Understanding

Doctors’
Performance
EDITED BY

JIM COX •JENNIFER KING • ALLEN HUTCHINSON • PAULINE McAVOY

Published in association with the National Clinical Assessment Service of the National Patient Safety Agency
Understanding Doctors’
Performance

Edited by

Jim Cox
Lead Assessor and Trainer, General Medical Council performance procedures Former Associate Director (Assessment
Development),
National Clinical Assessment Authority
Medical Director, Cumbria Ambulance Service NHS Trust

Jennifer King
Chartered Psychologist
Managing Director, Edgecumbe Consulting Group

Allen Hutchinson
Head of Section of Public Health ScHARR, University of Sheffield

and

Pauline McAvoy
Associate Director (Assessment Development),
National Oinical Assessment Service of the National Patient Safety Agency

Radcliffe
Publishing
Oxford • Seattle

F60T-X0S-QST9

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Radcliffe Publishing Ltd
18 Marcham Road Abingdon Oxon 0X14 1AA United Kingdom
www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.

© 2006 Jim Cox, Jennifer King, Allen Hutchinson and Pauline McAvoy Reprinted2006
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise without the prior permission of the copyright owner.
British Library Cataloguing in Publication Data A catalogue record for this book is available

from the British Library.

ISBN 1 85775 766 1

Typeset by Advance Typesetting Ltd, Oxford

Printed and bound by TJ International Ltd, Padstow, Cornwall
 About the editors
List of contributors iv V
Acknowledgements vi

Introduction 1

1 The impact of health on performance John Harrison and John

Sterland __ 4

2 A perspective on stress and depression Jenny Firth-Cozens 22

3 Misuse of drugs and alcohol Hamid Ghodse and Susanna Galea ___ 3&.

4 Cognitive impairment and performance

Kirstie Gibson, Luke Kartsounis and Michael Kopelman
48
5 Are psychological factors linked to performance? Jenny
Firth-Cozens and Jennifer King 61
______________ J
6 The role of education and training Elisabeth Paice ____________ &

Contents

7 The impact of culture and climate in 91

healthcare organisations Michael West
and Marion Spendlove
106
8 The influence of team working Michael
West and Carol Borrill
123
9 Leadership and the quality of healthcare
Jenny Firth-Cozens
134
10 Workload, sleep loss and shift work
159
Lawrence Smith
167

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Conclusions
Index

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About the editors

Dr Jim Cox
Lead Assessor and Trainer, General Medical Council performance procedures Former
Associate Director (Assessment Development),
National Clinical Assessment Authority
Medical Director, Cumbria Ambulance Service NHS Trust

Dr Jennifer King Chartered Psychologist

Managing Director, Edgecumbe Consulting Group

Professor Allen Hutchinson Head of Section of Public Health ScHARR, University

of Sheffield

Professor Pauline McAvoy

Associate Director (Assessment Development),
National Clinical Assessment Service of the National Patient Safety Agency

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 List of contributors

Dr Carol Borrill
Senior Lecturer
University of
Nottingham
Professor Jenny Firth-Cozens Consultant
Clinical and Occupational Psychology Dr
Susanna Galea
Clinical Lecturer and Specialist Registrar in Addictive Behaviour
St George's University of London
Professor Hamid Ghodse
Professor of Psychiatry and International Drug Policy Director,
International Centre for Drug Policy St George's University of
London
Dr Kirstie Gibson
Specialist Registrar in Occupational Health Guy's and St Thomas's
NHS Trust
Dr John Harrison
Clinical Director of Occupational Health Hammersmith Hospitals
NHS Trust
Dr Luke Kartsounis
Consultant Clinical Neuropsychologist Oldchurch Hospital
Professor Michael Kopelman
Consultant Neuropsychiatrist St Thomas's Hospital
Professor Elisabeth Paice Dean Director, London Deanery
Dr Lawrence Smith
School of Psychology University of Leeds
Dr Marion Spendlove
Research Fellow, Aston Business School
Dr John Sterland
Specialist Registrar in Occupational Medicine King's College
Hospital
Professor Michael West
Professor of Organisational Psychology
Aston Business School
Acknowledgements

This book arises from the work of a group convened and sponsored by the National

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Clinical Assessment Authority (NCAA), now the National Clinical Assessment Service
of the National Patient Safety Agency. The NCAA published a synopsis report
Understanding Performance Difficulties in Doctors in November 2004.
The editors particularly thank Dr Rosemary Field, Deputy Director of the National
Clinical Assessment Service, for her support, encouragement and advice. They are also
extremely grateful to Kevin Hunt and Sheila Mariswamy, who managed the project.

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Introduction

Like other health professionals, most doctors work hard, strive to achieve high standards
and provide excellent services for their patients. But there are more than 100 000
practising doctors in the UK and it is inevitable that some of them fail to meet reasonable
standards.
Doctors' professional performance has become the focus of unprecedented public
scrutiny. Most people had assumed that their donors were competent, but several highly
publicised cases in the United Kingdom showed how that trust could sometimes be
misplaced. Failings of paediatric cardiac surgeons in Bristol led the British Medical
Journal to conclude in an editorial: 'All changed, changed utterly' (Smith, 1998).
The medical profession had begun to address the problems of poor performance of
donors before these events made headline news, but public exposure of poor performance
made it more urgent to find solutions.
By 1995 the General Medical Council (GMC), the body responsible for regulation of
the medical profession, had obtained the necessary legislative framework to introduce
'Performance Procedures' which allow them to investigate and, if necessary, restrict the
practice of donors who may be putting their patients or the public at risk. The GMC
developed methods to assess both competence (what the doctor can do) and performance
(what the doctor does do) (Southgate et ai. 2001) which have been sufficiently robust to
withstand legal challenge. GMC performance assessments, quite properly since they are
intended to proten the public, concentrate on description of the donor's clinical
performance with reference to current standards. They are not designed to explain why
the donor's performance is substandard. Furthermore, the GMC has tended to concentrate
its work at the extreme end of the spenrum of poor performance, with procedures which
are more disciplinary than developmental.
In 2001 the National Clinical Assessment Authority (now part of the National Patient
Safety Agency) was created as a special Health Authority of the National Health Service
(NHS) to advise the NHS about the management of poor performance. Its staled aim was
'promoting confidence in doctors and dentists' (NCAA, 2004a). Like the GMC, it
undertakes assessments of performance but, unlike the GMC, its assessments are
formative, intended to clarify concerns and to make recommendations to the doctor and
the NHS body to whom the doctor is responsible. As well as assessing clinical
performance, an assessment includes, as a matter of routine, psychometric testing, an
interview with a behavioural psychologist and assessment by an occupational health
physician. The thrust of these assessments - and the impetus for this book - is to try to
explain the doctor's practice as well as to describe it. Understanding more about the
possible causes of a doctor's practice helps to inform the most appropriate
recommendations or remediation.
Regulators and other interested parties in other countries, particularly Australia, New
Zealand, Canada and the USA are also working on the same problems. In general, there
are three levels of assessment: screening whole populations of doctors (level 1), the
targeting of 'at risk' groups (level 2) and assessing individual practitioners who may be
performing poorly (level 3) (Finucane PM etal., 2003). Canadian provinces, for example,
have a number of well-developed level 1 (screening) and

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 2 Understanding doctors' performance

level 2 (targeted assessment) programmes. Although level 3 performance assessments

carried out in the UK are widely acknowledged as being the most highly developed in
the world, so far we have no well-developed system for level 1 or level 2 assessments
in the UK. They are likely to be introduced in the near future as part of the proposals
for regular revalidation of doctors. The assessment of the factors described in this book
would usually be part of a level 3 assessment but, of course, the causes of poor
performance are the same however they are assessed.
One of the most significant changes to affect the medical profession in recent years
is the recognition that being a good doctor is about more than just technical and clinical
competence, skills or knowledge. The dissemination of the GMC document on the
principles of Good Medical Practice (General Medical Council, 1998) has highlighted
and embedded the importance of non-clinical attributes including team working,
leadership, and communication. There is increasing evidence that complaints about
doctors revolve largely around their behaviour (Sanger, 1998).
So what are the factors that cause a doctor who can practise safely not to do so?
Why do some doctors successfully address their difficulties while others fail to do so?
What is the impact of such factors as physical and psychological health, cognitive
deterioration, personality, attitudes, values, beliefs, workload, sleep loss, shift patterns,
organisational culture, teamwork, leadership and life events and so on?
Early experience of including behavioural assessment as part of performance
assessment has provided some insights, as has the work of regulatory bodies in other
countries such as Canada, Australia and New Zealand. For example, Canadian
experience indicates that cognitive impairment may affect up to a third of poorly
performing physicians assessed in Ontario (Ferguson B, personal communication).
Similarly, although numbers are too small to generalise with confidence, a review of
the first 50 assessments carried out by the National Clinical Assessment Authority
revealed that two doctors (4%) were affected by cognitive impairment.
How widespread is poor performance amongst doctors? The international literature
has shown consistently for more than a decade that in the hospital workforce there are
around 6% of doctors with serious performance problems (Donaldson, 1994). Of those
whose performance has been assessed by one of the national bodies, only a small
minority are simply incompetent.
The themes of this book were first presented as a report for the NHS (NCAA,
2004b). We believe that this is the first time anyone has attempted to bring together
existing knowledge about the factors influencing a doctor's performance. Our aim is to
provide practical, evidence-based guidance to assist individuals, employers and
regulatory, educational and professional agencies that are faced with the challenge of
managing concerns about the performance of doctors. Although the primary focus is
on doctors, many of the issues are equally applicable to other health professionals,
including dentists.
Our initial literature search revealed a complex array of issues that can impact on a
doctor's performance. Some clear themes emerged and these provide the basis for our
chapter headings. Some themes, whilst crucially important, proved difficult to cover
satisfactorily in a single chapter - in particular, issues concerning ethnicity, equality
and diversity. These cut across many different topic areas. Rather than risk
oversimplifying issues of such sensitivity and significance we chose to address them,
as appropriate, as part of a number of chapters. There is a substantial and broadranging
international literature on the impact of ethnicity and diversity on human performance
and, to a lesser extent, on the performance of healthcare staff. Much of
the literature concludes that inequalities that impact on minority groups exist around the
world, in the whole field of human endeavour.
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 Introduction 3

Similarly, there is an extensive literature on safety and quality issues in healthcare

which lies beyond the scope of this book but which we recognise is central to the issues
relating to poor performance in doctors. Finally, although some high-profile cases
concern criminal or unethical activities, we have not addressed them in this book.
Procedures for dealing with them do not normally include performance assessment.
Chapters in the book were commissioned from experts who were asked to review and
analyse the relevant literature and address specific questions to develop our
understanding of the significance, assessment and possible remediation of factors that
affect performance. Each contribution was further refined by discussion and editing by
the working group.
We aimed to answer some important practical questions about each of the factors
identified:
• What are the factors that influence a doctor's performance?
• Why do the factors arise?
• To what extent docs each factor affect performance?
• What are the most effective methods for assessing each factor and its impact on the
performance of a doctor?
• To what extent does each factor affect the remediability of poor performance?
• For which factors has intervention been effective?
• How sustainable are changes which result from interventions likely to be?
• What are the questions for further research?
We are aware of many of the limitations of this exercise (and, no doubt, ignorant of
others). Nevertheless, we hope that this work will be a useful contribution to the world
literature on performance assessment and be of interest to regulators and professions
other than medicine in the UK and abroad. In the longer term we hope that the insights
gained from this work will help us to promote and restore confidence in our doctors.

