Current Issues Facing General Practitioners
AHPRA is considering revalidation of doctors in Australia. Should this become a requirement, doctors will need to demonstrate their competency in some way or another, in order to remain registered. The stated reason for this is to identify any doctor who is not working at a satisfactory level of competency. Whilst this may sound reasonable, it means subjecting 99.9% of doctors to a process which will be costly in terms of time and money, in order to weed out the 0.1% who need to be identified. Who would wear these costs? Is it reasonable to encumber 1000 doctors to find the one below standard? If this were a medical condition we would consider the numbers needed to treat of 1000 as totally unreasonable management.
AHPRA appears to be continuing the process of pursuing this course of action. Read the update of July 2016. You will note that
More importantly note that the Consultative Committee on revalidation is made up of the following:
- "On 16 August 2016, we will launch the interim report of the Expert Advisory Group (EAG) we established to advise the Board on options for revalidation that are tailored to the Australian healthcare sector. At the same time, we will publish the results of the social research we commissioned to find out what medical practitioners and the community think about what doctors should do to remain fit to practise."
General practitioners make up about 50% of the medical workforce. How well represented are they in the above?
- the Medical Board Chair, Dr Joanna Flynn AM
- the Australian Medical Council
- the Committee of Presidents of Medical Colleges
- the Australian Medical Association
- the Medical Deans Australia and New Zealand
- the Health Workforce Principal Committee of the Australian Health Ministers’ Advisory Committee
- the Medical Council of New South Wales health complaints entities
- pre-vocational training organisations
- professional indemnity insurers
- community representatives
The opportunity for input into revalidation will extend from August to November. The whole process seems to be progressing quietly and will no doubt do so unless something changes. If revalidation becomes a reality, AHPRA will claim that it created it with extensive consultation with the medical profession, despite the fact that few doctors in Australia knew it was coming!
- AMA - Australian Medical Association
- CAMERA - Collaboration for the Advancement of Medical
Education Research and Assessment
- AHPRA - Australian Health Practitioner Regulation Authority
- RACGP - Royal Australian College of General Practitioners
- ACRRM - Australian College of Remote and Rural Medicine
- MSF - Multi-Source Feedback
- CME - Continuing Medical Education
- CPD - Continuing Professional Development
- VHHD - Very High Human Development Countries
AHPRA says that it has " worked with the profession (through the colleges and the AMA) on a range of options to progress informed discussion and debate about this issue". Have these representative bodies made their members aware of what AHPRA is considering?
Click here to see what AHPRA says.
AHPRA has commissioned research to:
Note that the research was not commissioned to assess whether revalidation would achieve the deisred goals. The implication being that revalidation is a goal for AHPRA and that it is just deciding what form it will take. The results of the study are now available , click here.
- "establish the existing evidence base for the validity of revalidation or similar in countries comparable to Australia
- identify best practice and any gaps in knowledge for revalidation processes
- establish the validity evidence for revalidation’s effectiveness in supporting safe practice
- develop a range of models for the Australian context for the Board to consider."
AHPRA's next step is to appoint an "Expert Advisory Group to provide technical expert advice on revalidation and how any models recommended by the group can be evaluated for effectiveness, feasibility and acceptability" and to appoint a"Consultative Committee to provide feedback on issues related to the introduction of revalidation in Australia."
"The Board has set a 12-month timeline for the Expert Advisory Group to recommend one or more models for revalidation in Australia and provide advice on how these can be piloted. Details about models to be considered are included in the terms of reference. The social research will also be conducted over the next 12 months. "1 note that AHPRA is speaking as if this is a foregone conclusion.
The following links provide more information:
One of the key issues to note is that there is a lack of information that revalidation actually achieves what it is meant to do, ie identifying doctors who are performing poorly2
- Board Commissions Research on Revalidation, AHPRA website (as above)
- Starting the Revalidation Conversation in Australia, AHPRA Newsletter, Dec 2012
- Results of the commissioned study (by CAMERA)
- Medical Board Announces Next Steps on Revalidation, AHPRA website 15th September 2015
- AHPRA media release 15th September, 2015
- Revalidation: Do Doctors Need It? Australian Medicine (AMA), 31st May 2013
- Revalidation of Doctors or How to Spot the Bad Apples Australian Medicine (AMA), 2nd April 2015
- Revalidation: Burden or Benefit? Australian Medicine (AMA), 14th Jan 2013.
- Revalidation: Do We Need It? MJA Insight, 7th Fen 2014
- Australian Doctor's survey on revalidation
- Revalidation for Relicensing, Reflections on the proposed British Model, AFP, Volume 41, No.1, January/February 2012 Pages 70-72
- Revalidation, A Personal Perspective, AFP, Volume 42, No.11, November 2013 Pages 826-828
Below is a summary of some of the findings from the CAMERA study:
- Literature review of 49 VHHD countries:
- "Despite global interest in the use of revalidation, there remains a lack of unified agreement surrounding its definition, mechanisms and appropriate design."
- "Continuing medical education (CME)/continuing professional development (CPD) is the most frequently used method to inform ongoing professional development and medical regulation."
- Case study development:
- "The majority of the case studies reviewed (UK, Canada, New Zealand, USA, Germany, the Netherlands, Belgium) use peer review and/or clinical audit as an additional form of medical regulation."
- "All countries recognise eLearning/distance learning as a valid form of regulation."
- "Few countries (the UK and Canada) make a conscious effort to review patient complaints."
