Parts of this report are reproduced or adapted with permission from Price et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
When encountering a [doctor] who is not thriving, it is often difficult to figure out what is wrong and how to help. And when confronted with a serious violation of professional ethics or a repeated threat to patient safety, it is equally unclear what to do . . . Unfortunately, problems often become worse, and if uncorrected, result in harm to patients, disruption of the healthcare team, and occasional dismissal . . .
Proficient and safe doctors, operating efficiently within teams, are an essential part of the provision of high-quality and safe care for patients. If the performance of a doctor is lacking, patients may be at risk.3 Performance issues can be experienced by doctors at any stage in their careers for a variety of reasons, including health/well-being, personal reasons, the environment of the workplace, and not keeping up to date and participating in continuing medical education. Performance concerns are often complex and multifactorial, and can involve issues relating to knowledge, skills and professionalism.4–6 To ensure patient safety, it is vital that if there are questions about the performance of a doctor they are identified quickly and, where appropriate, addressed through remediation.7
Remediation is the process by which a doctor’s poor performance is ‘remedied’ and the doctor returned to safe practice.8 Remediation can be formally defined as ‘an intervention, or suite of interventions, required in response to assessment against threshold standards’.9 Threshold standards are set by regulatory bodies [e.g. the General Medical Council (GMC)] to keep patients safe. What actually constitutes a remedial intervention ranges from informal arrangements to complete some reskilling, through to more formal programmes of remediation and rehabilitation.10 It is generally agreed that there are three necessary components of remediation: (1) the identification of performance deficit, (2) remediation intervention and (3) reassessment of performance after intervention.11
Remediation has been classified as a ‘wicked’ problem the medical profession has struggled with for decades.12,13 One of the main difficulties relates to the fact that remediation has historically been conceptualised as a way of addressing a person’s lack of knowledge in a particular area. Although addressing knowledge is important, it is not enough to achieve behaviour change.12,14,15 The performance of a doctor is shaped by a variety of different contextual factors, including the attributes and skills of colleagues, system resources and organisational culture. Viewing remediation as merely an educational exercise, ignoring the contextual factors influencing competence in individuals, is unlikely to be enough to address significant performance gaps.12 In recent years, there has been an important shift in the conceptualisation of remediation towards being a behaviour change process (i.e. understanding what is necessary to produce lasting performance improvement for a particular doctor in a particular context).7,12
Remediation interventions are widely used in health-care systems across the globe to address underperformance. When we use the term underperformance, we are referring to situations in which a doctor’s performance is below the standards required to ensure safe practice. It is estimated that approximately 6% of doctors (i.e. approximately 9400 doctors) in the hospital workforce in England may be underperforming at any time and that 2% (approximately 4100) of all practising doctors will be undergoing remediation.10 These figures will have increased because of the process of revalidation, which is the UK’s relicensing system for practising doctors that is regulated by the GMC.8 Medical revalidation was introduced in 2012 as a statutory requirement. It is the procedure by which all UK doctors evidence that they are up to date and fit to practise. This is achieved by collating supporting information as part of an annual appraisal. Then, usually every 5 years, a senior doctor called the ‘responsible officer’ within an associated organisation (known as the ‘designated body’) recommends a revalidation outcome decision to the GMC. If underperformance is identified through the revalidation process (or through any other route), the responsible officer has a statutory responsibility to ensure that the designated body offers ‘training or retraining’.16 Specific guidelines for responding to a concern about a doctor’s practice have recently been published to support this process.17 Data from research evaluating medical revalidation suggest that revalidation is helping to identify such poor performance.18
It is difficult to quantify the real human cost of an underperforming doctor; however, approximately 12,000 patients die in England each year as a result of preventable medical errors.19 There is also the corresponding financial cost of these errors to consider. The NHS paid out > £2227.5M in medical negligence claims in 2017/18 alone.19 However, the true societal costs when things go wrong are unknown. The relatively few incompetent doctors need to be stopped from practising; however, there is a more widespread and difficult problem to solve that would improve the health of the public and patients in the NHS, and that is doctors who underperform. Remedying underperformance, where possible, is both a practical and a financial imperative, as doctors are in short supply and are expensive to train.20 There are shortages of doctors in particular specialties and geographical areas.21 The NHS in England, Northern Ireland, Scotland and Wales has been under extreme pressure to cut spending in recent years.22 On average, it costs £485,390 to train a general practitioner (GP) and £726,551 to train a consultant.23 Therefore, offering remediation to retain expensively trained but underperforming doctors is a logical financial solution.