References
Donaldson U (1994) Doctors with problems in an NHS workforce. BMJ. 308: 1277-82.
Ferguson B. Personal communication.
Finucane PM. Bourgeois-Law GA. Ineson SLand KaigasTM (2003) A comparison of
performance assessment programs for medical practitioners in Canada. Australia.
New Zealand, and the United Kingdom. Acad Med. 78(8): 837-43.
General Medical Council (1998) Good Medical Practice. General Medical Council, London.
NCAA (2004a) NCAA Handbook. NCAA, London.
NCAA (2004b) Understanding performance difficulties in doctors. NCAA, London.
Sanger J (1998) Putting the person in the appraisal. Clin in M^mt. 9: 195.
Smith R (1998) All changed, changed utterly. BMJ. 316: 1917-18.
Southgate L, Cox J, David T et al. (2001) The assessment of poorly performing doctors:
the development of the assessment programmes for the General Medical Council's
performance procedures. Med Educ. 35(Suppl 1): 2-8.

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Chapter I

The impact of health on performance

John Harrison and John Sterland

Introduction
There are few published studies on doctors' physical illnesses. Although doctors are
more vulnerable than others to psychological and psychiatric problems, it does not
appear that they are troubled by physical illness any more than are other people. That is
not to say that physical illnesses do not occur in doctors. A State of the Art Review
(Emmett, 1987) identifies infectious diseases, chemical agents, musculoskeletal
problems and stress as important occupational health issues for healthcare workers in
general. Most problems are exposure-specific. The Royal College of Physicians, in
association with the Faculty of Occupational Medicine, published a report concerned
with health risks to the healthcare professional (Litchfield, 1995). Chapters on
blood-borne viruses, tuberculosis and allergic respiratory disease were concerned with
healthcare workers in general; chapters on mental ill health, burnout and alcohol
problems were concerned with donors in particular.
The context of this review is the relationship between diseases in doctors and their
performance at work. The management of a surgeon infected with hepatitis B virus is
relatively straightforward in that there are objective tests for hepatitis B surface antigen
and there is clear guidance about fitness to perform exposure-prone procedures
(Department of Health, 2000). On the other hand, the management of a doctor whose
behaviour is at variance from a perceived norm, or whose decisionmaking processes are
unusual, is more difficult because of the professional independence of specialists and
principals in general practice. This may be compounded by doctors' attitudes to their
own health and an unwillingness to behave like other patients. Unfortunately, such
important topics have only recently become research areas.
Any significant medical problem that affects judgement and performance can
compromise a doctor's ability to provide good medical care. The American Medical
Association defines an impaired physician as 'one unable to fulfil professional or
personal responsibilities because of psychiatric illness, alcoholism or drug dependency'
(Boisaubin & Levine, 2001). It is estimated that approximately 15% of physicians will
be impaired at some point in their careers. In a recent review of evidence of ill health in
the medical profession in the United Kingdom only 1% of doctors who were referred to
the General Medical Council's (GMC) health committee had a problem with physical
health (Stanton & Caan, 2003). General Medical Council records show that 199 out of
201 doctors under supervision at the end of 2001 had problems with alcohol, drugs or
mental ill health.
In contrast to GMC referrals, reasons for ill health retirement include a greater
proportion of doctors with physical, rather than psychological, illness. The commonest
reasons for doctors taking early retirement from the National Health Service

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 The impact of health on performance 5

are psychiatric (33%), musculo-skeletal (27%) and cardiovascular (17%) illnesses

(Pattani, Constantinovici 8- Williams, 2001). Perhaps it is easier for doctors with
physical problems to admit that there is a problem, particularly if the job is of a manual
nature (such as in the interventionist specialties) so that the symptoms are obviously
disabling. It might also be expected that doctors will have better insight into the
implications of these illnesses with respect to their fitness for work. This may not be the
case when the problem is substance abuse or depression. Pension scheme rules are also
a factor, in that physical illnesses might be more likely to be assessed as causing
permanent ill health.
Because of the paucity of published data on physical illnesses in doctors, the first
part of this chapter considers the potential effects of physical illnesses on judgement
and performance and how they might be assessed. Doctors' attitudes and behaviour in
respect of their own health and wellbeing are also explored. Where possible, we
discuss the potential for occupational health interventions and improvement in
performance. This is consistent with an occupational health approach to the assessment
of fitness for work. This comprises a clinical evaluation of a worker, taking into
account the activities of the job and associated risks to health and safety, either to the
individual worker, other workers or to third parties. In the case of doctors, the third
parties include patients. Thus, impaired performance of a surgeon may be affected by
the onset of a Parkinsonian tremor affecting a hand, whereas a similar tremor in a
public health physician may have less relevance in terms of fitness for work.
Some physical illnesses can lead to cognitive impairment or co-existent psychiatric
illness. These are also discussed, but cognitive impairment is covered in more detail in
Chapter 4.

Chronic illness and disability

A comprehensive review of the health of healthcare workers, including ill health
amongst doctors, was carried out on behalf of a partnership of organisations convened
by the Nuffield Trust (Williams, Michie & Pattani. 1998). The major findings were of
ill health related to psychological disturbances and unhealthy lifestyles, including
excessive alcohol consumption. The review referred to a survey of junior doctors
indicating that they tended to report frequent minor illnesses, but that they rarely took
time off work. Self-prescription was common. Back pain was a feature in nurses, but
not in doctors. Cardiovascular disease was not reported by either doctors or nurses.
A recent attempt to quantify how many doctors are sick (Stanton & Caan, 2003)
combined a literature search with an enquiry of organisations including the
Department of Health and the GMC, and care organisations such as the National
Counselling Service for Sick Doctors. Not surprisingly, the results reinforced the
impression that psychiatric illness is the main affliction of doctors. It was noted that
calls for help about drugs and alcohol had reduced in recent years. This was felt to be
an indication of a reluctance on the part of doctors to seek help rather than a decrease in
the incidence of addicted doctors.
Shift-working for more than 6 years has been suggested as a risk factor for
coronary heart disease in nurses, albeit probably as a result of the combined effects
of smoking, increased body mass index, low levels of activity, hypertension and diabetes
(Stanton & Caan, 2003).
Doctors have low mortality rates (Carpenter, Swerdlow &• Fear, 1997). NHS
hospital consultants had less than half the mortality rate expected for the period 1962 to
1979. Low mortality was found for cardiovascular disease, lung cancer and other

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 6 Understanding doctors' performance

smoking-related diseases and for diabetes. Studies show excess mortality for doctors in
overdose of prescribed drugs and suicide in female doctors. A significant excess
mortality in anaesthetists from cirrhosis of the liver was felt to merit further study. Other
mortality studies have looked at deaths from smoking (Doll et al.. 1994a) and alcohol
(Doll et al.. 1994b). Excess mortality from smoking-related diseases was found between
1971 and 1991, compared to that between 1951 and 1971. However, those doctors that
stopped smoking before middle age had virtually no increased risk of mortality from
smoking-related diseases. The now well-known 'U'-shaped curve relationship concerning
all-cause mortality and the average amount of alcohol reportedly drunk showing that a
little alcohol is more beneficial than none, but that excess alcohol increases risk, was first
discovered in a study of male British doctors.
There is some information on physical illnesses occurring in junior doctors. A
dedicated occupational health service in the north-east of England has taken referrals of
junior doctors with health problems since 1996 (Harrison & Redfern, 2001). Unpublished
data reveal that doctors had a wide range of physical illnesses, including diabetes,
epilepsy, multiple sclerosis, asthma, low back pain, osteoarthritis, ulcerative colitis, viral
meningitis, neuropraxia, Hodgkin's disease and polycystic ovaries.
Further information about disabilities experienced by medical students and doctors
comes from a survey of deans of medical schools, postgraduate deans, associate
postgraduate deans and regional advisors in general practice carried out by a working
party convened by the British Medical Association (BMA) (British Medical Association,
1997). A long list of physical diseases was collated. The conditions reported most
frequently were paraplegia, hearing impairment, multiple sclerosis, visual impairment,
hemiplegia and epilepsy. More than half of the respondents had their condition prior to,
or developed the condition during, training at medical school. Disability was defined as
the end result of physical, mental or sensory impairment, or long-term ill health (which
can limit functional ability). Either case may result in loss or limitation of opportunities.
Impairment does not imply being unable to fulfil professional responsibilities, although it
may occur if suitable adjustments to the working environment are not made, or if
workplace attitudes militate against effective practice.

Some important chronic diseases and their effects

Diabetes mellitus is a common chronic condition which can affect doctors like everyone
else. It is referred to as an unseen disability (Hirst, 2003). It is not a contraindication to
clinical practice, but doctors working night shifts, or long and stressful hours, and not
eating properly and regularly must overcome problems of glycaemic control. Working
with low blood sugars at some point is almost inevitable. Some people with diabetes do
not have warning signs of hypoglycaemic attacks and so may compensate by allowing
their blood sugars to run higher than normal.
Occasionally, symptoms associated with poor glycaemic control, such as fatigue or
impaired performance during operating theatre sessions or in other safety-critical areas of
practice, may require occupational health support to modify hours of work and activities
undertaken. Loss of control may be a temporary phenomenon and support from
colleagues is required during this period. It is helpful if a doctor's colleagues are aware of
the diagnosis, although this has to be handled sensitively. The doctor concerned has to be
prepared to accept help and to acknowledge that they are not always in control of their
own health.
Epilepsy is another relatively common chronic illness that requires an occupational

