Strengthening the concept of validation is a much more worthwhile goal than further regulation, writes Dr Janice Bell
The term “revalidation” we should reject as a profession.
With its attention drawn to revalidation schemes at work internationally, the Medical Board of Australia has reframed the challenge for all of us to ensure our communities continue to enjoy safe quality care from every general practitioner in Australia. The intention of revalidation is well understood and accepted with genuine commitment – it is, after all, core college and professional business to ensure just that.
However, the case for revalidation as a stand-alone additional intervention to “re-validate” credentials – credentials already earned via robust, evidence-based academic educational, experiential training programs, credentials updated continuously through QI and CPD – is not a solid one.
After many years of operating in other countries, the evidence that a revalidation scheme achieves its lofty intention is far from compelling. Further, weighing up the validity, reliability, affordability, and practicality alongside intended (and unintended) consequences of revalidation, the value proposition is not convincing. Further, the opportunity cost of another layer in an existing quality framework redirects effort and resources from interventions for which there is much more evidence.
The attempt to prevent patient harm by profiling the apparently ‘at risk’ clinician – older, male and solo – is in my view divisive, unethical, unhelpful and based on thin evidence. The number of complaints against general practitioners is tiny, and better understood by much clearer trends, such as the type of patients seen, and a history of other complaints.
Even if there were irrefutable, actionable evidence correlating clinician characteristics with patient complaints and adverse events, the reasons are more likely to reflect a complex soup of selection loopholes, inadequate professional support and a lack of constructive clinical governance.
Such profiling is akin to rounding up all who fit the profile of a convicted juvenile criminal in Australia – typically black, young and male – before they have committed any transgressions, labelling them as potential delinquents, following them, and watching for slip-ups that could affect any of us from time to time – all without understanding the manageable antecedents or recognising the vast majority of this cohort never run into trouble with the authorities.
There is also the unexamined assumption that through subsequent interrogation – and perhaps some form of unfunded, vague “remediation” – “revalidation” will prevent these “at-risk” innocents from becoming delinquents. There is a place for remediation and renewal, of course, but only where there are evidenced gaps in needed competence and capability in a given context.
However, the regulators are entering the arena with a clear and very reasonable question, and our colleges need to answer by reviewing and – where necessary – reshaping the various ways we currently act to protect the public and our doctors.
Firstly, we should embrace any opportunity to review and reshape systematic and contextual clinical governance. As an international colleague observed recently, measuring the safety and quality outcomes of an individual practitioner is largely meaningless, given the small number of patients seen, even in a lifetime, and attribution even more so when there are so many variables and steps in the patient health journey.
But we can assess the quality and safety of systems and organisations, especially with the advent of cheap, accessible, comprehensive clinical data and timely, robust analytics. Not only can we identify room for improvement; we know consequent changes really do impact the patient and clinician experience and outcomes.
Secondly, we should review and where necessary strengthen our well established validation tools – selection into the profession, programmatic assessment during training, awarding of fellowship to be for those “fit-and-proper” and not only for those passing the examination.
“After many years of operating in other countries, the evidence that a revalidation scheme achieves only its lofty intention is far from compelling.”
From 2017 onwards, the general practice colleges will assess who is suitable for training, and who will subsequently become a valuable fellow in our profession. Regulators have long had clinicians under their purview who were a concern long before they entered a training program; even as early as medical school. College-led selection provides a preventive approach to quality control for our profession.
I am also hopeful the colleges will soon use a similar selection process to assess who can work as a general practitioner anywhere in Australia, and determine what mentoring, training and assessment is required under all government general practice workforce schemes.
Thirdly, we should ensure our QI and CPD are of the highest educational standard, relevant and practical to the work of each general practitioner. It must include the opportunity to receive and reflect on feedback. This follows the international trends and is a focus in the MBA report on revalidation published last spring.
Fourthly, we need to take seriously the unique challenges of our work, and support those who undertake it at significant risk to their own social, psychological and physical health. The wounded healer metaphor is as valid today as it has been through the ages because being one builds our understanding, compassion and commitment for our patients, while keeping us humble and curious. The metaphor only works to the point where our wounds build empathy and expertise; and not beyond towards exhaustion and ennui, experienced exclusively and insidiously if not addressed systematically, early and preventively.
Many general practitioners, including our registrars, are seeking mentoring and supervision just as exists for most other caring professions. If we were to invest here – instead of more regulation – I would expect a much greater impact on the well-being of our doctors and their patients, with concomitant reduction in harm to both. At least it would be worth trialling as an alternative to more regulation.
The term “revalidation” we should reject as a profession. We should embrace and indeed strengthen the concept of validation, and specifically the role of continuous professional development in protecting patients; the place of support for all of us in such a demanding profession; and in replenishing, enhancing, modernising our knowledge, skills and behaviour on the bedrock of our qualifications and fellowship.
