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A colleague used to call them ‘Shipman letters’ - those thank-you cards and positive-feedback notes you’re supposed to present at your annual review to prove you aren’t a psychopath.
Of course, as everyone knows, Harold Shipman would have had no difficulty providing effusive letters from his devoted admirers, all blissfully unaware they were praising a serial killer.
Since evidence-based practice, however, has not yet managed to penetrate into the appraisal process, we’re still expected to hand in anything patients have given us that helps demonstrate our worth – even if it’s only the gift tag off a box of chocolates.
It’s a weird system. For a start, the number of thank-you notes you receive reflects many other things besides how good a doctor you are. Everyone knows surgeons get far more than anaesthetists, for example. I suspect pathologists get none at all, no matter how brilliant their take on a frozen section.
An obstetrician with a low-risk practice performing elective sections can expect a bumper crop: if they work in abortion or antenatal diagnosis, maybe not so much.
More seriously, though, lovely as it is to receive a thank-you or any other token of appreciation, something about knowing you’ll have use it as a tool for professional advancement takes the edge off. However truthfully you tell yourself that nothing you did for that patient had an ulterior motive, the fact that you’ll turn their gratitude to your own advantage makes you question yourself. Sometimes the ‘thank you’ refers to something intensely private – I have a case in mind which for obvious reasons I won’t describe here – and then, even if the card gives nothing away, it feels wrong to share it.
And then there’s the dreaded multi-source feedback. For juniors, you can choose who you ask to complete it, so all it proves is that at least seven people you’ve worked with don’t think you need striking off.
This may seem like quite a low bar, but it’s still stressful. Worse, for weeks leading up to the assessment, I find myself questioning every routine bit of courtesy or helpfulness: am I buttering people up so they write nice things about me? I know, really, that I’m not – but it’s still an uncomfortable feeling.
When completing feedback, almost everyone finds something nice to write, however generic (my favourite was ‘Speaks fluent English’, which is just as well as it’s my only language). The only time I was asked to complete a form for someone I really didn’t feel I could be positive about, I didn’t: it would have felt too cowardly to write behind their back what I hadn’t had the nerve to say to their face.
Most people get through their annual review year after year without incident. Yet somehow, at the end of the process, I always feel faintly dirty. As if, like Shipman, I was a crook trading on my ‘bedside manner’ and winning ways to profit from a system too blinded by bureaucracy to recognise what was really going on.
By the Secret Doctor. Read the blog and follow @TheSecretDr on Twitter and on Facebook
I just refused to do this. I had a small private OH practice and did no advertising, but the patients kept coming back; this, I felt, was evidence enough. Going any further would have made me feel unable to sign off on being honest. That was another worthless bit; even the most dastardly doctor is unlikely to declare themselves dishonest in writing! I was glad to retire, and re-validation was the final push.
Whoa. These cards are intended for you and no-one else. Don’t distort their worth. You need to keep them and look back at them when you’ve had a bad day. Psychologists suggest that about three of them will balance up a negative happening/comment or whatever. See Liz O’Riodan TEDX talk on her “Jar of Joy” https://youtu.be/Wc1PIAG8Bgg The Appraisal process should still be an educational conversation between two people for the benefit of one and you can bring to it whatever you feel helps your reflection and insight.
Appraisal & revalidation are tiresome & expensive games played by doctors to try to convince patients & their political masters that they are fit to practice. They wouldn't have stopped Harold Shipman or Ian Paterson. They just add another bureaucratic burden to overworked doctors. There are no appreciable gains for patients from them. However, they do provide an additional source of income for appraisers & they give the GMC a raison d'etre which goes some way to explain why they haven't yet been abandoned.
Thank God I'm retired.
Great points here, I've got my appraisal next week and have made a decision not to upload thank you cards and tags. They are personal, difficult to keep safely with GDPR, and the sender has not consented to them being shared. It feels cheap and pointless to use them to 'show off'.
So true !
Totally agree with above comments. Appraisal and validation were significant factors in my taking early retirement.
