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LAST week, the Medical Board of Australia released a Professional Performance Framework, designed for patient safety. We believe it is a fair and practical approach to ensure that all doctors in Australia practise safely.
Surveys in Australia repeatedly show that patients trust their doctors. Trust is precious, and each medical practitioner has a role in building and preserving it. This trust is based on community confidence that doctors will keep their knowledge and skills up to date and practise ethically and safely throughout their working lives. The Professional Performance Framework will support doctors to take responsibility for their own performance and encourage the profession collectively to raise professional standards and build a positive, respectful culture in medicine that benefits patients and doctors.
The Professional Performance Framework is the Board’s response to the report of its Expert Advisory Group (EAG) on revalidation. The Board has accepted the evidence provided by the EAG and its recommendation to adopt an integrated approach that will improve public safety and better identify and manage risk in the Australian health care setting. The EAG advised the Board to maintain and enhance the performance of all doctors practising in Australia through efficient, effective, contemporary, evidence-based continuing professional development (CPD) relevant to their scope of practice, and to proactively identify doctors who are either performing poorly or are at risk of performing poorly, by assessing their performance and supporting their remediation whenever this is possible. The EAG identified that age, professional isolation and multiple complaints are all risk factors for poor performance.
Under the five pillars of the Professional Performance Framework:
- Strengthened CPD includes practitioners having a “CPD home” and participating in its CPD program; ensuring that their CPD is relevant to their scope of practice and based on their own professional development plan, and completing at least 50 hours of CPD per year that includes reviewing their performance, measuring their outcomes and educational activities.
- Active assurance of safe practice involves identifying practitioners at risk of poor performance and managing that risk.
The Board expects that the vast majority of doctors with identified risk factors will demonstrate their ability to provide safe care to patients and remain in active clinical practice.
The EAG has identified increasing age as a risk factor for poor performance. The Board is proposing to require practitioners who provide clinical care to undergo peer review and health checks at 70 years of age and 3-yearly thereafter. The outcome of health checks and peer reviews will not be reported to the Board unless there is serious risk to patients.
The EAG also identified professional isolation as a risk factor. The Board plans to provide guidance to help practitioners identify the hallmarks of professional isolation and manage the risk from it, including by increasing peer review in their CPD.
- Strengthened assessment and management of medical practitioners with multiple substantiated complaints includes formal peer review of performance for practitioners with multiple substantiated complaints.
- Guidance to support practitioners involves the Board continuing to develop and publish clear, relevant and contemporary professional standards to support good medical practice. This includes a revised Code of Conduct, as well as revised and new registration standards.
- Collaborations to foster a positive culture of medicine that is focused on patient safety, based on respect and encourages doctors to take care of their own health and well-being. This includes the Board working with the profession and others to reshape the culture of medicine and build a culture of respect. This also includes encouraging doctors to take care of their own health and wellbeing and to support their colleagues, and urging governments and other holders of large data to make it accessible to individual practitioners to support practice improvements.
The Board’s Professional Performance Framework is evidence-based, integrated and builds on existing initiatives. It will be implemented progressively, with some elements already in place and others requiring significant planning, consultation and development. Nothing is going to change tomorrow for doctors in Australia.
We will work with the profession and the community to develop the detail. Already, most specialist colleges are taking their CPD programs in the direction we propose. We will encourage sharing of best-practice approaches across the profession and work to develop mechanisms for recognising approved CPD activities between colleges and employers to minimise duplication for doctors.
The EAG report clearly sets out the evidence about predictable risk of poor performance from age, professional isolation and multiple substantiated complaints. However, we have more work to do to develop and implement effective and practical ways of screening for these risks. We will develop and provide guidance about the hallmarks of professional isolation and how these can be managed, including by increasing the peer review components of CPD. We will require practitioners who are subject to multiple substantiated complaints to participate in formal peer review, recognising that there may be differentiation in notification rates between fields of practice and that it will take time and experience to identify appropriate thresholds for this action.
We recognise that introducing a requirement for peer review and health checks for doctors over the age of 70 is the most contentious of our proposals.
We are not seeking to drive older doctors out of practice or place undue burdens on them. We believe that the evidence about potential risks associated with ageing requires us to assure older doctors and their patients of their continuing capacity to provide safe care. We will commission expert clinical advice about what kind of health checks will be helpful, what kind of cognitive screening is useful and when it is warranted, and then work with the profession to develop these.
