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AUSTRALIA’S ongoing efforts to improve professional development and information sharing in clinical practice negate the need to adopt a UK-style revalidation system for doctors, says AMA president Dr Steve Hambleton.
“We need to make sure we maintain our currency and continue to improve health outcomes, but in terms of value for money, making everybody go through a 5-yearly process of 360-degree evaluation is not needed in the Australian health system”, Dr Hambleton said.
He said the “world had moved on” since the UK’s General Medical Council first proposed revalidation in 1998. The UK system was launched in 2012, with a similar system being considered by the Medical Board of Australia.
Dr Hambleton was commenting on an MJA “For debate” article by Professor Kerry Breen, adjunct professor at Monash University’s Department of Forensic Medicine, who has called for broader debate about the proposed revalidation system. (1)
“The medical regulator and the medical profession might be wiser to first more clearly identify what the problem is that revalidation is trying to fix and then examine what methods might best suit that aim”, Professor Breen wrote
“It seems illogical and unnecessarily costly to introduce an additional layer of assessment of all doctors when there is general agreement that most doctors strive to maintain and enhance their knowledge and skills and are rarely the subject of complaint. This is even more problematic without an evidence base to indicate that revalidation will achieve its stated aim.”
Dr Hambleton agreed that it was important to consider what problems a proposed revalidation system was trying to fix.
“We do have some of the best outcomes in the world with the current system and to impose on that unique system a solution developed in another area, particularly when the world has moved on … we certainly do have the right to question it”, he said.
Dr Hambleton said Australia did not lack confidence in the profession, as was the case in the UK when its revalidation scheme was first mooted, but the AMA recognised the need to “close the gap between what we know and what we do”.
This was being achieved with mandatory continuing professional development (CPD) and clinical audits, and by all professional colleges encouraging self-analysis and comparison, he said.
The adoption of the SNOMED CT-AU system to standardise the terminology in clinical medicine would also provide a “rail gauge” for communication between clinicians that would enable them to measure and compare outcomes, Dr Hambleton told MJA InSight. (2)
“Australia is at the threshold of an enormous increase in the ability to share and analyse information that we can utilise to improve CPD, minimise unwarranted clinical variation and you will get better outcomes for the profession and better outcomes for the public”, he said.
“Measure and compare is a really powerful way of minimising clinical variation and maximising outcome and it’s something that clinicians are already demonstrating that they want to embrace.”
Dr Joanna Flynn, Medical Board of Australia chair, said the MJA article offered interesting perspectives on the issue of revalidation.
“We welcome contributions to this important discussion and are monitoring the debate closely. The Board continues to have an open mind”, she said.
“We are considering the evidence from overseas experience and will work closely with our stakeholders to determine the best course for Australia to help ensure that any registered medical practitioner has up-to-date knowledge and skills to provide safe care.”
In the MJA paper, Professor Breen said the most attractive immediate option for the board might be targeted assessment of the competence of doctors believed to be at highest risk of poor performance. “Research indicates that appropriate targets may be doctors who have been the subject of more than one substantiated complaint, and older doctors”, he wrote.
Dr Hambleton said he didn’t think “age per se” was a problem. “But if there are problems, then it may be worth a closer look.” He said supporting older doctors in career transition might be a solution when older doctors were beginning to struggle with some aspects of their practice.
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Dear sir, I have a question about validation.
We completed Installation Qualification (IQ), operational Qualification (OQ) and Performance Qualification (PQ) of a Machine but after 8 month we changed the machine from previous location to new location. Now my question is that do we have to perform IQ,OQ,PQ again?. Please give me suggestion.
For the first time in 30 years I have been complained about by two patients.
One of these ladies opened the batting by saying emphatically “You do know that I have CSA, don’t you?”. After dealing with her presenting problem as outlined in her GP’s referral, I ventured out into enquiring about her ‘CSA’. That ultimately earned me no brownie points in that my questions were described in her letter to APHRA as “an onslaught of insults, inappropriate questioning, and extremely unprofessional practice.” In fact in three pages of handwritten notes the only record I made was that of “sex childhood abuse, 12-18-cousin” and in my conclusion “ov dysfunction ? contributed to by CSA”. The Board insisted that I undergo a rape counselling course at my own expense- for a practice in which I have seen one rape case in 20 years and that was properly brought to court.