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 The impact of health on performance 7

health assessment of fitness for practice. Unfortunately, there is still a stigma attached to
the diagnosis of epilepsy that can discourage doctors from admitting the problem to their
colleagues, let alone to patients. Although infrequent seizures may not unduly affect a
doctor's ability to practise, frequent seizures can be very disruptive to the delivery of care,
especially in an era of intense pressure to meet clinical targets. Once again the main
concern relates to safety-critical jobs. Considerations such as lone working and driving
are important particularly if, for example, doctors are on call and attend urgent clinical
cases alone.
The duration and nature of the aura are important. If there is sufficient warning before
the onset of a seizure, most areas of practice can be considered. The frequency and nature
of seizures are also important, as are any identified triggers. As well as affecting the
victim, tonic-clonic seizures can be disturbing to other health workers.
If there is sufficient warning the doctor can go to a quiet area before the onset of the
seizure. It is important that others around ensure that no harm results and that they are
trained to realise that there is no need to panic or to intervene unnecessarily and that, after
the seizure, the doctor will feel drowsy and may wish to sleep for several hours.
Complex partial seizures may manifest themselves as absences or automatic
behaviour. During their occurrence the doctor may be unresponsive to questions or
instructions. This can be unsettling for patients, carers or, in paediatrics, parents.
Multiple sclerosis is relatively common, usually beginning in the early years of
working life. In any deanery or NHS region it is likely that there will be several junior
doctors and two or three career grade doctors, either in hospital practice or in general
practice, with the condition. Its nature is variable. Relapses may occur intermittently,
causing periods of temporary unfitness followed by long periods of fitness to practise.
Other cases progress more steadily.
Problems with eyesight, mobility and/or co-ordination are typical occupational health
issues to be addressed. Adjustments can be made to assist doctors with mobility problems
including the provision of electric vehicles for moving around hospitals. Upper limb
ataxia may be a more significant disability. In one case a junior doctor in paediatrics was
able to continue in clinical practice despite lower limb problems, but when her left arm
became affected she had to give up routine practice and adopt a teaching role. Some
doctors with multiple sclerosis lack insight into how badly they are affected. In such cases
it is necessary to confront them with their problems in as sympathetic a manner as
possible. It is also important to see the wider picture, not just the disability. Attitudes of
peers and seniors are very important.
Parkinson's disease presents later in life and is unusual in junior doctors. Typically it
will present in a hospital consultant or a GP principal. The four cardinal signs of
Parkinson's disease - tremor, rigidity, slowness and difficulty in starting and stopping
walking - contribute to the disabilities of the illness (Marsden, 2000). The

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 8 Understanding doctors' performance

patient 'shuffles', handwriting becomes small and untidy and rapid movements of hands
and feet are impaired. Drug therapy can control symptoms initially, but may cause
long-term problems. Such problems mean that continuing to practise medicine after the
diagnosis has been made is unlikely unless a new restricted role is available. Surgeons
normally have to cease to operate once the diagnosis has been confirmed, even if their
symptoms can be controlled by medication. From a clinical governance perspective,
the risk to patients of an adverse outcome due to failure to control symptoms, albeit
intermittently, is too great.
During excerbations. ulcerative colitis can cause malaise and tiredness as well as
the need to leave the workplace to use the toilet. Associated conditions, such as uveitis
or arthropathy can also be problematic. In addition, treatment of severe exacerbations
can cause steroid-induced behavioural changes that create difficulties if the doctor has
tried to continue in clinical practice. In an extreme case, apparent abnormal behaviour
caused by steroid treatment led to disciplinary proceedings.
Rheumatoid arthritis or sero-negative arthritis can interfere with clinical practice, if
a doctor is required to spend a lot of time standing or walking, or must maintain set
postures at work, perhaps in anaesthetics, surgery or interventional radiology. Arthritis
of the hands is particularly important if manipulation of instruments is a feature of the
job.
Hepatic failure may result from cirrhosis, which may be a result of alcohol abuse, or
infection with hepatitis B or C virus. Hepatic encephalopathy may result from liver
failure. In some cases encephalopathy is sub-clinical inasmuch as routine clinical
examination is normal, but psychometric assessments reveal impaired brain function.
Safety-critical jobs, such as surgery, should be avoided, unless the doctor is part of a
surgical team and does not have ultimate responsibility for decision making.
Chronic renal failure Although many of the disabling symptoms associated with
renal failure requiring dialysis can be counteracted by erythropoietin, there remain
concerns about fitness to practise for doctors in safety-critical jobs. Glomerular
filtration rates of less than 20 ml/min are usually associated with symptoms such as
lassitude. Although commercial pilots would be prevented from flying (Raymond
Johnston, Chief Medical Officer of the CAA - personal communication), in some cases
treatment by regular nightly peritoneal dialysis may control symptoms sufficiently to
permit limited work, including assisting at surgery.

Deficient vision
This has been shown to be important when assessing histopathologists (Poole eta/.,
1997). Out of 132 doctors, 13% had colour deficient vision. Fourteen were dcutan
(green colour deficient) and 1 was protan (red colour deficient). Doctors with colour
deficiency were significantly poorer at identifying test slides than doctors with normal
colour vision. In addition, the severity of colour deficiency correlated with the number
of mistakes made, including missing mycobacteria, amyloid or Helicobacter pylori.

Depression caused by physical illness

Physical illnesses associated with depression include HIV infection, neurological dis-
eases (Parkinson's disease, Huntington's disease, epilepsy and stroke),
musculo-skeletal complaints, heart disease and diabetes mellitus. A past history of
depression increases the probability of recurrence of depression during medical illness.
Diagnosing depression in the physically ill can be difficult because symptoms may
be due to the underlying physical illness. Strategies to counter this have been described

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 The impact of health on performance 9

(Parker 8- Kalucy, 1999) including an 'inclusive' approach (taking account of all

symptoms, irrespective of cause), an 'exclusive' approach (ignoring potentially
confounding features such as anorexia and fatigue) and an aetiological approach
(discounting symptoms that are considered solely due to the medical condition).
A measure that has been developed to be used for people who are medically ill is
the Hospital Anxiety and Depression Scale. However, simple screening measures,
such as merely asking ‘Are you depressed?', might be as sensitive as more complicated
measures (Parker 8 Kalucy, 1999).
When depression is present, treatment using conventional methods can make a
major impact on health and wellbeing.

Illness and behaviour

Many doctors are reluctant to see other doctors about their health. In 1995 an
Australian randomised sample postal survey of doctors' attitudes towards their own
medical care (with a 44% response rate) showed that whilst almost one-fifth had
marital or emotional problems, 3% admitted to alcohol problems and 1% to drug
problems, only 42% had a GP and few had discussed their problems with them (Pullen
etal., 1995). A 1999 New Zealand questionnaire study on a random sample of doctors
found that although many claimed to be working under substantial stress, relatively
few had regular health assessments. A case was made for regular checks (Richards.
1999). A Spanish questionnaire survey of 795 doctors showed that 49% did not have a
family doctor, 82% self-prescribed and 47% did not attend occupational health
appointments (Bruguera et a!.. 2001). In a more recent 2003 Australian study of 896
doctors with a 40% response rate, 90% said that selftreatment of acute conditions was
acceptable and 25% would self-prescribe for a chronic condition. Slightly more GPs
than specialists thought it was difficult to find an acceptable doctor (Davidson 8
Schattner, 2003).
In the UK, a postal survey of GPs and consultants in the South Thames area found
in 1999 that although 96% of the doctors were registered with a GP, little use was made
of their services. A quarter of GPs were registered within their own practice and 11 %
looked after members of their own family. Almost a quarter of consultants would
bypass their GP to obtain consultant advice. Most donors prescribed for themselves
and their family (Forsythe, Calnan 8 Wall, 1999). Only 11% of GPs reported
availability of occupational health services compared with 95% of consultants, most of
whom had never used them for preventive purposes. Presented with illness scenarios
affening themselves, GPs were more likely to self-medicate and go to work than
consultants. Within the family, for a child with tonsillitis, GPs were more likely to
prescribe an antibiotic but worry less than consultants, and were less likely to call a
donor out or attend at A8E. Perceived barriers were access, confidentiality, lack of
occupational health services, and difficulty in finding locum cover for GPs and
consequent expense. Overall, the pinure presented was of senior
donors with high levels of stress, anxiety, and depression taking very little time off
work for illness in general but needing long periods off when they did.
Doctors may deny that they have health problems, and colleagues may collude.
Such an approach may run against GMC advice which is that doctors should not rely on
their own assessment of risk to patients (Brooke, 1997; General Medical Council,
2001).
Many doctors express the idea that illness is inappropriate for doctors. A 1997
British study interviewed 64 doctors with illness of a month or more and found that
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 10 Understanding doctors' performance

cultural values, reinforced by the organisation of medical work, discourage doctors

from seeking and obtaining appropriate help when they are ill (McKevitt & Morgan,
1997).
Despite average illness rates, young doctors appear to take less than average sick
leave, developing maladaptive patterns such as working when unfit, self-prescribing,
and informal rather than formal consultations (Baldwin, Dodd & Wrate, 1997a). The
usual response is to go to work and wait and see what happens. Although formal
consultations for physical illness are marginally more popular than informal ones, for
mental illness the likely response was to see a friend or colleague. A third of this study
population of young doctors was not registered with a local GP and most had a poor
idea of the role of occupational health.
In a linked study, specific stressors on doctors, e.g. multiple emergency admissions,
deaths, and 'menial' tasks, were linked to physical and mental health and performance
measures (Baldwin, Dodd & Wrate, 1997b). A feeling of being overwhelmed by work
had the biggest impact. This correlated with almost all measures of health outcome,
including the number of physical illnesses doctors had had in the last year. The more
hours worked, the more likely that the doctors would complain of somatic symptoms.
Guidelines exist for seeking help and advice when ill. In 1995 the BM A produced
ethical guidance about doctor-patients and their families (British Medical Association,
1995). They were endorsed by a working party of the Academy of Royal Medical
Colleges (Academy of Medical Royal Colleges, 1998) and by the General Medical
Council (General Medical Council, 1998).
Why, when they are ill, do doctors behave differently to the general population?
There may be many reasons why doctors are reluctant to be perceived to be ill. A
qualitative research project using 88 case histories taken from a sample of 1200
Norwegian physicians revealed a pattern of denial and delay in seeking help, despite
the occurrence of symptoms that would have suggested diagnoses of concern if they
had occurred in patients (Christie & Ingstad, 1996). The doctor who becomes ill has
difficulty in admitting the illness. This may be compounded by a role conflict
concerning being a patient and a doctor at the same time. The treating physician may
also have a role conflict in that he/she is also a colleague. Doctors come to believe that
they will not become ill, that doctors should be strong and tough and not overdramatise
illness. There is also concern about other people finding out that they are ill, as this may
demean them in the eyes of colleagues or patients. This can lead to marked isolation.
Doctors do not make good patients. Part of this is an inability to cede control of care
to another. In many cases the doctor-patient knows best. Conversely, sometimes
doctors are not allowed to be patients. Doctor colleagues find it difficult to relate to the
ill doctor as a patient. There is a difficult balance to be struck. Even when there is a
desire to be treated as a patient, healthcare professionals have a

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 The impact of health on performance I I

tendency to speak to patients in a rather patronising manner and to use language

that is inappropriate for someone who is medically trained (Coulter, 1999). The
challenge is to use appropriate language and encourage appropriate participation in
management decisions whilst not assuming specialist knowledge and ensuring
concordance with treatment and advice.
Another explanation is that a non-medical patient is free to construct an explanatory
model of illness, whereas a doctor is constrained by his or her knowledge of disease and
previous professional experience (Ingstad & Christie, 2001). The doctor's perception of
what it is like to be ill is based on the observation of patients who are ill. This can be
frightening if previous experience was limited to treating patients with life-threatening
illnesses, or frustrating if the previous experience was of patients with chronic disease.
It is interesting, although not surprising, that interviews with doctor-patients reveal a
common belief that encounters with personal illness strengthened them as doctors.

