THERE has been a long-held expectation and obligation within the medical profession to take responsibility in identifying and managing predictable risks to patient safety in the deliverance of clinical care. Across the health sector, there has been increasingly rigorous debate regarding revalidation systems to ensure continued professional development (CPD) and clinical competence of medical practitioners.
The premise of this has been that evidence-based approaches to CPD drive clinical practice improvement and better patient outcomes, notwithstanding the dispute of whether CPD compliance alone is in fact sufficient to ensure ongoing competence.
Under the Health Practitioner Regulation National Law, which governs the operations of the National Boards and the Australian Health Practitioner Regulation Agency (AHPRA), there are currently strict requirements in Australia mandating health services’ adherence to appropriate credentialing and CPD practices in making decisions related to the appointment and re-appointment of individual medical practitioners.
The Medical Board of Australia has developed a Professional Performance Framework to design and conduct screening and remediation approaches to a number of risk factors identified in literature as markers of poor clinical performance. Of these, the evidence for age-related risk of poor performance is particularly strong (here, here, here and here). For practitioners of an advanced age, potential age-related cognitive decline presents a greater level of individual risk with respect to their ability to continue professional practice. Within the five pillars of the Framework, the second pillar of “active assurance of safe practice” highlights increasing age as a known risk factor for poor performance. The Board “plans to propose” requiring targeted screening of practitioners over the age of 70 years and above, who are providing clinical care, to have regular health checks and formal peer reviews. These checks are designed to assure patients, individual practitioners, employers and regulators of doctors’ continuing ability to provide safe clinical care.
Age-related risk to clinical practice is a bitter reality that we all will eventually face as our careers grow and mature. The most learned clinicians, the most adept surgeons and the most ambitious of professionals will all be faced with acknowledging an eventual decline in function, and will be required to exercise a high level of insight and judgement in modifying their clinical (or non-clinical) practices in response. Interestingly, multiple studies looking at cognitive performance data appear to indicate that self-perceived cognitive changes in memory does not in fact align with objectively demonstrated cognitive outcomes (here, here and here).
While most clinicians practise safely and are suitably self-aware to retire and/or reduce their clinical practice scope at the appropriate point, there is a minority of individuals who may be either unaware of their deficits or in denial of them.
While the Medical Board’s Professional Performance Framework itself is rather non-committal in its language of the proposal for targeted screening of advanced age doctors, there is mention of embedding this requirement in a new registration standard. As the new standard is yet to be “informed by legal advice, and subject to extensive consultation and regulatory processes”, it unfortunately does not provide any substantial direction and guidance for health services and medical leaders in supporting and managing advanced age practitioners at the present time.
Helping medical practitioners through this transition of their careers is perhaps one of the most daunting discussions for medical leaders to undertake. This is particularly the case for new and junior consultants in the field of medical management.
Medical leaders will invariably face this scenario at a time when a senior doctor is not only be confronting their own mortality, but are also faced with having to prove their professional functional competence. This is a dangerous cocktail with the potential to generate an emotionally charged situation of extreme sensitivity and hyper-vigilance in safeguarding the individual’s self. Medical leaders charged with ensuring safe clinical practice and the wellbeing of the medical workforce within health services and hospitals must therefore approach any discussions, with respect to revalidation, credentialing and scope of clinical practice delineation reviews of these doctors, with an abundance of caution and a great deal of empathy.
In fact, in their submission to the consultation on revalidation that was undertaken by the Medical Board of Australia, the Royal Australasian College of Surgeons wrote “there is now irrefutable evidence that demonstrates that cognitive and technical skills decline with age, at a time when they may be under less scrutiny by clinical governance processes or undertaking locum work across a number of hospitals. However, there is a deficit nationally in guidance on how to approach the issue of ageing and surgical performance”.
In facing this challenge from the perspective of a large metropolitan health service, we undertook a rational and sensitive approach to reach a decisive stance on this issue.
The first step was to bring the issue to the attention of and enable senior clinicians and peak governance committees to seriously consider the question of competence assurance of advanced age practitioners. Hospital medical advisory committees (or equivalent) proved an ideal platform for the initial debates, discussions and challenging of opinions. An interesting observation during this process was the somewhat widespread unwillingness or inability of discussion participants to commit to any one or other position on the issue. This was undoubtedly due to the contentious, highly sensitive nature of the topic and the current absence of any definitive regulation or direction to follow. However, it was unanimously agreed that it was an issue in dire need of an immediate solution.
During this initial process of engaging clinicians and hospital leaders, the importance of presenting a ready-made proposal for the group to then consider became clear. Facilitating consequent discussions about the advantages and disadvantages of adopting this proposal proved far more productive than merely requesting the group to provide the answer to the problem from first principles. This also helped to circumvent some of the inherent decision-making inertia that was observed.