We believe that there is no place for a compulsory retirement age for doctors and we value the contribution older doctors make. Our approach is designed to provide both assurance and support for their continued safe practice.
Read more about the Board’s Professional Performance Framework and the full report of the Expert Advisory Group on revalidation.
Dr Joanna Flynn, AM, is the Chair of the Medical Board of Australia.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
Older doctors/specialists are the best. They listen and care with a manner that is only available to those with experience. I say this at a young 48 who needs constant primary care.
Implementing an age for review is discriminatory and a waste of resource to say the least.
Surely if us ( as a patient ) are not happy with a said PROFESSIONAL we would make a complaint for further investigation or just find another practitioner?
After all isn’t that what the board is for? If you receive no complaints, why subject and demean people of a certain age who have attained such valuable experience?
Australia does not need nor want to be in a predicament of less practitioners than there already appears to be.
One of the problems with regulation is that behaviour that is dictated by regulation is no longer the subject of ethical decision making. This is the source of the trouble with mandatory notification, as noted above, it is OK if made in good faith.
Secondly, regulations need to work and the cost of the regulation, which will be considerable in this instance, needs to be justified by the benefits, which in this case is unlikely.
So, what will be the conditions for the health assessors? Will they be subject to penalties if they do not declare that old doctors are unwell and incompetent, as is clearly the opinion of the Medical Board, and the doctor, who is cleared is then the subject of a notification. Who will assess the assessors?
Hi Sue. Those are indeed startling statistics that support the need for some form of review. However I believe AHPRA would need to show age-related rates in support of whatever cutoff age is chosen. I think 70 is too young but then again at 66, I would.
I think the real resistance comes from a general distrust of AHPRA’s approach to complaints, itself (in NSW) rooted in the ‘guilty until proven innocent (and you can never be proven innocent)’ attitude & behaviour of the HCCC under a previous Commissioner, who had sufficient hubris to declare that the rules of natural justice and procedural fairness did not apply to the Commission’s investigations.
Regardless of whether or not that attitude pervades AHPRA, it is something AHPRA needs to address clearly and positively if it is to win the trust of the medical community.
Hi, Greg. I don’t know how the proposal for an age 70 cut-off was reached, but I am aware of the problems of older practitioners, from a twelve-year term on the Medical Board (mostly served pre-AHPRA). The paper I referred to describes the experience from that time. This section of the abstract is particularly relevant:
“Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns – the “workhorse” and the “dabbler” – were observed, as was a culture of postponed retirement due to a sense of obligation and working “until you drop.” Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.” More than half with cognitive impairment, 12% with frank dementia – still working until reviewed.
There is no doubt that mental flexibility and the acquisition of new skills is affected by increasing age – though medical practitioners start at a high baseline of cognitive ability. Whether this cuts in at 70 – or 75, or 80 – will clearly be variable, but a system clearly needs some sort of cut-off for an audit filter. Those who have suffered severe trauma or vascular disease, cancer or major surgery are likely to start cognitive decline earlier. Presumably those who are screened and found to be fully functional may continue to practice, at whatever age.
It’s important to realise, though, that isolated older practitioners may not be aware of their limitations. IF their patients are also elderly, keeping on “doing what they have always done” may no longer benefit their patients. Long-term patients are often reluctant to complain, even when they perceive their doctor is “losing it”, due to respect for the long relationship. That’s why more than waiting for complaints might be necessary.
Is age 70 too young? Perhaps – we would need to see the underlying evidence.
I am a female doctor and have been a GP for nearly 40 years, solo for 20 of those. I am nearly 66 and now work in 2 to 3 different practices, part time. I was planning to work till 70 or just over. My partner, with whom I do not live, retired a few years ago, and is enjoying life. I enjoy working and have some patients whom I have known and treated for > 35 years. I am familiar with them, their history, their families, ( I delivered a few of their children) and extended families, and their place in the community. Although I have a lot of interests outside work, I wish to work a bit longer. However with this policy being introduced, I have now decided to retire in 2 or 3 years time. I don’t want to have to jump through any more hoops than I do now. Financially I would be better off working longer. Sadly, I may then be eligible for the age pension, so will be costing the government, rather than subsidising Medicare, and paying them taxes.
