A critical review of the Medical Board of Australia’s proposals for revalidation.
For these remarks I have reviewed comments about revalidation from the Medical Observer and from the Medical Board of Australia’s press releases and information on its website.
It seems if you are male, or ‘old’, or in solo practice, or from ‘some’ overseas countries you will be targeted for being ‘at-risk’. Who decides who will be targeted? Will medical colleges refer or notify certain of their members to the medical board police? On what basis? Population screening to find ‘cases’ (i.e. bad doctors) only works effectively if the base rate of ‘abnormality’ is reasonably high. We are not told what the base rate of ‘bad’ doctors is in Australia. If it is very small (which I suspect) the screening of whole populations of targeted doctors will be a waste of resources and will just be a bureaucratic assault on the profession.
The process will require additional resources – medical board doctor policemen and policewomen – and will grow the medical board bureaucracy requiring additional registration fees. The medical board will outsource the process to the medical colleges (via ‘strengthened CPD’) and the colleges will welcome the opportunity to charge their members additional membership subscriptions!
The compliance costs for private practitioners will be onerous. Public sector and other employed doctors will have less of a burden as they can tell their employer that compliance with the revalidation process will need to be done during paid work hours. Compliance costs will be an unfair burden on private practitioners.
I am also amused that in the medical board’s press release the usual appeal to ‘evidence-based approaches’ to CPD is invoked. But there is no substantial or replicated evidence provided that shows that certain types of CPD or even revalidation itself has significant positive effects on medical practice or patient welfare. There is a lot of ‘opinion’ from bureaucratic stakeholders who might benefit from it that revalidation is a ‘good idea’, but so far little supported argument that persuades me. I would be open to be convinced otherwise by robust evidence.
The Medical Board of Australia website notes there will be specific attention directed to ‘at-risk’ and ‘poorly performing’ practitioners. Who determines who are in these categories? Maybe you are one if you have blue eyes, or some age-related or physical or racial or religious characteristic or if you get social media attention from groups with a barrow to push. I hope not. But this aspect demands close scrutiny.
One of the ‘core’ features of the Medical Board’s approach to revalidation is ‘Strengthened CPD’. The fingerprints of the medical colleges are all over this policy. Many college fellows, and particularly those in private practice, only engage with their college in order to get the annual CPD certificate that they need for renewing their medical registration. Much clinical education and skills development and discourse between practicing clinicians is now done through specialty societies and interest groups. Without CPD many colleges would become irrelevant. The proposal of the Medical Board to make strengthened CPD a core element of revalidation preserves the life of colleges that otherwise may have been extinguished if CPD does not continue to be an exclusive offering of these colleges.
The Medical Board of Australia asked Plymouth University UK to prepare a report on revalidation. The Plymouth University report includes the following acknowledgement that there is no evidence that revalidation works (see section quoted from the report below). So why are we embarking on a project that has no significant evidence to support it? The Medical Board of Australia often appeals to ‘evidence based’ approaches, yet when it comes to revalidation its own commissioned report says there is none.
Plymouth University Peninsula
Schools of Medicine and Dentistry
The evidence and options for medical revalidation in the Australian context
Final Report
Dr Julian Archer, Miss Rebecca Pitt, Dr Suzanne Nunn, Dr Sam Regan de Bere
10/07/2015
“The literature therefore concludes that no singular approach to medical regulation works best under all conditions. Creativity and diversity are therefore required. These conclusions strongly resonate in the Australian context and the current learning preferences of their medical professionals. More research is needed to identify which aspects of the educational activities and types of combinations are most effective for regulatory purposes as these conclusions are currently absent in the revalidation literature.”
In summary, in my view there is little evidence or support in the Medical Board’s press releases or information provided about revalidation that would justify any additional bureaucratic ‘big-brother’ regulation of the medical profession. The existing CPD programs of the medical colleges and GP and specialist societies are sufficient.
A critical review of the Medical Board of Australia’s proposals for revalidation
I copied the comment below from Medical Observer. Note Joanna Flynn’s comment:
“Most of the practitioners in the at-risk group 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,” says Medical Board chief Dr Joanna Flynn.
It seems if you are male, or ‘old’, or in solo practice, or from ‘some’ overseas countries you will be targeted. Who decides who will be targeted? Will medical colleges refer or notify certain of their members to the medical board police? On what basis? Population screening to find ‘cases’ (i.e. bad doctors) only works effectively if the base rate of ‘abnormality’ is reasonably high. We are not told what the base rate of ‘bad’ doctors is in Australia. If it is very small (which I suspect) the screening of whole populations of targeted doctors will be a waste of resources and will just be a bureaucratic assault on the profession.
