How to Get an Appraisal That Doesn’t Suck

Dr Susi Caesar: I think the main problem is a lack of understanding of the basics. What you said at the beginning was — surely your appraisal is a pass-fail, and if you don’t understand it as a quality improvement tool, if you don’t understand it as an opportunity, once a year with a peer, to just stop in a confidential protected headspace and thing, then it’s set up incorrectly from the very beginning.

Rachel Morris: We’ve all been there, up till 3am, getting the paperwork together for our appraisal, and wondering if we’ve done enough CPD to pass it. Love it or hate it, all of us working in a professional capacity to undergo some sorts of Professional Regulation. In the UK for doctors, this is predominantly through an annual appraisal process and for many other professionals, your organization will require you to do some sort of annual review. We may see our appraisal purely as a tick box exercise to be insured. But what if it could be an opportunity to spend some significant time reflecting on ourselves and our work with a critical friend who genuinely has our best intentions at heart? But it’s getting a good appraisal really worth the time we need to spend on it and how much CPD Do we really need to do?

So in this podcast, I’m joined by Dr. Susi Caesar GP, appraiser, an expert on the transforming power of a good appraisal, who has all the answers. We talk about how to get the most out of an appraisal, how to document your learning and continuous professional development over the course of a year, and how to take ownership of the process yourself so that you can get an appraisal which transforms your mindset and your practice. So join us to find out just what we get so wrong about what an appraisal ought to be. How to get the same sorts of support in other ways, even if it’s not an official appraisal. And join us to find out the answer to the golden question, do we really need to get 50 hours of accredited CPD?

Welcome to You Are Not A Frog, the podcast for doctors and busy professionals in healthcare and other high-stress jobs, who want to beat burnout and work happier. I’m Dr Rachel Morris, a former GP, now working as a coach, speaker and specialist in resilience at work. Like frogs in a pan of slowly boiling water, many of us have found that exhaustion and stress are slowly becoming the norm. But, you are not a frog. You don’t have to choose between burning out or getting out. In this podcast, I’ll be talking to friends, colleagues, and experts — all who have an interesting take on this and inviting you to make a deliberate choice about how you will live and work.

When we talk about CPD or continuous professional development, we often mean updating yourself on the latest guidance, learning how to do that really difficult technical thing, or reading tons of the latest scientific journals. But, I strongly believe that what you need to develop yourself in terms of increasing your self-awareness, getting crucial skills for looking after yourself, or dealing with those tricky challenges in life, matters as much, if not more than increasing your theoretical knowledge. Actually, there’s no such thing as personal development that won’t benefit your working life too. That’s why for every episode of You Are Not A Frog that we record, we produce a short self-coaching workbook to go with the episode. It contains a short summary of the episode, links to further resources, and some questions and activities to help you reflect on what you’ve heard and put your learning into practice. It’s totally free and will help you document your CPD and more importantly, make a difference to your life. It’s those constant small changes that in the end will make a huge difference to you. You can sign up for free in the link in the show notes.

Before we start the episode, I wanted to let you know that we’re currently looking for doctors to help us run our resilience programs in health and social care. So, if you love teaching and training, and also have some experience in coaching, then please do get in touch with us at hello@youarenotfrog.com.

It’s great to welcome onto the podcast today, Dr Susi Caesar. Now, Susi is a GP and an appraiser. She’s an appraisal lead and she’s passionate about the approach to appraisal. She’s worked as the Royal College of General Practitioners medical director of revalidation and she’s currently the Regional Director for the Wessex Appraisals Service. She also chairs the Academy of Medical Royal Colleges Professional Development Committee, and she’s very soon to be the RCGP Medical Director of Primary Care Development. So that’s a pretty huge portfolio, Susi.

Susi: It sounds like it, doesn’t it? But all those roles overlap and have great synergy. So, if you sum it all up as I’m a GP, who’s passionate about appraisal, that probably hits the spot.

Rachel: It’s really fantastic to have you here, as someone who has so much experience in this and, I know you thought very deeply about this as well. Because I really wanted to do a podcast on appraisals. Although, I know that appraisal might not be the sexiest thing, but I think it’s really, really important. To be honest, I think a lot of people, whether you’re a doctor and other healthcare professional or just working in another job, when you hear the word ‘appraisal’, your heart just goes, “Oh, I’ve got to do my appraisal.” It just feels like another one of those things to do. I mean, is that the attitude you generally find, or do you think people’s attitudes are changing every little bit?

Susi: I think people’s attitudes are changing. It was probably summed up for me when one appraisee said recently, “We shouldn’t call this appraisal. It’s the word that gets people down. We should call it appreciative inquiry, and then everybody would look forward to their appreciative inquiry.” I think there is something about understanding how we came historically to the place where we have a process of medical regulation that is essentially based on an annual appraisal, together with an assurance that there are no concerns down the clinical governance route and professional governance route. But, the problem is, the no concerns bit. If you’re an ordinary doctor, where there are no concerns, you don’t even notice. You only see the annual appraisal process. So, calling it an annual appreciative inquiry would probably help you to feel a lot better about it.