I think there will soon be a mass exodus of 70 year old doctors from general practice.
i feel that peer review will be open to bias and abuse, eg if done by doctors who practise in the same geographical area, or have a grudge against the doctor being reviewed. I have had an experience where I had a vexatious legal claim made against me by a patient. The specialist who gave his opinion in the case was a gynaecologist, who is supposed to be based in my local area, and neither myself or my colleagues had ever heard of him. (While this is not really a peer review situation, he was an expert witness, and his opinion was taken into consideration. Luckily the claim came to nothing.)
Sue, I don’t see how this article supports the MBA proposal for peer review of medical practitioners over 70 years of age. First, there is no comparison made (at least in the abstract) with a younger cohort of doctors, who may have similar or higher rates of depression, drug abuse, etc – especially given the pressures at that age of parenting as well as following a medical career. Second, it is likely that seriously impaired doctors would have been detected by either or both of the health screening/cognitive assessment and history of substantiated complaints proposed by the MBA. I do not see any evidence to support a peer review process, the dangers of which I have pointed out in my earlier post.
Here is a relevant publication from the journal Psychogeriatrics
https://www.cambridge.org/core/journals/international-psychogeriatrics/article/physician-dont-heal-thyself-a-descriptive-study-of-impaired-older-doctors/6CEC71601C06934DA5896BB18DCB9ADF
I wonder whether the medical board has discussed the over-70s screening test with the federal Department of Health.
Currently, such an employment medical would not be eligible for a Medicare rebate, including any tests associated with it such as blood tests, x-rays or ECGs. While the Hippocratic principle is to treat one’s colleagues for free, clearly it is an imposition on doctors to have to perform the equivalent of an insurance medical every 3 years on a colleague. Currently, any doctor who included any part of an employment medical in a Medicare-billed service would be breaking the law.
In other industries, for example commercial aviation where health checks are routine and compulsory, the employer pays. A thorough medical runs into thousands of dollars when blood tests and imaging are included. (GST must also be paid on these screening services.) This would produce a massive commercial disincentive for employment of over 70s (and as a corollary, mid to late 60s) medical practitioners, especially women who average less practice revenue generation.
Perhaps Dr Flynn could clarify whether the medical board intends to have its own review doctors who will be funded from the board’s budget, or whether it expects doctors to pay for their own assessments. This would be a severe financial burden to those who are in ‘professional isolation’ such as a rural or remote bulk-billing practice.
Does the medical board value older doctors’ contributions enough to fund their compulsory health checks?
Who revalidates AHPRA board members? How can any healthcare professional have any confidence that they are being regulated “safely”?
Peer review has its limitations and deficiencies, as I know from personal experience, having both published and reviewed articles in the medical literature over a 25 year period. Who is going to do the peer reviewing of the over-70s? Colleagues, who may have a conflict of interest? Academics, who lack experience or understanding of the daily grind and time pressures in private practice? Who is going to compose the inevitable guidelines to be used by the peer reviewers? Where is the evidence for a threshold of competency at 70 years of age, as opposed to 65 or 75? Who will review the reviewers? What appeal process is available if one feels that a review has been conducted unfairly or reached inappropriate conclusions? Who is to pay for all this reviewing? The Medical Board’s proposals are counter-productive as they will involve considerable time and expense which would be much better spent doing actual CPD.
Still unsure what evidence supports the planned age testing . Seems discriminatory and poorly thought out. I thought there were discrimination laws against such an approach . Wasn’t aware that age above 70 caused such problems. Should it apply to judges, politicians, world leaders, businessmen?? And again what evidence for in going 3 year assessments?
If age is an increasing impediment why do various Boards and Tribunals have aged and retired members?
Is this why AHPRA and the hated VCAT have the reputation they do, when it comes to attending to medical issues in a speedy, humane and trustworthy manner?
Who is watching the watchers? Nobody with any power or interest it seems.
I post this anonymously as I trust neither organization to do the right thing.
With permission for the author Dr David Richards, Gold Coast Queensland, this contribution may interest readers.
Where is the evidence that age affects doctors’ ability?