The process will require additional resources – medical board doctor policemen and policewomen – and will grow the medical board bureaucracy requiring additional registration fees. The medical board will outsource the process to the medical colleges (via ‘strengthened’ CPD) and the colleges will welcome the opportunity to charge their members additional membership subscriptions!
The compliance costs for private practitioners will be onerous. Public sector and other employed doctors will have less of a burden as they can tell their employer that compliance with the revalidation process will need to be done during paid work hours. Compliance costs will be an unfair burden on private practitioners.
I am also amused at the medical board’s press release (see immediately below) that the usual appeal to ‘evidence-based approaches’ to CPD is invoked. But there is no substantial or replicated evidence provided that shows that certain types of CPD or even revalidation itself has significant positive effects on medical practice or patient welfare. There is a lot of ‘opinion’ that revalidation is a ‘good idea’ from bureaucratic stakeholders who might benefit from it, but so far little substantial argument that persuades me. I would be open to be convinced otherwise by robust evidence.
Press release
“Evidence-based approaches to CPD best drive practice improvement and better patient healthcare outcomes.
The Medical Board has gone public with its proposal for an overhaul of the national revalidation system. It has opened up a consultation with a view to producing a concrete set of recommendations in mid-2017.
Here are the most important bits:
- Thousands of potentially underperforming doctors would be subjected to screening and assessment to ascertain whether they’re putting patients at risk. The assessments would affect doctors deemed “at risk”.
This raises the question of which doctors should be targeted. The report cites international research indicating the most significant risk factors for complaints are older doctors, male doctors, the number of previous complaints faced by the doctor, as well as the recency of the complaints made against them. Solo practitioners working in isolation from peers, as well as IMG doctors trained in certain countries, also increased the risks of future patient complaints, the report states.
“Most of the practitioners in the at-risk group 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,” says Medical Board chief Dr Joanna Flynn.
- Those who are found to be performing badly under the revalidation system would be subject to further screening and assessment
The idea is to identify whether or not they are practising safely, and whether they would benefit from remediation. Doctors found to pose a more serious risk to patients would be subject to a more “intensive peer-mediated process”, possibly to the point where the medical board would become formally involved.
- All doctors would have to undergo “strengthened” CPD.
This should be “smarter not harder”, meaning regulators want to make it more effectiveness but not more time-consuming.
- All doctors would have to undergo some form of peer review for their performance
This could be based on clinical audits or discussions of cases or critical incidents they have faced. One option is review based on feedback from peers, medical colleagues, co-workers and patients. It’s not clear how often the reviews would take place. Doctors in the UK currently undergo revalidation every five years. But failure, in theory, would mean doctors being stripped of their registration.”
More from the Medial Board website below.
“The core features of the proposed approach are:
- Strengthened CPD: Evidence-based approaches to CPD best drive practice improvement and better patient healthcare outcomes. Strengthened CPD, developed in consultation with the profession and the community, is a recommended pillar for revalidation in Australia.
- Identifying and assessing at risk and poorly performing practitioners: A small proportion of doctors in all countries is not performing to expected standards at any one time, or over time. Another group of practitioners is at risk of poor performance. Developing accurate and reliable ways to identify practitioners at risk of poor performance and remediating them early is critical, with considerable transformative potential to improve patient safety. It is equally critical to identify, assess and ensure there is effective remediation for practitioners who are already performing poorly.”
From the Medical Board of Australia website – see press release below. Note the comment on ‘at-risk’ and ‘poorly performing’ practitioners. Who determines who are in these categories? Maybe you are one if you have blue eyes, or some age-related or physical or racial or religious characteristic, or if you get social media attention from groups with a barrow to push. I hope not. But this aspect demands close scrutiny.
“proactive identification and assessment of ‘at-risk’ and poorly performing practitioners”
“16 August 2016
Medical Board consults on revalidation in Australia
Strengthened continuing professional development and screening for at-risk doctors should underpin future approaches to revalidation in Australia, according to an expert report to the Medical Board of Australia.
The Board asked for advice from an expert advisory group on revalidation, about what it should do to make sure that medical practitioners in Australia maintain and enhance their professional skills and knowledge and remain fit to practise medicine.
