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APPRAISAL APPRAISED

By Hamish McLaren
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

All my life, I've hated forms. I hate their enforced circumscription, their prying, their imposition upon us of a particular philosophical outlook, their templating of information in a particular way. I have a deep suspicion of any form that requires an accompanying booklet of guidelines on how to fill it in. This suggests to me that behind the form lies the burgeoning bureaucracy of a huge industry whose sole purpose is to ensure the propagation and the dissemination of the form.

I hate the obtuseness of forms, their obfuscation, their impenetrability. And I don't think it's me. I make no claim to be an intellectual giant, but I've got three university degrees and membership of two medical colleges - I only mention it to make the point that I've been educated, excruciatingly, to breaking point. I hate the expression "can't get my head round" (- "it's doing my head in doc!" -) but for once I will use it: I can't get my head round these bloody forms.

What forms? GP Scot 1, GP Scot 1.4, GP Scot 1.6a, GP Scot 1.6b, GP Scot 2,

GP Scot 2.2, GP Scot 2.3, GP Scot 3a, GP Scot 3b, GP Scot 4, GP Scot 5a,

GP Scot 5b

I had better come clean: I was about to say that I am an appraiser manqué, but that is not strictly accurate. I was an appraiser for a year. I stopped at the end of March. I am an appraiser perdu. And it was the form-filling that lost me.

I want to be careful here. The prospect of somebody pulling out of a project and then proceeding to bad-mouth it is not attractive. I enjoyed appraisal. I enjoyed the training and the subsequent work. I made friendships, learned a lot, and for the most part was tremendously impressed by the work of my appraisees.

But...

You can tell there's a "but".

I have to ask what it is that appraisal achieves. An academic general practitioner recently told me that he had carried out a competency review on a doctor who thought that warfarin was an antihypertensive agent, and that the INR was an index of the degree to which the blood pressure was controlled. My comment was that this man could not possibly have been a doctor. He must have been an impostor. He had never been to Medical School, and nobody had bothered to check his references. We all have lacunae in our knowledge, but, with respect to the warfarin, this particular gap surely extended to the horizon and indicated a global ignorance and incompetence. And I wondered, if I had been this man's appraiser, would I have rumbled him?

For it is possible to fill in the forms, and even to talk round the forms, without knowing any medicine. They are an import into medicine from the theoretical world of education. Personal development plans are all the rage in our universities. Every student and every teacher must have one. Well, we must be careful where we import our ideas from. It is surely the worst kept secret in the land that education is in crisis, that while our political masters trumpet the phenomenal success of school-leavers' exam pass rates, our university lecturers wring their hands in dismay at the lack of basic literacy and numeracy skills of each new student intake.

I don't believe any of my patients could care less whether I have a PDP or not. They want to know that when they come to see me, I will treat them with respect, courtesy, and kindness. I will not try to harm them, cheat them, or abuse them. Instead, I will offer them a consultation. I will take a careful history, and carry out such examination and investigation as to render a diagnosis, or differential diagnosis, upon whose basis I can offer a treatment or management plan that my medical peers would not regard as eccentric. I will be prepared to discuss with my patients the risks and benefits of the proposed treatment. My patients won't expect me to know all the answers, but will expect me to know when I am out of my depth and when it is necessary to seek specialist advice from colleagues. And that about sums it up.

General Practice is a discipline peculiarly amenable to quality control by virtue of the fact that all general practitioners essentially do the same thing. Our modus operandi is the medical consultation. We may have other interests, in minor surgery, occupational medicine, mental health, and a host of others, but our core business remains the same. We see patients. Surely the best way to demonstrate that I can carry out a medical consultation of an acceptable standard is to do just that - to demonstrate it. A guru or two from the college - and I would place this business firmly in the hands of the college - could sit in on my morning surgery and just watch. Afterwards we could sit down with the patient records and talk about - well, anything really, from the management of asthma and hypertension and depression and the febrile child to the appalling condition of my handwriting, my reluctance to spend too much time in front of a computer screen, and the existence of some annoying behavioural tic I'm not yet aware of. We could even go out on a couple of home visits.

I'm sure my performance would be far from perfect and no doubt the college representatives would suggest, perhaps even insist, that I brush up on some areas. I think I would be keyed up for the occasion, but it is after all what I do, and I - and most of my fellow GPs - have been sufficiently bloodied by undergraduate and postgraduate exams in the past that the occasion would pose no real threat.

As a means of appraisal it would be simple to understand, simple to organize, and, I suspect, relatively inexpensive. It would be effective. I don't think the man who didn't know what warfarin did would last five minutes.

And, most of all, it would make sense to the public.

But I can't see it happening. Frankly, it's too simple. We seem to have lost our taste for simplicity. Instead, we bury ourselves in the morass of the GP Scot forms. A friend of mine, a Lothian GP, who once remarked that he thought the best form for a GP appraisal would be a blank sheet of paper, has just been informed that due to financial constraints he and his colleagues will not be appraised this year. Not to worry, the Trust has said. Your revalidation will not be jeopardized as a result of this.

That's a strange reassurance. Imagine an airline company saying to its pilots, "Due to financial constraints, you don't need to be checked out on the simulator this year. But don't worry, your licence will not be jeopardized." Do you imagine that, if they knew, confidence and moral would be high among the airline's passengers?

Other online articles by Hamish MacLaren can be found at:
hoolet edition 50 - Pilchard
hoolet edition 49 - Truth or Dare?
hoolet edition 48 - Zeitgeist
hoolet edition 47 - Appraisal Appraised
hoolet edition 45 - Truth or Dare?
hoolet edition 44 - Reverie in a Sauna
hoolet edition 43 - Bump Up
hoolet edition 41 - Mayhem, Clock and Anti
hoolet edition 40 - Christmas Night on Call

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.