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.


Poll

There is no evidence that revalidation of doctors improves health care
  • Strongly agree (56%, 15 Votes)
  • Agree (37%, 10 Votes)
  • Neutral (4%, 1 Votes)
  • Strongly disagree (4%, 1 Votes)
  • Disagree (0%, 0 Votes)

Total Voters: 27

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16 thoughts on “Doctors’ revalidation and registration: fairness for all

  1. Graeme Banks says:

    The slow death of general practice continues. Thanks.

  2. Anonymous says:

    How about all doctors on AHPRA RACGP and AMA boards ALL go first – show the rest of us how easy it is.

  3. Anonymous says:

    I recently renewed my driving licence until 2022 – by which time I will be 79 – without ny quibble from the state government. I enjoy my 6 speed manual turbo charged sports car. Each year now I fill in an online form confirming my fitness. I would only be required to get my GP to fill out the form if I had certain conditions. This seems a bit pointless because I could lie on the form, but requiring the GP to provide the form for me and all others of my age and perfect health anuually would waste a lot of time and money.

    The same would apply to all soft forms of medical revalidation via AHPRA.

    However, if I start having frequent minor accidents (as dinstinct from occasional fines for transiently exceeding the speed limit) it may be appropriate to require me to get my GP to fill in a form for me. Perhaps AHPRA could use a similar method based on the frequency of valid reports and complaints rather than adopt a technique that can only expand the bureaucracy and the cost.

  4. Anonymous says:

    Truthfully, this article makes me totally bilious and depressed. Who gets to test these postulated great and the good testers by the way.
    This is the exact same self-flagellating bureaucratic miasma that has driven hordes of medical practitioners in the UK to flee that country or leap into early retirement leaving it desperately short of practicing doctors.
    This article merely apes all the failed UK stupidity of ten years ago and it’s virtue signalling everywhere just leaves me cold..
    Require that the legal profession, dentists, vets, scientists, nurses, politicians, all public servants, generals, admirals, wing commanders, plumbers, accountants, builders, electricians, engineers all to have to submit themselves to this ridiculous exercise in self abasement and inquisition and then just imagine the reaction of these groups and general community to this exercise. In truth, it really does seem only fair that everyone in this country should enjoy the same privileges as doctors for doing their job.
    On the plus side however, just imagine how many new jobs could be created in Canberra in operating this policing industry and just how big a department could be created.
    By the way there is absolutely no evidence whatsoever that this bureaucratic exercise in so called revalidation has made one iota of difference to medical outcomes in the UK NHS except to further demoralise an already hounded medical workforce.

  5. Dr Jan Sheringham says:

    I have to agree with my “Anonymous “ colleague above – I see little if any evidence that revalidation or re-testing is needed(to manage/deal with a problem), nor effective in performing the task! All those responsible for direct patient care are now obliged to carry out QI/CPD activities within their craft group to permit the ongoing access to the relevant speciality AND professional registration, so despite the perceived current limitations of this process, I see no evidence of improved community safety by imposing yet another layer of red tape towards the latter stages of one’s career as a heath professional!

    Surely it makes better, and frankly, less bureaucratically expensive sense, to have the relevant Royal Colleges modify their CPD programs in ways that ensure we all remain up to date in our ongoing therapeutic systems of diagnosis and management. Age-related re-validation/retesting is actually illegal under discrimination law, which has forced some states to even review their driver licencing regulations on just this basis UNLESS they can produce research which justifies such an approach. I have yet to see such evidence produced either in UK or here which demonstrates such validity within the healthcare setting.

    Perhaps AHPRA can show those of us who hold these or similar opinions the errors of our ways – I have yet to see any such “proof” advanced. And thank goodness I will not be obliged to deal with this mess now that I only hold non-practising registration in early retirement (and approaching 75!). Good luck to all who must deal with this issue just when they thought their lives were getting easier!

  6. Anonymous says:

    My understanding is that the Medical Board of Australia is going down the path of using CPD as the method of revalidation/recertification rather than setting up special exams on a five or ten-year cycle. This seems reasonable to me as long as the CPD requirements do not become an exam proxy. Any targetting of a physician group based on gender, age, racial background, skin colour, country of birth origin etc is discrimination, pure and simple. Just imagine the outrage if the Medical Board of Australia targetted all indigenous Australian medical practitioners for examination based on their membership of a group – that of being an indigenous Australian. The only medical practitioners that might justify additional scrutiny are those whose recent track record shows multiple proved infringements of professional standards.

