ABSTRACT
Professional isolation appears to be associated with underperformance. We developed a set of professional isolation indicators and asked 26 experienced members of the Medical Council of New Zealand’s Competence Advisory Team, composed of senior medical educators and performance assessors, to list and describe indicators of professional isolation and ascribe a weight to each. We wanted to know if doctors found to be underperforming were more professionally isolated than those performing satisfactorily. The difference between the sample and the control group was significant: doctors underperforming were more professionally isolated than their peers. This paper should be regarded as an early communication of an interesting, but still unproved, hypothesis.
INTRODUCTION
Professional isolation appears to be associated with underperformance1, but is poorly defined.
Isolation can be geographic, professional, strategic, resource-related and even psychological: being physically apart from with large population centers, involved in a one-doctor practice or excluded from the planning and decision-making process, which leads to a lack of resources. Isolation tends to feed on itself unless the medical professional accepts as a challenge the need to adapt in order to survive (adapted from Walton, 2000).2
“Professional isolation stifles professional growth. There can be no community of learners when there is no community and when there are no learners.”3
“It is clear that professional isolation perpetuates professional ignorance,” Eisner said of teachers4, and apart from advancing age, lack of contact with peers appears to be the factor most clearly associated with loss of competence in physicians.5,6
We developed a set of indicators of professional isolation using the expertise of assessors of physician performance in New Zealand.
In an open email survey we had previously asked 26 experienced performance assessors and members of the Medical Council of New Zealand’s Competence Advisory Team to list and describe indicators of professional isolation, and to ascribe a weight (1 = unimportant, 5 = very important) to each; they were not prompted. The assessors were lay and medical professional people who had trained and participated in assessments of the performance of practicing doctors about whom concerns had been raised. The members of the Competence Advisory Team were senior medical educators and performance assessors. Their involvement gave face validity to the list. This process is detailed elsewhere,7 and the indicators of professional isolation and their descriptors are shown in Table 1.
Indicators of professional isolation
In New Zealand, a doctor’s performance can be assessed for any reason, but in practice is assessed after considering concerns raised by the Health and Disability Commissioner (HDC), the Health Practitioners Disciplinary Tribunal (HPDT), the Accident Compensation Commission (ACC), Medical Council of New Zealand (MCNZ), Complaints Assessment Committees (CAC), peers, patients or others. A layperson and two doctors from the same discipline conduct the assessment using standard instruments and, upon finding a doctor is underperforming, may recommend remedial education.8
We wanted to know whether those doctors found at assessment to be underperforming, were actually more professionally isolated than those performing satisfactorily.
METHODS
The study covered the five years beginning Sept. 1, 1999. The sample consisted of all doctors who had been found at performance assessment during that period to have been underperforming, and the control group consisted of the next doctor practicing in the same (or similar) discipline who had been found at assessment to be performing at a satisfactory level. There were 19 doctors in each group. Cases and controls were not matched for variables such as age, time since graduation or gender.
Members of performance assessment committees (three for each doctor, except for one doctor who had a one-person review) were asked retrospectively to assess the degree of professional isolation they had observed in the doctors whose performance they had assessed, using the checklist of eight indicators of professional isolation. They were asked to respond “yes”, “no” or “don’t know” to each indicator. The “yes” responses were summed and the mean calculated (0–8) for each doctor and for each indicator (0–3), and the study and control groups compared using Student’s t-test.
RESULTS
Table 2 shows the characteristics of the study and control groups. One hundred reviewers (of a possible 112; response rate 89 percent) responded. Doctors found to be underperforming scored higher (mean 4.44 “yes” responses) in combined measures of professional isolation than those found to be performing at a satisfactory level (mean 3.41) (Students t = −3.29, p = 0.0022; see box plot Figure 1). Reviewers scored individual indicators as set out in Table 3.
Characteristics of the study and control groups.
Box diagram showing mean professional isolation scores (Y) for doctors performing satisfactorily (A) and underperforming (B) (Students t = −3.29, p = 0.0022)
Mean number of “yes” responses for each professional isolation indicator.
DISCUSSION
Several circumstances combine to confound these results.
The control group comprised doctors whose performance had given rise to concerns, and who had subsequently been selected for assessment – their professional isolation may have been a factor in the presentation of a concern, or in the determination that they should undergo assessment, so that scores for professional isolation in the control group may well have been higher than those in the general population of doctors.
It was a retrospective survey, relying on the memories of assessors, about events that took place as much as five years earlier: inevitably recollection would vary. Assessors were aware of the outcome of the assessment and are likely, with recall bias, to have scored higher than doctors they knew had been found to be underperforming.
With those reservations, the difference between the sample and the control group was significant: doctors underperforming were more professionally isolated than their peers. The degree to which isolation results from underperformance, or causes it, is open to speculation.
As to the individual markers, only “Cultural barrier” and “MOPS and CME failure” showed statistically significant differences between the two groups, though the absolute mean scores for “Personality and behavior”, “Solo” practice, “Poor colleague relationships” and “Stress” were considerably higher for both groups. Again, the degree to which individual indicators of professional isolation precede or follow underperformance, is speculative.
Some of these indicators of professional isolation should be obvious enough to alert colleagues, whose consequent intervention to reintroduce a doctor to the peer group could have the secondary effect of alleviating underperformance. Peer group surveillance is well recognized as an important factor in the maintenance of professional standards.
This paper should be regarded as an early communication of an interesting, but still unproved, hypothesis. We intend to start a prospective study using self-score and reviewer instruments to assess professional isolation and to try to replicate this work internationally.
REFERENCES
- 1.↵LewkoniaR. Educational implications of practice isolation. Medical Education2001; 35: 528– 529.
- 2.↵WaltonP. Isolation and professional adaptation. Paper given at 10th IAALD World Congress, Dakar, Senegal, 24–28 January 2000. Available from http://www.iaaldcee.hu/dakar2000/papers/walton.htm.
- 3.↵BarthRS. Improving schools from within: teachers, parents, and principals can make the difference. Jossey-Bass Education Series (Paperback), p 18.
- 4.↵Eisner,EW. The kind of schools we need: personal essays , Portsmouth, NH: Heinemann, 1998.
- 5.↵NortonPG, DunnEV, SobermanL. What factors affect quality of care? Using the Peer Assessment Program in Ontario family practices. Can Fam Physician1997; 43: 1739– 1744.
- 6.↵St GeorgeIM. Should all general practitioners be vocationally registered? NZ Family Physician 2004; 31: 17– 19.
- 7.↵St GeorgeIM. The cost of solitude: professional isolation and performance. Accepted by the Journal of Continuing Education for the Health Professions, April2006.
- 8.↵TraceyJ, SimpsonJ, St GeorgeIM. The competence and performance of medical practitioners. NZ Med J2001; 114: 167– 70.
