David Zigmond: Competence or compliance? The corrosive cost of professional practitioner appraisals

david_zigmond2Current appraisal systems sacrifice more of value than they can assure. Clarifying why and how this happens gives us wider insights into our ill faring welfare systems.

“The more laws, the less justice”
German Proverb

Some healthcare management axioms seem incontestable: all our healthcarers should have a good standard of human and technical competence; these should then be held within a firm frame of moral probity. Therefore we need systems for professional appraisals, then validation.

Such is the easy rhetoric, but the meaningful implementation is proving much trickier. Generally, only those who administer the current appraisal system talk with conviction about its relevance or validity: the captive practitioners talk instead of obstructive rituals of submission, of unwisely prescriptive authority, and of a growing culture of forensic mistrust, even pre-emption.

This is not what was intended. What has happened and why? This decade spanning portrait may clarify.

2005: An early appraisal
I was asked some sensible questions about my practice, attitudes, and coping strategies on a paper form, which I completed in careful free text, writing with a favourite fountain pen. What was required was not tediously long or complex: my experience was meditative and calmly satisfying. Contact with my appraiser, Dr C, was similar. Dr C liked my idea of joining me in a morning surgery: she sat with unobtrusive but close attention as I encountered a wide range of human, administrative, and biotechnical problems.

Later, over a light lunch, we discussed her observations and her many thoughtful questions. Satisfied quickly with my more administrative and biomechanical skills, we were able to linger with searching dialogue in healthcare’s often troubled thickets: how do I maintain my mojo and my interest over so many years? How do I deal with the many people whose needs are opaque or intractable? What is my way of expressing or resolving conflict? When do I turn to guidance or instruction? With whom?

I liked this appraisal: we generated and sustained a dialogue that was collegial and discriminating. Through this I sensed that the nature of my practice, and myself as a practitioner, were sharply but imaginatively perceived and understood. “Thank you,” she had said on leaving, “it has been very interesting seeing how you approach these problems. You have given me much to think about in my own practice too.”

Yet such human discrimination was too intelligently fragile to survive, and Dr C’s professional discernment has been perceived as too risky by some in government. Therefore we must devise processes that can be procedurally rolled out and which will eliminate the vagaries of personal discrimination.

In the past 10 years, administrators, academics, and management consultants have all refined our new Shibboleths of systemisation and standardisation. Such mandates can then vaunt a comprehensiveness that assures the system is fail safe. To keep all this on track requires elaborate computer systems: these become the automated executives—to specify, prescribe, and monitor compliance from all.

Such mass management is certainly achieving compliance of a kind. More certain are the financial costs. Is this worthwhile? And are there other, more serious, costs?

2015: A contemporary appraisal
By now the civic engineers and their administrators have implemented our more extensive, comprehensive, and standardised system. In general practice it is called an “Appraisal Toolkit”—a term that implies a depersonalised world of defined and atomised tasks, all subsumed to a master plan.

Entering this Cyberland makes explicit the many tasks for submission. Dozens of boxes require answers in a form of electronic interrogation. There are systems of quantification for diarised professional and educational meetings and study time. Rigid formats ensure “correct” plans for professional development and patient complaints.

This mandated system of thinking and responding is very different from my long modi operandi: I have never had such development or study plans or diaries. Despite (I think because of) my professional self-motivation and autonomy, I have had an exemplary professional record as a frontline practitioner. For several decades I have had negligible contention with patients, consistently high satisfaction rates, and an esteemed creative academic output. Is this not substantial in vivo evidence of my competence, to learn and to do?

I ask Dr L, my new appraiser, if he will join me in a surgery session, to sample such evidence. He demurs, explaining that we must stick to the Toolkit format: improvisation is forbidden.

This seems to me a madness of abstraction: the system is not interested in what I do only what I say about what I do—self-constructed statements.

Dr L answers as the system’s apologist. He does not make the rules and nor do I. We must be wise enough to know when to be quiet. Then the increasingly frequent and fatalistic refrain of obedience: “Just do it; we’ve all got to. That’s the way it is.”