Although offering remediation to underperforming doctors makes sense on a practical and financial level, there is another important reason related to the ‘duty of care to doctors’.24 Rather than ‘striking off’ or ‘firing’ a doctor who is underperforming, providing the necessary support and remediation, and the opportunity to improve, is imperative in a caring workplace. The GMC states that its aim is to ‘protect patients and the reputation of the profession’ (Reproduced with permission from General Medical Council.24 © 2015 General Medical Council). Once this has been achieved, the GMC says that it also has a parallel duty of care to the doctors to encourage and enable remediation in suitable circumstances.24 Remediation is therefore important for a doctor’s personal and professional development, as well as their patients’ safety and well-being.
Despite the importance of remediation in the regulation of doctors and in ensuring patient safety, research on remediation is lacking.12,25 Three systematic reviews and one thematic review have been conducted on remediation across the continuum of medical education.11,25–27 All four reviews on the topic of remediating doctors identify a lack of research that would provide a firm theoretical base to guide remediation interventions. The reviews were also unable to identify why particular interventions work for some doctors and not for others (i.e. detailed analyses on important contexts were missing):
. . . we cannot delineate precisely what works, and why, in remedial interventions for medical students and doctors.
This issue was also highlighted by research recently commissioned by the GMC, which investigated the impact on doctors of undertakings (i.e. remediation measures agreed with the doctors), conditions (i.e. remediation imposed on the doctors) and official warnings.24 The study had a small sample size; however, the outcomes suggested that stipulating remediation in some cases engendered more reflective and safer practice, but in other cases it engendered more defensive or unchanged practice.24 In other words, the same interventions were producing different outcomes in different contexts and for different doctors. An important issue that has limited our deeper understanding of remediation interventions for doctors has been the way in which systematic reviews have been carried out. In particular, the previous systematic reviews on remediation use inclusion criteria that were too restrictive (e.g. by study design, intervention type) and, hence, were only able to draw on a narrow body of literature. In summary, ‘rigorous approaches to developing and evaluating remediation interventions are required’.25
To design high-quality remediation interventions, it is fundamental to understand the theory of how remediation of doctors is supposed to work, for whom and the contexts that lead to different outcomes. Our review will make an empirical contribution to the existing body of knowledge by developing a programme theory of how remediation of doctors is supposed to work, for whom and in what contexts. The review will enable us to develop recommendations for the tailoring, design and implementation of remediation interventions for underperforming doctors. Finally, this research will produce new knowledge about a poorly understood area of health-care delivery that has a direct impact on the standard of care received by patients.
Review questions
Aim
The REalist SynThesis of dOctor REmediation (RESTORE) review aimed to identify why, how, in what contexts, for whom and to what extent remediation interventions work for practising doctors to restore patient safety. The review was structured around the following objectives and review questions.
Objectives
- To conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.
- To provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.
Review questions
- What are the mechanisms by which remediation interventions work to change the behaviour of practising doctors to produce their intended outcomes?
- What are the contexts that determine whether or not remediation interventions produce their intended or unintended outcomes?
- In what circumstances are these remediation interventions likely to be effective?
The next chapter provides a detailed description of the methods utilised in the review. Chapter 3 presents the results, followed by the discussion in Chapter 4. Finally, the conclusions and recommendations are presented in Chapter 5.