Assessing doctors in difficulty: the assessor experience

There are inherent difficulties in addressing the problem of a doctor who is underperforming in some way.

Many doctors in difficulty believe that they have been unfairly treated and this may be the case in some instances. Assessing a doctor in difficulty creates an emotionally charged situation which requires careful handling.

Megan Joffe is a clinical and organisational psychologist and works for the Edgecumbe Group. In this article Megan explores the assessment experience from the point of view of the assessor and explores the difficult balance between empathy and objectivity that the process requires.

In this article I would like to offer my personal reflections on the experience of assessing doctors from the behaviourial perspective. I hope that it will illuminate the process somewhat and provoke discussion and further sharing on such an emotionally charged topic.

I want to make it clear that that I am not required, and clearly nor am I able, to assess a doctor’s clinical performance. My role is to make an assessment of the doctor’s behaviour and take a view on the prognosis for behaviour change. As a result, I am interested in how the doctor interprets the meaning of their experiences, as well as their insight, motivations and values. Getting to this information, which is very personal and often an emotional experience for the doctor, is the first challenge. Putting it all together into a coherent and objective report is the second and, arguably, more difficult challenge. Therefore, my reactions and reflections detailed here are both my professional and personal experience of assessing doctors in difficulty. They come firstly from my mindset as a clinical and organisational psychologist, and secondly as an individual who has to make a short, intense connection with another person and then has to judge them.

The context of the assessment

It seems strange but many doctors have little or no experience of psychologists, so often come to the assessment with their own (mostly incorrect) pre-conceptions. As a result, I have to work hard to establish rapport and get over their initial responses which vary from anxiety to anger and anywhere in between. We must to get on during the interview and the doctor must talk. The behavioural assessment is based on the experience in the moment with the doctor, the here-and-now; how he relates to me; (I will use the masculine gender for convenience) how he formulates his questions and answers; what he chooses to tell me and what he doesn’t. These elements, combined with the psychometric data, help me to construct a picture of the doctor.

The doctor and I spend 5 to 6 hours in a small room, talking. This is an intense, emotional experience for both of us, but especially for him. We touch on personal and sometimes very intimate feelings and experiences. I have the "professional authority" to ask about anything, but, in my experience, the majority will tell me more than I want to know, without much probing. The overwhelming feeling I get from this stage of the process is the relief they get from being given the opportunity to tell their story, without interference or need for editing. They often say they have not spoken to anyone else in such depth about their referral. For all doctors, maintaining face is important with colleagues, so this highly emotional experience is rarely explored outside the room. Some report that they don’t even tell their spouse The Assessor Experience 2 13/10/2005 or partner what has happened. In this sense, I imagine the process is cathartic for the doctor.

However, the experience is intensified by the high personal stakes for the doctor. They often feel their past record is tainted; their future bleak and the whole experience unfair, not to say humiliating. The stakes are high, careers and futures are at stake, if not in reality then certainly as a perception by the doctor. They feel they have little choice but to participate in the assessment. They arrive at the interview with a range of feelings and expectations which are obvious in their behaviour and interaction with me. Many doctors are indignant, angry, hostile, defensive, frightened, fearful or any combination of these emotions. Behind all of these feelings is a desperate anxiety and feeling of powerlessness and a deep sense of humiliation that many struggle to articulate. For a doctor used to professional autonomy and authority, this isn’t a welcome feeling. As a result, some doctors present themselves as arrogant and in control; but this behaviour, more often than not, is an attempt to hide the fear and anxiety.

Spending this intense, intimate time with the doctor, often leads them to view me as having power I certainly do not possess. They want reassurance that things will be alright and that they won’t be punished; or that their futures are secure. I cannot help feeling sorry for some of them, for example the doctor with an exemplary record referred for behaviour which seems related to stress, only a short while before retirement. In this context, the challenge to maintain objectivity and also be empathic, enquiring and kind, while not unusual for a psychologist, is nevertheless demanding.