Assessment of doctors with alleged performance problems

Doctors and dentists assessed by the NCAS routinely undergo an occupational health
assessment. It is an holistic assessment comprising an exploration of physical and
mental health, workplace and social factors, as well as their relevance to remediation.
The context of the assessment is unusual in that referred doctors are not seeking help
with health problems and they may wish to hide evidence of illness or of behavioural
problems. The doctor concerned can choose how much and what information to
disclose. In any clinical assessment, the history is the important component on which
diagnoses are based. Examination will confirm the history and facilitate an assessment
of the severity of the problem. Occupational health assessments are concerned with not
only the existence of medical conditions, but also their impact on fitness to work and on
performance at work. Thus, generally speaking, medical examination focuses on the
salient features highlighted by the history obtained, with a view to assessing functional
capacity.
In some circumstances it is necessary to identify specific health problems, or to
exclude their existence. Occupational health assessments sometimes take place because
of concerns of poor performance, or in association with disciplinary procedures. The
identification of illness might lead to financial penalties or even loss of employment
and so this might encourage the individuals to conceal, for example, that they are ill or
misusing drugs or alcohol.
The ethics of such assessments are not always straightforward. Whilst knowledge
of a doctor's medical condition that might put the health and safety of the public at risk
should be disclosed, how far should one go when relatively minor conditions are
discovered? Similarly, in the absence of a history of illness, or supporting information
to indicate ill health, how far should the screening process be taken?
The choice of any screening tool must satisfy well-established criteria with respect
to validity, reliability, accuracy, acceptability and cost-effectiveness. It must be clear
why the test is being done and what will happen when the results are obtained. The
ethics of managing a case can be considered with recourse to the principles of ethical
practice: beneficence, autonomy and confidentiality (Alklint, 2004). One choice is to
do nothing, which carries the risk of not dealing with a health problem for which
rehabilitation is available or which could lead to further

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 12 Understanding doctors' performance

illness. Intervention, on the other hand may highlight a problem, if it exists, but it
must be handled carefully and confidentially, on a need to know basis.
Whilst recognising the primacy of protecting patients and the public, an occu-
pational health assessment should not harm doctors who are referred either directly or
indirectly, for example as a result of a report sent to the referring Trust. The latter is
particularly important because the Trust has no right to gain information about the
doctor's health without explicit permission being given beforehand and because.
normally, the doctor will return to work in the Trust and could suffer as a result of the
information provided. The autonomy of the occupational health service must be
emphasised.
The assessment should be evidence-based as far as possible. This is difficult, with
respect to physical illnesses, because of the paucity of published information on the
subject. Baseline demographic information should include data on birth, current
address, address of GP and work address. There should be a training and employment
history and a medical history. The referred doctor should be given the opportunity to
volunteer information about any symptoms or health concerns, before undertaking a
specific review of key symptoms for the main system categories. Specific questions
about drug and alcohol intake are essential. In addition, questions about any
involvement with the police, or convictions, such as drink driving, can be helpful in
building up a picture of social behaviour. A physical examination is required in every
case, although it is acknowledged that this is done as an evidence gathering exercise to
identify possible illness or exclude markers of disease. This approach can be refined as
the evidence base builds up and the findings can be linked to other aspects of the NCAS
assessment and the outcomes following the recommendations to the Trusts. A
suggested template for assessment is in Appendix A.

Aging and work ability

It is well known that age-related changes occur concerning the functions of specific
organs or organ systems (Ilmarinen. 2001). Examples of age-related decline are
decreases in cardiorespiratory capacity, muscle strength, hearing acuity and speed of
response. From an occupational health perspective, how can the effects of aging on
performance be assessed?
In physical jobs 'working capacity' is a term used when assessing fitness for work.
In mentally demanding jobs, 'job performance' or a new concept, the 'Work Ability
Index' (WAI), might be used to assess the relationship between the resources of
individual workers and the demands of their jobs (Ilmarinen, 2001). It is a ques-
tionnaire designed to be administered to workers over the age of 45 years, as functional
decline can be detected from the age of 30 years, becoming significant around the age
of 50 years. However, some workers reach their working peak before the age of 50
years, hence the inclusion of younger workers.
An individual's capacity for work includes:
• health and functional capacities (physical, mental and social)
• education and competence
• values and attitudes
• motivation.

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 14 Understanding doctors' performance

Drug and alcohol dependency may militate against remediation, as will impairment
of cognitive function.

Physical illness and cognitive impairment

Cognitive impairment is a feature of some physical illnesses including multiple
sclerosis, Parkinson's disease, peripheral vascular disease (PVD) and stroke.
In one study 36% patients with Parkinson's disease had evidence of impairment
within 2 years of diagnosis (Foltynie et al., 2004).
A recent study of PVD and cognitive function (Waldstein et al., 2003) included
patients with stage II peripheral arterial disease (intermittent claudication), stroke,
hypertension and normal blood pressure. There was a clear progression. Those with
normal blood pressure performed best, with increasing cognitive impairment through
the hypertensive patients to the PVD patients and the stroke patients.
Cardiorespiratory fitness may be a predictive factor for preservation of cognitive
function (Barnes etal., 2003). A 6-year longitudinal study of non-institutionalised
adults aged 55 years and over found that baseline measures of cardiorespiratory fitness
were positively correlated with preservation of cognitive function in healthy older
adults.
Elevated serum cholesterol in middle age might also be a risk factor for cognitive
impairment in later life. A Finnish study of subjects taken from two larger projects
(North Karelia Project and FINMONICA - Finnish Multinational Monitoring of Trends
and Determinants in Cardiovascular Disease) has shown that high serum cholesterol in
mid-life (55-69) increased the risk of cognitive impairment 10 years later. However,
cholesterol level or hyperlipidaemia was found to be a factor in other PVD studies
(Phillips & MateKole, 1997; Waldstein et al., 2003). Cigarette smoking, based on
smoking histories, does not appear to be a risk factor in isolation.
Depression may also cause symptoms of cognitive impairment. Cognitive deficits
may be subtle and not detectable using brief screening tests (Foong &• Ron, 1998).
Self-reported problems with memory or learning may be reliable indicators that formal
neuropsychological assessment is merited. Because impairment may be progressive,
the identification of cognitively impaired doctors is important with respect to
remediation and future fitness to practice.

Asperger’s syndrome
Although it is not strictly a mental health problem, some doctors have Asperger's
syndrome, a form of autism which is associated with high IQ (Anon, 2004). Such
doctors may achieve academic success but difficulty at work. The diagnosis may be
delayed, or never made. There is no cure but, with understanding and occupational
health support, effective work may be possible.
Symptoms of Asperger's syndrome include;
• Being a loner ill-suited to teamwork.
• Seriousness with an unusual sense of humour.
• Having little or no common sense and lacking 'street credibility'.
• Generating novel and unusual 'off track' solutions to problems.
• A pedantic inflexibility making it difficult to handle all the changes that come with
working in the NHS.

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 18 Understanding doctors' performance

Alcohol

Drugs

Neurological

Musculo-skclctal

Cardiorespiratory

Forensic (e.g. drink-driving conviction or other involvement with the police)

Social

Beliefs: (work-relatedness)

Examination: Declined

Mental health screening tools:

Type Score Reference Comment

Vision: Distance: Near: Intermediate:

Hearing: Conversation: Rinne/Weber:
Urinalysis:
Height: Weight: BMI:
Drug/alcohol screen:
Physical:

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19 Understanding doctors' performance
 Chapter 2

A perspective on stress and depression

Jenny Firth-Cozens

Mental health problems in doctors have been the focus of researchers' attention for
decades, with good longitudinal studies allowing us to consider their long-term
predictors, in particular of general occupational stress, depression and substance abuse.
The focus on these areas is not arbitrary, as findings show that doctors suffer from
elevated levels in each, compared to the general public or to other professional groups
(Firth-Cozens, 1999b; Ghodse, 2000), while other psychiatric conditions such as
psychosis and personality disorders are likely to occur in similar proportions to any other
population. This chapter focuses primarily on studies of stress and depression since they
are highly related, though the frequent comorbidity between depression and alcohol use
will also be discussed where appropriate. Substance abuse in general is the focus of
Chapter 3.
The chapter looks at the levels of stress and depression in doctors and their effects
upon patient care, discusses their individual and organisational causes, and finally
outlines interventions to reduce the problem.

Levels of stress and depression in doctors

Reported levels of stress in health service professionals - especially in doctors and nurses
- are higher than those in British workers as a whole, with around 28% showing
above-threshold symptoms at any one time (Wall etal., 1997). This study and others
which measure stress use instruments that provide indications of general psychiatric
morbidity in a population; for example, the General Health Questionnaire (GHQ), a
well-validated measure of stress (Goldberg, 1978) which is particularly useful in judging
levels of psychiatric morbidity in the community, but which has also been shown to be a
reliable measure of work-related stress in a population. Where measures of depression
rather than stress are used, studies show the prevalence of depression in UK doctors to be
of the order of 10-20% (Ghodse, 2000), similar to the United States; current US estimates
are that approximately 15% of physicians arc impaired through depression or substance
misuse at some point in their careers (Boisaubin & Levine, 2001 ).
Figure 2.1 describes the findings of a UK longitudinal study (Firth-Cozens, 2004)
where both stress and depression have been considered in a group of medical students
(n=314) who became general practitioners and hospital doctors. These data support the
general findings described above which show that stress is a larger problem than
depression in doctors, but both behave similarly; in fact in this study the relationship
between the two is around r=0.7 on each assessment. The first column shows the
percentage of British workers above threshold on the 12-item version of the GHQ. This is
compared with the last four columns, which show the

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26 Understanding doctors’ performance

In addition to the effects on patient care and on the doctors themselves, these mental
health problems are expensive to organisations in terms of sickness absence,
suspensions, litigation and early retirement. The most common reason for a doctor taking
early retirement from the NHS is psychiatric (Pattani, Constantinovici &• Williams,
2001). Because the direct and indirect effects of stress and depression on patient care are
manifestly significant, the causes for these problems need to be understood so that
remedies can be put in place.

The individual and organisational causes of stress and depression

in doctors
There has been a considerable debate over the last two decades about the relative
importance of individual factors and occupational or life factors in terms of predicting
stress and depression, but evidence shows that both will play a role. For example,
depressed students who become psychiatrists are likely to remain depressed, stressed and
dissatisfied 17 years later; on the other hand, depressed students who become
pathologists have much lower levels of subsequent stress and higher job satisfaction
(Firth-Cozens, Lema & Firth, 1999). Despite similar levels of initial depression, one
group has made a career choice which gets them particularly close to patients who may
have similar problems, and they are not helped by this; while the other group has chosen
to work as separately as possible from patients, which has been beneficial in some
respects. It seems from this that some work conditions can go some way towards
alleviating the experience of stress. This literature, on person-job fit, has rarely been
considered in medicine.
This section considers the principal individual and organisational causes of stress
found in the literature. Since stress, depression and alcohol use are likely to have a
number of highly related causes, and since co-morbidity is such a feature of their
presentation, the literature reported under this section principally refers to 'stress' unless
the evidence indicates differences for other conditions.