Dr David Richards
22 February 2017
A recent comment piece asserted that “there is a growing body of evidence that increased age, and increased length of practice, is associated with poorer quality care.”
If correct, this would justifiably require “a robust and independent process of ensuring ongoing fitness to practise.”
Unfortunately, the review referenced in the comment piece has methodological flaws and leaves a number of questions unanswered.
Here, I shall endeavour to address these questions from a cursory search of the literature.
1. What is the extent of the danger posed by ageing doctors to the Australian public?
Last year, the Expert Advisory Group reported to the Medical Board its recommendations regarding re-credentialing of doctors, including an in-depth examination of the available evidence.
Its interim report says:
“International research indicates that about six per cent of medical practitioners are poorly performing at any one time. No Australian research has yet reliably identified how many medical practitioners in Australia fall into this category. Future Australia-specific research should confirm this number. In the meantime, the EAG believes that action is required to identify, assess and where possible remediate all of these practitioners, in the public interest.”
In other words, there’s no evidence in Australia but lots of concern from abroad.
The only country that has a mandatory universal re-credentialing process is the UK. The USA, Canada and New Zealand all have systems in various states of evolution.
One way of evaluating performance is so called Multi-Source Feedback (MSF).
Citing Campbell and colleagues (2008), the interim report states:
“The age, gender, and ethnic group of the doctor were not independent predictors of feedback scores from patients or colleagues, a result that the authors described as ‘gratifying’ and which is important potentially in a multicultural society such as Australia.”
Perhaps MSF is too insensitive to expose bad practices? What about complaints? Surely everyone complains about old people?
According to an 11-year observational study in the UK, results from which were published in 2014, the relative proportions of doctors at higher risk of being complained about, being investigated or receiving a sanction or a warning showed that the highest risks arose for:
· Male doctors overall;
· Male doctors over 50 years old who are non-UK graduates; and
· Male GPs aged 30–50 years who are non-UK graduates
Now we’re getting somewhere, this is the smoking gun!
Unfortunately, however, the study authors go on to say that over the 11-year period (2001–2012), the annual referral rate was five per 1,000 doctors, with referrals usually coming from NHS managers.
What? Only 0.5% rate of complaint? And mainly from the infamous NHS managers? That’s disappointing.
Then there is a 2014 cross-sectional study from the UK — titled Disciplined doctors: Does the sex of a doctor matter?
It found:
“Of the 329,542 doctors on the medical register, 2,697 (0.8 per cent) had sanctions on their registration, 516 (19.1 per cent) of whom were female. In the fully adjusted model, female doctors had nearly a third of the odds (OR: 0.37, 95 per cent CI: 0.33 to 0.41) of having sanctions compared to male doctors. There was evidence that the association varies with specialty, with female doctors who had specialised as general practitioners being the least likely to receive sanctions compared with their male colleagues (OR: 0.26, 95 per cent CI: 0.22 to 0.31).”
Okay — the numbers being sanctioned may be low, but they are mostly men. I knew it! Comparing the age groups:
Ah, so the under-35s are saints! Not quite. As the authors explain, it’s because the majority are working under supervision.
2. What has been the experience overseas?
I contend there is not a lot of evidence to say older doctors are the menace being suggested.
But surely re-credentialing is a good thing, yes?
This is a polemic from a young British doctor:
“I undertake continuing professional development each year — I study and attend courses to meet a target for hours spent learning, I have to provide evidence of this and show that I am continuing to improve as a doctor.
I must audit my work, analyse and show I have learnt from any complaints, report any significant events in my practice and target my learning to these. I must survey staff, clinical colleagues, and my patients to get their honest feedback on if I am a good doctor or not.
If I do not complete this every year, I face having my license to practice removed. Every 5 years I must present a summary of these annual appraisals to the GMC. They have the power to decide if I am fit to practice, to remain as a GP in the NHS. All the courses I go on, the online modules I do, the textbooks I read, I pay for myself.
Every year the government moves the goal posts with changes in QoF targets. Every year it becomes harder and harder to meet them all and still provide basic services.
Many of these targets are highly controversial amongst doctors, often drawn from consensus opinion, not evidence based facts which have been shown to improve patient care. GP incomes drop as the government push harder and harder, and the doctors take home less each month to keep the practice running.”
