Transforming the review process from a punitive, deflating experience to a valuable one that strengthens the relationship between physician and organization.
With increasing health system consolidation and growing pressure to standardize care delivery, ineffectual annual performance reviews have flourished. These physician performance assessments are often superficial, and comments are not actionable, timely, nor constructive, leaving physicians feeling deflated. At their worst, these assessments may contribute to physician burnout. Meaningful
physician engagement is essential to organizational success.
Despite their common use, little has been written about how to do physician reviews well. We propose a framework for an annual physician performance review that aims to learn about the physician, share organizational values, and identify
specific improvements to achieve individual and organizational goals.
"The time on the clock turned to 1:59 p.m. I clicked a final button to complete my visit note in the electronic medical record and locked my computer. Sliding my chair neatly under my desk, I made my way from the office I shared with our practice’s physician assistant, dietician, and pharmacist down the hall to our practice manager’s office. It was time for my first annual performance review since completing residency, and I anticipated generally positive feedback. I had excelled in medical school and performed well in a competitive residency program. I felt confident. I was not anxious. Knocking lightly on the practice manager’s door, I was motioned inside to the chair next to her desk. Shuffling some papers, she gathered up a few and turned away from her computer to face me. We made small talk about the latest antics of our toddlers and plans for the weekend.
She cleared her throat and turned to the papers in her hands. We glossed over rows of metrics and checkboxes, all with “Meets Expectations” or “Exceeds Expectations” selected. Then she moved to the 360-degree feedback, elicited anonymously from all staff in the clinic. “Well,” she said, sighing, “the staff say you’re ‘tough.’” The downward inflection in her tone and a disapproving cast of her eyes said it all. I was “not a team player” and I, “asked a lot” of the staff. There were no concrete examples and no suggestions for improvement.
My cheeks burned and my mouth went dry. I had never received feedback like this before — my “performance” whittled down to checkboxes and unsubstantiated claims by anonymous staff members. Was this what it was like in the “real world?” Clearly, I would need to make adjustments. Was there something wrong with me? Had I been mistaken about my skills all along? Was I a bad doctor? A bad teammate? The practice manager clearly disapproved of my performance. What about the medical director?
Perhaps there was more feedback that day, more positive takeaways. I don’t recall. My only desire was to rush back to my desk and bury myself in my work until the clock struck 5:00 and I could go home. Passing the clinical workspace, I wondered which staff members found working with me burdensome. Who smiled to my face and then scowled behind my back?
As a new physician, still forming my professional identity and building up my confidence as an independent provider, I found that annual performance reviews devastating. For months, self-doubt hung over me and crept into my interactions with team members. I felt isolated. Subsequent reviews induced anxiety and dread. Boxes were checked, feedback given. Expectations were met or exceeded, but not my expectations. The annual performance review, an opportunity to engage me as part of the team and support my development and that of the practice, failed. I wanted to be an integral member of a successful and high-functioning team providing excellent care to patients, but I ultimately left the practice."
When a new physician joins a practice, he is scrutinized by other physicians and workers for a period of time. Usually, the physician is employed for two years or more depending on the practice. At the end of that period if all is well he/she may be offered a partnership. However, in today's world it is more likely the clinic is a corporation or LLC. The physician may be offered stock and not require a buy-in. Nevertheless, the initial shock transferring from an academic world to the commercial world is a shock. The neophyte physician is ill-equipped to be evaluated by an administrator.
Without a doubt, a well-functioning interdisciplinary care team is essential to success in every industry. But is there another business where the success of an individual “franchisee” is as integral to the financial success of an organization as a primary care physician is to her local clinic site? With burnout affecting an estimated 50% of physicians in some specialties and each physician turnover costing $500,000–$1 million to an organization, failing to fully engage physicians in the annual review process may be proving costly.
In a recent Medscape survey of more than 15,000 physicians, “lack of respect from administrators/employers, colleagues, and staff” was identified by 1 in 4 physicians as contributing to burnout. Feeling like a “cog in a wheel” was identified by 1 in 5.
A New Model for Physician Reviews
How We Got Here
Medical groups and hospital systems have undergone rapid consolidation and the rate of growth of health care administrators has risen exponentially, far outpacing the growth of frontline physicians. With this influx of health care leaders trained in business models and pressured to standardize processes across hundreds, if not thousands, of physicians, the problem of awkward and ineffective physician performance assessments has spread. Often, the same person reviewing the receptionist, phlebotomist, and medical assistant also delivers the physician performance review.
Prior to each review conversation, physicians are provided with their standard quality, productivity, and patient experience data and asked to reflect and complete a self-assessment. Additionally, we ask each provider in this self-assessment: “What do you love to do and how can we get you more of it?” and set goals related to enhancing fulfillment in practice. These prompts are modeled after the “humble inquiry” behavior for leaders described by Edgar Schein and used at the Mayo Clinic as a tool to frame physician performance reviews. The humble inquiry approach emphasizes building a collaborative relationship and approaching the conversations with genuine curiosity and vulnerability, believing that we have much to learn from clinicians about how to improve care for our patients.
Where do we go from here?
We include in the review packets our organizational goals and performance data related to the quality of care, patient experience, and physician and staff experience. Also included are data at the clinic and physician level, when available. We aim to have physicians answer the question of “What is my role” in the organization’s success, being sensitive to the problem of physicians feeling like they are “cogs in the wheel.” By sharing individual, team, and organizational performance, we strive to emphasize the connection of individual physicians to their local teams and to the organization.
Addressing the risk of burnout during the review is a high priority for our organization. To demonstrate clearly as an organization that we value healthy and balanced physicians, we chose to include a page listing each physician’s vacation balance. If the vacation balance is excessively high, it allows the medical directors to broach the subject of burnout in a nonjudgmental manner. Any physician would be loath to tell a fellow worker about burnout.
In today's world where physicians are constantly being evaluated or judged the very real possibility of being reported to a medical board strikes terror in the heart of a new (or old) doctor. A medical board has the authority to suspend or place a physician on probation. Despite being vocal about physician rehabilitation, the process is punitive emotionally and financially.
Dedication to serving the interest of the patient is at the heart of medicine’s contract with society. When physicians are well, they are best able to meaningfully connect with and care for patients. However, challenges to physician well-being are widespread, with problems such as dissatisfaction, symptoms of burnout, relatively high rates of depression, and increased suicide risk affecting physicians from premedical training through their professional careers. These problems are associated with suboptimal patient care, lower patient satisfaction, decreased access to care and increased health care costs.
Addressing physician well-being benefits patients, physicians, and the health care system. Governing bodies, policymakers, medical organizations, and individual physicians share a responsibility to proactively support meaningful engagement, vitality, and fulfillment in medicine. Furthering these ideals within the culture of medicine and across its diverse members may help to strengthen health care teams and improve health care system performance.
