Working with Physicians

This post summarizes some lessons learned from my experience working with physicians on a particularly touchy subject – their performance. This is done to assist those working with physicians in the future, and those who lead performance appraisal (PA) activities for other highly autonomous professions (e.g., architects, professors, lawyers).

Working with physicians is both a joy and a challenge. Physicians are compassionate, motivated professionals with expertise needed for patient care and health system improvement. However, medicine is also a highly autonomous profession, resisting oversight or interference from government, administrators and private interests.

Context

For the last half-century, the mantra “know thyself” underpinned PA approaches for physicians. Professional development and performance management activities were based entirely on self-assessment. [1] Few Canadian physicians receive feedback about where or how to improve their performance. Furthermore, many physicians have no forum to discuss improvement strategies with colleagues. [2] Physicians at my organization reported this approach left them “flying blind.” A medical leader reported his only PA occurred when he joined the organization in the 1980s. Another physician was told she had low self-confidence when she asked a colleague for feedback on how to improve her practice.

However, things are slowly changing. The medical establishment is increasingly familiar with the limitations of self-assessment. This includes the Royal College of Physicians and Surgeons, which now values assessment and feedback-related professional development activities at 3:1 maintenance-of-certification hours compared to 1:1 hours for conferences, clinical rounds and journal clubs. [3] Healthcare organizations have responded, and are providing new supports to assess and enhance physician performance, including multisource (360°) feedback, peer coaching, training, and regular feedback on quantitative performance metrics.

Lessons

Well-designed PA approaches can capitalize on physicians’ competitive, analytical nature, and their motivation to improve care. While there is plenty of advice in the literature, here are four suggestions:

  1. Value their time. Be succinct and efficient. Time is money for most physicians (literally). 
  2. Partners, not employees. Few physicians are employees (including facility-based specialists, such as surgeons). They are independent business people granted privileges to perform certain procedures within certain facilities. Allow them to co-create and tailor interventions, when possible.
  3. Clarify the value to, and impact on, their patients. Physicians’ primary interest is the care of their patients (both as professionals and business people).
  4. Data quality is important (but the pursuit of perfection is futile). While physicians are often quick to challenge performance data and identify methodological problems, good data is a powerful driver of behaviours change. [1, 4] An often repeated joke is “in God we trust; everyone else must have data.” 
  5. Coaching helps resolve cogitative dissonance. True for many professions, physicians benefit from discussing PA feedback with a trusted colleague or mentor. [2]

Ross Graham MSc CHE serves as the Leader, Physician Performance Enhancement at the Vancouver Island Health Authority. Ross is also an active health services researcher and has published on a variety of management and policy topics. 

References

  1. Eva, K. W., Regehr, G., & Gruppen, L. D. (2012). Blinded by “insight”: Self-assessment and its role in performance improvement. In Hodges BD, Lingard L (Eds.), The Question of Competence: Reconsidering Medical Education in the Twenty-First Century. (p.131-54). Ithaca, NY.
  2. Eva, K. W., & Regehr, G. (2013). Effective feedback for maintenance of competence: from data delivery to trusting dialogues. Canadian Medical Association Journal, 185(6), 463–464.
  3. Royal College of Physicians and Surgeons of Canada. (2014). Framework of Continuing Professional Development Activities. Ottawa, ON. 
  4. Reinertsen, J. L., Gosfield, A. G., Rupp, W., & Whittington, J. W. (2007). Engaging physicians in a shared quality agenda. Institute for Healthcare Improvement: Cambridge, MA.


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