Revalidation should focus on lifting skills and confidence instead of targeting "bad doctors", experts say
While some Australian GPs fear adopting a revalidation scheme aimed at picking up underperforming doctors could lead the profession into a quagmire of bureaucratic box-ticking, international experts say a balanced approach can benefit both doctors and patients.
Medical Board of Australia Chair Dr Joanna Flynn confirmed in August the board would introduce pilot reforms in mid 2017 to strengthen professional education and detect doctors at risk of falling below professional standards earlier.
“Many, many doctors are practising well into older age but some of them, for a range of reasons, are slipping down,” Dr Flynn said, releasing the interim report by the board’s expert advisory group on revalidation.
Changes under the UK’s revalidation regime during the past four years appear to be dramatic: 33,500 doctors have given up their licences to practice and 3500 have been stripped of their credentials.
But Una Lane, director of the UK General Medical Council’s Registration and Revalidation program, told a conference last week that the majority of the 35,000 doctors who abandoned their licences were retirees or had been working overseas and were never going to work again in the UK.
She said the clear-out had made the medical registration system more meaningful and noted encouraging feedback on the benefits for doctors and senior colleagues involved in the appraisal process.
However it was too soon to make grand claims about the success of the scheme introduced in 2012 in improving patient care, she said.
“How do we know it’s working?” she asked, addressing delegates at the International Association of Medical Regulatory Authorities conference in Melbourne.
“There’s anecdotal evidence of emerging poor performers being identified earlier, some evidence of that, and some evidence of doctors reflecting more about their practice and how to apply the principles of good medical practice.
“Is it making a contribution to safer and high-quality care? That’s a really challenging question,” she said, adding it was difficult to separate the influence of revalidation from other factors bearing on the health system.
An academic study currently underway will attempt to quantify the success of the revalidation program in reducing the risks of poor practice.
The new UK system of annual appraisals with revalidation assessments every five years was less of a burden to introduce because all NHS doctors were already meant to undergo routine appraisals by senior colleagues; although compliance rates had sunk as low as 10% in some NHS organisations.
“Appraisal was meant to be in existence across the NHS from 2002, as was the process of senior medical officers at
board level in every organisation having responsibility for the clinical care provided by doctors to patients and in hospitals,” Lane said.
“So in terms of the resource issue, most of that structure was already in place. It just wasn’t happening or not happening effectively.”
The new system had brought a sharp increase in appraisal rates and also shown encouraging benefits for some 10,000 appraisers who took on the demanding roles of reviewing the practices of the 230,000 doctors in the UK.
“Actually (the appraisers) find it incredibly valuable; they really enjoy working with their colleagues through the appraisal process, they find out a lot about the individual that they are appraising and they see it in that supportive context. I think that is key,” Lane said.
In New Zealand, a pilot program of Regular Practice Review is underway for “general scope” doctors which focuses on improving a practitioner’s everyday work routine and includes observation of their practice.
Extensive consultations
Joan Crawford, strategic program manager of the New Zealand Medical Council, says this is part of a “push and pull” approach, mandating stringent requirements for one group of doctors while working with others on reviewing professional recertification principles.
“We wanted it to be profession-led as much as possible,” she said.
The approach has been guided by extensive consultations with doctors and was based on an understanding that targeting “bad doctors” would be a waste of time and effort.
“We had big working groups and involved them along the way, so we knew what wasn’t going to work. One of them was, don’t put in a system to detect the bad doctor when really what you are trying to do for 98% of doctors is to improve the standard of practice.
“We spend huge amounts of effort and energy getting people engaged and bringing them along. It takes years to put in a new program, whether it’s pre-vocational training or recertification. You can’t just mandate something and put it on the profession. Bringing them along for the ride is the most important lesson I’ve learned.”
The New Zealand scheme is user-pays and the emphasis is on a collegial approach.
In the earliest consultations with doctors, she said the medical council spoke of having two aims: to identify bad apples in the medical fraternity and to improve quality.
“We got told by the profession very clearly, that you can’t have a process that’s going to do both really well,” Ms Crawford said. “So we focused on quality improvement; we recognise that this may (also) pick up some poor-performing doctors, and in fact it has. But there are different processes that deal with them.”
In a recent survey, more than 70% of doctors in the New Zealand scheme agreed it was a much more positive experience than they had anticipated; 67% found it useful, 59% said they would recommend it to their colleagues, and more than half said they had made changes to their practice as a result.
Two weeks before the exercise, by contrast, only one-third had thought it would be useful; generally, they had expected a tick-box exercise, were nervous about being assessed and didn’t think they needed a review.
A year later just under half the doctors continued to report changes in practice.
“Therefore, I think it would be fair to say, changes are being maintained over time, changes that are described as likely to improve the quality of care they provide to their patients,” Crawford said.
“While these are self-reported changes, however, they do provide some evidence that the scheme is achieving its aims for many of the participating doctors.”
Dr Richard Doherty, dean of the Royal Australasian College of Physicians and a member of the MBA experts’ committee, told the Melbourne conference delegates the college was undertaking an early roll-out of team-based practice reviews in New Zealand in preparation for the requirement being extended to vocational groups.
“It’s based on the idea that people do work in teams; that’s part of a complex process that’s being sorted out at the moment. There’s an individual element, including multi-source feedback for the individual, as well as team reviews and individual performance data that come together.
“It’s fair to say that it’s complex, and the challenge for us will be scalability – how you can roll it out across larger groups, larger services. New Zealand is more centralised (than Australia) and that’s one of the advantages they have there.”
In both the UK and New Zealand, research on revalidation has uncovered strikingly similar issues that highlight the isolation many doctors experience.
Doctors in the New Zealand study said they appreciated “knowing where you stand” in relation to other doctors and felt the interaction with a senior colleague had boosted their confidence.
Many said it was the first time since they had gained their qualification that they had been given feedback from a colleague about their practice and they found it helpful.
In the UK approach, Lane said, the appraiser was not passing judgment but looking for ways to be helpful to the doctor undergoing appraisal.
“They are intended to be there as a supportive colleague identifying what the issues are at the doctor’s practice and how they can help develop a proper personal and professional development plan.”
In both countries, surveys about the effectiveness of revalidation of doctors in boosting public confidence revealed similar reactions.
“People were shocked. They couldn’t believe we weren’t doing it already,” Crawford said.
The New Zealand Medical Council has been encouraging the country’s medical colleges, which are accredited to conduct doctor recertification, to develop their own regular practice review procedures and says many have the work well in hand.
The Australian regulatory authority’s decision to push ahead with a revalidation pilot program drew criticism for an apparent focus on profiling “at-risk” doctors.
The report recommended a two-pronged approach, including a strengthening of CPD requirements and the adoption of measures to ensure “proactive identification and assessment” of poor performers, with consultations to continue this year and a pilot scheme to be adopted in 2017.
The report conceded little was known about the effectiveness of remediation programs in improving doctors’ performance.
“The current knowledge-base about remediation processes and outcomes is not as well developed as knowledge about performance assessment, and is fragmented and diverse,” it said.
However, Dr Flynn said any reforms needed to be “practical, effective and evidence-based”.
The report noted the risk of doctors slipping below accepted professional standards increased with age, also pointing to those who worked in isolation.
“Most of the practitioners in the at-risk groups will be able to demonstrate that they are performing satisfactorily, just as most people who are screened in a public health intervention do not have the disease for which the screening program is testing,” Dr Flynn said.