Rachel: Yeah, totally. Or even something like, “It’s your annual. Let’s get your career back on track.” conversation. “Let’s make you feel happier. Let’s set some goals.” I think the — and we probably need to talk about this as the elephant in the room to start off with, and I don’t know how this works in other professions, but I think the medical appraisal processes is slightly tainted, because it is in a way, a performance review. You do have to tick that there’s no concerns about the doctor, and you do have to sort of pass your appraisal, don’t you?

Susi: Absolutely not. Appraisal is not a pass-fail exercise. It’s not summative; it’s a quality improvement tool. Really, the summative bit happens outside appraisal in the governance routes. You do have to engage with your appraisal. The only really important thing is that you engage — if you’re on maternity leave, long term sick leave, on a sabbatical, it’s perfectly reasonable to have an approved missed appraisal. But, you do need to have engaged and talked to your responsible officer or spiritual person about why you’re not having one in that given year. Otherwise, it is possible to remove a licence to practice because you’re not engaged with the process.

Rachel: So it’s much more about engagement. There’s very few sort of, actually summative, “Is this person good enough bits in the appraisal?”

Susi: I would say that it’s really important to think of your appraisal as your opportunity to talk about what you actually do, how you keep up to date at what you actually do, how you review that to say whether what you actually do on a Friday afternoon is know what you know you shouldn’t be doing, and what feedback you have on it. Those are the high level principles that could apply to any profession at all. It’s not specific to medicine. It’s why a portfolio-based process is so much better than a high-stakes exam.

Because, for example, in America, they use a resetting of basic entry level high-stakes exams once every five years as their process of demonstrating the doctors stay up-to-date and competent. But, it’s only demonstrating competence in knowledge, and it’s only demonstrating competence at the knowledge of entry level medicine. Of course, you and I know the plethora of ways in which people’s jobs can vary — almost no one has exactly the same job, even as someone with the same job title in medicine. So, being able to explain what you do, and yes, how you historically qualified for it, but more importantly, how you actually keep up to date for what you do now, that I think is where — I mean, I’m going to be controversial here. I think the GMC were brilliant. I think they’ve played an absolute blinder, and this is world class, because it can apply to absolutely everybody no matter what you do.

Rachel: When I’ve been coaching doctors and other senior leaders in other professions, if they are struggling with their work, it’s not ever due to a lack of knowledge. It’s not because they don’t know enough technical stuff about the subject or enough — really specific things. It’s always due to other stuff, such as relationships, where they’re working, or time management, or looking after themselves properly. So, all these other skills, which of course, you can’t possibly demonstrate in an exam. So, you’re right, I think not having to demonstrate that really, really specific knowledge every five years, that’s that’s a massive bonus really.

Susi: I’ve spent — I mean, people have talked about, “I’m so scared about regulation revalidation. I’m going to leave.” I think if people were told they had to sit a high stakes exam, I think, it’s much more likely that they would leave.

Rachel: Oh, gosh, tell me about it. I think I did how many years of exams just like you, and I never want to take another exam in my life, I tell you. So, that’s really interesting. I think, another criticism, perhaps of the appraisal process that people might have, is that they just experienced really rubbish appraisals, and they maybe haven’t gotten on with their appraisal, or their appraiser has just acted like it is purely a tick box process, and they feel that they’ve put a lot of work and effort into it for not much gain — for someone else to tick them off saying, “That’s okay.” I can imagine in other professions as well. A lot of people just see their appraisal processes as just a chance for their boss to nail them for more KPIs, and goals, and objectives for the next year, rather than a true personal development process. I want to start off by asking you, is the main problem that we don’t take enough responsibility for our own appraisal? Or is it something else?

Susi: I think the main problem is a lack of understanding of the basics. What you said at the beginning was, surely your appraisal is a pass-fail. If you don’t understand it as a quality improvement tool, if you don’t understand it as an opportunity, once a year with a peer, to just stop in a confidential, protected headspace, and thing, then it’s set up incorrectly from the very beginning. So, understanding the basics to set it up from the beginning to be useful to you, to understand that your appraiser’s job is, yes, to be a critical friend, but the emphasis is on the friend, who’s holding up a mirror to say, “Wow, have you noticed all the good things you’ve done over the last year?” Have you actually taken the time to stop and say, “Okay, what if that was really meaningful to me? What can I bottle and do more of? And what didn’t work well, and what do I want to do less off?”

I think, really well-trained appraisers deliver appraisals that people can find cathartic, transformational, wonderful. Some of the feedback that we get back from the appraisals in Wessex Appraisals Service are just such powerful, touching records of how this single transaction has suddenly brought the joy of the job back or enabled somebody to stay in medicine. So, when I see social media, really diatribes against appraisal, I just think you must have had an awful experience that doesn’t bear any relation to the experience that I have. But, of course, I am lucky. I helped set up the systems. I do know how to get the most out of it.

