The chair of the Medical Board of Australia, Joanna Flynn, has announced that the board will consult with the profession before proposing a new revalidation scheme. Revalidation is a mechanism by which doctors can confirm they are up to date in their particular field and fit to practice. The UK’s General Medical Council started conducting such checks in December.
Members of the public are entitled to a sense of security when they visit any professional. This is particularly important when they visit doctors because the stakes are often higher. We should all be able to expect that competent care will be provided and that our personal information will remain private.
But problems immediately arise when we explore the definition of “competent care”. All learned colleges have elaborate processes of training and assessment to ensure that new entrants into fields, such as general practice, are of sufficient quality to be able to practise independently in Australia.
Those processes are static – they confirm at a set point in time that an individual is “safe to be let loose on the public”. That’s all fine but how then can those professionals maintain and improve their capacity?
Current processes are focused on individuals participating in various activities and subsequently submitting evidence to the Australian Health Practitioner Regulation Agency (AHPRA). Provided APHRA gets your money and no one complains loudly about you, you stay in the game.
But that doesn’t prove you are still competent to practice.
Doctors are as human as their patients, although not all on both sides of the fence seem to remember that all the time! They develop physical and mental health issues, they age, and they sometimes lose interest in what has been their main line of work for decades. Sometimes they’re aware of these changes, sometimes not. Equally, sometimes their patients notice, but many times they don’t.
The quality of care provided by a doctor can fluctuate, or go into a permanent decline. It can sometimes drop below what might be deemed an acceptable level. External factors, such as heavy workloads must also be acknowledged. A sleep-deprived doctor is never as efficient as a well-rested one, and a waiting room full of sick patients deprives them of the time necessary to sort out complex patients properly.
So how can standards be maintained and patient confidence in the doctor justified? Doctors are more likely to favour some sort of peer review system. Effectively, this means their assessments would be done by their peers. Some stakeholders would raise concerns about this being “a closed shop”.
Some would say revalidation checks just mean more bureaucracy and assessment, all at a cost once more to be passed on to the poor patient. Time-poor doctors don’t need additional non-clinical burdens. They need to be allowed to get on with seeing their patients, with appropriate self-directed activities to maintain and update their skills and enthusiasm.
Perhaps the best environment in which a doctor’s abilities can be preserved and enhanced is the medium-sized general practice of between five and ten GPs, working both full and part-time, supported by practice nurses and allied health workers. Add to this mix some medical students to regularly ask probing questions, and be taught via a mixture of didactic and hands on methods.
Learning is inevitable in such an environment as teaching is the opposite side of the same coin. Bring in young GPs in training and hospital residents on rotation and the mix is complete. What’s more, peer support is maximised in such a setting.
Contrast this with both solo practice and corporate practice. In the former, the doctor can easily become isolated, the workload can be such as to impair involvement in professional development, and adequate study and recreation leave is often an impossibility. Burn out is a major risk, together with falling out of touch with recent developments in clinical medicine.
Corporate practices, on the other hand, must focus on producing a return for the shareholders. That doesn’t preclude the practice of good medicine, but does establish an inevitable tension between competing priorities. Large practices often have trouble maintaining continuity of care, with patients tending to hop in the shortest queue.
The wealth of knowledge that a patient’s long-term doctor possesses about that individual is literally priceless. It’s central to delivering the best possible care to an individual on a particular occasion. And it can also be incredibly efficient because of the pre-existing knowledge brought to the table. All this is easily lost in a corporate practice.
So what to do? For starters, don’t add any more bureaucracy. It just makes the process less efficient and the participants more frustrated. Encourage medium-sized teaching practices to be the standard for general practice in Australia and the structure will take care of itself. And promote the concept from the first day of medical courses, so that future doctors regard it as a completely routine part of being a medical practitioner.