, trying to understand what is going on here and considering as many possibilities or options that could be part of the problem helps in supporting the doctor toward change.
A diagnostic framework.
Below is a framework I have progressively modified over the years. I use if because it leads me into considering the best approach to remediation.
 
This model considers core areas that impact on performance. Each of the areas may overlap and interact. Your role is to work out where the greatest point of leverage or point of influence may be.  

1.  Foundations for learning

These are the fundamentals someone needs to have to learn. Without these, it is going to be very hard work for someone to improve. I have found that in particular, self awareness, awareness of context and ability to learn from experience are critical and can be hard to change. It is possible, but will take a lot of effort from both sides involved. Interpersonal skills can be learnt. I am not so sure about how people learn common sense, which seems to be not so common.
Knowledge.
This is a common area we blame for underperformance. We all have to have a background base knowledge level to function as a doctor. There is a significant level of assumed knowledge in all doctors. There will be some that have missed some core knowledge areas that can influence their performance. Often these are attempted to be hidden through embarrassment and so they need to be looked for in doctors who are not performing.
 
As an educator, our role is not to make the person learn, but to help them find the most effective and efficient way to learn as well as guidance on what they need to learn. 
 
Skills.
These are the individual behaviors that the doctor has to perform to be able to act out their roles in a meaningful and effective way. These are not just physical skills such as suturing and taking a blood pressure, but also communication skills and clinical reasoning skills. These are better observed by watching the doctor perform in their work, rather than self-reporting by the doctor. If they are deficient then we have to decide if this as a result of lack of the skill, lack of knowledge about the skills or is it that they don’t have a good role model to see how the skills are meant to work. If they have the skill but are not using it, is this because they do not perceive this as being valuable or part of their role or are they not motivated to use it, or do they not have the confidence to use the skill.
 
Both knowledge and skills are areas that can be taught and learnt by anyone who has the pre-requisites for learning. Specific strategies are available for each different skill.
 
Professionalism: Roles
These are the clusters of behaviours that are expected to be learnt and used in the activity of being a GP. These include being a learner, a communicator, a diagnostician, an educator and others.
Difficulties arise when: -

• there is uncertainty in what their role is meant to be. This can commonly occur when changing from PGY2 to the first GP terms.

• there is conflict between expected roles within the job or between roles within the job and outside, e.g. when expected to provide after hours cover and the role as a parent.
• there is too much rigidity in the roles. The supervisor may have very strict expectations of how the doctor is expected to perform within their practice.
• there is too much flexibility in the roles. There may be no guidance at all in the way a doctor is expected to act or respond in the work situations.
• there is a lack of role commitment. The doctor does not believe that this is an appropriate role to take on. They may think that being a listener is not a valuable or reasonable role to perform as a GP.

 
Interventions in relation to roles initially involve role clarification, or assistance in role conflicts. Where motivation is high, this can be a very rewarding area to work, as often dramatic change can be observed.
 
Professionalism: Attitudes and Motivation
This is the value placed on the activity and the behaviour by the doctor. How interested are they in working and behaving in the way they are being directed to. This is influenced by their belief in the value of the activity as well as by their confidence in their ability to carry the behaviour through. A doctor who is unmotivated will either openly reject your approaches or accept information with a tacit acceptance but with no intention of using the information.
 
If this is the principal area driving poor performance, approaches used in motivational interviewing and behavior change become important, as this is in essence what we are seeking this doctor to do.
 
Personality, Cultural Traits, Talents.
These are the more inherent components of the person that influence their behaviour. They are things that they are born with, or develop as a result of their upbringing from family styles or cultural factors. This is the place where personality disorders may become evident. They tend to be less amenable to change. However this should not be a first label to apply. Other areas should be explored before attributing the difficult to this area.
 
Systems.
This is the structure in which we practice as a doctor. The computers used, the MBS, PBS, set-up of the practice and the systems and protocols that the practice uses to operate. There may be problems in this area that cause a doctor to underperform. There may be a lack of understanding about how the system works in a particular practice, or the system itself may be inappropriate or broken resulting in problems.
 
As you may recognise, if this is the principal area, work may need to begin with the system around the doctor before on the doctor themselves.
 
Health of individual and family.
This important component needs to be always considered. The physical and mental health of the doctor and their family may have major ramifications in ability to perform and ability to change. If the doctor is suffering from some significant underlying emotional or physical illness then there performance will be significantly reduced. Also if the doctor has a significant family problem then this will impact on their performance. Acting on the other areas without identifying this area will result in sub-optimal change.
 
All of the above factors interact to varying extents, hence the overlapping diagram. You may identify difficulties in a number of areas. Your approach then is to consider what are the priority areas and where might I have the greatest point of leverage, or the greatest potential impact. Also it is important to note that what is perceived to be a primary area may change through a remediation process, as with your curiosity, you discover other factors you were unaware of, or placed less value on in your initial assessment. Thus this process of assessment needs to be repeated as any remediation or support activities are instituted.
 
Next steps after diagnosis
Making a diagnosis is not the end of the assistance we need to provide to an underperforming doctor. To reinforce a point, the diagnostic framework used links to the different categories of interventions that could be implemented.
To put it simply
Knowledge: Strategies that enhance knowledge including learning styles, wrote learning, and relevant study techniques
Skills: Skills training processes with demonstration, and rehearsal
Systems: review of the systems to see if they are appropriate, understood or need modification
Doctor and family health: requires external assessment and support
Professionalism: this needs to use the skills in motivational interviewing and behaviour change.
Personality, Cultural Traits, Talents: These may require a greater understanding and an assessment of whether there is the ability to influence or change these behaviours. Cultural awareness and cultural training may help. Self-awareness and awareness of context become critical for improvement in this area.
 
Sometimes we may feel we have to find the one solution to a problem. It is like finding the man in the picture below. 

This may give you satisfaction, but will limit your consideration of the multiple and interacting factors that contribute to underperformance. Your role is to identify the range of factors and then identify the ones you can influence, choosing the ones that have the greatest point of leverage or impact on the presenting problem.
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The work is often not easy. It is though very important, for that doctor and for all the patients they see for the rest of their career.