Individual causes
Life events
Stress and depression are strongly linked to life events, especially those concerning loss,
and these are probably summative in their effects (Turner &• Lloyd, 2004). Young
doctors in particular often suffer from a number of life events (moving jobs and houses
frequently, relationship problems, marriages, new babies and young children, for
example) and some of these will come together over the early years of their careers.

Gender
As we mentioned above, women hospital doctors are an at-risk group for depression,
particularly if they are working full-time and have children (Firth-Cozens & Bonanno.
1999). Unlike their male colleagues, differences in symptoms do not appear when they
are students but only in the first postgraduate year, and so are likely to be more
job-related than in men (Brewin & Firth-Cozens, 1997). A large

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30 Understanding doctors' performance

as a functional team, whose members work together to achieve them, with different roles
for different members) have lower stress levels than those in teams which do not meet
these criteria. In addition, the study of house officers shows that those who know they are
in a multidisciplinary team have significantly lower stress levels, feel more supported,
and think their skills are being used better than those who do not realise they are in
multidisciplinary teams. Clearly, if you recognise the breadth of your team you have
more people to go to for support and, as house officers, feel that your skills are more
valued than if you see yourself simply at the bottom of a medical hierarchy.

Control
A factor consistently found to be a stressor in organisations in general is having low
discretion or control over how the job is carried out (Payne and Firth-Cozens, 1987).
Although this is less of a problem in medicine, general practitioners in particular see the
control they have enjoyed over their working lives as being gradually eroded by policy
changes, and this is a major factor in their intentions for early retirement, which in turn
impinges upon patient care (Newton et al., 2004).

Overload and resources

Workload is dealt with fully in Chapter 10. Its relationship to stress levels is usually
complex and not always apparent in medicine (Baldwin. Dodd & Wrate, 1997).
Nevertheless, the finding that frequent overtime relates to heavy alcohol use in women 24
years later (Michelsen & Bildt, 2003) is disturbing. It may be that cross- sectional studies
or brief longitudinal studies simply cannot capture these longterm effects. In addition, the
tiredness that may follow long hours lowers mood and this can make other aspects of the
job, such as a complaint or the death of a child, more difficult to endure.
What is usually overlooked in research is the effect of a lack of resources on overload
and stress levels: if dependable staff with whom you are used to working are not available
in adequate numbers, if equipment is poor or absent, if the workload is so unremitting
that there is less time for proper communication or support, then stress levels will
undoubtedly rise and patient care will deteriorate. Although not fully tested, evidence for
this commonsense hypothesis is emerging from the safety literature (Carthey et al.. 2003;
Roberts, 1990).

Stressors in medicine
The factors mentioned above are universal in their potential effects, but there are also
stressors peculiar to medicine. These are likely to differ at different times and at different
points throughout a career, and also by the way they are measured. For example, using
the Sources of Stress Questionnaire (created from previous literature and findings to
quantitatively assess the perceived levels and frequency of particular named stressors) it
was found that relationships with senior doctors were a major issue (Firth-Cozens, 1995).
However, asking the same young doctors to write about a recent stressful incident
brought out primarily descriptions of patients' death or suffering. More recently, senior
doctors report that their sources

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34 Understanding doctors' performance

Bissell L and Skorina JK (1987) One hundred alcoholic women in medicine. JAMA. 257(21):
2959—44.
Blau SJ and Zuroff DC (1992) Interpersonal relatedness and self-definition: two proto-types for
depression. Clinical Psychology Review. 12(5): 527-62.
Boisauhin EV and Levine RF. (2001) Identifying and assisting the impaired physician. American
.Journal of the Medical Sciences. 322( 1): 31-6.
Brcwin C and Firth-Cozens J (1997) Dependency and self-criticism as predictors of depression in
young doctors. Journal of Occupational Health Psychology. 2(3): 242-6.
Broadbent DE et al. (1982) The Cognitive Failures Questionnaire (CFQ) and its correlates. British
Journal of Clinical Psychology. 21(1): 1-16.
Brooke D, Edwards G and Taylor C (1991) Addiction as an occupational hazard: 144 doctors with
drug and alcohol problems. British Journal of Addiction. 86(8): 1011-16.
Caplan RP (1994) Stress, anxiety and depression in hospital consultants, general practitioners, and
senior health service managers. BMJ. 309(6964): 1261-3.
Carlson HB and Dilts SL (1994) Physicians with substance abuse problems and their recovery
environment: a survey. Journal of Substance Abuse Treatment. 11: 113-19.
Carter AJ and West MA (1999) Sharing the burden: team work in health care setting. In: J Firth-
Cozens and RL Payne (eds) Stress in Health Professionals: psychological and organisational
causes and interventions. John Wiley & Sons, Chichester, pp. 191-202.
Carthey J et al. (2003) Behavioural markers of surgical excellence. Safety Science. 41(5): 409-25.
Caspi A et al. (1997) Personality differences predict health-risk behaviors in young adulthood:
evidence from a longitudinal study. Journal of Personality and Social Psychology. 73(5):
1052-63.
Center C et al. (2003) Confronting depression and suicide in physicians: a consensus statement.
JAMA. 289(23): 3161-7.
Crow SM el al. (2003) A prescription for the rogue doctor, part I - begin with diagnosis. Clinical
Orthopaedics and Related Research. 411: 334-9.
Czander WM (1993) The Psychodynamics of Work and Organizations: theory and application.
Guilford Press, New York.
Derogatis LR. Liptnan RS and Covi L (1973) SCL-90: an outpatient psychiatric rating scale -
preliminary report. Psychopharmacology Bulletin. 9(1): 13-20.
DiMatteo MR et al. (1993) Physicians' characteristics influence patients' adherence to medical
treatment: results from the medical outcomes study. Health Psychology. 12(2): 93-102.
Domenighetti G et al. (1991) Psychoactive drug use among medical doctors is higher than in the
general |>opulation. Social Science and Medicine. 33(3): 269-74.
Dumelow C, Littlejohns P and Griffiths S (2000) Relation between a career and family life for
English hospital consultants: qualitative, semistructured interview study. BMJ. 320(7247):
1437-40.
Dunbar M. Ford G. Hunt Kand Der G (2000) A confirmatory factor analysis of the Hospital Anxiety
and Depression Scale: comparing empirically and theoretically derived structures. British
Journal of Clinical Psychology. 39: 79-94.
Farmer JF (2002) Return to work for junior doctors after ill-health. Medical Journal of Australia.
177(1 Suppl): S27-S29.
Firth J and Shapiro D (1986) An evaluation of psychotherapy for job-related distress. Journal of
Occupational Psychology. 59: 221-33.
Firth-Cozens J (1992) The role of early family experiences in the perception of organizational stress:
fusing clinical and organizational perspectives. Journal of Occupational and Organizational
Psychology. 65 (1): 61-75.
Firth-Cozens J (1995) Sources of stress in junior doctors and general practitioners. Yorkshire
Medicine.!: 10-13.

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Chapter 3

Misuse of drugs and alcohol

Hamid Ghodse and Susanna Galea

Introduction
Substance misuse problems are amongst the most prevalent of health factors affecting
doctors' performance. For example, a survey of house officers revealed that 56% drank
alcohol in excess of recommended safe weekly limits and 10% used illegal drugs
(Brooks, 1998). Misuse of substances can affect a doctor's performance both directly
and indirectly. Direct effects are largely dependent upon the type of substance misused
and the nature and extent of misuse. Indirect effects include psychosocial
complications such as financial difficulties, social withdrawal and isolation,
involvement in criminal activity, and the blurring of professional boundaries.
Impairment in performance due to misuse of substances is difficult to detect,
especially if substance use has not reached a level of dependency (i.e. use is frequent
but not a daily occurrence).

The extent of the problem

The misuse of drugs and alcohol by doctors has been described in several studies.
Stuart and Price (Stuart & Price, 2000) described the difficulties in investigating the
epidemiological literature on such high risk groups. One of the main difficulties is
related to variations in definitions used. Methodological difficulties include retro-
spective self-reporting, varying demographic characteristics of the sample, non-
representativeness of respondents and under-reporting by respondents. Despite such
difficulties it is clear that doctors and healthcare professionals are a recognised high
risk group for substance misuse and its consequences (Bissell &• Hagerman, 1984).
Studies comparing substance misuse among doctors with the general population
frequently report higher prevalence rates among doctors. An early study reported that
physicians were 30 to 100 times more likely than the general population to become
addicted to narcotics (Brewster. 1986). Another study (Hughes eta/., 1992) reported
that physicians in the US were more likely to use alcohol and prescription drugs, such
as benzodiazepines, but less likely to use tobacco and illicit substances, such as cocaine
and heroin, than the general population. The General Household Survey for Great
Britain (Rickards etal., 2004) did not give specific data on doctors but reported on
drinking and smoking patterns in various socioeconomic levels, as defined by the
National Statistics Socio-Economic Classification (Walker et al., 2003). Those in
managerial and professional occupations consumed 12.7 units of alcohol per week,
compared to 11.3 for those in routine and manual occupations. Similarly, compared
with those earning £200 or less per week, those with a weekly income of £1000 or more
were twice as likely to have drunk more than 8 units for men and

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42 Understanding doctors’ performance

Effects of drugs and alcohol on performance

Poor performance related to drug and alcohol misuse is the result of both the direct
effects of the substance itself and the indirect effects such as associated financial
difficulties, relationship problems and criminal activity. The same factors that cause
misuse of drugs and alcohol in doctors can also have significant impact on their
professional performance.

Direct substance effects

Substances exert their effects through complex biological pathways. Different
substances have different chemical and pharmacological properties which affect
different parts of the central nervous system. Furthermore, drugs and alcohol have
rewarding and reinforcing properties which give them their addictive potential.
Sedative and hypnotic substances such as alcohol, opiates and benzodiazepines may
directly influence a doctor's performance through their depressant effects. Alertness
and co-ordination are affected to varying degrees depending upon the nature and extent
of substance misuse. Similar dangerous direct effects such as increased activity and
impaired attention can be observed with use of stimulants, such as amphetamines and
cocaine.

Doctor-centred factors
The aetiological factors mentioned in the previous section, such as stress levels,
burnout, psychological traits and experiences, all contribute to both substance misuse
and impaired performance. Substance use also potentiates further stress and ill health.
The resultant impact is gradual deterioration in performance.
Compared to other doctors, those experiencing burnout are significantly more likely
to engage in suboptimal patient care (32% compared to 11%) (Shanafelte/a/., 2002).
The evidence indicates a link between stress, substance misuse, job dissatisfaction and
underperformance (Firth-Cozens, 2000; Jones eta/., 1988; DeMatteo et al.. 1993) (see
Chapters 2 and 5).

Work-centred factors
High standards and demands, combined with a culture of denial and avoidance,
provide fertile ground for substance misuse, underperformance and suboptimal patient
care, particularly if this is associated with denial. Inadequate support and training are
associated with feelings of inadequacy, stress and misuse of substances (Chrome,
1999). Self-diagnosis and self-prescribing, although perhaps resulting in fewer
sickness days, are themselves performance issues. General Medical Council guidance
is that doctors should not treat themselves or their families (General Medical Council,
1998). Many organisations have their own policies which prohibit such practices,
which may trigger capability procedures at work.