It was no comfort to me that she commented to my secretary that “…the transsexual nature of the Dr was unusual..” It seems that transphobia may be alive and well.
The second patient also had a litany of complaints centering around her weight (BMI 38.3) and her comment that “I felt that she took a dislike to me before I even entered her room”. This on account of being weighed and measured that forms my routine and constituting what I would regard as best practice.
I am now to face a ‘panel’ of five persons to explain my management of this lady’s problem. I certainly feel oppressed by this bureaucracy that is clearly dysfunctional and incompetent. It seems to me that APHRA should undergo an enquiry itself generated by a question from the floor of the Federal Parliament.
Primary care nurse’s concern is not “age related”, ie, because the person was old. Rather it is “with people doing things for which they were inadequately trained in the first place”. This an objective concern. Competency to know what one’s role is, particularly in the patient-treatment team setting, is not within the “revalidation” process, as it was not the person’s role in the first place. I came across another example, where a female air ambulance officer attended to transfer a patient, who had renal shut-down, from a regional hospital to Adelaide. Whomever she was speaking to accepted that the inotrope be changed to Adrenaline infusion, on the basis that the ventricle was not contracting. In fact what this person, ? a nurse, was looking at was the retained inverted Echo image of the enlarged left atrium and competent mitral valve, in sinus rhythm with contraction globally but limited, that she imagined to be an image of the left ventricle!. Objectively, revalidation does not apply in this situation, as the decision and influence she wished to assert was outside of her level of expertise and training. Errant decision making outside of one’s field of training is not subject to revalidation. One may well ask, “Will team function be subject to evaluation and the complaints process be subject to revalidation, as it was never validated in the first place?”. So what is needed? A System of Evaluated Decisions, including party and joint decisions of the Medical Board, AHPRA and Tribunals, in order not only to protect the public and guide doctors, but as the basis of an ethical, values-based and just, functional, not dysfunctional, society.
If i may borrow words of comment by PeterL to John Dwyer’s article in this issue: “Only small people are subject to laws and principles. Doctors are increasingly accused of conflicts of interest … The push for greater accountability of front line medical staff is characterised by hypocrisy and hidden agenda. Accountability should be a founding stone of civil society but has become the catch carry of those seeking to justify their bureaucratic existence by the harvest of easy targets. It seems (if) you wish to cheat, aim big and ally yourself to a legal infrastructure where cheating is given a legalised whitewash.” In other words join forces with the Medical Board (MB), AMC and AHPRA. Reliance and expectation that AHPRA monitor their own performance was political or menacing and foolhardy permitting MB’s duplicitous indiscretions. The MB’s agenda and dogma, their clandestine modus operandi of obtaining all the evidence beforehand, at the health professional’s expense, ensures their self-protection and self-interest. The MB benefits by undermining public confidence where confidence and trust exist. Tribunal collusion, where rules of evidence are not applied, is reprehensible. MB representation on such Tribunals is not even seen by MB or such Tribunals as a conflict of interest. It requires investigation as a matter of URGENCY – called for in the joint interest of both the public and health professions.
The Medical Board (MB) and their dogma is the epitome of bad science, bias, perversity and agenda driven self interest. Even in areas Prof. Breen suggests, “old” doctors and repeated complaints, evidence is lacking. MB allegations are themselves contrived and formulated on vexatious and erroneous complaints made by patients, and bear no relation to the complaint the patient is making. Often they are indefensible and termed “boundary issues” without definition of what the boundary is. Findings do not reflect nor are they proof of bad performance. In fact in my experience, merit attends those who stand up to the Medical Board’s pronouncements, allegations and contrivances made on the basis of vexatious, misrepresented, frivolous and factually erroneous complaints. The MB President’s response, “we (MB) are monitoring the discussion closely”, is an indication that their approach is subjective and unable to be validated. Similarly and unfortunately, in areas noted above, that Prof. Breen and Dr Tony Marshal ( contribution, above) feel safe that they are not included in, repeat the same folly that the MB engages in, by generalising and being subjective and having no factual basis. Any subjectivity from whomever is the problem. Objectivity and evaluation by an independent group made up of experienced doctors who also have experience in MB abuse is needed to evaluate, educate and engage others in an objective, accountable and accountability evaluation process of MB and conspiring Tribunal members and judges, in the public interest and to positively guide doctors and all health professionals and the self appointed and self acclaimed regulators.