Rachel: Yeah, I think that that’s an interesting point. You do need to get a good appraiser, and in some occupations and in some professions, you can’t often choose your appraiser. You just have to go with your boss, etc. But, then I guess I’d be saying, “Well, if your boss is not giving you a very good appraisal, then find a different mentor or coach or someone that can actually give you that coaching appraisal-type process that does allow you to reflect, that allows you to get feedback about yourself, and a critical friend.” I love that phrase, ‘a critical friend.’ So, if we start on the appraiser side of things, how do you be a good appraiser? How do you be a really good critical friend and run something that’s actually going to be helpful for someone?

Susi: You learn really good communication skills. You listen hard. You ask open questions that don’t drill down too quickly into all that you ask clarification questions and things. But, essentially, you tell the person, “This is your protected head space. Time to stop and think. What do you want to think about? If I’m going down rabbit holes with my questions and you think this is not being as useful to you as it could be, stop the appraisal. Tell me, let me refocus. Because as an appraiser, my aim for this two and a half, three hours is to give you my undivided attention and my coaching, mentoring skills to help you look back over the past year and reflect on what you’ve learned, what insights you’ve gained, what impact that’s had, but also then to plan for the coming year in the areas of your life that are most important to you.” And they are often not professional or they’re at that overlap between the personal and the professional.

One of the things I am particularly proud of in the Appraisal 2020 Process that we are enabled to bring in during the pandemic, is that there is now a focus for every doctor every year on just checking in that you have the support you need to maintain the health and wellbeing that you need to carry on practising safely and effectively. I think we’re very good at putting ourselves last, and the adage that you can’t pour from an empty cup has never been more true than in the pandemic.

Doctors have gone above and beyond in every area of their practice — in the hours worked, in the number of patients seen, in the types of jobs they’ve taken on, in the speed with which they’ve assimilated new ways of working. Sometimes, particularly in General Practice, against the backdrop sometimes of media bashing. And doctors who’ve done all that are quite tired and sometimes overwhelmed by the magnitude of the job. So, having time to stop and think about making the job more manageable, providing care in the way you want to rather than the way you feel being told to, those are the things that I’m passionate about. I’m passionate about best patient care. I think a happier doctor delivers better patient care. Therefore, I think, if we, in appraisal can support people in rejigging the balance of what they do or getting rid of minor irritations or even major irritations and changing up what they do, I think it makes a huge difference.

Rachel: Yeah. I 100% agree with you about that. You know lots of sort of communities with doctors around — permission, permission to thrive in work and in life. When you say the communication skills with the appraisers, to be able to do that — I’m listening to that guy — well, that’s learning how to coach. Is it a pure coaching approach? Was there some other stuff in there as well?

Susi: I think it’s more like learning how to be a good GP. But taking three hours to do it in rather than 10 minutes. I wouldn’t want you to think that if you put your GP hat on, you go with a medical approach, because I didn’t mean that. I just meant GPs are really good at communication skills. It’s part of their training from the beginning. I am a trained ILM, level 7, executive coach and mentor. The key difference that I see is that appraisal is once a year and coaching is an ongoing relationship, at a frequency determined by the coachee or the mentee.

Clearly, there are different people who have different models of coaching and mentoring. But, if you believe that the answers lie in the person themselves, whether that’s the eagle model of mentoring, or whether that’s the ILM version of coaching, what appraisal is not, is the senior leader telling you what to do — hierarchical version of mentoring, or the tennis coach telling you how to hold your racket better version of coaching. It’s very much the version that’s about giving space and time to think, so that the person can identify what their key priorities are, and then work through options, which is not to say the appraisers are not also a great resource for signposting. If you do lots of appraisals, you come across loads of examples of great practice. So, to offer those as a smorgasbord of options that somebody may not have considered, makes a lot of sense, but to say, “Oh, I’ve seen how you should do this. This is what you must do.” Now, that’s completely inappropriate.

Rachel: It’s about asking the right questions, isn’t it really? Knowing the right questions to ask and then be able to point people in the right direction, but then again, leaving the responsibility in the choice with the person. I mean, I do think it’s important to have somebody that you respect. So, I think if you’re an experienced GP of 20 years, you’d probably find it quite difficult to have an appraiser, who was very, very newly qualified and didn’t have as much experience in the practices. Yeah, I mean, have you seen those sorts of mismatches or do you not think that?

Susi: Ultimately, I don’t think it matters. I think that the communication, coaching, mentoring interview, motivational interviewing skills are generic. Certainly in the Wessex Appraisal Service, we do a lot of appraisals, where GPS appraise into secondary care, appraiser in the independent sector, researchers, pharmaceutical, charities, so you don’t need credibility in terms of doing the same job. In fact, there is some pretty good evidence that it’s better to have an appraiser from outside your clinical department if you’re in a secondary care trust. Because within the department, it’s hierarchical. It’s hard to work out how to talk about relationships within the department, for example, because everybody knows everybody. If you’re appraised by someone from a different clinical directorate, it gives you the opportunity to open up and really explore things that might make an improvement. I don’t think the person needs to be experienced in the same field. I do think they need to be really well-trained and then supported, and have ongoing calibration and feedback from every single appraisal that they do in order to maintain their skills as an appraiser.