Non-work factors
Misuse of drugs and alcohol is associated with several complications. For instance,
relationship problems, self-neglect, financial problems and engagement in criminal

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46 Understanding doctors' performance

DeMatteo MR. Sherboume CD. Hays RD and Ordway L (1993) Physicians' characteristics influence
patients' adherence to medical treatment: results from the medical outcomes study. Health
Psychology. 12: 93-102.
Firth-Cozens J (2000) Interventions to improve physicians' well-being and patient care. Social
Science and Medicine. 52(2001): 215-22.
Firth-Cozens J (1998) Individual and organisational predictors of depression in general practitioners.
British Journal of General Practice. 48: 1647-51.
Firth-Cozens J (1995) Sources of stress in junior doctors and general practitioners. Yorkshire
Medicine. 7: 10-13.
Firth-Cozens J (1992) The role of early family experience in the perception of organisation stress:
fusing clinical and organisation perspectives. Journal of Occupational and Organisational Psy-
chology. 65: 61-75.
Firth-Cozens J and Morrison L (1989) Sources of stress and ways of coping in junior house officers.
Stress Medicine. 5: 121-6.
Forsythe M, Calnan M and Wall B (1999) Doctors as patients: postal survey examining consultants'
and general practitioners' adherence to guidelines. B MJ . 319(7210): 605-8.
Fox ML, Dwyer DJ and Ganster DC (1993) Effects of stressful job demands and control on
physiological and altitudinal outcomes in a hospital setting. Academy of Management Journal.
36(2): 289-318.
General Medical Council (1998) Doctors should not treat themselves or their families. Available at:
w w w .gmc-uk.org/standards/default.htm.
Graske J (2003) Improving the mental health of doctors. BMJ Careen. 13 December: si 88.
Grassi L and Magnani K (2000) Psychiatric morbidity and burnout in the medical profession: an
Italian study of general practitioners and hospital physicians. Psychother Psychosom. 69:
329-34.
Hughes PH, Brandenburg N. Baldwin DC Jr, Storr CL. Williams KM. Anthony JC and Sheehan DV
(1992) Prevalence of substance use among US physicians. Journal of the American Medical
Association. 267( 17): 2333-9.
Joiner I (2000) The Sick Doctors Trust - Addicted Physicians Physicians Programme. In: H Ghodse,
S Mann and P Johnson (eds) Doctors and their Health. Reed Healthcare Limited, Surrey, pp.
87-95.
Jones JW. Barge BN. Steffy BD, Fay I.M, Kunz LK and Wuebker U (1988) Stress and medical
malpractice: organizational risk assessment and intervention. Journal of Applied Psychology. 4:
727-35.
Joranson D. Ryan K. Gilson A and Dahl J (2000) Trends in medical use and abuse of opioid
analgesics. Journal of the American Medical Association. 283: 1710-14.
Lcmkau J, Rafferty J and Gordon R Jr (1994) Burnout and career-choice regret among family
practice physicians in early practice. Family Practitioners Res Journal. 14: 213-22.
McGovern M, Angre D and Leon S (2000) Characteristics of physicians presenting for assessment at
a behavioural health centre. Journal of Addictive Disorders. 19: 59-73.
Paice E (2000) Early identification, diagnosis and response. In: H Ghodse, S Mann and P Johnson
(eds) Doctors and their Health. Reed Healthcare Limited, Surrey, pp. 21-9.
Paris R and Canavan D (1999) Physician substance abuse impairment: anesthesiologists vs other
specialities. Journal of Addictive Disorders. 18: 1-7.
Persaud R (2005) Post-traumatic stress disorder in doctors. BMJ Careers. 26 February: 86-7.
Pines A and Aronson E (1988) Career Burnout: causes and cures. Free Press, New York.
Pines A and Maslach C (1978) Characteristics of staff burnout in mental health settings. Hospital &
Community Psychiatry. 29: 233-7.
Prochaska JO and DiClemente CC (1982) Transtheoretical therapy: toward a more integrative model
of change. Psychotherapy: theory, research and practice. 19: 276-88.

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 50 Understanding doctors' performance

possible diagnoses. By a process of logic, experience and assessment of probability the

doctor must narrow down the possible list until a final diagnosis is reached.
As medicine is always changing, a competent doctor must try to keep up with new
developments and be self-motivated to undertake continuing learning. This may be
structured in lectures and conferences or unstructured based on daily reading and gaps in
knowledge picked up when seeing patients. As a consequence of these demands a high
level of accurate self-knowledge and honesty is required for professional practice
together with a higher degree of self-motivation in a busy schedule.
In many cognitive disorders such as head injury or the early stages of Alzheimer's
dementia, remote memories are relatively preserved but current and recent memories are
substantially impaired (Kopelman, 1989). Consequently an affected individual may
present with increasing problems in holding new information long enough to make a
decision, and learning new material can be particularly difficult. There is an extensive
literature on memory disorders within neuropsychology but surprisingly little work on
memory impairment in doctors.
As we noted earlier, the term 'executive function' refers to the ability to plan, organise
and prioritise activity. It also refers to mood regulation, motivation and self-discipline.
When the frontal areas of the brain are damaged, the so-called 'dysexecutivc syndrome'
develops and the patient may become extremely apathetic and unable to decide what to
do next. The doctor needs good executive abilities both to treat an individual patient, i.e.
conduct a consultation, take a history, organise the information and treatment and to
oversee a practice, office or department. Again there is an extensive literature on
executive dysfunction but very little about the condition in doctors.
Aspects of cognition are also critical for the performance of psychomotor skills. For
example, visuospatial skills are involved in a wide range of everyday activities and a
doctor who becomes impaired cannot perform competently. A radiologist or
histopathologist with a visual field defect and/or visual inattention, due perhaps to a
cerebrovascular accident, may not be able to perceive stimuli in the hemispace
contralateral to the lesion, and so may miss abnormalities without being aware of this
difficulty.
Similarly the surgeon must remember the tasks involved in a number of operations,
the order in which to perform them and must be skilled in physically performing these
tasks. Surgeons must have particularly good visuospatial functioning and a high degree
of fine motor control and co-ordination. If any one of these key areas of functioning is
damaged, their performance is affected. There is now work being undertaken to look at
surgical performance and it is possible using simulators and optical motion tracking to
monitor dexterity and technical ability (Moorthy et al.. 2003).

Examples of neurological disorders affecting neuropsychological

function
This section aims to introduce some common conditions leading to a decline in cognitive
functioning, namely, various types of dementia, alcoholic brain damage, head trauma,
brain injury and depression. The ways these conditions can affect

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 Box 4.2
Case study: Physician in his 50s- 10 years after road traffic accident (Walsh,
1991)
54 The
Understanding
patientdoctors' performance
had been unconscious for 8 days after the accident. The brain damage
resulted in uninhibited behaviour, double vision and anosmia (a common
indicator of frontal lobe damage). He returned to work within a few weeks but
appeared to have an altered personality leading to conflict with his partners in the
practice and increased irritability and angry outbursts. He had previously been a
diligent and easy-going person. He managed to continue his medical practice for
10 years, working alone with the help of his wife. Functional deficits appeared to
be related to misinterpreting new information, inattention, forgetting names and
arrangements and unpredictable behaviour. Formal neuropsychological testing
revealed poor attention to complex instructions and difficulty solving complex
and arithmetical problems. These findings indicated frontal lobe dysfunction and
indeed a CT scan showed extensive damage to the frontal lobes. He seemed to
have coped in the workplace because his wife had helped to organise his working
life.

Case study: A dangerous private pilot (Thieman, 2004)

A 45-year-old pilot was involved in an alcohol-related fight and suffered a right
basilar skull fracture. An MRI confirmed contusions in the left temporal area and
some intracerebral bleeding. He had aphasia and difficulty writing and was
rehabilitated over a 3-month period. He had persistent speech and motor problems
and little insight into his limitations. He also had a right visual field defect.
His job involved having to ferry aircraft for sale and, due to his expressive and
receptive speech problems, it was felt that a return to work was unlikely.
Despite this he returned to flying and the FAA revoked his licence after he made
errors thought to have resulted from his neurological condition. He still carried on
flying and incurred serious infringements in procedures. Eventually the case went
to court and an expert witness felt that his cognitive damage had led to his poor
judgement and lack of insight into his impairments.

Depression
Depression can affect cognition but the difficulty often lies in deciding whether it is the
actual depression itself that has caused the impairment or another underlying condition
like dementia or brain trauma. In addition, medication can also affect cognition, for
example, anticholinergic agents or steroids. The general view is that

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 58 Understanding doctors’ performance

abstinent, it will be appropriate to reassess cognitive function - although studies in heavy

drinkers show that improvements following abstinence can gradually accumulate over a
matter of years. Rare cases of psychosis will need appropriate psychiatric intervention,
and the risks of relapse need to be taken into account when planning for the future career.
Personality change following frontal lobe damage can be much more intractable and
difficult to manage - fitness to work needs to be assessed very carefully.
Similarly, treatable medical conditions need to be managed appropriately, such as in
the case of Parkinson's disease. Newly diagnosed space-occupying lesions will need
appropriate surgical intervention: more problematical may be decisions about the future
career, once surgical and other cancer interventions have been completed. Findings from
the neuropsychological assessment will be particularly important here. In the case of a
dementia, anticholinesterase medications and memantine are available: their benefits are
limited and, once a donor has reached this stage, he/she is extremely unlikely to be fit to
pranise. In cerebro-vascular disorders, the most important aspect of management consists
of minimalising the risk of further vascular episodes with anti-hypertensive agents,
statins, aspirin, encouragement to give up cigarettes or alcohol, etc. Again, the
neuropsychological assessment is critical: a doctor may be able to practise after a
relatively minor cerebro-vascular episode, but more generalised vascular changes will
make him/ her unfit to practise. Medical intervention in head injury depends on the
specific requirements of the patient, but the most important factor in recovery is time, and
repeated neuropsychological assessments may be required to make the decision as to
whether the victim is fit to return to practise.
Referral to a rehabilitation unit may well be appropriate, particularly in head injury, as
the doctor may benefit from psychological and occupational therapy interventions. These
vary from part-time outpatient programmes to full-time inpatient centres. Psychological
strategies for coping with memory disorders include the use of external aids, such as
computers, a diary, a pager system, etc., or the use of 'internal' strategies to improve
memory, e.g. errorless learning, the use of mnemonics (Wilson, 1999; Kapur, Glisky &
Wilson, 2002). Such strategies may be helpful to a practising doctor with relatively minor
cognitive impairments (Evans, 2003). Those with more severe impairments may benefit
from such rehabilitation, but they are unlikely to return to work.