I cannot accept this. I need to ask Dr L how it is that we’ve become so passively compliant, so impoverished of autonomous spirit and intellect as a profession? My question is rhetorical, but Dr L’s answer is more interesting.

He draws a percipient sketch of our recent evolution and predicament: we have all become more nervous and mistrustful. So everyone is trying to stop or prevent bad things happening—or at least make gestures to pass muster. So, the public look to the politicians, who turn to planners and experts, who prod executive bodies, who then have to micromanage the practitioners . . . And here we are!

Where is that?

Our welfare services are being stymied in an unprecedented way by low morale, dissatisfaction, wearied antipathy, and alienation.

The perverse evolution of our professional appraisals is a microcosm of what has happened and why. Smaller still, my discourse with Dr L is like a biopsy: it bespeaks risks and loss far beyond.

David Zigmond is a GP in London.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.

  • Dr Kishor Vasant

    GP Appraisal have evolved since 2004. Early appraisals were less structured and obviously more flexible. Current appraisals use electronic online tools, and although reasonably flexible do not really allow sitting in consultations and having long conversations over dinner. What is more worrying is that Dr Zigmond seems to questioning the probity of all appraisers and those GPs who have successfully taken part in GP appraisal over the last 10 years. I am sure this was unintentional. It appears that he has a problem with the current appraisal system in general and his GP appraiser in particular. It would be more useful if he could make constructive suggestions to improve the online toolkit. Does he know that he can in fact request a change to a different appraiser?
    Many thanks to Dr Zigmond for starting this blog.

  • David Zigmond

    I am grateful for Dr Kishor Vasant’s response to my article. In his
    brief blog he makes several points: each indicates well the complexity of our problem.

    1. He refers to ‘electronic online tools [of Appraisal being] reasonably flexible.’

    But reasonable to whom?

    My argument is the reverse: it is that the elaboration of the complex
    electronic Appraisal Toolkit has become incrementally more burdensomely inflexible – more procedural and densely packed. The consequence is an increasing abstraction from the very realities we are trying to address. Even if this is administratively expedient it loses our human sense and sensibility with the appraised – the procedure’s yield degrades to the officious: desiccated shells of compliance, not intelligent views of competence.

    A mandatory and itemised questionnaire tells us something very different from a candid, colleagueial dialogue. A proffered answer is not a conversation.

    2. He refers to my ‘seeming to be questioning the probity of all appraisers …’

    I am sorry that I have not been clearer, and thus have been misconstrued. My position is very different and rather more serious: any doubt and antipathy have never been personal. All my Appraisers have been personally courteous and diplomatically helpful – but year on year I have seen how the evolving electronic system of interrogation and task-setting has reduced their latitude to make wise discriminations. So it is that we have lost our more authentic and fruitful dialogues: ‘I know it makes no sense, but just do it … we’ve all got to’ has actually been said to me, and on more than one occasion.

    So, I have no personal criticism of Appraisers, but I do have very substantial critique of the system – the Appraisal Toolkit – that has become so cumbersomely hegemonic. Good individuals are inevitably compromised by bad systems – that is one definition of a bad system. In these we all become victims, perpetrators or bystanders … or opponents. The last is a more autonomous but hazardous choice, and one I am making now.

    3. He asks if a different Appraiser would help?

    No. Changing my Appraiser merely parries the more important problem. I am instead urging direct and candid debate about the unintended consequences of this kind of formulaic, electronic human processing: Technototalitarianism. (Edward: Shot in His Own Interest:
    Technototalitarianism and the fragility of the therapeutic dance. Journal of Holistic Healthcare Volume 2, issue 4, November 2005).

    For those of us not yet in serious trouble, we need something much lighter, leaner and more humanly responsive; more dextrous and intelligently discriminating.

    It is the loss of such interchanges – our dumbing down – that is seriously devitalising and stupefying our profession now. Electronically mediated Appraisals are instrumental to this.

    4. Lastly. his appeal for ‘useful constructive suggestions’.

    Yes, I have many – but they are about restoring our live and difficult human discourses, not replacing them by ever-expanding procedures of electronic informatics and control.

    Encouragingly, this exchange could be one small step in that direction.