  7. Graeme Romans says:

    This is authoritarianism.
    Are doctors better educated than they were in 1980? No, they are less capable and offer less comprehensive services. Thanks to bureaucratic intervention/
    Has the bureaucracy protected GP’s from frivolous complaints against them? No. They have increased the forums for complaints and facilitated complaints.
    Has the increased oversight improved general practice? I challenge you to provide evidence that there has been a positive outcome that outweighs the obvious negatives to GPs themselves.
    Has the bureaucracy reduced the rate of litigation? No. It has increased.
    Is litigation a negative force that is forcing/has forced GPs to refer unnecessarily thereby increasing costs and wasting time and money? I know this to be true.
    You already have the power to act against doctors whose competence is in question.
    To impose ageist interventions you must reasonably establish an expected benefit that outweighs the authoritarian intervention.
    I look forward to retirement.
    I love my work.
    I hate the increasing bureaucracy.

  8. Geoff Chapman says:

    AS has been suggested. let the examiners sit the exam first, and preferably one formulated by Full Time Country GP’S,
    who have to do everything from surgery to obstetrics, to cardiology , respiratory, gastroenterology, ophthalmology,
    haematology ,orthopaedics, paediatrics, ENT, and a few more. I wonder how many of our “brothers” at AHPRA, and all the other little bureaucracies would pass, or would their average be the qualifying mark ?
    And let’s be sure that EVERYONE, irrespective of age does the same exams.
    Gee, do you think my idea will get off the ground ?
    These academics live in Disneyland.

  9. Anonymous says:

    I am aged 74 and have been working as a consultant general physician for 38 years and have not had a complaint ,so far against me. I was hoping to continue working for another 5 years but 2 events have convinced me to retire at the end of this year:-
    1. Department of Health questioning the item numbers that I use.
    2. AHPRA and the RACP changing the the rules re the way CME points can be acquired-making it very difficult for a solo elderly practitioner in private practice like myself to satisfy this bureaucratic imposition which makes little or no difference to the standard of care we provide.
    Many of my patients ,some of whom I have been seeing for 20 + years, are very disappointed ,and so am I.

  10. Chris Briggs says:

    I am a GP, now over 10 years fellowed, that agrees completely with revalidation. I’m surprised it appears so controversial…surely those who are clearly competent doctors should have nothing to worry about, those who are a bit worried might be encouraged to reflect and do some extra learning, and those that are completely incompetent shouldn’t be practicing anyway.

    I would much rather sit an exam, or some other meaningful revalidation every 3 years, (and maybe even improve and reflect on my own skills, in addition to ‘passing’), if it were to replace the need to tick off 150 points of mostly useless CPD, which could be achieved by attending drug dinners and conferences in a nice hotel, or even worse, complete the PLAN submission!! I wouldn’t expect it to be the RACGP exams all over and the preparation that goes with it, and so a day out of our working lives every three years to demonstrate that we are doing a great job (for most of us), shouldn’t be a concern.

    I wonder whether most of the criticism is from more experienced doctors? I am often in awe of some of my more experienced colleagues, who are an amazing asset to communities across Australia, and experience cannot be taught or replaced. However, none of us are perfect, we can all improve, and in medicine in 2019, things change…a lot, and quickly.

    As a GP, in other professional roles, and as a normal ‘Joe Blow’, I am too often embarrassed by the standard of care that our profession provides, and I suspect that public perception of our competence as a profession as a whole is declining. If we are so bothered by appalling MBS rebates (as we should be), or want to go about changing the public expectation for bulk billing, then perhaps we need to demonstrate a better standard of care to the public, or perhaps more specifically, reduce the episodes of care that are below the expectations of the patient, the public, and our peers.

    I imagine most doctors using a forum such as this are the more motivated and engaged subgroup, and probably not the ones that need to worry. But I also imagine most of you reading this can think of examples you have come across that would support an argument for revalidation, even if just for that person, regardless of whether you personally agree with it or not.

    I don’t think revalidation can work if it is targeted to certain groups, it needs to be universal to be relevant and valid. However, if it is done well, (and I appreciate that is a big ‘IF’), then we should all be able to actually get something out of it, even those amazing GP’s amongst us that would pass with flying colours! It might be informal reflection, about what we would have been worried about if it came up during the revalidation process (ie our weak spots), or formal feedback on how we did and areas for improvement.

    If revalidation was clinically relevant, replaced some of the current (useless) requirements, did not add a substantial administrative burden, was universal (rather than targeted), and provided feedback, then I am all for it. It can only increase the standard of care, which is what we should all be aiming to do every day.

  11. Dr Jag Gill says:

    Firstly, why do we have to have revalidation, irrespective of age? The problem that this is trying to solve really does not exist! It is a perceived problem, but if AHPRA wants to feel it is doing a good job it should deal with reported cases by patients, doctors and possibly also by mischief makers! Deal with reported cases fully and carefully, and perhaps have these activities carried out by good investigators supported by the best in the field that the report alleges. I note that most of the reported cases are often treated as an “unpleasant task, and the action quite inadequate, as it should always be followed by some good level coaching to improve standards, in various ways such as retraining, forced hospital training where appropriate under strict supervision, or examinations where appropriate. Aging affects different individuals differently, so use age appropriate training if deemed required, which may include deregistration!
    In areas where direct patient care is not involved, such as administration, evaluation where required can be carried out, and retirement advised/forced! All of these should be cheaper! Why spend vast amounts of money dealing with really few problems! Remember that patients can always sue doctors and so affect their continuing practice if deemed appropriate by deregistration!