Conclusion
Where there is an actual or suspected cognitive impairment in a doctor, neuropsychiatrie
and neuropsychological assessments, as well as an occupational health assessment, are
obviously essential. From the above, it will be seen that such assessments can be complex
and multidimensional as cognitive functioning is affected by such a wide range of factors
and a variety of medical and psychiatric disorders. In general, assessment will need to be
carried out by relevant experts, as many doctors and even occupational psychologists are
not expert in assessing what get called 'higher functions'. No quick questionnaire is
available to perform this task, and it is very unlikely that it would be possible to construct
such a test. Moreover, it needs to be emphasised that, to date, occupational medicine and
occupational psychology, on the one hand, and neuropsychiatry/neuropsychology.

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62 Understanding doctors’ performance

What are the psychological factors that influence doctors’

performance?
Attitudes
It is generally accepted within organisations and across industries, particularly those
which are high risk, that staff need appropriate attitudes to enable safe, thoughtful care to
take place. This has been demonstrated on the individual level in the aviation industry
where a series of studies showed links between attitude and performance in terms of
aircraft management and safety. The pilots had some time previously completed safety
attitude measures and were later independently rated as pilots along a scale from
'outstanding' to 'extremely poor' (Helmreich et al.. 1986). Comparing the attitudes of
those being scored at these two extremes, the study found that they differed most
significantly in the following:
• My decision-making ability is as good in emergencies as in routine flying situations
(superior-disagree).
• Captains should encourage their First Officers to question procedures during normal
flight operations and in emergencies (superior-agree).
• Pilots should be aware of and sensitive to the personal problems of fellow crew
members (superior-agree).
• There arc no circumstances (except total incapacitation) where the First Officer should
assume command of the aircraft (superior - disagree).
These results show that being the type of person who wants total control, who feels
invincible, and who is probably a poor team player, makes the worst pilot. The authors
talk of the 'macho' pilot, the one who 'does not recognize personal limitations due to
stress and emergencies, does not utilize the resources of fellow crew members, is less
sensitive to problems and reactions of others, and tends to employ a consistent,
authoritarian style of management' (Helmreich et al., 1986: 1200).
In terms of ability to change, the authors later showed that crew resource management
training changed these attitudes appropriately for most pilots (Helmreich & Wilhelm,
1991). However, the attitudes of one group actually became less appropriate over the
course. Those pilots who were low in both autocratic traits and expressive interpersonal
characteristics, as well as being poor in performance, actually developed worse attitudes.
The authors nicknamed them the 'no stuff', as opposed to the 'right stuff' (interpersonally
good, not autocratic, and high performers) and the 'wrong stuff' (those who were
autocratic but performed well), both of whom changed their attitudes still further for the
better. They conclude that this has the worrying implication that 'the types of individuals
who seem to need the training most may be less likely to be influenced in the desired
manner' (Helmreich &• Wilhelm, 1991: 298). These results very much show the
importance of different leadership styles for safety and quality but also that, for most
people, they can be changed for the better (Firth-Cozens & Mowbray, 2001).
Despite these findings, the relationship between an individual's attitudes and his or her
performance is by no means clear (Schaper, 2002). People can learn to behave in ways
which are appropriate (such as police learning not to arrest young black men with no
obvious cause), but still retain the same attitudes (such as racism). Although findings
vary at this individual level, there is nevertheless evidence that

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A widely based literature search has resulted in only one example of assessing the
relationship between personality and healthcare risk (Rabaud et ai. 2000). However,
there is a very large and relevant literature from the areas of health psychology and social
psychology looking at both risk perception and personality factors linked to risk taking.
Although a few studies involve risky workplaces such as Antarctica (Burns fr Sullivan,
2000), most focus on groups such as those who do extreme sports or who take part in
unsafe sex, or who are criminals, gamblers or drug-takers. In these studies, not
surprisingly, risk taking has been seen as a bad thing, leading to poor outcomes.
However, sometimes having an ability to take risks can be a positive attribute depending
on the context: for example, a meta-analysis (Stewart 6- Roth, 2001) has shown
entrepreneurs to have an appropriately higher risk-taking propensity than managers.
Even in healthcare, it has not necessarily been seen negatively; for example, one study
examines nurses who become managers and who may not have sufficient risk propensity
to deliver services more intensely, faster, and at lower cost (Smith & Friedland, 1998).
Most studies focus on the negative aspects of risk propensity, and it is this area which
has implications for patient safety. The first research area to consider is risk perception -
the fact that some people can see danger more easily than others. This is an important part
of healthcare since, if a doctor or nurse is able to see risk, then it is likely that he or she is
more likely to do something to avoid it. One way to encourage greater risk perception is
to increase mental readiness (McDonald, Orlick & Letts. 1995), to visualise each case -
for example, each operation - beforehand so as to anticipate every risk which might arise
and how these can be tackled. High Reliability Organisations (HROs) use this method of
anticipating and planning for future surprises to help create safe scenarios (Rochlin, 1999).
Research shows that some of our best surgeons appear to do this (McDonald, Orlick &
Letts, 1995; Carthey et al., 2003) and there is no reason why this ability cannot be taught.
Just because people can see risk, it does not necessarily follow that they will avoid it.
Some people are positively attracted to risky activities and actions. The association
between being able to perceive risk and changing one's behaviour accordingly is not so
clear-cut (Bums &• Sullivan, 2000). Similarly, others may believe, with unrealistic faith,
in the protection and infallibility of their safety systems. Studies of coping strategies have
shown optimistic faith to be good for one's mental health, but it may be that a certain level
of pessimism is necessary for delivering good healthcare. Risk perception increases
dramatically once people sustain a major incident: for example, after the destruction of
some towns by Hurricane Hugo, huge precautions were put in place by those who had
been hit in order to prevent future damage on that scale. However, the towns nearby
which the hurricane by chance barely missed were much less likely to make changes
(Norris, Smith & Kaniasty, 1999): their risk perception remained low. Even if objective
data on hazards, such as reports of death or disability, are given, studies show that
strongly held views on risk levels are actually quite resistant to change (Slovic, 1987).
We do learn from our errors and experiences (rather than from data alone), but we may
not always learn the right things; so various forms of defensive medicine may arise from
the experience of being sued or complained against, while a death from an early
discharge from hospital may lead to a doctor always keeping patients in hospital too long.
If people are still attracted to the risks they see. then their behaviour falls within the
area of the risky personality known as sensation-seeking. The concept of

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potential parallels with doctors. Medical training has a strong emphasis on the tech-
nical skills, but the transition to consultant or principal in general practice requires a
much more complex range of interpersonal and management skills. Doctors are
particularly vulnerable during and shortly after these transitions to a leadership role, often
with little training or insight into what this role requires. Medical students making the
transition to becoming a doctor are similarly vulnerable. The stress and pressure of these
additional responsibilities may trigger self-defeating characteristics.
Hogan and Hogan (1997) developed an inventory to assess the dysfunctional
attributes of employed adults with a view to identifying characteristics that underlie
career derailment and to show how these characteristics impede leadership effectiveness.
Hogan's research, based on the DSM-IV classification of personality disorders, identified
three main factors, described as the tendencies to 'blow up, show off or conform' when
under pressure. These correspond with and are based on Homey's original distinction
between three types of behaviour under pressure: moving against, moving away and
moving towards (Homey, 1950). This led to the development of a psychometric tool, the
Hogan Development Survey (HDS), for use in occupational, rather than clinical, settings,
which can identify these self-defeating characteristics. This is a tool with great potential
for diagnosing some of the behaviours that may be contributing to derailment in doctors.
Hogan's work is useful because it focuses on the behaviours that get doctors into
trouble, which may often be remediable, rather than the reasons behind these behaviours,
which may be less easily remedied. In particular Hogan highlights the concept of
'overplayed strengths'. This is a more constructive route to remediation because it
potentially encourages a focus on strength rather than weakness - helping the doctor to
recognise where a particular behaviour can be helpful in certain situations, but a problem
in others. This has similarities with the MBTI characteristics where each dimension is
seen as producing positive aspects of behaviour unless used to extremes.
Can derailment be prevented? Leslie and Van Velsor (1997) argue that simply moving
to a different organisation does not always prevent further problems since the critical
factors stem from interpersonal skills and ability to adapt, rather than from the norms and
values of the organisation. In order to change, the person needs to be willing, and
supported, to work on some relatively tough development issues- including self-esteem
and the need for control. Understanding why it may be difficult to relate comfortably to
others, to be able to learn in the face of change or to be able to let go of the need for
personal achievement in order to develop the team may involve facing issues about trust,
security or need for power. These are insights usually associated with good
psychotherapy since the learning that results from such insights often involves a high
degree of emotional investment.
Leslie and Van Velsor argue that derailment is a useful lens through which to view and
understand the leadership role as it can bring to the surface some important issues about
organisational demands and the ways in which people are responding to change. They
highlight the wealth of studies that show that not being able to learn from experience is a
major, if not the major, factor in derailing careers.

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74 Understanding doctors’ performance

of their own ability may be less receptive to negative feedback. Paradoxically, those
with low self-confidence who are highly self-critical are also hard to educate because
they are alert for anything that sounds like criticism, and they become defensive when
they hear it (Blatt & Zuroff, 1992). Because of their defensiveness, they have trouble
testing their ideas about how others perceive them. Because they avoid negative
feedback, they experience difficulty in reorganising their mental models. It is also
argued that it is the people with average self-confidence who are the easiest to
educate. They take reasonable responsibility and are willing to believe negative
feedback, but they have enough self-confidence to try new ways of thinking and
behaving. They will listen to criticism and feedback and use it well.
3 Perceptiveness about others: Those who understand what motivates others may be more
receptive to learning. People differ quite substantially in terms of how insightful they
are about other people (Hogan & Hogan, 2001). Linked to the studies of emotional
intelligence (Goleman, 1998), perceptive people can quickly and intuitively
understand what motivates others, and avoid management practices that gratuitously
upset and alienate their staff. Research in this area is controversial. There is an
increasing number of psychometric tools for identifying emotional intelligence with
variable reliability and validity. Nevertheless, the concept is gaining currency in the
management field as helpful in highlighting the impact of such attributes as empathy
and sensitivity on managerial performance. These attributes are now accepted as part
of the principles of the GMC's Good Medical Practice. More research is required to
establish which measure of emotional intelligence could be useful in the medical
context.
A number of psychological tests have done well in terms of predicting performance in
some parts of medicine and in other settings. A fertile area for further research is to
establish personality norms for doctors whose performance gives cause for concern, and
compare these with norms developed for all doctors. This would help to identify more
clearly the role of personality and attitudes in predicting a doctor's performance.

Conclusion
This review shows that there are potentially important ways that personality and other
individual characteristics might be affecting performance and behaviour in medicine. In
most areas these links are well established in other groups, but have rarely been applied
within healthcare. Where they have been used in healthcare they follow the same pattern
as elsewhere. Because of the rarity of this application, particularly within medicine, this
review has not been able to be categorical about the implications for such areas as
selection or adaptability. Nevertheless, the evidence from other areas is often strong and
the implications for medicine are important. More than anything else, this review shows
the need for a systematic research programme in this area.

