Once all the issues have been defined, a management or Remediation Plan should be drawn up. All issues, whether relating to clinical skills or otherwise, should be included in the plan. Most Remediation Plans will relate to clinical capability and most will be of short duration. Longer plans and those that relate to serious concerns should generally be prepared and implemented with the assistance of an external expert.
Remediation Plans should:
- be developed in consultation with the GP and any important stakeholders, such as AHPRA or the practice
- be tailored to the GP’s needs
- address all the concerns
- have clear objectives
- have a set time frame
- have provision for evaluation of the outcomes
- have defined actions with respect to the outcomes.
Employers and practices may not have the requisite resources and skills to appropriately manage performance concerns. In that event, advice and/or assistance should be sought from an expert in the field of performance management or the RACGP.
Clinical capability (clinical knowledge and skills)
Various clinical skills interventions are available; however, the following points require highlighting:
- The type of intervention will depend on the cause of the performance problem. If the root cause is not addressed, change is unlikely to occur.
- A well-considered, practically oriented and tailored management plan that addresses all the issues is more likely to be successful.
- The learning environment must be supportive.
- The GP needs to be fully engaged. Possible interventions include:
- tutorials to address knowledge and clinical skills deficits
- case discussion, including random case analysis
- audit of clinical notes and prescribing
- role-play of clinical scenarios
- direct observation of consultations with feedback.
Rural and remote locations present their own particular challenges with respect to suitable interventions, how they are to be implemented and the provision of mentorship and/or supervision for the GP.
Health and personal issues
When a clinical capability problem has been identified, consider whether a concurrent health issue exists. It is not unusual for a health problem to be either the cause of the performance problem or the result of it.
Any significant illness, whether physical or mental, acute or ongoing, has the potential to:
- affect judgement or performance
- impact on patient care
- impact (to varying degrees) on self, family and friends, colleagues and work capability.
The health problems that affect performance more frequently are:
- psychological disturbances (eg depression, anxiety)
- substance misuse (eg drug and alcohol misuse)
- physical ill health as a result of stress
- fatigue, jadedness and burnout.
Burnout is a complex syndrome that results from the stresses of daily practice, with heavy workload and time pressures being the predominant factors. Burnout consists of emotional exhaustion, cynicism towards patients and low personal accomplishment (encompassing poor motivation, loss of self-confidence and self-deprecation). Burnout can lead to psychological disturbances and substance misuse. Signs of burnout should immediately raise concerns for patient safety as well as the safety of the affected GP.
Doctors are often reluctant to admit that they have a problem and engaging them is not always easy. In the first instance, concerns regarding a GP’s health and wellbeing should be addressed with the GP, either by the practice or a respected colleague. The GP should be encouraged to seek the necessary help from a doctor and/or psychologist. If they do not have their own GP, they should be encouraged to find one or to contact one of the organisations that provide timely access to medical care for doctors.
It is not appropriate for a GP to have as their treating doctor a friend, colleague, counsellor or psychologist in the practice that they work in.
It may be appropriate for the GP to take time off in order to address their problems, even though they may be reluctant to do so. Rural and remote locations can present particular challenges with respect to taking time off. Referral to AHPRA may be necessary when there is concern for patient safety and the GP does not comply with advice and when the concerns are not addressed.
Chronic illness and disability are not contraindications to clinical practice. Once again, patient safety is paramount. Allowances and adjustments can be made so that the GP may function to the best of their ability. Advice and/or assistance in achieving this may be sought from:
- the GP’s treating doctor(s)
- a rehabilitation physician
- an occupational physician
- an allied health professional, such as an occupational therapist or physiotherapist, who has knowledge of the GP’shealth issues and is in a position to advise.
While there is significant overlap between the roles of the rehabilitation physician and the occupational physician, the occupational physician is possibly better positioned to provide independent advice and support for the GP and the practice.
Attitudes and behaviour
Unprofessional behaviour, such as personal grievances and personality clashes, can have a significant impact on the GP’s functioning in the workplace, as well as on the functioning of that workplace. Practices are encouraged to have a professional behaviour policy in place that:
- identifies the expected professional behaviour
- identifies the possible consequences of unprofessional behaviour
- supports the development and maintenance of a culture of professionalism within the practice
- is committed to the early identification of, and response to, professional behaviour problems
- provides suitable mechanisms for monitoring and addressing problematic situations
- provides suitable mechanisms for addressing serious and/or continued breaches of professionalism.
It will be very difficult to manage concerns effectively without a policy that identifies the expected behaviour, including the consequences of serious and/or continued breaches of professionalism.
Work environment and systems
It is not in the scope of this document to provide recommendations for managing issues relating to the work environment; process, systems and other organisational factors; and industrial relations matters, such as employment contract disputes. However, all these issues have the potential to indirectly precipitate a deterioration in performance (either on their own or in conjunction with other problems) and resolution will generally occur by:
- face-to-face discussion between the disputing parties
- a formal mediation process
- seeking legal advice.