Doctors’ revalidation and registration: fairness for all

THE question of “revalidation of doctors”, especially of older ones, arises from time to time. The Medical Board of Australia has developed a Professional Performance Framework, part of which is a proposal to:

“require practitioners who provide clinical care to have peer review and health checks at the age of 70 years and 3-yearly”

Even an algorithm has been suggested, to spot the doctors needing re-education pre-emptively. The PRONE-HP tool, developed by Spittal and colleagues from the University of Melbourne,

“showed particular promise for flagging doctors and dentists at high risk of accruing further complaints.”

Of the many questions regarding the need for revalidation in the first place, perhaps the easiest to answer are the “whether” and the “why”.

There would be very few among us who would deny that some of us may not be fit to practise.

Given the multitude of facets of a doctor’s practice, the main questions to ponder are:

• Whom to revalidate, if not all?
• How to revalidate, to be fair to all?
• When to revalidate, and how often?

The “whom” would clearly include those who have had multiple complaints upheld against them or have been convicted of indictable offences. As a professional group, there should be little difficulty reaching a consensus in this regard.

The real question here is defining the complaints; that is, whether to consider only complaints that have resulted in deregistration or suspension or to include those that have resulted in a warning as well, and so on. On the other end of the spectrum we may consider a periodic “resetting” examination for all doctors, including those who work for the Medical Board of Australia or the Australian Heath Practitioner Regulation Agency (AHPRA).

The statistical data of the current regulatory authorities including AHPRA, the Health Services Commissioner (Victoria), the Office of the Health Ombudsman in Queensland, the NSW Health Care Complaints Commission, the Health and Community Services Complaints Commissioner in South Australia, the Health and Disability Services Complaints Office in Western Australia, the Health and Community Services Complaints Commission in the Northern Territory, and the Tasmanian Health Complaints Commissioner, should come in handy for determining the “whom”.

This is to emphasise that to target an entire specific group of doctors due to age or race or place of qualification for revalidation, because a small number of them may have reduced physical and mental capacity, is not fair, in my opinion. The Medical Board of Australia’s recent decision to single out all doctors over 70 years of age is not justifiable.

Obviously, revalidating 88 000 medicos is not an easy task. Even if the actual financial cost was not an issue, the opportunity cost would be huge in any professional’s dictionary. Yearly revalidation would therefore be unacceptable to all but the most zealous. A 10-yearly interval is a lifetime for many and so much can happen in a decade.

Something in between – perhaps 3-yearly, as the Medical Board suggests, or 5-yearly could perhaps be a starting point to test waters.

Registration of FMGs and OTDs

Perhaps before embarking on a wholesale revalidation of the profession, we could review the current validation process that we use for screening our international medical graduates (IMGs) and  overseas trained doctors (OTDs), and ponder the difficulties in dispensing any degree of fairness for them.

The scale of problems with registration of this group has been documented in detail, by a Parliamentary inquiry that makes for very interesting reading.

“ … in formulating the report’s 45 recommendations the fundamental aim has been to reduce red tape, duplication and administrative hurdles faced by IMGs whilst ensuring that the Australian standard continues to be rigorously applied.

“ … Nearly one third of the IMGs who made submissions requested anonymity, citing fears that their chances of progressing through accreditation to registration would be compromised if it became known that they had commented publicly. The Committee also receive approaches from a number of IMGs, who while keen to air their concerns informally, refused to make formal submission to the inquiry fearing negative consequences.

“Key themes emerged as the inquiry progressed, with a significant proportion of witnesses describing a system lacking in efficiency and accountability, and importantly, one in which IMGs themselves often had little confidence. Many IMGs also felt that they had been the subject of discrimination, and anti-competitive practices and that this had in some cases adversely affected their success in registering for medical practice in their chosen speciality.”

Suffice to say that, after several decades, Australia’s medical profession as a whole is still struggling with proposing a fair and equitable method of assessment for our IMGs/OTDs.

As I personally suggested in my own submission to the inquiry, a handful of currently practising doctors in any specialty could be invited as volunteers, to sit a set examination (call it in this case DRE: Doctors’ Revalidation Examination). The volunteer doctors’ scores averaged out could be considered the minimum requirement or pass mark expected of all the others. Obviously, the score would vary in each examination depending on the performance of the cohort of volunteer examinees. The cohort could include the leaders of the specialty or the most enthusiastic proponents of the scheme.

It should be noted that it would make no difference if the volunteers were freshly qualified or senior practitioners. The examination would test a doctor’s essential theoretical and clinical competence, and even psychological attributes, values and so on (as desired and agreed by the whole of the profession and/or their leaders) that must be attained by anybody wishing to continue practising medicine independently in their own specialty.

The current Australian Medical Council examination format could be used as a starting point, but it could be modified to combine both the written and practical components of the current examination into a single exam.

The examination in the new format should practically eliminate all possible discrimination and bias with regard to the examinees’ racial and cultural background and place of their graduation and even age and so on. As well, this would and should obviate any need for cumbersome and non-standardised interviews. In other words, it should screen practitioners only on the basis of their competence to practise safely and not because they are merely over 70 years of age.

The overriding principle in any and all of this ought to be fairness and absence of any bias and discrimination against any particular group, whether it is race, colour or age.

Dr Tony Marshal is a GP with 30 years’ experience, in Frankston, Victoria. He is the author of Human machine, owner’s manual and basic trouble shooting, and a former columnist for Australian Doctor and Medical Observer.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.