Ian St George

1
The cost of solitude the effect of
professional isolation on performance

• Ian St George
• Medical adviser,
• Medical Council of New Zealand

Ian St George MD FRACP FRNZCGP DipEd Medical
Council of New Zealand
2

• Professional isolation adversely affects
  clinical performance.
• Lewkonia R. Educational implications of
  practice isolation. Medical Education 2001 35
  528-529

3

• In New Zealand, general practitioners who were
  not vocationally registered (i.e. not registered
  as specialists) were more likely to be performing
  at a substandard level than their vocationally
  registered peers.
• St George IM. Should all general practitioners be
  vocationally registered? NZ Family Physician
  2004 31 17-19.

4
What are the characteristics of professional
isolation? Can we measure it?
5

• email survey
• 26 experienced performance assessors and members
  of the Medical Council of New Zealands
  Competence Advisory Team
• list describe markers of professional
  isolation, and to ascribe a weight (1
  unimportant, 5 very important) to each.

6
Response rate 63, n 16
7

• Personality and behaviour (4.6) Ranges from
  self-sufficient, independent personality, through
  lack of insight, self importance, lack of
  humility (arrogance), to work attitude such as I
  know it all anyway, I have no need to engage
  colleagues in discussion, I dont like change,
  so I will avoid it, suspiciousness and
  difficulties in accepting feedback, to
  inappropriate physical or sexual behaviour,
  aggressiveness or bullying, and personality
  disorder.

8

• Solo practice (4.4) Prolonged solo rural or
  geographically isolated practice of any kind,
  including specialist or rural GP specialist in
  small provincial city particularly when the
  doctor chooses to do this and especially people
  who choose to work as solo practitioners in urban
  areas.

9

• Poor colleague relationships (4) Difficult
  doctor who does not establish local or national
  collegial relationships awkward, unlikeable
  person poor communicator not a member of
  professional group (e.g. college).

10

• Outlier practice (4) Doctors displaying or
  expressing techniques or beliefs outside current
  accepted practice, such as engaging in
  complementary or alternative medicine
  advertising selling potions overprescribing,
  over-investigating.

11

• MOPS or CME failure (3.9) Doctor fails to attain
  education points, has done minimum continuing
  professional development (CPD) in the last two
  years, is an irregular or infrequent attender at
  regular group meetings (eg audit, morbidity and
  mortality meetings), has limited access to peer
  reviews and grand rounds, or cannot because of
  isolation attend colleague discussions outdated
  technology no Net access or email contact with
  colleagues.

12

• Specialist in only private practice (3.5).
• Stress, no relief, complaints, job
  dissatisfaction (3.5) Serious, continuing
  emotional stress (family, work, financial) or
  health concerns drug use on 12 call with
  limited locum cover or no locums available
  fatigue through work overload a tragic patient
  outcome or patient complaints job
  dissatisfaction has fallen out with, or has
  unsupportive employer uncooperative business
  partners.

13

• Locum, itinerant or part-timer (3) includes
  frequent changes of practice.
• Cultural barrier (3) From country or culture
  with a less collegial approach than that in this
  country or isolated by language barrier.
• Male gender (3).

14
Professional isolation and performance a
case-control study

• Were those doctors found at competence review
  to be practising at a substandard level, actually
  more professionally isolated than those
  practising satisfactorily?

15

• Cases controls for
• age,
• specialty,
• registration status,
• referring agency
• Cases gt controls for
• men,
• OTDs,
• country doctors
• 89 response (n 100)

16
Boxplot shows Controls (A) and Cases (B). Y
mean number of yes responses for markers of
professional isolationStudents T -3.29
(p0.0022)
17
any thoughts?