Rachel: It’s like being a good coach, isn’t it? Actually, sometimes you’re a much better coach, if you know nothing of the context because you can just be really curious and go — when someone says, “Well, of course, it’s always like this.” You go, “Is it always like that? Is it really always like that? Is that something you’re just assuming there?”

I always remember, I had an appraisal — this was like, a long time ago. I mean, it was just one comment my appraiser said. I was sort of saying, “Oh, I’m really miserable. I think I’m in the wrong career.” This person sort of talked to me and said, “Actually, I think you just need a bit of a change of —- change your workplace. Then I did. I changed where I was working, and everything got a lot better. So, I think there is something about when you are mired in the day-to-day issues, having someone else who can just take more of a bird’s eye view that, like you said, not mired in the same issues as you. Because when you’re in that, it’s very, very difficult to see a way out of it. I think, that would apply to some of the listeners that work in other roles that get appraised by their their bosses or their line managers. Often their line manager is also mired in the same culture, in the same “Oh, we’re so overwhelmed.” Or that department is being really tricky that it is much more difficult to be neutral. So again, I would think it would be important, if you’re not getting what you need from your direct appraisal, from your line manager or your boss, to find someone else who can give you the same sort of thing a coach or a critical friend or something, or even a thinking partnership with somebody else.

Susi: I mean, it’s really interesting. So, my brother, who’s a consultant of plastic surgeon, he says, “What I do is I go out with my mates, somewhere private. We discuss all the problematical stuff. We discuss where we want to go with our careers and our practice, and all the work life overlap balances, and I’ve sorted it out with my mates down the pub.” Not literally because that’s all confidential. But, in principle, if we all had the right sort of friends, we wouldn’t need this. But, so many of us work in isolation. Also, many of us sacrifice ourselves and our social contacts because other things have become overwhelming in our lives, whether it’s children or elderly parents or work. Then, we don’t have those places to rationalise, sort out, prioritise, just talk things through. What appraisal means is it reduces the inequality of access to support because every single person gets one appraisal every year. But, absolutely, I’m with you. If you need more regular support, the appraisal should be signposting as a PDP goal. Find a coach, find a mentor, set up for some reverse mentoring if you’re a senior leader, do some co-mentoring with a colleague. One way or another, find the support that you need on a regular basis, not just as appraisal. But an appraisal’s good touch point to check on, “Did that work out? Can we readjust the goal? Does it need tweaking to make it even more effective next year?”

Rachel: I guess that’s why it’s actually really, really good. That is an absolute requirement for revalidation to have a yearly appraisal because we all know that those people that often need the services the most never access them. So, if they absolutely have to, as long as we can make sure the appraisal- the appraisers are all really well-trained and really good at that communication. Actually, that’s got to be good for everybody, right?

So I’d love to move on. Now, let’s just talk about what you can do yourself to get a good appraisal. Now, you’ve got a bit of a framework and a bit of a list of things. So, where would you start with that?

Susi: I would start by saying, the big thing that is off-putting, even to me, is if you feel that you’ve got to produce this whole feed-the-beast burden of documentation. So, one of the other things in Appraisal 2020 that we were able to do was rebalance how much you need to do to prepare for your appraisal, in terms of documenting written reflection. I think it’s quite important that people see the difference between keeping up to date, which clearly you do all the time, every day, every time you see a patient, where you don’t know that eponymous syndrome that their hospitals just said they’ve got or whatever it happens to be, and you look it up. Keeping up to date takes hours, but it’s real, and it’s on the job, and you don’t even notice it. Mostly, it’s professional habits that you have a reading, listening to podcasts, like this one, perhaps, or talking to colleagues about patients or seeking advice from the advice and guidance lines. You just keep up to date all the time.

But, if you suddenly have to pull those professional habits that might be subconscious up to your conscious awareness and write them down, that’s tedious and can be a huge barrier to actually even engage in properly with reflection about, “What’s the most important thing I’ve learned this year? What differences had that made to my practice or my patients?” So, I think, the first thing to do is to recognise that you do not need to feed the beast. There is not an overwhelming burden of documentation that you’ve got to produce. The guidance on the Appraisal 2020 model was that tested across GPS and doctors who are part of the Academy Professional Development Committee, you could prepare for your appraisal — the written reflection in 30 minutes.

As I said, that’s not the keeping up to date. It’s not the reviewing what you do, but it’s the reflecting on. They’ll keep you up to date and reviewing what you do, and your feedback can be done in 30 minutes. I think that shifted people’s perception of their appraisal. Because if you haven’t come into it with a resentment, you’ve done too much. That was a waste of time. Then, you could sit down with your appraiser and have a really good conversation about what’s really important.

