This paper is a personal reflection about making appraisal more challenging and therefore hopefully more effective.
Typically as with most things in medicine there will be no easy answers here nor didactic methods of approach but more an exploration of themes around challenge and the forms it might take.
I hope the paper might stimulate discussion around this area and perhaps be taken up for a work group at an appraisal study day. This would certainly help my own personal development. I feel that there are likely to be lessons that can be shared with educationalists so hopefully this paper may also be of interest to GP trainers.
The impetus for this paper came from feedback from recent appraisals where two appraisees felt the process had not been as challenging as they had expected. After personal reflection I wondered whether this was a good thing…..or not!
To give structure to this issue I have broken down challenge into six areas and will consider these in turn. Each area relates to where challenge might be considered to originate. These areas are:
- External Indirect
- External Direct
- Post Appraisal Reflective
I think the main areas of appraiser importance for me personally are areas 3) to 6).
External indirect challenge
By this I mean challenge that has been set by external agencies such as Government or local Care Trusts. For example the new GMS contract introduced the QOF of care. The QOF criteria are largely evidence-based and address both clinical and non-clinical practice performance. It follows that a practice can examine their QOF figures and identify areas of need. The challenge to the practice and therefore the individuals within the team is how to address these areas and how the relevant tasks can be built into both Practice and Personal Plans. It would therefore seem reasonable that these areas might be explored during the appraisal and how the development of strategies might follow.
External direct challenge
This refers to an external challenge where a doctor needs to respond to criteria and requirements set by outside agencies. These may be considered similar to summative type assessments that a registrar faces. At the present time for GP’s this may include compulsory training in areas such as Child Protection or Resuscitation and applies whether they are developmental needs or not. In the future it may include Revalidation if the final package is appraisal-based but that is beyond the scope of this paper.
This refers to Team and Individual needs being recognized by processes occurring within the practice. At a basic level this might include dealing with complaints which can highlight a variety of needs .Within more evolved practices internal challenge could arise from clinical audit, detailed significant event analysis or perhaps 360 degrees feedback. The appraiser could encourage and explore these types of initiatives during the interview and point the way for additional resources where required.
This is an extremely important area and refers to a GP’s personal drive to improve and to respond to challenges set individually. Personal needs may be identified by reflection, log diaries, discomfort logs etc. I guess this is an important part of all our own individual make-ups but the intensity of personal drive will differ from GP to GP.
Ideally the preparation for appraisal (ie Form 3’s) will be part of this reflective process. Hopefully this will be further demonstrated in a doctor’s developmental files.
What should the appraiser do to promote this? We should probably identify whether this process does occur and it may be occurring even if it doesn’t appear on the forms or in files. The next challenge is in firstly trying to encourage this process further and secondly to ensure effective recording that the process is taking place. Perhaps this is one key area for further work!
Challenge set by the appraiser
The appraiser can try and assess an individual team’s and doctors responses to challenges in each of the above areas and encourage reflection, action and recording. Tasks identified might form part of a doctor’s next PDP. The appraiser needs to consider how to approach areas which have not obviously been addressed. We might be able to identify some areas for consideration through the Form 3’s and development files before the interview. We have time to plan how to approach these in a constructive, positive way rather than implying criticism which might put a doctor on the defensive. Ideally ideas for development should be learner-centred (ie come from the appraisee themselves) and the appraiser simply facilitates this process. Gentle probing with generalized open questions may be necessary to explore certain areas e.g in the section about working with colleagues: “What do you think your partners think are your strengths?”
Other areas may only become transparent during the interview. These can really test the skills of the appraiser. The appraiser needs to be quick-witted enough to think on their
feet and be flexible to adjust to unexpected needs. Strategies to cope with the unpredictable are needed. There may be appropriate comparisons here with the doctor-patent consultation when we just don’t know what is coming next!
Perhaps this another area for further work and a group could use role play for example to look at real problems experienced during appraisals.
I am not sure whether other people are the same as me! Some doctors appear to think incredibly intelligently on their feet and come out with smart, strong ideas and initiatives. For me ideas come late and slow and for some perverse reason seem to occur at some ridiculous time in the night! The same applies to the appraisal process. I seem to generate ideas and thoughts after the interview and wished I had thought of these at the time. Likewise the appraisee may be reflecting on the same discussion and formulating different ideas. The appraisal report can be used to explore and further develop these ideas but I feel this should be explicit within the report. The opportunity to share, amend and even further develop the report is important here.
On a final note regarding challenge; if the appraisal has been thought-provoking and causes both the appraisee and the appraiser to go home and reflect in depth then I think the process has been ultimately successful and very worthwhile.