Underperforming Doctors

Personal and professional development for general practitioners is nothing new but has become much higher profile with a much greater focus on audit, significant event analysis, personal development plans and reflective practice. This provides an opportunity to build on traditional values of patient care as well as learning from and supporting colleagues. Regular appraisal of doctors and the evolving process of reaccreditation should provide a vehicle for earlier detection of problems and provision of appropriate support for doctors when needed.

The concept of under-performing will inevitably raise concerns and controversy. Some cases will be clear cut and need to be addressed quickly to protect patient safety. However there are a number of situations in which qualitative assessment can be dismissed as being subjective and invalid. Quantitative assessment (e.g. not reaching quality targets) can also be dismissed as being as much due to practice (e.g. computer problems) and secondary care resources and not a reflection on the individual doctor. There is also a clear link between the health and well-being of a doctor with the organisation in which they work.¹

All doctors under-perform at times - we are all human! Rather than entering into a very personal vicious cycle of guilt, deep negative self analysis and criticism and deepening self doubt; use the mechanism of critical case analysis to openly share cases where we have under-performed in a protective group environment within the practice. Having regular monthly meetings with practitioners all contributing their mistakes or "near misses" of varying severity means that the environment is less threatening - and all should welcome the opportunity to learn from the mistakes of others. Try and identify why things went wrong but focus "what could be done to make it better, or prevent a recurrence" - thus identifying learning needs which can direct future individual or practice learning events.

The causes of a doctor to under-perform cover a range of very different problems, e.g.:

• Personal:
  • Poor training for general practice
  • Lack of continuing education
  • Isolation from colleagues
  • Physical health problems
  • Mental health problems including alcohol and drug abuse
  • Stress related to work or domestic situations
  • Low morale
  • Burnout
  • Excessive workload
• Practice:
  • Poor practice infrastructure
  • Poor relationships within the practice
  • Poor premises and facilities
  • Financial pressures
  • Inadequate staffing levels

When you discover a colleague has under-performed, it is important to discuss with him/her your concerns at the earliest opportunity, but in as sensitive and supportive manner as possible - you might suggest the doctor presents the case at the next significant event meeting so he can share the problem and get some fresh ideas - perhaps the practice policy or protocol needs changing etc.. It is very often an enormous relief for the doctor to discuss difficulties and, whatever other actions are required, the provision of support for the doctor has to be in the best interests of the doctor, practice and patients.

This is fine if the doctor is aware of their under-performance. It can be extremely difficult if the doctor concerned has no insight or is not willing to co-operate or share his problems. Doctors have an obligation to work with colleagues to monitor and maintain the quality of the care provided and maintain a high awareness of patient safety. This includes not only direct patient care but also taking part in regular audit, responding constructively to the outcome of reviews, appraisals and significant event audit in order to help reduce risk to patients.

We must protect patients from the risk of harm posed by another doctor's, or other health care professional's, conduct, performance or health. Where there are serious concerns about a colleague's performance, health or conduct, it is essential that steps are taken without delay to investigate the concerns, to establish whether they are well-founded, and to protect patients. If there are reasons to believe that a doctor or other health care professional may be putting patients at risk, this must be discussed with an appropriate person from the employing authority, such as the medical director of the PCT or an officer of the Local Medical Committee. It is always a good idea to get advice from an impartial colleague or contact a defence body, a professional organisation or the General Medical Council. Who to contact will depend on the nature and degree of concern.