There is in a way, now that we’ve recognised that the verbal facilitated reflection with your appraiser carries equal weight with the written or recorded, if you did little audio costs to record your reflection, with the internal recorded reflection beforehand, the external facilitated reflection is like a second loop of reflection that carries at least equal weigh — if not more. Then, your appraisers are also primed to ask you questions about, “What was most exciting about how you kept up to date this year? What made a difference? What was your peak experience? What did you learn the most from? What difference did that make?” Those sorts of positive questions are part of the Appreciative Inquiry elements of appraisal.

Rachel: I think that’s gonna make a huge difference. We all keep up to date. Anyway, of course, we do. Remember a few years ago, one of my colleagues — she submitted 230 hours of CPD for her appraisal. I documented every single hour of those. I just thought, “Oh my goodness, that must have been a nightmare for the appraiser to wade through all that.” But we are constantly doing stuff. Every time you watch a documentary on television about the interesting panorama thing last night about maternity care, that is sort of educating yourself and keeping up to date, but it’s your right. The only thing is that I’m not recording it every single time. So, what you’re saying is, it’s not removed the requirement to keep up to date and to do a significant amount of hours of keeping up to date because you have to do that as a doctor, but it’s removed the requirement to have to document it all and reflect on it all and prove that you’ve done it. Is that right?

Susi: Absolutely. What I do, I have an app on my phone, where, when I do something that is a formal learning event, like the RCGP conference, I open my phone, type in the title, it gives me the date. There is a record of my log of which day that happened. I used to have a bottom drawer of certificates and things all stuffed in, that I pulled out at the end of the year and tried to put in date order and try to organise. I did resent that, because it was useless time except to feed the beast. But, by having an app that records the most important bits of my learning, I usually find that I’ve got a better reminder when I come to do that 30 minutes of reflection at the end of the spread of what I’ve done over the year, and it triggers ideas about highlights what I’ve done. I’m very kinesthetic. I’ve got loads and loads and loads of stuff into the private notes. But, I don’t put it into the learning points that my appraiser has to read because I don’t see any reason for my appraiser to have to read the notes that I’ve made. I don’t think it’s important to make notes if you’re not kinesthetic. There are people who take things in brilliantly in an auditory way or need to do visual diagrams or flowcharts and things.

Rachel: I think, even if you’re not a doctor, if you’re in another profession, where, of course if you’re a lawyer, you need to keep up to date on what’s going on in that particular field that you’re working in, it’s good to almost keep a little bit of a record anyway. So, you can just see, and you can remind yourself, and you can see the journey you’ve come on over the year, and you don’t need, necessarily a specific app that you can use — all these note taking apps on your phone, or whatever. So, create that thing for yourself, where you can just bang something down, we can bang your thoughts down. When you’ve had them, I have a journal that I do every morning. I’m constantly just writing little bits in there and think, gosh, if I look back over that, that’s really quite a good record of what’s…

Susi: You don’t have to scan it into your appraisal portfolio or take photos of every page. You need to write three or four sentences and paragraph maybe about the fact that you have a journal and what you do with it.

Rachel: That is very good to know. Because believe me, no one wants to read my journal. There’s far too much about different food and what I’m doing at the weekend in there. But, I think in medicine, we are a little bit obsessed with CPD points and certification and stuff. Do any of the Royal Colleges still require officially certified CPD points?

Susi: I can’t speak for all the Royal Colleges. They have their own representatives. I think that there are some really good college CPD programs. For example, the Royal College of Psychiatrists mandate that you discuss cases in a peer group to calibrate your practice. That strikes me as an example of best practice. But, what is true, is that it has become overwhelmingly obvious that bean counting 50 credits is unhelpful. It leads to tensions where there shouldn’t be any tension.

What we realised in the pandemic was that everybody did hundreds and hundreds of hours of keeping up to date, without counting any of them. Because you were looking at Worldometer everyday, you were listening to the news everyday, you were talking to colleagues all the time, you were having emergency meetings.

At some points in a pandemic, in general practice, everyday to change how you adjusted things in the practice for your patients and recording that would have been completely inappropriate and disproportionate. So, I think there’s something about being sensible and choosy, and recognising that nobody cares about 50 credits. The GMC don’t count credits; they don’t mandate a particular amount of CPD. The GMC say, you have to do enough to keep up to date at what you do. Now, that’s actually a much harder challenge, is to work out what’s enough to keep up to date on what I do. But, I discussed that with my appraiser, and I say, “This is what I’ve done. I felt like a bit too much this year. What do you think?” And we have a discussion about it. Or, “I really feel as though I’ve not done enough breadth of clinical stuff this year, because it’s all been COVID.” And they’ve said, “Don’t worry, that’s true for everybody. I bet you still looked up things when you had a patient with something else.” And I say, “Oh, yes, of course I did.” But that’s not what I’ve been thinking about when I’ve been thinking about my CPD.

Rachel: Yeah, it’s just treating people like adults, isn’t it? And professionals like, you know what you need to keep up to date with — I mean, what would an appraiser do if they did an appraisal, and thought, this person’s genuinely done nothing?