The real question, here, is defining the complaints, e.g. whether to consider only those that have resulted in certain real level of penalties/sanctions or to include a slap on the wrist too and so on. On the other end of the spectrum we may consider a periodic “resetting” examination for all. The statistical data of the current regulatory authorities including AHPRA, Health Services Commissioner (Victoria) and its equivalents in different states, should come handy for the former group. How: “Peer review” is an honourable concept amongst true professionals; however it is not a very practical or scientific technique and is not expected to be of utility at least in the scale contemplated here. Perhaps before embarking on a wholesale revalidation of the whole profession we could review the current Validation (vs. Revalidation) process we use for screening our Foreign Medical Graduates (FMGs) and ponder the difficulties in dispensing any degree of fairness for them. The scale of problems with this group has recently been documented in detail, by a Parliamentary inquiry that makes a very interesting reading. Suffice to say here that after several decades, Australia’s medical profession as a whole is still struggling with proposing a fair & equitable method of assessment of these FMGs.
Of the many questions apropos Revalidation of doctors perhaps the easiest to answer is the “Whether” & “Why”! This is because there would be only few fair-minded amongst us who would deny that there may well be few of us that were just not up to scratch either from the start or are no longer fit to practice. Given the multitude of facets of a doctor’s practice , the main questions therefore to ponder are : Whom to revalidate or all? How to Revalidate? To be fair to all When to Revalidate (and how often)? Whom: I do not imagine it would be contentious to say that “whom” would clearly include those who have had multiple complaints upheld against them or been convicted of indictable offences. These complaints may have been by the patients or colleagues. As a professional group, there should be little difficulty reaching a consensus in this area.
Just exactly what it is it with the MBA, that we as GP’s are required to undergo such humilitation as recertification at their whim?
Medicine is the most over-regulated sector of the community, and as one of my patients said to me only today, “some people dont accept that medicine cant keep patients alive indefinitely.” Yes, patients DO die, and in so doing it doesnt mean that the doctor has been negligent. The Presient of the AMA should be puting the case forward in stronger terms than exressed here, in support of GP’s who are a soft target these days from every angle.
Propents of this initiative need to first explain the problem they are tyring to fix. Considering the huge number of medical consultations each year, how many signficant errors are made on a percentage basis? What does an analysis of medical board notifications show and what are the quantified trends? What are the estimated costs to society of medical errors? Surveys continue to show that the Australian medical profession is highly trusted, so that criterion is not a valid reason for any new initiative.
They then need to prove that revalidation will have an effect, given that we already have the CPD system. They then need to give alternatives, with research evidence to demonstrate the benefts of different approaches – including doing nothing.
Then they need to do a transparent cost-benefit analysis to prove that the massive direct and indirect costs of CPD plus revalidation will be less than the benefits. This must include the opportunity cost of doctors’ time, which could be spent providing care.
Finally, assuming their analyis shows the benefits outweigh the costs, they need to show that the proposed expenditure in terms of time and money would not be better spent elsewhere in the health system, elsewhere in government spending, or even in lower taxes.
Until these criteria are met, the initiative should be opposed.
I am sure most practitioners strive for best practice and keep themselves up to date. However I know of a older registered nurse doing completely incorrect lead placement for ECGs (only discovered after months of employment by a student nurse) simply because it was assumed on her employment that her qualification implies a certain skill set. Recency of practice should always be considered before any health practitioner performs even the most basic tasks. My main concern is with people doing things for which they were inadequately trained in the first place. In my view there are certain skills that should require specific accreditation and no health practitioner should be performing them unless they are appropriately trained eg spirometry, casting and childhood vaccinations.
Re-validation seems to serve only three purposes: 1. Training us at jumping through hoops set by our future clerical masters. 2. Raising fees. 3. Selling the public the idea that the nanny state is necessary to protect them and thus justify the growth of the clerical class.
Yes I am cynical after 40 years of medical practice, but I have historical perspective.
Professor Breen has exposed the unclothed emperor in the form of the Medical Board of Australia. What indeed are the quality and safety problems demanding such a solution? Before embarking on a system of re-certification, the validity of compulsory CPD as a tool to improve the safety of the Australian public should be established. The MBA and its political controllers have relied on “public expectations” in the absence of evidence for its registration requirements to the frustration and substantial expense of registered medical practitioners.