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A.J. McKay
Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, U.K.
Correspondence to: A.J. McKay, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, U.K.
Keywords: Appraisal, revalidation, self-regulation Surg J R Coll Edinb Irel., 1 June 2003, 157-159
In 10 years, the medical profession in the U.K. has moved from a loose system of self regulation, through reluctant and patchy compliance with recorded continuing medical education (CME) to statutory obligations for 5-yearly revalidation which will control the issuing of a licence to practise for all doctors. The profession initially viewed these changes with dismissive cynicism, but the new rules are now being viewed with trepidation and paranoia. Royal Colleges can still play a central role in the development of the Revalidation process and must work together to develop appraisal as a meaningful tool to be used for the benefit of patient and doctor
Twenty-five years ago the medical profession in the United Kingdom and Ireland seemed content. Doctors worked till they were 65 and some even sought extensions to their contracts. Bad medical practice rarely made it to the front page of any newspaper and practice insurance cost very little. How times have changed! Were our predecessors hiding enormous problems? Were complacency and insularity endemic? Was the system of selfgovernance fatally flawed? Whatever the answers to these questions, 25 years on we find ourselves in a transformed profession. High-profile medical disasters seem to be a weekly occurrence; morale in the profession is at an all-time low and talk of early retiral dominates hospital coffee rooms. To cap it all, every doctor is now going to have to demonstrate fitness to practice and registration will depend on satisfactory completion of the revalidation process. There is no point in wistfully looking back at the “good old days”, because revalidation is now upon us and the challenge is for the profession to use the change for the good of both doctor and patient alike. Even if the system “wasn’t broke” someone has certainly set out to “fix it”.
It seems extraordinary that only seven or eight years ago no doctor in the United Kingdom or Ireland was required to provide any objective evidence of continuing medical education, nor demonstrate fitness to practice, but the profession has now moved to an acceptance of Continuing Professional Development (CPD) as a statutory obligation. In general terms it accepted this change with reasonably good grace, although the percentage of participants in the CPD process varies from as low as 40% to as high as 70% within the different disciplines.
A still more dramatic change is now evolving after the Government invited the General Medical Council (GMC) to develop a new system that would reassure the public about the fitness to practice of every doctor in the country. In other countries such a process is sometimes termed “re-certification”, but within the United Kingdom the word “revalidation” was chosen.
In February 1999, the GMC decided that the attributes of a good doctor, as set out in Good Medical Practice, would be the framework within which all doctors would be revalidated.1 Unfortunately, the revalidation process had developed in parallel with the decision that the Chief Executive of a National Health Service Trust would be responsible for the clinical performance of each of the doctors within that Trust. This new zone of responsibility became known as Clinical Governance. While these two processes were developing the British Medical Association (BMA) was negotiating with the Government on a new medical contract for both hospital-based and family doctors. After negotiation, the BMA proposed that annual appraisal should be the basic building block of the revalidation process. The emergence of these new concepts and their implementation left the profession confused, a little sceptical and somewhat threatened. However, revalidation is now a fact of life and on 14 November 2002 an order was submitted to Parliament to amend the Medical Act in order to enter the changes in the statute book. It is anticipated that this will become law in 2003.
While the BMA had been negotiating with the Government and while the GMC had been striving to change the law, the Academy of Royal Medical Colleges in the United Kingdom had established a CPD Advisory Committee and subsequently a Revalidation Committee. Both these bodies (with major input from individual colleges) sought to produce sample documentation that might be used to inform the revalidation process. The result of the work done was the emergence of what has become known as a folder or portfolio. Every doctor will be responsible for completing the folder with the intention that the content of the folder will profile an individual’s practice. The folder will contain factual information not dissimilar to an abbreviated curriculum vitae; it will contain an agreed job plan; it will contain evidence of participation in CPD and a personal development plan.
As the early experiences of appraisal emerge it is becoming clear that most appraisals are being conducted on a onetoone basis and the commonest arrangement is for the clinical director to be trained in appraisal methods and then to arrange an annual appraisal of each of his staff. Once again the nomenclature has tended to confuse, rather than clarify this process. Conceptually, appraisal should be a constructive and non-threatening experience which allows the individual to reflect on a year of activity, discuss both the good and not so good aspects of work undertaken and then to agree an appropriate self directed development plan. Unfortunately, many published documents have used the word “appraisal” but have meant “performance”. The Medical Act 1983 (Amendment Order 2002) gives the GMC the power to assess competence as well as performance, but measuring competence has proved to be an elusive goal.2 Many countries - including the United States - have accepted that a reliable and objective measure of performance is virtually impossible to achieve and have gone down the route of five-yearly re-examination of factual knowledge, taken together with evidence of CPD and a statement of probity and appropriate practice from a senior member of the local medical team.3 In practice, it becomes very difficult to objectively measure performance, especially if it is tied to patient outcome measures. The GMC, therefore, has encouraged each College to interpret the component parts of good medical practice and produce documents defining criteria, standards and evidence in relation to each part. The GMC has insisted that it is necessary to have supportive evidence for each statement within the folder and, thus, to triangulate the contents. It is envisaged that an annual appraisal - satisfactorily completed - will be agreed by both appraiser and appraisee and documentation signed to that effect. The content of the folder will remain in the ownership of the individual, but every five years the process of appraisal will be reviewed by an external group. It is likely that this external group will comprise a member of the local health trust, a member of the medical profession (perhaps a representative of the Specialty Society or the Royal College) and a member of the lay public. If the process is deemed to satisfactorily demonstrate that the individual is competent to practice, then such an individual’s name will remain on that component of the register for those doctors in continuing clinical practice.
