1. Preparing for difficult medical appraisals Identify potential areas of difficulty within the appraisal process Understand the possible causes for these difficulties Develop strategies for dealing with difficult appraisals 1

2. Appraiser concerns 2

3. What doctor problems could make an appraisal difficult? Preparation Too much or too little documentation, supporting information or reflection Attitude Arrogant/cynical/dependent/disengaged Special cases Poor performance Conduct issues Illness Whistleblowing 3

4. Preparation: time to postpone the appraisal? Potential conflicts of interest (allocate a different appraiser) No pre-appraisal documentation/illegible documentation Late receipt of pre-appraisal documentation with no time to prepare No previous summary of appraisal or PDP from last years’ appraisal Inadequate supporting information Unsuitable venue Lack of protected time 4

5. Attitude – don’t take it personally! 5

6. Special cases Try as far as possible to crystallise: Are patients at risk? Should the appraisal continue? What action are you going to take? How you can signpost clearly the next steps to doctor. Sometimes it is appropriate for the appraisal to continue but for the appraiser to take action in the way that the appraisal is written-up or the appraisal statements are signed-off 6

7. Summary –reality is complex In practice, doctors do not conform to stereotypes (unless they are choosing to play a single role). Difficult appraisals will usually involve a mixture of some of these attitudes and behaviours. The high flying doctor may also produce too much meticulously organised paperwork and then reveal that it is all fuelled by alcohol as a stress reliever. Being an appraiser is a privilege but it is not easy and there are no perfect answers. 7

8. www.revalidationsupport.nhs.uk Handling unexpected serious concerns arising during the appraisal discussion Discussion: Has anyone here had to suspend an appraisal discussion because of a serious concern? Exercise: A chance to try out different ways of reacting to a doctor who reveals something for the first time during appraisal that raises serious concerns about their conduct, capability, or health. [21]