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Why Anagrams Are Better Than Acrostics

Author and Collaborators: Dr Susi Caesar, Dr Ed Sheridan, Dr Sue Bowen, Emma Pierce, Jools Mumford


Medical Appraisal is an annual intervention reaching all doctors in the UK.¹ (Sir Keith Pearson, Taking Revalidation Forward). It supports professional development, accountability, and patient care. To be effective and acceptable to the profession, all doctors should receive the same high standard of appraisal, and the appraisal outputs (summary, PDP, and appraiser statements) should reflect the quality of the appraisal discussion and be applied consistently.

By adopting a Mastery Learning Structure², we have demonstrated that well-designed and repeatedly-applied assessment, against the same standards, can drive learning³ and behaviour such that all appraisers can ultimately achieve the desired level of competence in production of appropriate appraisal outputs, although some may take longer than others.

QA Tools as Acrostics, Acronyms and Anagrams

Several quality assurance (QA) tools have been developed that give marks for the inclusion of particular elements of the appraisal discussion of interest for appraiser training. Most, in order to facilitate recall, have been twisted to fit into an acrostic pattern. Such tools include LEARN IT⁴, PROGRESS⁵, EXCELLENCE and the initial SUPPORTS QA tool. In contrast, ASPAT is an acronym for the NHS England Appraisal Summary and PDP Audit Tool. While having the advantage of being short, acronyms are not immediately memorable and have no associative benefits.

The SUPPORTS QA tool reviewed here was developed in the Wessex Appraisal Service and introduced by the Academy of Medical Royal Colleges as part of the Library of Materials to support Appraisal 2020. Like its predecessors, it aimed to facilitate the rapid acquisition of the skills needed to summarise an appraisal well - with subtle improvements to capture the new elements of the rebalanced appraisal 2020 process.


Between October 2020 and March 2021, the SUPPORTS QA tool was used by appraisal leads in a variety of settings. In Wessex, Senior Appraisers expressed their dissatisfaction as the tool felt ‘jumbled’ and ‘out of order’ - making it necessary to jump back and forth in the text, and creating an unnecessarily burdensome task. A working group set up to examine alternatives concluded that the elements of the tool did fit their QA needs, but their order did not. The simple solution was to remove the acrostic form of the SUPPORTS tool and re-order the steps. Continuous quality improvement methodology led to other changes to increase the consistency with which the tool could be applied by different appraisal leads.

Discussion and Next Steps

The above diagram shows how easily the acrostic form carried forward from previous QA tools made SUPPORTS more disordered and confusing than it needed to be. By re-ordering the tool we reduced the ‘out of order’ feeling found by the Senior Appraisers while doing the QA. The simple adjustment from acrostic to anagram dramatically improved the ease of use of the tool. In addition, the working group realised that previous QA tools included marks out of 2 or 4 with little guidance as to what should be covered between the ‘room for improvement’ and ‘well done’ scores.

The new SUPPORTS format makes it clear how and where the scores should be applied on a point by point basis rather than the previous, more subjective, process. This allows for greater uniformity and standardisation across the QA tool and allows for more specific feedback. The ‘Support’ step also has been given a new emphasis on the future, not just the challenges of the past year. It focuses more heavily on the wellbeing of the doctor with a new “How are you” rating scale, ensuring that the tool is suitable to support the aims of Appraisal 2020.


Overall, the rearranged nature of the updated SUPPORTS QA tool is a dramatic improvement. This version takes appraisal QA beyond the previous appraisal 2020 focus, making it fit for the future and medical appraisals beyond the COVID-19 pandemic.

Our evaluation demonstrates that using the acrostic form for QA tools can make them less user-friendly, even if the name is memorable. A simple rearrangement makes the work easier and the tool better fit for purpose. In this case, anagrams are better than acrostics (and acronyms).