An internal position statement necessitating annual “reviews” for reappointments and recredentialing of all doctors over the age of 70 years was developed and presented to the peak clinician group for debate. The position was modified in response to feedback from craft group consultations, peak credentialing and appointments committees and senior clinicians. An ongoing process of consultation further allowed for peer review and peer support structures to be considered and incorporated within the position statement.
The position statement was underpinned by a strong commitment to provide a non-discriminatory, individualised and procedurally fair approach in supporting all advanced age medical practitioners to continue to deliver safe clinical care where possible. Key parameters aligned to the organisation’s values and by-laws were then developed as part of the position statement.
These parameters included considerations of individual medical practitioners’:
- planned volume of clinical activity and/or proposed modifications to scope of clinical practice;
- annual and total procedural and consulting activity since the start of their first accreditation at the organisation;
- annual and total procedural and consulting activity external to the organisation;
- clinical outcomes including mortality rates, complications and/or any incident reports;
- hospital outcomes, including unexpected readmissions, return to theatre rates and prolonged length of stay;
- staff and patient feedback and complaints; and
- participation in continuing professional development and/or peer review activities in alignment with the requirements of the specialist medical colleges.
The position statement further stipulated that the above parameters be reconsidered at least every 12 months for medical practitioners aged 70 years and above. An appeals process was also set up supporting any medical practitioners’ right to appeal decisions made on the basis of these parameters. This was in alignment with the initial commitment that was made to ensure a procedurally fair approach, and helped strengthen the position.
The next challenge was the practical implementation and impact management of this relatively bold position statement. Consistency, transparency and fairness of the process, and allowing for consideration of individual and contextual circumstances, respecting the individual and their inherent degrees of sensitivity to the issue were crucial and were continually upheld. Respect and understanding of senior doctors in each instance are essential, as (in most situations) it may fall to medical leaders who are relatively junior to them to conduct these difficult discussions and competency assessments.
To aid this task and ensure a reliable standard was upheld, a segmented guideline outlining key behavioural, practice and cognitive components relevant in competence assessments was then developed. The guidelines encompassed a self-reflective component that the medical practitioner in question would be encouraged to contemplate, as well as a checklist of key points to guide the discussion. Key components of this guideline are outlined in Table 1.
|Table 1: Discussion checklist (self-reflection to be encouraged at each point)|
|Medical practitioner’s planned volume of clinical activity||Does this represent a decrease in activity compared with recent/current activity levels?|
|Current and/or intended participation in an on-call roster||What is the plan for managing this?|
|Intention to modify scope of clinical practice||Reflective capacity|
|Medical practitioner’s annual and total procedural/consulting activity||Within and external to an organisation|
|Clinical outcomes (including mortality rates, complications, incident reports)||Comparisons with colleagues|
|Hospital outcomes (including unexpected readmissions, return to theatre rates, operating time and prolonged length of stay)||Comparisons with colleagues/peer organisations|
|Staff/patient feedback and complaints||Further inquiry as indicated if relevant|
|Continuing professional development (CPD) plans||Alignment with specialty college CPD requirements|
|Approach to navigating new/emerging medical advances/clinical practices||Particularly any that may replace or enhance components of their current practice|
|Intended involvement in teaching and research||Continue and/or modify?|
|Wellbeing and health checks||General practitioner support? Medical care support?|
|Retirement plans||Insight and judgement|
The art of discussion
While checklists and questionnaires certainly have a place in aiding consistency and comprehensiveness of such discussions, the true art of engaging doctors in sensitive issues such as this cannot be replaced or overlooked.
It requires a great deal of emotional intelligence and reflective capacity on the part of medical directors/administrators who are facilitating these discussions. One must be able to continuously modify and adapt their approach, style of conversation, and demeanour. Careful observation and attention to body language, tone of voice, unintended posturing, choice of vocabulary, and emotional undertones of the individual being questioned or assessed are a crucial aspect of what will determine the success or failure of this method.
Adequate time and opportunity for the doctors to self-reflect and judge their capacity for themselves must be allowed for during each interaction. Acknowledging any apparent sensitivities from the outset and actively exploring those emotions and/or even reluctance to participate any such discussions will help neutralise tension and unintended emotional bearings. Splitting the discussion into manageable blocks and conducting them over a number of days is another technique that may be preferred by some. This will be particularly useful if any serious concerns are flagged which may hinder our ability to reach a mutually agreed outcome with the medical practitioner.
No doubt we will see progressive developments, additional research, and regulatory guidance in this area as well as in the broader medical practitioner revalidation approach in the coming years. While these changes will be greatly welcomed and adopted into our daily administrative practices, this article has attempted to outline an experience of a practical and standardised approach that perhaps may prove helpful to medical administrators in the interim.
Dr Sidney Chandrasiri is Group Director (Academic and Medical Services) and Deputy Chief Medical Officer at Epworth HealthCare.
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.