Abstract
I can take criticism. I think.
But when we were first told that we would be getting feedback on numbers seen during a shift I felt outraged. You can't assess my work using numbers! What about empathy? What about rapport? What about clinical acumen?! One colleague told me she was going to complain, another said she simply wouldn’t open the email.
That was almost 2 years ago. I started working on an out-of-hours pilot in our local emergency department (ED) and am still happily doing shifts. Patients are triaged and, when appropriate, are seen by a GP rather than an ED clinician. We are expected to see and discharge patients, where appropriate, without laboratory tests, just as we would in daytime general practice. This care pathway is now being used in many areas of the country in a bid to relieve the pressures on Accident and Emergency (A&E) departments.
The number of patients seen and the numbers sent back to the ED for further evaluation were to be closely monitored to assess the efficiency of the service. What was new to most of us was that this information was being collected about individual GPs and fed back to each of them.
Quantitative data collection rightly informs much of current NHS policy. Most of us are used to seeing our practice prescribing rates compared with others in the same locality. Personal, qualitative data is also very familiar. We are familiar with multi-source feedback and patient satisfaction questionnaires. This, however, was my first experience of personal, quantitative feedback. This was the first time that I might have my ultimate fear confirmed – I would finally know if I was the slowest consulter in the universe.
I opened the first email attachment long after I received it and very late at night in a flurry of bravado. There it was in black and white … I was … bang on … average. Totally average. Boringly average. Comfortingly average.
It was a balm to my deep insecurity about time management. A wonderful cure for imposter syndrome – definite proof that I was performing on a par with my peers. Other colleagues reported similar feelings. It turned out everyone was having the odd nightmare shift with complex patients and IT setbacks. We are all doing the same job of caring, diagnosing and discharging – and trying to be efficient.
Just as I was starting to get complacent about my feedback, about a year ago, I received a more detailed assessment. The service manager had noticed that my discharge rates (the number of people sent home after consulting me) were consistently lower than my colleagues. In truth I had ignored this part of the data – feeling that as a relatively inexperienced GP it was right that I had a lower threshold for sending people back to the ED for further tests. I felt I was practising more cautious medicine.
In fact, I was referring on to specialties less often than others. She pointed out that where a diagnosis is almost certain without tests, it is appropriate to refer straight to a specialty (as you would during in-hours work). She asked me to bear this in mind when I was thinking of sending someone back to A&E.
Now, being aware of consequences beyond the immediate clinical outcome is not new. No doctor, from ancient Mesopotamia to the modern-day USA, has had access to unlimited resources. It is entirely correct that I, working in a cash-strapped NHS, should be aware of how my resource allocation compares with others. I do not believe it has affected my clinical judgement – my main concern always remains the well-being of the person in front of me. And while we should be very wary of assigning value based on simple, numerical data, it may be a useful tool for highlighting differences in practice.
As I’ve become more experienced, my numbers have improved. Is my consulting style more efficient or am I simply better at negotiating the computer system? It is impossible to say. The truth is that this kind of data in isolation tells us very little. However, my personal experience has been positive, an affirmation of my normality and numerical reassurance that I’m probably doing OK.