One of the areas that is causing concern for the profession is how they are to obtain the evidence to support the statements within their folders. In some areas this will be relatively easy. Royal colleges issue certificates confirming participation in CPD and these can easily be submitted as evidence.
Each trust will provide evidence of the number of outpatients seen, the number of operations performed and the general working rota of an individual doctor. Teaching rotas can be provided to show an individual’s commitment to teaching and in some universities it is possible to obtain student feedback on their perception of an individual’s teaching performance. Sadly, there are also areas where it is extremely difficult to provide supporting evidence and the GMC Technical Committee has been looking at the use of patient satisfaction questionnaires and professional colleague surveys as possible tools which might be used by an individual to support the content of his folder. 4,5
Surgeons are particularly vulnerable to appraisal based on league tables and incomplete outcome measures. This is not something that we should tolerate. While our college examinations are being analysed in depth to ensure that they are fit for purpose, and while competency assessment is dominating the thinking of all educationalists, it is vital that these same criteria are applied across the profession. It is entirely inappropriate that standards should be set for surgeons, which cannot be applied to geriatricians, psychiatrists or dermatologists. Clearly outcome measures will vary, but the overall standards expected must be the same. An honestly completed folder should profile practice, demonstrate peer group review of outcome and confirm compliance with agreed best practice guidelines where they are available.
All of these changes are in the process of development. At the moment; the profession is sceptical and a little frightened of this process, but it is certain that revalidation will not go away. In the publication “Tomorrow’s Doctors”, which has so changed the structure of undergraduate teaching, great emphasis was placed on the need to develop knowledge, skills and attitudes.6 It is often attitudes that bring us into conflict with the general public and it is that very element which is so difficult to quantify and profile within the printed word of a folder. We are probably still 30 months away from the start of a full cycle of revalidation when the GMC will begin to examine the evidence submitted by individual doctors and it is unlikely that the results of the five-year revalidation process will emerge until 2005 at the earliest.
The profession must not lose sight of the benefits which this new system could bring. Having started by suggesting that the profession was content 25 years ago, it is my conviction that the profession was content, but was tending towards complacency. The tragic and highly public cases that have emerged in the last 10 years, where gross incompetence has been shown, highlight the fact that the profession was not adequately policing every member and it was possible to continue practising medicine in the United Kingdom with a level of competence that was unacceptable. Even now there is great concern about how the revalidation process will function for those doctors who do not have access to a well constructed appraisal system, and who conduct all of their practice as independent private practitioners. All such doctors will now be required to comply with the new rules or risk losing the right to practice. Failure to comply with the CPD rules never carried such a sanction. It is vital that the profession approaches this major change in their performance assessment requirements with an open and constructive mind. The process will be patchily implemented in the first few years and will inevitably change with time. Great faith is being placed in the appraisal system yet the validity of this tool is by no means certain and the impact and role of the new Postgraduate Medical Training Board is yet to be determined. For the present, the profession remains at the centre of developing the new process and we have the opportunity to keep the process practical, flexible and realistic. If we fail to grasp this opportunity then the entire revalidation process will be taken from us and, if we lose the right to self-governance, then the changes of the past 25 years will seem trivial in comparison.
REFERENCES
1. General Medical Council: Good Medical Practice.
London GMC, 1998
2. Buckley G. Revalidation is the answer. BMJ 1999; 319: 1145-46
3. Norcini JJ. Recertification in the United States. BMJ 1999; 319: 1183-85
4. Ramsay PG, Carline JD, Inui TS, Larson EB, LoGerto JP, Wenrich MD. Predictive validity
of board certification by the American Board of
Internal Medicine. Ann Intern Med 1989; 110: 719-26
5. Ramsay PG, Wenrich MD, Carline JD, Inui TS, Larson EB, LoGerto JP. Use of peer ratings to
evaluate physician performance. JAMA 1993; 269:
1655-60
6. General Medical Council: Tomorrow’s doctors. London GMC, 1993
Copyright: 20 March 2003