3. What are the solutions?
Fair enough! But surely there are good outcomes? Surely there’s evidence to show all this interrogation improves patient outcomes?
Archer (et al 2015), writing about the UK context, maintains “no one has yet properly articulated what we are trying to achieve” in revalidation.
They found that although much energy has been employed into revalidation in the UK context, there have been too many prior assumptions made about the possible impact on patients and healthcare safety and quality.
And from the interim report:
“The lack of robust processes surrounding optimal remediation was recognized in the UK, with the formation of a Steering Committee on Remediation to assist thinking for revalidation. In Australia, equally, these weaknesses should be addressed. Continuing research to confirm the efficacy of remedial interventions will be needed.”
If you ask a plumber he’ll say you need a washer. Regulators regulate, that’s all they know and they will always search for new opportunities to send in the Goon Squad. That’s how they make their living, to them it’s improving productivity!
We’re intelligent enough to spot a furphy when we see one. Compared to other countries, Australia gets incredible value for money from its primary care sector.
There are many challenges and our system must evolve to deal with the rising burden of chronic disease as our population ages, ironically a problem our older GPs are probably well placed to relate to and manage effectively.
If we apply ourselves intelligently and work collectively we can meet this challenge. We’re all in this together, young and old.
Excellent points. I for one, having been in the GP business for 40 years now, half of it being before the days of compulsory CME points, and all that goes with that, and the latter half under that compulsory system. I can state, without a shadow of a doubt, that I enjoyed my CME, and got way more out of it in the ‘before’ period.
There are a number of reasons why that is, but mostly because of the freedom to chose what I wanted out of it. Areas that interested me made me want to dig deeper. Areas where I felt somewhat deficient, I also sought out especially. By being able to do that, I got the most out of it without spending so much time just chasing a points target, so avoided CPD points burnout. With compulsory targets, one ends up often attending for the points, often rather shallow or repeated events, and not because one gained much in real terms out of going. Now there’s this re-validation by another name, and this health and competency idea for older docs – like me, eg.
Many of these arbitrary up-scaling of requirements such as the above have already been instituted overseas, yet none have furnished any hard evidence they make a positive difference to practice standards. However, the one thing they do is have a really negative affect on doctors. They hate them, universally. So often when programs like this are considered, those coming up with them, (usually those who won’t be affected – other than it showing them doing something), think only whether it ‘can be done’, but no so much ‘if it should be done’. In other words, they ignore the golden rule… “if it ain’t broke – don’t fix it”..!
I would put money on it, if someone finally had the courage to say, “bugger it – all this effort on all these people’s part, yet no really hard evidence of benefit – let’s just scrap it all, and go back to the suggested policy anonymous above mentioned, ‘self-directed’ learning. I bet there would be a collective sigh of relief round the whole country, followed by such thunderous clapping, it would sound like a summer storm approaching. More to the point, docs all over the country would start enjoying their jobs again. And in my view, the best performing doctor is a happy doctor. Always has been – always will be..! I may not be Sam Kekovich, but most would agree, I’m right..!
PS. Please get rid of those stupid I’m not a robot things. They are so over the top, I will never post on here again. It took me about 7 attempts to get past the damn thing. Maybe I am a robot..?
Dear Dr Flynn,
Einstein once said
“Any intelligent fool can make things bigger and more complex. It takes a a touch of genius and a lot of courage to move in the opposite direction.”
It seems to me that the Medical Board and AHPRA have not taken heed of this truth. While action is required to cull out practitioners not meeting a current standard and who are genuinely dangerous to the population, you yourself admit that in Australia trust in the medical profession is very high and evident in the Australian population. To use a drift net proposal that targets all practitioners at any age (seventy) as is suggested may damage good practitioners and also allow bias to be introduced.
You also indicate that research is needed to evaluate health and performance screening processes and the utility of this approach. Might I say that is also needed for many of the processes that are used currently by AHPRA. As an educator of undergraduates, and having had a keen interest in trying to predict the potential to identify traits that predict future performance of medical students in the workplace as doctors, I know the evidence is very poor and not reliable in individual circumstances. There is a very loose coupling of this data and there is no tight coupling in the literature to give any confidence for its usefulness. Also my experience over many years of CPD and CME is that there are some practitioners who are able to practice at a questionable ethical standard yet satisfy all the College requirements and some occupy senior positions in our Colleges and Associations. It may be best to target this group of medical practitioner before starting on the rest.