‘Regulation is about keeping the public safe and managing risk to patients. Part of this involves making sure that medical practitioners keep their skills and knowledge up to date,” said Board Chair, Dr Joanna Flynn AM.
‘We are committed to finding the most practical and effective way to do this that is tailored to the Australian healthcare environment,’ she said.
The Board today launched a consultation on revalidation and published a discussion paper and the interim report of the expert group. The interim report proposes a ‘two by two’ approach to revalidation in Australia:
- Two parts: Strengthened CPD + proactive identification and assessment of ‘at-risk’ and poorly performing practitioners
- Two steps: Engage and collaborate in 2016 + recommend an approach to pilot in 2017.
This ‘two by two’ model represents evolution, not revolution, in the requirements for doctors to make sure they provide safe care to patients throughout their working lives, the report states.
‘An integrated approach will be most effective. CPD alone, however rigorous, may not identify the practitioner who may be putting the public at risk. A regulatory approach, however thorough, cannot reliably, single-handedly improve the quality of care provided by most competent doctors,’ the report states.”
One of the ‘core’ features of the Medical Board’s approach to revalidation is ‘Strengthened CPD’. The fingerprints of the medical colleges are all over this policy. Many college fellows, and particularly those in private practice, only engage with their college in order to get the annual CPD certificate that they need for renewing their medical registration. Much clinical education and skills development and discourse between practicing clinicians is now done through specialty societies and interest groups. Without CPD many colleges would become irrelevant. The proposal of the Medical Board to make strengthened CPD a core element of revalidation preserves the life of colleges that otherwise may have been extinguished if CPD does not continue to be an exclusive offering of these colleges.
The Medical Board of Australia asked Plymouth University UK to prepare a report on revalidation. The Plymouth University report includes the following acknowledgement that there is no evidence that revalidation works (see section quoted from the report below). So why are we embarking on a project that has no significant evidence to support it? The Medical Board of Australia often appeals to ‘evidence based’ approaches, yet when it comes to revalidation its own commissioned report says there is none.
Plymouth University Peninsula
Schools of Medicine and Dentistry
The evidence and options for medical revalidation in the Australian context
Final Report
Dr Julian Archer, Miss Rebecca Pitt, Dr Suzanne Nunn, Dr Sam Regan de Bere
10/07/2015
“The literature therefore concludes that no singular approach to medical regulation works best under all conditions. Creativity and diversity are therefore required. These conclusions strongly resonate in the Australian context and the current learning preferences of their medical professionals. More research is needed to identify which aspects of the educational activities and types of combinations are most effective for regulatory purposes as these conclusions are currently absent in the revalidation literature.”
In summary, in my view there is little evidence or support in the Medical Board’s press releases or information it has provided about revalidation that would justify any additional bureaucratic ‘big-brother’ regulation of the medical profession. The existing CPD programs of the medical colleges and GP and specialist societies are sufficient.
I support CPD everyone should keep learning but agree that the risk assessment and cost must be reasonable.
Hi Phillip I agree. In their own report they reported that only 6% of doctors are underperforming at any given time and that most of these ‘self correct’ to ‘self remediate’ and they themselves acknowledge this is the preferred way. I also note that they make the claim that ‘evidence based CPD’ the ‘best drives practice’ but on what evidence do they base that claim? There is much in our practice that drives our practice, and much of it is not evidence based but essential. I am not satisfied with the review of the EAG that it will add benefit to our profession nor to the public, but it will increase bureaucratic satisfaction as you say. the age of people ‘at risk of complaints’ they say is 35 or above, so essentially, anyone in private practice…
They say they want to ‘keep the public safe’ but their proposed measures do not appear to have endpoints to be measured. Its well known that most complaints come from communication breakdown and not medical negligence. Burnout rates are 50-60% in medicine and is a high associator with decreased patient satisfaction and increased risk of medical errors. Rather than applying a punitive system which they are ‘calling’ ‘non punitive’ the board would be better suited in my opinion to appreciating the stresses and strains that he medical profession are under and focus on ways they can bring about a more supportive culture, focus on professional health and well-being thus decreasing burnout rates, which would automatically decrease patient complaints decrease medical errors and increase commitment to ongoing learning thus abrogating the need for imposition of rigid impersonal restrictions and regulations which lack meaning and do not actually add value to daily private practice.
If we make systems about people, then people do well and both patients and doctors will be kept ‘safe’. Doctors are people too.