THE Medical Board of Australia has released a research report on revalidation as part of a “conversation” on its introduction to Australia.
It is hard to dispute the general idea that doctors, like any other professionals, should be up to date and fit to practice.
However, the precise purpose and preferred approach to revalidation remains unclear. Is revalidation simply a formative process to support ongoing learning and improvement, or does it also seek to identify and intervene with poorly performing doctors?
And if screening doctors to identify those who are unfit to practise is one of the goals of revalidation (as many patients would reasonably expect), does such an approach stack up against the evaluation of public health screening programs?
Here I outline four areas for consideration.
First, an effective screening program should target an important problem with a well understood natural history.
There is little question that doctors whose performance is impaired due to health, conduct or performance concerns pose a risk to the public. Current best estimates are that, at any given time, 1%‒2% of doctors are impaired in their ability to practice, and fewer than 5% account for around 50% of patient complaints.
The natural history of unsafe practice varies — some doctors practise safely for many years before a health condition or other life stressor makes performance dip, while others lag behind their peers from the start.
A more sophisticated understanding of the epidemiology of doctors who have health, conduct or performance issues may help us to identify early warning signs of deteriorating performance.
Second, screening tools should be capable of differentiating between high and low risk individuals to identify genuine concerns, while minimising the resource and personal costs associated with false positives.
All screening tests— including commonly used approaches to revalidation — are imperfect. Self-assessment relies on doctors’ limited ability to recognise their own deficiencies, written exams bear little resemblance to clinical practice, complaints underrepresent certain voices, and practice audits may not probe beyond “surface compliance”.
The recent report on revalidation provides a helpful overview of the strengths and limitations of each approach. Importantly, the report suggests that a targeted approach, based on risk factors such as age, practice type or complaint history, may improve the performance of certain revalidation tools compared with a one-size-fits-all approach.
Third, screening programs are of little benefit if effective remediation for identified problems is not available.
When dealing with doctors in difficulty, the long-term objective is to support them back into safe practice, not to “weed them out” (although in rare cases this may be the only realistic solution).
Much has been written on the importance of health programs for impaired doctors. However, there is little hard data on the comparative effectiveness of these programs. Even less is known about the most effective interventions for doctors with performance or conduct concerns.
This dearth of evidence is worrying given the potential risks to the public of an ineffective approach to remediation.
Finally, the screening program as a whole should be acceptable, cost-effective and sustainable.
The costs of revalidation are both direct (producing assessment tools, administering the program and following up on concerns) and indirect (distraction from clinical care, anxiety and inconvenience).
At a broader social level, the time and resources devoted to revalidation are then lost to other aspects of health care.
On the other hand, a program that ensured all doctors were up to date and fit to practice would carry great benefits for patients, health systems and the profession as a whole. Understanding these trade-offs will help ensure the appropriate and sustainable allocation of resources.
As doctors we have an obligation to ensure that the trust and confidence the community has in our profession is well founded.
Revalidation offers a beguiling option for achieving that goal. However, history is pock-marked with examples of public health screening programs that were introduced with more enthusiasm than evidence.
To avoid a similar fate for revalidation in Australia, we need a transparent debate regarding the intended aims, costs and benefits of revalidation, an ongoing investment in research to improve the targeting and performance of revalidation tools, and a commitment to using evidence-based interventions to support struggling doctors back into safe practice.
Dr Marie Bismark is a public health physician and health lawyer at the School of Population and Global Health, University of Melbourne. Her research focuses on the role of clinical governance, regulation and patient complaints in improving the quality and safety of health care. On Twitter: @mbismark
Acknowledgements: Thanks to Margaret McCartney @mgtmccartney who inspired this article with her tweet of 10 June 2014: “revalidation is a screening test of unproven efficacy and unquantified harms”
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