Susi: They would get very, very curious about why. Because there is some pretty good research evidence. Sarah Marwick in 2017 did some work around red flags for doctors needing support and being unable to engage with your appraisal, being unable to do that half hour of reflection that fulfils your portfolio requirements. That is a real red flag for serious stresses, either in your personal, professional life or your health. So, clearly, we said in the Appraisal 2020 process, even if an appraisee has brought nothing, go ahead with the appraisal. Be curious, use the ability to facilitate verbal reflection, and sometimes it might be, they’re absolutely fine. They just didn’t have time to write anything down. But, often the ones who were very busy but fine, did have time to write down the half hours worth of stuff about their achievements, challenges and aspirations, and whether that needed any support. Just to the tip box a bit, it was the people who were really struggling, who had had major practice crises or major family crises, or many bereavements or been trapped by COVID in a variety of ways, they were the ones who really needed the appraisal the most, but perhaps hadn’t been able to prepare anything in advance.

Rachel: That makes a lot of sense. So, it’s a warning sign, isn’t it? That if you haven’t managed to do that, then you might have not managed most of the stuff. There’s obviously something else going on. What are the red flags do people look out for them?

Susi: One of the other things that everybody worries about—when you do a new appraisal training, appraisers say, well what if somebody suddenly chooses their appraisal as the moment to admit they’re doing something really dangerous to themselves or to patients? Far more likely that it’s going to be a health-related issue that they themselves feel suicidal or or that they are risks of themselves than patients? But what if somebody does that? And the answer is that we have to train people really well. Because although it’s exceptionally rare in this protected environment, in an atmosphere of trust, if something has created already, cognitive dissonance and you know, something’s not right, your cry for help might come out in this environment.

But actually, that’s the same as general practice consultation, we all have patients whose cry for help is usually in the “Oh, by the way, doctor”, at the end of what has seemed like a mundane consultation, where they’ve just tested us out, they’ve just checked that they’ve got the trust and the confidentiality, that they feel safe to disclose, and then they disclose the historic abuse or the domestic violence or something dreadful that’s going on in their lives at that moment, or their most serious healthwork. I think it’s exactly the same in appraisal, that an appraisal can be used as a cry for help. And, those are a different type of red flag that you would want to recognise as the appraiser and to support. And, it might be the case that you had to stop an appraisal, if somebody presented so severely depressed that they were suicida. Because actually, they need other help. They don’t need a formal process, they actually need support on that day to put things in place to protect them.

Rachel: I think it’s often sort of somewhere between the two, actually, because I’ve lost count of the amount of emails I’ve had from people who’ve been listened to the podcast and say,”Just wanted to feedback about what happened to me. I didn’t realise how burnt out I was until I had my appraisal. And I had such a good discussion with my appraiser who was so helpful. I ended up taking time off and doing what they say they pointed me towards some really good resources.” And actually, the appraisal was a real turning point for them. Because I think with doctors and other people who are just so overwhelmed, the problem is your working environment where all your colleagues are pretty much the same as you so you look around and think, “Oh, this is normal, this is normal, everyone feels like this.” And then you get to the appraisal and your appraiser goes “That’s not really it’s not normal. I hate to tell you this, but actually, it seems to me, let me reflect back on what I’m seeing here.” And you suddenly go, “Oh, you’re right.” Incredibly valuable to have someone who can be that mirror.

Susi: And I mean, my very first year of appraisals back in 2002 to 2003. I did some totally informal research in Cheshire, in the appraisal that we instituted. And the question was, how many of your appraisees do you think are worth close to the edge out of the points of appraisal at that point, and that’s 20 years ago, it was 3%. The following year, having had their first appraisal, having done something to sort out whatever had been bothering them, it had gone down to not point 5%. And I mean, it’s a very vague phrase, isn’t it close to the edge, we now understand a lot more about burnout. We now know it’s an occupational hazard. It’s not an illness, but it’s a hazard that in the caring professions were particularly vulnerable to. I think it’s really important that we talk more about burnout and the risks of burnout, and the things you can do to protect yourself against burnout, which is one of the reasons why so many appraisers recommend the You Are Not A Frog Podcast.

Rachel: Oh, wonderful and if you’re an appraiser out there, who has been recommending this podcast, thank you, thank you so much. It’s interesting. This is a bit of a side note, but whenever I do sort of keynote talks or courses I put up the stress curve in a performance pressure curve and asked people to rate where they’re—I don’t want to get too personal for them, rate where their colleagues are, do they think they’re at peak performance or just starting to slip off the curve into area three, or going all the way down the curve into burnout and four, I would think Susi, most people, I think 75 to 80% of people are rating themselves and their colleagues that area three or four right now.

Susi: I think that’s inevitable. Because we have pulled out all the stops as a profession, we have turned out for our patients in a way that I think most professional doctors would have expected. But perhaps people outside would not have recognised that degree of professionalism was there until they saw it for themselves, not just doctors, I would hasten to add, but all of the people involved in the caring professions, including out in social care in the community, who I think sometimes did the hardest jobs of all and sometimes with the least support.