Very much agree with the comments here. Have had thankyou gifts/cards over the years of being in the system, and mostly from patients I would never have expected them from. I don't think I have ever 'uploaded' them or shown these cards to anyone other than my cat. I wish medicine would stop draining every inch of enjoyment out of being human. Making decisions over what to do with something that was only intended to lift the spirit. Most tags and cards ended up in confidential waste, and I have only a few for keepsakes so far (kept in a file with portfolio as work related but not as part of public or shared portfolio) . I agree with above, these do not validate you as a clinician or as a person or as an employee in any way. Situational judgement multiple choice question (pick one answer only) 'if you recieve a thankyou note or gift whilst at work from a colleague or patient or a passerby on the street or a neighbour whilst you are wearing your work ID. Do you a) burn it as it is patient identifiable b) upload it to portfolio or show it off at interview to elaborate on how much your patients appreciate you and what a wonderful job you think you have done c) declare it as you may be in trouble for not declaring it and it's not up to you to determine the value of the card or 'gift' or d) you should scan it and submit by email to the head of employment /HR and submit it as a compliment (because it is owned by the employer as we are all exactly the same and no one should be seen to have taken all the credit?
As fo answer b) this is utter nonsense. I would even go so far as to see this as potentially narcissistic and possibly encouraging of negative personal traits that I am sure Shipman, as someone above said, had tonnes of thank you cards and whatever else he manipulated out of situations for personal gain. Showing off these tokens would feel wrong in every way but on reflection perhaps keeping them as keepsakes is weird too? I really don't know how I feel now. I hope I don't receive any more!
Couldn't agree more: high time for an all-doctor survey on the value of the revalidation process as it stands: without wishing to prejudge it, I'm pretty sure 95% would opt for a simpler, shorter, less jargon-filled, appraisal and procedure: with such a shortage of medical man hours evident from waiting times and waiting lists, and the almost certain knock-on effects of significant subsequent mortality / morbidity, what on earth are the GMC doing about urgently reviewing the need for such an extravagant and bureaucratic process. I'd vote anyone in who aims to sort this.
I resonate with almost everything here, apart from the fact that I am sadly not yet retired - my appraisal is in 10 days time and I still haven’t uploaded all the requisite information because I have been too busy guess what, actually doing my very demanding coal face inner city GP job. We are short staffed, underpaid and pressed on every side & yet still have to jump, nay dance and pirouette through this ridiculous hoop every year. It’s very depressing. Thank you secret doctor for voicing this patient expressed gratitude paradox. We are no longer trusted professionals continuously making complex judgements, we are reduced to a website offering to prove our worth and justify our very existence. Utterly fake. Don’t even get me started on CQC...
Sanctimonious humbuggery. The live blood of appraisal.
I too have stopped presenting them at appraisal. I don’t believe there is any compulsion to do so. I will tell my appraiser (truthfully) that I have received a number of thank you cards and gifts of appreciation. I do not want to demean the act of gratitude by using it for what is perceived to be ‘evidence’ of good practice. It is time the Appraisal process grows up into an adult professional interaction. Placing any worth at all on this element maintains my impression that it is an infantile process that fails to achieve its objectives, and is a waste of professional time and public money.
Agree agree agree
So now what?
How do we go from here to making a change?
I took up the offer of free coaching from NHSE and found that to be a much more useful exercise to reflect and plan for the next phase of working
True - it's a game and I sympathize with the sentiments expressed by our retired colleagues. Since you could do it on line I find the whole process remarkably pain free (as long as you have a sensible appraiser), and I was one of those dragged kisking and screaming into it. As for the thank you cards - I NEVER put them in my appraisal and have never been asked why not. I did have a lot of wine at Christmas, which are not being declared either, just drunk with thanks!
I am an appraiser. I do not receive specific payment for this (although I do try and do this in my working hours). The appraisal itself should be a supportive and reflective discussion - if you feel that these types of messages help your reflection or development then include them, but if you don't then don't! Most such feedback is fairly generic, but I have had occasional ones (usually from colleagues rather than patients) that are more helpful because they actually say something specific about what I did well and (even more useful) what I could do better.
I agree the revalidation element that is connected into the appraisal can be more like box-ticking but I try to be clear about that separation of these two elements and have had some feedback (not anonymous) to say that the appraisal discussions have been helpful, especially from colleagues thinking about making a change. I suspect there may be an element of getting out what you put in though as if you don't engage with the appraisal in this way then you won't get very much out of it. I have certainly done appraisals where its clear that people just want to get through the process with the minimum of effort.
I have never used my thank you cards for appraisals. I have always just said that I receive many thank you cards. You are right - they are often very personal.