I had a Significant Event recently. Not, you understand, a real significant event such as a bereavement or a son getting married; but a Significant Event involving a Patient. You know — the kind we make notes on and proudly enter in our appraisal portfolios. The Event was the discovery that a patient’s mild but long-standing anaemia was almost certainly a side effect of treatment with carbamazepine. Not that significant (although finding that I had made the same discovery a couple of years ago and forgotten did make it moderately Significant for me personally), but it did set me thinking.
The thinking concerned side effects of drugs. The most widely quoted evidence about such effects comes from data on patients admitted to US hospitals.1 Up till now I have tended to think that such data doesn’t apply to UK primary care. But then I used to have the same attitude towards the overuse of antibiotics causing bacterial resistance, until I had to read a paper we published in the BJGP.2 Out of interest I used the standard method in our practice of bringing up matters for discussion. I took it to our half hour coffee break, a three-line whip affair attended by all the doctors working in the building each morning. I asked my colleagues several questions. How good are we at recording side effects of drugs? Do we know how frequently they occur? Should we standardise and beef up our method of recording in order to gather some data on frequency? The answer to the first question was, as you would expect, variable; for the other two there was a consensus that the effort would be considerable, with little to be gained from such an exercise. End of discussion.
Except that, in order that this should qualify as a Significant Event, it has to be Documented, Discussed at a Significant Event Audit (SEA) Meeting, Action Taken as a Result has to be Recorded, and the whole turgid, clanking bureaucratic process reported to the PCT. Our next SEA meeting is not scheduled to take place until several weeks after this event has already been discussed over coffee. By then it will have lost all immediacy and become stale; no longer significant though still, of course, a Significant Event. It’s not the first time this has happened. Quite the other way around: when matters come up that are genuinely significant it would be irresponsible and arguably negligent to wait until the next SEA meeting. Instead they are discussed (over coffee); a decision is taken immediately and communicated to everyone in the practice about what needs to be done in order to reduce the chance of a recurrence.
Rather to my surprise I have become an enthusiast for annual appraisals. It has brought to professional life a requirement that I should spend a modicum of time every year thinking about my clinical practice; what I have got out of the various educational activities; what I want to do in the next year; and planning to achieve them. This is healthy for professionals, and equally an important component for anyone wishing to defend the idea of a self-regulating profession. I argued for this kind of approach more than 20 years ago,3 and now recognise that most of us (including myself) need some kind of impetus or control to make sure we do it. In passing, I retain my scepticism that this kind of process is going to identify under-performing doctors, but that’s another story, and not the point of this piece. However, weighing down the educational process with the managerial machinery runs the risk of turning it into a ritualised box-ticking exercise and squeezing all the educational value out of it. We did wonder if we should attempt to designate our coffee breaks as SEA meetings every time one of us brings up some interesting clinical or administrative problem. While that might make sense to us, and might be acceptable to the PCT, it’s playing a rather silly game by the managerial rules. As long as we agree to the use of appraisals to support revalidation, I am gloomy about retaining their value as an aid to continuing education.
Footnotes
Footnote. In the weeks following the first event, I identified five other similar side effects. I may therefore be correct that such events aremore common than I had previously thought.
- © British Journal of General Practice, January 2011