Understanding Doctors' Performance

Abstract

This book is a scholarly and concise review of the evidence so far. This shows a disturbing picture of committed professionals experiencing disproportionate stress and failure in a hostile workplace. The book is short, well written and authoritative. Many chapters are a model of the painstaking evaluation of evidence. Particularly useful are those on stress and depression (including some reference to organisational causes), the psychological factors linked to performance and the account of workload, sleep loss and shift work. Perhaps not surprisingly in a first edition, it has not ventured into detailed consideration about the defects in training and organisation that have produced such a challenging workplace and poor record of caring for the vulnerable employee. There is evidence that working for the NHS carries a higher risk of personal stress and failure than other British institutions and that depression and suicide are uncomfortably common especially in women. This is of particular concern at a time when the feminisation of the work-force proceeds apace and our dependence on women in medicine is growing and irreversible. It is perhaps most worrying that the book leaves us with the clear impression that a profession that should be most focused on the care of others has developed a culture in which the way that doctors treat their colleagues leaves so much room for improvement. There are serious concerns here about the nature of true professionalism because of the well-documented prevalence of interpersonal disputes, ineffective team-working, bullying and harassment. Recent work by the General Medical Council, royal colleges, the National Clinical Assessment Service and deaneries has shown that the general levels of skill and understanding required by consultant surgeons, trainers and trusts are worryingly low. There are serious implications here for patient safety not only because of individual failure but because those failures put vulnerable patients at even greater risk. Since the events at Bristol more than a decade ago, much has been learned about doctors' performance but much less about the causes and opportunities for improvement. Like other industries, about 6% of the work-force will show significant performance concerns in any one year but health professionals are particularly at risk because of the sensitivity of their work, the variety of problems they face and the poor standard of support in the NHS today. Repeatedly, the key features of dysfunctional NHS practice are brought into focus. These include the illusion of independent practice and the inappropriate dependence on trainees to provide the service. We should be concerned that, after many years of training, surgical consultants often lack the skills to develop effective team-working and leadership. Overall, therefore, the book raises more questions than it answers. Perhaps the most important of these is why so little of the effort that has been directed to exposing poor performance and its management has been redirected to improving the chaotic and arbitrary environment in which so many doctors have to work. This book is strong on symptoms. I hope that the next edition will also look at the underlying political and organisational causes and the opportunities for improvement.