The role of the assessor

As a clinical psychologist, I have been trained to recognise my own feelings in relation to the client or patient so as not to have the relationship skewed by my own emotions and experiences (commonly known, in psychoanalytic terms, as transference). To ignore these feelings would be neglectful and would probably lead to my construction of the case and the conclusions I reach being mildly or even strongly influenced by my feelings. Therefore, it is important to explore them outside of the session, perhaps in a supervision session for example. This process recognises the feelings as real, but frees me from having them unknowingly interfering in the assessment.

Personally, it is the frightened, fearful and humiliated doctor who poses the biggest emotional challenge for me. I naturally want to support, sympathise and help them, but that isn’t appropriate in the assessment role. Here is a simple model which helps me in my interaction with the doctor. Those of you familiar with Karpman’s Drama Triangle will recognise it. It is commonly drawn as a triangle with a role noted at each point of the triangle:

This triangle can be looked at from several points of view. Some doctors do seem to me to be the victim of politics and power, or of organisational ineptitude and laxness. They are sometimes convenient scapegoats and so could be viewed as victims of persecution. Other doctors seem to be the persecutor themselves, in the sense that their interpersonal behaviour has made victims of others through bullying and harassment. Many doctors see themselves as victims and externalise the blame to others: the system, the Trust, the Medical Director, the other doctors, a particular nurse and so on. Some doctors in the victim role experience me as persecutor because I am asking them about how their behaviour has contributed to the situation they now find themselves in. Other doctors may view me as having power and being able to rescue them.

My challenge is to be experienced as none of these roles. I endeavour to ensure that the doctor experiences their interaction with me as being enquiring, empathic and fair.

The larger organisational system

My role as a psychologist qualifies me to look at the doctor as an individual. My experience as an organisational consultant has led me to look at the broader picture and never to see the individual in isolation from the environment or system in which they operate. In fact, it is often impossible to ignore the role of the system in providing a ripe context for the doctor’s problems to surface and in maintaining these problems, despite its various attempts at solving them.

It is challenging not to make sympathetic comments which could categorise me as rescuer, particularly when the doctor is in distress, and where it appears that he might be a victim of organisational dynamics or power play, rather than a victim of his own inadequate interpersonal skills, for example.

It is impossible to ignore the role of power in organisational behaviour. Power can be used for various reasons, it can be used to play; it can be used instrumentally to achieve an end and it can be used for political reasons. In the organisational power game it is inevitable that some individuals are scapegoated, victimised or become lightning rods for trouble. Without too much effort, they find themselves embroiled in interpersonal dynamics which overwhelm them and leave them feeling powerless. This is a common feature of organisational behaviour and not at all restricted to the Health Service. What is particular to the Health Service is the length of time the situation is often allowed to continue; how often the doctor is completely surprised by the allegations because no one has ever given him feedback and how intransigent the system can be. In addition to this, the Health Service is a system in a state of constant change, operating under a continuous low level of stress which can exacerbate individual problems.

In Conclusion

During the assessment, I work very hard over the intense period that I meet with the doctor to establish rapport and gain their confidence. After the assessment, I never see them again and am often left dissatisfied by not knowing what happens to them, especially when the individual appears to have been the object of unfair treatment.

Nevertheless, I must produce a report. Sometimes the conclusions and recommendations are as clear as daylight to me. Whether they are achievable is less clear. I usually have faith in my prognosis about what the doctor as an individual can achieve. My faith in the system is less strong and I often feel anxious for the doctor whose difficulties are a systemic mixture of individual and organisational ingredients which do not complement each other.

I leave the assessment wondering how the doctor will get on afterwards and try hard to deal with my frustration with the system. I certainly hope that, whatever the outcome for the doctor, the time they spent with me was cathartic. I hope my empathy came across during the assessment and that I didn’t make them feel I might be their rescuer, or their persecutor. My wish is that they left the assessment feeling they had been heard and understood.