- "Canada also randomly selects doctors who have been in independent (private) practice for more than five years and/or older physicians (70+) to undergo peer assessment representing a uniquely targeted approach to revalidation"
- "The use of a high stakes examination appears to be unique to the USA."
- "Belgium was the only case study reviewed that offers a financial incentive for revalidation engagement."
- Tertiary review of existing revalidation activity literature:
- "Revalidation and its associated activities have been shown to encourage beneficial professional changes to varying levels of effectiveness."
- "CME/CPD has been shown to be effective at encouraging long term developments in physician attributes including knowledge, attitudes and communication skills. These changes are further enhanced when CME/CPD is interactive, targeted for small groups of physicians within the same discipline, utilises repetitive exposures and offers dynamic/live media use. Online CME/CPD has been shown to be equally as effective, if not more, than live CME/CPD in terms of improving physician knowledge, skill competence and clinical decision-making offering a series of additional advantages."
- "Appraisals are reported to be the single most important activity to encourage change in physician performance posing significant beneficial outcomes including increased motivation, career development and job satisfaction."
- "Multi-source feedback (MSF) has also been shown to encourage substantial improvements across a range of non-clinical domains including interpersonal skills, communication and professionalism."
- "Clinical audit has been shown to be effective although this conclusion is not unanimous with organisational failings (e.g. poor management, lack of support) reported to be the most cited reason behind ineffective implementation."
- "The central location of self-directed learning and assumed ability of physicians to accurately determine their own learning needs is not well supported by the literature."
- "There is evidence to suggest an inverse relationship between knowledge/performance and number of years since certification/registration."
- "Interactive CME/CPD, appraisal, review of patient complaints and MSF are the most well supported revalidation activities."
- Literature review of revalidation activity combinations:
- "In line with established principles of adult learning theory, there is strong evidence to suggest using a multitude of educational techniques that foster interactivity and engage in facilitated feedback is most beneficial. Evidence suggests this is most effectively achieved through ‘blended learning’ – a hybrid model of learning where traditional methods of education (e.g. face to face CME/CPD) and more modern techniques (typically online learning) are combined. Blended learning has been shown to be both an effective and attractive form of learning across numerous populations with demonstrated abilities to enhance knowledge retention and significantly alter clinical behaviours and intentions."
- "The literature therefore concludes that no singular approach to medical regulation works best under all circumstances."
- "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."
- Models developed:
- Model A
- "represents a low level model of revalidation operated entirely online. Running over a period of five years, (duration typically adopted on a global scale) doctors would be required to produce an annual online portfolio/supporting information evidencing: participation in mandatory self-directed CME and MSF. These would both need to be signed off by a line manager or equivalent profession or professional body once a year with the fifth signature needed to achieve a recommendation for revalidation approval. Engagement in this model would be cost effective, potentially available nationwide provided internet access was available, easy to administer and relatively easy to assimilate into daily workloads. It would demonstrate that doctors are up to date but not necessarily fit to practise providing a single regulatory response. There is a strong reliance on internet access, limited opportunities for reflective and collaborative learning and missed opportunities to target ‘at risk’ physicians (e.g. 60+ or in independent practice for 5 years or more). The heavy reliance on self-directed CME may also prevent beneficial development. In regards to conforming to the GMP code, model A would assess seven components offering limited levels of content validity."
- Model B
– "would also operate over a five year period seeking to resolve the deficiencies identified in model A. Doctors would be required to present an online portfolio/supporting information detailing: engagement in directed CME (no self-directed option), facilitated online learning, bi-annual appraisals for targeted groups (physicians aged 60+ or those in independent (private) practice for five years or more) and participation in MSF from a specified number of patients and colleagues. A revalidation appraisal would be undertaken for all doctors every fifth year. Model B has the opportunity to assess 16 components of the GMP framework, provide enhanced MSF opportunities and engage in bi-annual appraisals for specific groups. There remains a limited opportunity for reflective practice, a lack of regular appraisals for all Australian doctors and the development of potential hostility surrounding exclusively directed CME."
- Model C
– "finally model C comprises of both formative and summative components. Model C ensures doctors are both up to date and fit to practise representing a dual approach to revalidation. Doctors would be required to evidence: engagement in self-directed and directed interactive (minimum level of 25%) CME, facilitated online learning, blended learning, annual appraisals, participation in MSF with accompanying facilitated feedback and a review of patient complaints. Similar to the other models presented, model C would operate over a five year cycle with every 5th appraisal acting as a revalidation recommendation. Model C rectifies the vast majority of concerns raised in the previous two models. Possible hostility and lack of effective development arising from CME are addressed by combining both self-directed and directed CME. Doctors would therefore be required to attend a core of similar CME events providing continuity but would maintain freedom amongst their CME choices beyond this. Blended learning (where traditional methods of teaching are combined with more modern options) will help to incorporate the vast majority of learning preferences identified in the Australian context and close the current gap between evidence and practice given its demonstrated ability to improve knowledge retention and physician performance. All physicians would engage in annual appraisals providing valuable reflective practice opportunities and would therefore be in receipt of the full benefits of facilitated appraisals/feedback. A review of patient complaints would provide an additional layer of reflective practice and ensure that the patient voice was both heard and acknowledged. Although acknowledged given the high percentage of private physicians, Model C offers the best model of revalidation informed by the current evidence base and is most likely to assure both safe, and overtime, better practice to the betterment of patients."