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Chapter 6

The role of education and training

Elisabeth Paice

Introduction
This chapter reviews the evidence that educational factors, before and after qualification,
have an impact on the performance of doctors. Do the attributes of students entering
medical school predict their subsequent performance? Does the curriculum or teaching
style favoured by the school make any difference? What are the features of an effective
postgraduate training programme, and what are the obstacles to learning? Can poor
performance be prevented, predicted, detected early or remediated within the
undergraduate, postgraduate and continuing professional development system in place in
the UK?
The factors within education, training, appraisal and continuing professional
development (CPD) are summarised in Figure 6.1.

Basic medical education

Attributes of medical school entrants and their subsequent performance
Most medical schools would wish to turn away any applicants who were unlikely to turn
into caring, conscientious and competent doctors. The challenge is to know how to
recognise them. Admission to medical school is competitive in most countries, and most
of those applying have good scholastic records and are scientifically inclined. Selecting
from this pool is difficult and a great deal of research has gone into looking at the factors
that predict success in completing the course. Less is known about the factors that predict
subsequent clinical performance. The UK Committee of Deans and Heads of Medical
Schools commissioned a systematic review of factors believed to be significant
predictors of success in medicine. The review examined data on the predictive validity of
eight criteria that have been studied in relation to the selection of medical students:
cognitive factors (previous academic ability), non-cognitive factors (personality, learning
styles, interviews, references, personal statements) and demographic factors (sex,
ethnicity). They found that previous academic performance was a good, but not perfect,
predictor of achievement in medical training, accounting for 23% of the variance in
performance in undergraduate medical training and 6% of the variance in postgraduate
competency. A strategic learning style, white ethnicity and female sex were all also
associated with success in medical training (Ferguson, James & Madeley, 2002). Having
said that, a rich and complex social, ethnic and class mix results in more socially able
graduates (McManus, 2003; Crosby et al., 2003).
Assessment and examinations
The final examination is the point at which students prove their readiness to become
doctors. Scores achieved on certification and licensure examinations taken at the end of
medical school show a sustained relationship, over 4 to 7 years, with indices of

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82 Understanding doctors' performance

preventive care and acute and chronic disease management in primary care practice
(Tamblyn CM/., 2002). However, traditional final examinations are not as good as
Objective Structured Clinical Examinations (OSCEs) in predicting the performance of
recent graduates in their pre-registration house officer year (Probert eta/., 2003). A move
to more OSCE-based examinations is occurring and should be welcomed.

Fitness to practise and transfer of information

Traditionally medical students have been allowed more latitude in their behaviour than
would be acceptable in registered practitioners. Youthful high spirits, including
drunkenness and anti-social behaviour, have been tolerated. Recently, however. and as a
result of some extreme examples of irresponsibility, procedures have been put into place
to review medical students and pre-registration house officers whose behaviour or health
calls into question their fitness to practise. Despite passing their qualifying examinations,
in extreme cases such individuals are not allowed to become fully registered medical
practitioners. In less extreme cases, information about a new graduate is transferred from
medical school to those supervising their first Pre-Registration House Officer (PRHO) or
intern post. The purpose of such information is to identify students who are at risk of
becoming poor performers and who may need extra support. A transfer of information
system has been developed and implemented successfully by Imperial College London.
Students complete a form summarising their medical school career in terms of exams,
performance, health and behaviour, which is sent to the clinical tutor of the hospital
where they are to work. The results of the first two years suggest that students do not
falsify their reports and that useful information is transferred by this route, although
students have expressed concern about having to provide negative information about
themselves (Frankel & English, 2004).

The pre-registration year

A tough transition
The first experience of working as a doctor can come as a shock. Final-year students are
responsible only for themselves. They decide when to go to sleep and when to get up,
when to study and when to relax. They are at the top of the medical student hierarchy. As
new house officers, they are at the bottom of the medical hierarchy. There are jobs that
must be done and the needs of patients come before the most basic and pressing of
personal needs. Virtually everyone seems to be authorised to order them about. On top of
that, they have to cope with being very close to the human tragedies of disease and death,
often with little time, support or recognition of their understandable distress (Paice eta/.,
2002b). Pressures in the organisation often prevent new doctors from having control over
their work or time for reflection.

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88 Understanding doctors’ performance

transformable into a learning plan (Handfield-Jones et al., 2002). Where performance has
slipped beyond a certain point the effort required to regain an acceptable level may be just too
daunting to be contemplated (Bahrami & Evans, 2001). It remains to be seen whether
assessment of competence, as part of the process of revalidation and relicensure in the UK, is
regarded by practising doctors as high- stakes and threatening, or as helpful in focusing
attention on their areas of need.

References
Bahrami J and Evans A (2001) Underperforming doctors in general practice: a survey of referrals to
UK Deaneries. British Journal of General Practice. 51 (472): 892-6.
Crosby FJ et al. (2003) Affirmative action: psychological data and the policy debates. American
Psychologist. 58(2): 93-115.
Dean B et al. (2002) Causes of prescribing errors in hospital inpatients: a prospective study. The
Lancet. 359(9315): 1373-8.
Delva MD et al. (2002) Postal survey of approaches to learning among Ontario physicians:
implications for continuing medical education. BMJ. 325(7374): 1218.
Department of Health (1993) Hospital Doctors: training for the future. Department of Health,
London.
Ferguson E, James D and Madeley L (2002) Factors associated with success in medical school:
systematic review of the literature. BMJ. 324(7343): 952-7.
Feudtner C, Christakis DA and Christakis NA (1994) Do clinical clerks suffer ethical erosion?
Students' perceptions of their ethical environment and personal development. Academic
Medicine. 69(8): 670-9.
Firth-Cozens J (1992) The role of early family experiences in the perception of organizational stress:
fusing clinical and organizational perspectives. Journal of Occupational and Organizational
Psychology. 65( 1): 61—75.
Firth-Cozens J, Lema VC and Firth RA (1999) Specially choice, stress and personality: their
relationships over time. Hospital Medicine. 60(10): 751-5.
Frankel A and English S (2004) Transfer of information from medical schools. Hospital Medicine.
65(3): 170-3.
General Medical Council (2001) Good Medical Practice [online] (3e). www.gmc-uk.org/standards/
default.htm [Accessed on 22 September 2004).
General Medical Council (2003) Tomorrow's Doctors: recommendations on undergraduate medical
education [online]. General Medical Council, www.gmcuk.org/med_ed/tomdoc.htm [Accessed
22 September 2004|.
Goldman L and Lewis J (2003) Cases of professional and personal conduct. Employing Doctors and
Dentists. July/August: 5.
Handfield-Jones RS et al. (2002) Linking assessment to learning: a new route to quality assurance in
medical practice. Medical Education. 36(10): 949-58.
Hays BC et al. (2002) Is insight important? Measuring capacity to change performance. Medical
Education. 36(10): 965-71.
Heard S et al. (2002) Using a competence framework to select future medical specialists. Hospital
Medicine. 63(6): 361-7.
Hicks B (2000) Time to stop bullying and intimidation. Hospital Medicine. 61(6): 428-31.
Hughes F (2002) Can we improve on how we select medical students? Journal of the Royal Society
of Medicine. 95(1): 18-22.

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92 Understanding doctors’ performance

• Stories, jokes and jargon: Commonly told stories about a particular success
or the failings of management; humour about the finance department for
example; and jargon or acronyms (most NHS organisations have a lexicon of
acronyms and jargon and the language is often impenetrable to outsiders).
• Physical environment: Waiting rooms, dining rooms, toilets. Are all spaces
clean, tidy and comfortable, or is it only the areas on public display? Are
there decorations such as plants and paintings and good facilities such as
water fountains?

The meanings of all these aspects taken together tell us about the underlying culture of
the organisation, i.e. shared meanings, values, attitudes and beliefs (Schein, 1992).
Managers have been particularly interested in how to 'manage' culture and considerable
resources have been spent trying to 'shape' organisational cultures and create, for
example, 'a service culture', 'an open culture' or 'a people culture'.

What is organisational climate?

A closely related concept to organisational culture is 'organisational climate'. Central to
most, if not all, models of organisational behaviour are employees’ perceptions of the
work environment, referred to generally as 'organisational climate' (Rousseau, 1988). At
the broadest level, organisational climate describes how organisational members experience
organisations and attach shared meanings to their perceptions of this environment
(James & James, 1989). Schneider (1990) suggests that organisational climate
perceptions focus on the processes, practices and behaviours that are rewarded and
supported in an organisation. Most also agree that individuals interpret these aspects of
the organisational environment in relation to their own sense of wellbeing (James,
James & Ashe, 1990).
Individuals can describe the organisational environment both in an overall global
sense as well as in a more specific, targeted manner. In relation to the global organ-
isational environment, James and James (1989) describe four dimensions of global
organisational climate, which have been identified across a number of different work
contexts. These are:
1 role stress and lack of harmony (including role ambiguity, conflict and overload,
subunit conflict, lack of organisational identification, and lack of management
concern and awareness)
2 job challenge and autonomy (as well as job importance)
3 leadership facilitation and support (including leader trust, support, goal facilitation
and interaction facilitation, and psychological and hierarchical influence) and
4 work group co-operation, friendliness, and warmth (as well as responsibility for
effectiveness; James & McIntyre, 1996).
James suggests that individuals develop a global or holistic perception of their work
environment (e.g. James & Jones, 1974) based on their experience in these four

Bahan dengan hak cipta

 Understanding Doctors’
Performance
Like other health professionals, most doctors work hard, strive to achieve
high standards and provide excellent services for their patients. But there
are more than 100 000 practising doctors in the UK and it is inevitable that
some of them fail to meet reasonable standards.
Managers and senior clinicians need to be able to identify why doctors
underperform. Understanding Doctors Performance addresses the possible
reasons for underperformance, and covers specific areas such as education
and training, physical and mental health, workload, personality,
organisational culture, drug and alcohol misuse, and cognitive impairment.
It draws together evidence and describes the factors (apart from clinical
competence) that adversely affect performance and how they can be
prevented, identified, assessed and addressed.
This practical and easy-to-read book is invaluable for NHS managers,
medical directors, chief executives and board members, along with directors of
human resources in healthcare and healthcare professionals interested in
the assessment of performance or the management of underperformance.
Other Radcliffe books of related interest
The Good Appraisal Toolkit for Primary Care
Ruth Chambers. Abdol Tavabie, Kay Mohanna and Gill Wakley
Healthcare Performance and Organisational Culture
Tim Scott. Russell Mannion. Huw Davies and Martin Marshall
Prescription for Change for Doctors Who Want a Life. Second Edition
Susan E Kersley
ABC of Change for Doctors
Susan E Kersley
Know Yourself - The Individual’s Guide to Career Development in
Healthcare
Anita Houghton Effective People
leadership and organisation development in healthcare Stephen Prosser
The Good Mentoring Toolkit for Healthcare
Helen Bayley. Ruth Chambers and Caroline Donovan

www.radcliffe-oxford.com ISBN
1-85775
Electron«: catalogue and worldwide
online ordering facility

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