There are many statements in the Experts report that are challengeable and not verified by scientific study. In fact peer review is not uniformly carried out in Australia and on many occasions has been used incorrectly. Just stating that peer review is required for reviewing performance without defining what is “credible and honest peer review” is a potentially dangerous position and it we know that some good practitioners have been damaged by this form of review when it is incorrectly used. The best and most historically significant example of the is Ignaiz Semmelweiss who in 1850 championed hand washing to save lives. There are many other less well known examples.
Your mention of the code of conduct is reasonable but nothing in that code of conduct defines the fact that vexatious (dishonest) complaints by colleagues is unprofessional and in itself should be an indication for review of fitness to practice in medicine. Doctors in Australia are not protected against the misuse of reporting (complaints, notifications) by colleagues for whatever reason as long as they state that they made the complaint “in good faith”. This form of bullying should be called out and also punished by AHPRA and the Medical Board. AHPRA, the Medical Board, Colleges and Health Practitioners know that this happens. In the work place even the threat of it can be used by colleagues and can be damaging and cause great distress. On occasions some practitioners suffer professional isolation because of the biassed behaviour of their colleagues. There are documented cases of this in Australia and the Medical Board and AHPRA have not called these behaviours out either.
Einstein also said “Not everything that can be counted counts, and not everything that counts can be counted”. Again the Medical Board and AHPRA has not recognised that associations or correlations are not necessarily causal factors
I would suggest that this report gives us no confidence that the mechanisms suggested will be ” smarter and not harder”. Previous experience is that compliance becomes more difficult, bureaucracy grows, form filling increases, costs increase and satisfaction for health practitioners falls when such good intentions are implemented but not validated and then lead to unintended consequences. The data on which AHPRA and The Medical Board is basing its decisions is not strong, conclusive or advanced enough to introduce all of the recommendations without and unbiassed legitimate review.
John Stokes
The Board claims to have evidence of advancing age and poor performance. How robust is it? What is the evidence for a performance “cliff” that occurs at age 70 or is this bureaucratic convenience?
The Board has a duty to provide detailed cost/benefit analyses for these proposals. After all it is the medical profession that in the final analysis has to pay for all this stuff. Doctors need to be convinced that the cost in time and treasure is worthwhile,
Two years ago, at 72, I bought myself a new high powered sports car. The state government did not quibble about renewing my driver’s licence for 10 years because of my clean record. (I’m youthful and healthy for my chronological age anyway.) Would it not be more appropriate and efficient to save the jumping through hoops for those there have been complaints about?
I attend most of my college CME events – more consistently than most colleagues – but would not like to be compelled to attend and pay for college run courses as most of those I attended in the past were rehashes of subjects I had already read about on line. So I gave them up, saving my time for more useful CPD.
GLAD YOU ARE AGAINST COMPULSORY RETIREMENT AGE. THOUGH STEPPING DOWN/BACK TO ALLOW CAREER PROGRESSION OF YOUNGER COLLEAGUES IS DESIRABLE. CHRONOLOGICAL AGE IS A 19TH CENTURY CONCEPT AND BISMARK WAS ON A WINNER INTRODUCING PENSIONS WHEN LIFE EXPECTANCY WAS <70.
NO LONGER! THIS CENTURY NEEDS ABILITY TO BE USED AS LONG AS POSSIBLE; NOT DISCARDED..
Thank you for the outline. I appreciate and acknowledge the positive intent of these measures. One must always look at the potential downside in any legislative changes though?
Is it the suggestion of the Medical Board that having a ‘CPD home’ will make conducting CPD through a college compulsory? Is this a step towards compulsory college membership which colleges will naturally have a vested interest in, although college interests don’t always match those of their fellow members (see managerialism in our colleges in this journal). Many practitioners are quite capable of managing CPD requirements to an ‘equivalent standard’ themselves – can they be ‘home schooled’ so to speak? Furthermore it is not currently a requirement for a doctor to be a fellow of college for AHPRA registration (specialist or otherwise). Is it the intention of the Medical Board to make college membership compulsory (akin to ‘forced unionism’)?