  12. Anonymous says:

    Dr Briggs, your well intentioned discourse unfortunately overlooks two important facts.
    1. There is absolutely no evidence whatsoever that this UK sourced exercise in stultifying oppressive bureaucracy has made one iota of difference to the improvement of medical practice or health outcomes in rhat country. It was introduced as a totally punitive populist political exercise against individual doctors there due the Dr Shipman and Bristol Hospital cardiac scandals in the late 1990s early 2000s. No attempt to validate its effectiveness was ever considered. It was just dumped on the medical community as a fait accompli.

    2. The cost of the bureaucracy has been massive. It has failed dismally, essentially driving doctors out of the professioninto early retirement or overseas or even dissuading potential candidates from undertaking a life in medicine in the first instance.

    It is not in the least surpising. given the slavish aping that the ‘health’ bureaucrats in this country have for copying failed UK NHS intiatives 5 to 10 years on, that AHPRA is heading down that pathway. The first rule of any government bureaucracy is to constanly expand: Boyles Law of Bureaucracy.
    Chris this exercise is not benign at all and the cost of operation will be massive and largely borne by you as the treasury will not falling over itself to fund it. Careful what you wish for and please move away from the Mea Culpa mundset when dealing with bureaucracies.

  13. Dr Louis Fenelon says:

    Professionals are individuals with the capacity to determine their own need for maintaining the quality of their practice. No profession has so many eyes on it at all times. Bad eggs are pretty obvious, but they seem to be quite common within areas of the system that supposedly have the highest level of surveillance – ie the public health system. Prove to me a new examination system will make any difference.
    Is it time to rename doctors Medical Exploited rather than Medical Professionals?

  14. Anonymous says:

    I became a GP because the discipline provided me with endless opportunities for resolving my curiosity about human problems. I have been involved in many seminars and study programs over many years, I am now 72 years of age. There have been several fatuous complaints against me, none of which were followed by any warnings or disciplinary actions. The complaints resulted from my not following the dictates of patients which would have resulted in possible harm to the patient, or to the patient’s underestimating my level of understanding of his/her devious ways. I was twice the subject of a ‘Performance assessment’, which is quite a traumatic experience for the patients and should be discontinued as a matter of urgency. I was then subjected to a performance review, despite my not feeling well having had an accident and ongoing concussion. (I was told the interview would go on whether I was present or not). As a result of this interview I was given limitation of 40 patient interviews a day, and eight hours of work a day 5 days a week. My supervisor however expected me to help improve the effectiveness of the practice as there were many complaining reviews about long waiting times on the internet site of the practice. Thus on many days I was obliged to see more than 40 patients per day. For this infringement of Medical board ‘s condition, my right to practice medicine has been cancelled and I am being referred to the “1ribunal”., perhaps to be deregistered for ever. This is a warning to doctors – you do not have to be the cause of significant disability or mistaken judgement, you could be very knowledgeable, you are judged ‘guilty’ before any proof is presented, and you will receive not a gram of support from your colleagues, your professional insurance or the Medical board.

  15. Ian Hargreaves says:

    I am always intrigued by this, as those doctors who want ”to spot the doctors needing re-education pre-emptively” remind me of my anaesthetist’s story about his father, who was sent for re-education after the fall of South Vietnam.

    As a registered UK GMC doctor, I have observed their relentless progress to a massive medical revalidation industry, which is uniformly condemned by those who are subject to its processes, supported by the many who are paid to implement it, and has no scientific basis whatsoever.

    The proponents of revalidation are loathe to elaborate on precisely what it is supposed to do, and in terms of informed financial consent, what its costs are. Neither do they list benefits, detriments, and risks as shown in an RCT. I am unaware of any jurisdiction which has subjected its own revalidation program to an RCT, to assess its effectiveness.

    Perhaps those who are in favour could write a submission for this novel medical procedure to obtain TGA approval. Can they convince an independent arbitrator that it is worthwhile? After all, someone has to fund this, presumably the general taxpayer, or our patients through higher fees.

    For a snapshot of the UK experience (and to save me repeating my comments) try: https://gmcuk.wordpress.com/2017/10/09/gps-view-changing-revalidation-on-the-ground/

    Or the executive summary: “As it stands, if revalidation was an operative procedure, with unproven benefits, obvious detriments and costs, and unquantified risks, no sane patient would give informed consent, and no reputable health authority would allow such an uncontrolled experiment to be performed on human subjects.”

  16. Ian Hargreaves says:

    Again, after the GMC revalidation was assessed by the government’s Umbrella review, and found to have no positive evidence of benefit: https://gmcuk.wordpress.com/2018/05/11/appraisal-and-its-role-in-professional-development/

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