But therefore, if you keep on pouring, no matter how caring, without replenishing what’s in the car, you are going to burn out. And the important lesson from all of this is hypocrisy. In the original Hippocratic Oath put in, you have an obligation to look after your health and well-being for the sake of your patients. I think a lot of us have forgotten that and the pandemic has reminded us, and now it’s formalised in the Appraisal 2020 process. With a simple how are you question, which is the rating scale. If you’re fine, you don’t need to talk about it. If you’re not fine, but you’ve got loads and loads of other support, you don’t need to talk about it. But if you’re actually less fine than you’d like to be, and you’ve got no one else to talk to, here is an opportunity to talk and then to signpost other appropriate resources.

Rachel: It strikes me that we need to be getting that Appraisal 2020 process and be doing it for each other all through the year and thinking partnerships, not just our appraisal.

Susi: I absolutely agree. I mean, I am very enthusiastic about thinking pit stops and thinking partnerships and the work of Nancy Klein and time to think. I really believe that a thinking pit stop that takes 15 minutes regularly with a colleague, where you do one for each other can make an enormous difference to focusing your energy it can short cut weeks of going round the same loop, very positive about that. But I think that could possibly be the subject of a whole separate podcast.

Rachel: So maybe we should come back and do one on thinking partnerships, Susi. So We’re nearly out of time. But I’d love to just go through quickly these, you’ve got these 10 Top Tips, How To Make your appraisal really good for you. And this is all around, I guess taking control of what you can take control of. So what have you got on your list there.

Susi: So firstly, understand the basics and we’ve talked about that. Secondly, tailor your learning to your preferences. Don’t let anybody else tell you how to learn. You are already a very sophisticated learner—do what works for you. But don’t go overboard about recording it. Only record what’s valuable to you to record because you might actually want to look it up later or sufficient to act as an aide memoire to show the spread of what you did. Then make sure that you’re benefiting from your appraisal. If at any point in the appraisal, you realise this is not being useful to you, you’re sitting there feeling bored, stop it. Tell your appraiser: change direction, say actually what I really want to talk about is there is something about finding out your best way to reflect. I think reflection is a little bit scary as a word.

I think different people get put into the position at the end of medical school where they’re told to reflect they don’t quite know what people mean. Working out what works for you, in terms of thinking about what you do, reviewing what you do, whatever words you choose to use that’s not reflect, you will end up with your appraiser being able to say, “Oh, that’s my reflection.” Yeah, I think that’s important. The other thing that we haven’t talked about at all is creating a relaxing environment. There is no way that you can have a good reappraisal if you’re worried about being interrupted all the time. If you’re carrying an on-call beep, if you don’t have sufficient time to get into the things that are really important to you. It’s setting up the appraisal appropriately in the first place with privacy, freedom from interruptions, access to the internet and all the facilities you might need.

Taking regular comfort breaks, especially if you’re doing it online, as we are so much at the moment, roughly once an hour. I say, let’s get up and have a movement and comfort break, that stops you sitting there crossing your legs thinking I need to go to the loo, but I didn’t tell my appraiser. Build this in so that it’s relaxing from the beginning, and build a rapport with your appraiser at the beginning, those few minutes or chat about what you’d been doing socially, it’s all understanding each other’s background, that’s really important for the relationship of trust that you’re going to need to have a good appraisal. So invest in it, and don’t see it as unprofessional or unnecessary, because it’s actually the boundary setting, the building rapport is really, really important.

Then, the other really top tip is just the night before your appraisal, give it 5-10 minutes, think about what you most want to get out of it. If you come into any sort of meeting with somebody who’s there to help you and you’ll have a clearer idea of what you want to get out of it, you’re more likely to get it out of it. Share examples of good practice and celebrate your successes. Because often, especially doctors, but I suspect lots of high-flying professionals have real imposter syndrome, and never take on board the compliments and only take on board the criticisms and complaints. And it can really remind you about the things that give you joy in your job, if you are actually forced to stop for a few minutes and actually think about what’s gone really well.

What your successes are and how you might share them with other people. But the main top tip, and we talked about this right at the beginning is take ownership, take ownership of your appraisal, it’s yours. It’s not anybody else’s, it’s not the appraisers, it’s not the RO’s, there are some outputs that are useful for them. But that’s actually more for the appraiser to write up and the RM to look at your appraisal meeting that precious headspace time. That’s yours, so use it.

Rachel: Well, I mean, there’s so much in that Susi, but I love that thing about take ownership, it is yours and the things that you can really do. Anybody can do it as a set that intention. I love that it’s same with coaching, a good coach will always say at the beginning of the session, what do you want to achieve from this session, what do you want to know, by the end, you don’t know now, set the goals. And I love the thing about learning in the way that you want to learn. I think for so long, we thought that professional development was literally sitting in a course, sitting listening to somebody else speaking and taking notes.

And I guess part of it is because we’ve got all these electronic courses now we’ve got e-learning there’s lots of webinars and things. But you might learn better by reading a book or listening to a podcast, for example, while you’re walking the dog, or on a peer to peer group discussion or something like that, so I think yeah, really recognising what sort of learner you are. And I love the bit about just not making it too onerous. I was just thinking with You Are Not a Frog, I mean, just take a screenshot of episodes that you’ve listened to. Then you could just that would be reminder, wouldn’t it that you could that you could talk about and the other thing that we do to try and help people but help people, I guess embed their learning as we do for every single episode provide a CPD reflection form. So you can just actually answer some of the questions and think about how that applies to your life.

So that is free to anybody. So if anybody wants the CPD reflection forms, just click the link in the show notes and you can sign up for those and if you’ve done your forms, you can then keep them that will remind you about what you’ve learnt and maybe give you something, a basis of something to discuss if he wants to with your appraisal.

Susi: So mine is, you don’t need to use templates, nobody’s going to criticise you if you haven’t. But if it suits your learning style, it’s a really easy way to prompt yourself to think in a structured way.

Rachel: It’s great. Let’s see. So the final thing I’d like to ask when you say taking ownership, is it possible to choose your appraiser? What if you get someone that you don’t feel that you click with that’s not the right style for you, that’s far too focused on stuff that’s not important to you? What can you do about that?

Susi: So the first thing is, I don’t think choice of appraiser is appropriate in the NHS, because, unfortunately, the really good ones get overwhelmed and the new ones who are building their experience, you might be really good if they had enough experience, don’t ever get the chance. You need to be able to even add a workload between your appraisers. So you need some form of allocation. But it’s always allocation with veto and the veto is first the doctor has the chance to say “This is my own GP. I don’t want them as my appraiser as well.” So you don’t have to give an explanation. You can just veto for no obvious reason at all or it might be we had a relationship with her medical school and all we’ll find our other partners, but I still would prefer not to be appraised by—

Rachel: its gonna be awkward.

Susi: Yeah. Random allocation is transparently fair. But you have a veto and exercise your veto. And if your next person you’re allocated still isn’t suitable, exercise it again. So you’ll have your first appraisal and at the end of that, you should routinely get a chance to give feedback about your appraiser, which should include the question, do you want to have this appraiser again, yes or no? If you don’t want them again, just say no, there is no criticism of you. There’s no harm to your revalidation requirements, whatever, it doesn’t work for you change it as quickly as you can.

Rachel: Wow, there’s been so much there, Susi, that’s been really, really super helpful. So I know, we just got your 10 Top Tips in a second, I’m gonna ask if your three overarching top things that you would suggest to people, but in a second, if people want to contact to find out more about your work, and I know that you’ve kindly offered to give us the link to your 10 Tips article, so we’ll put that in the show notes. But how can people contact you?

Susi: So susi.caesar@nhs.net is my email address or I’m available on LinkedIn Susi Caesar.

Rachel: Okay, so contact her via LinkedIn, or email. So what are your three overarching tips?

Susi: You can’t pour from an empty cup, so look after yourself. There is a toxic culture of self sacrifice among doctors in particular, where you put yourself last and slipped down that stress response curve to burnout without even noticing that along the way, you’ve given up your coffee breaks, you’ve given up your lunch break, you’ve given up the things that make your job fun. As soon as you notice that you’re doing that stop and start putting those really important things back in. Apart from taking ownership of your appraisal, there’s something about taking ownership of your working life and your work leisure balance. It isn’t something that should get done to you, it is something that should be within your control and if you feel as though it isn’t get help, whether it’s coaching, mentoring, thinking partnerships. However, but if you feel that your work, leisure balance is out of your control, get help and support in just making tiny incremental changes to bring it back into your control.

Rachel: Brilliant, thank you and I sort of jotted down, three things that really jumped out at me is number one, if you don’t have a good appraisal system, wherever you are, if you’re not in the sort of the medical appraisal system, then seek out someone who can do that for you be it a coach or a mentor. Or if you enjoy this and benefit from it, then get it in between your appraisal as well. And there’s loads of coaching and mentoring support that’s available for free right now in the NHS isn’t there, so really seek that out. And don’t forget about other stuff as CPD — it doesn’t just has to be the specific knowledge base stuff does it? It can be other things which are often almost more important than the pure knowledge stuff. And make sure that you take ownership of your own learning and learning the way that you most enjoy that’s going to actually serve you the best.

Susi: One thing I loved in an appraisal recently was when I said what’s the most important thing you’ve learned this year and the doctor thought about it and said, “I’ve learned that I’m stronger than I thought I was.”

Rachel: Wow, I love that. I think that’s a perfect note to finish on. I think we are all stronger than we think we are. I think we are all much more resilient than we think we are because look what we’ve already dealt with. And we’ve already come through and what we need to do is maintain that for the long term without burning ourselves out in the process. Thank you, Susi, thank you so much for being here. Definitely gonna get you back. If you don’t mind at some point that we’ll talk about thinking partnerships. That will be great. Thank you.

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