Continuing medical education: Maintaining standards in British and Canadian medicine: the developing role of the regulatory bodyBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7132.697 (Published 28 February 1998) Cite this as: BMJ 1998;316:697
- Lesley Southgate (), professor of primary care and medical educationa,
- Dale Dauphinee, executive directorb
- a Centre for Health Informatics and Multiprofessional Education (CHIME), University College London Medical School, Whittington Hospital Campus, London N19 5NF
- b Medical Council of Canada, Ottawa, Ontario, Canada
- Correspondence to: Professor Southgate
This is the sixth in a series of seven articles looking at international trends and forces in doctors' continuing professional development
While health care is being reformed throughout the Western world, another change has emerged without as much public attention: the appearance of strategies to increase the degree of accountability of medical practitioners. As part of this interest in accountability, the scope of standards for practice has widened to include activities beyond the traditional actions of regulating bodies, such as dealing with doctors' misconduct and impairment and relying on patients' complaints to detect these. The approaches to and pacing of these changes differ, but the underlying trends are the same. Strategies to anticipate and prevent a decline in doctors' performance are now a central concern for regulating bodies, which are increasingly adopting proactive or interventional methods. 1 2
We describe the recent changes in the ways in which the medical profession is regulated in the United Kingdom and some developments in Canada to enhance doctors' performance. We will discuss the implications flowing from the introduction of a minimum standard, the methods by which it is defined and assessed, and the emerging approaches to monitor and enhance doctors' performance.
Forces for change
In both North America and the United Kingdom the pressure for greater accountability of doctors is being felt at all levels of governance and regulation of practitioners: in hospital standards committees, in utilisation review by public agencies and third party payers, and in various professional regulatory and licensing bodies.3 The movement is away from the traditional approach of primary reliance on setting standards for entry into practice and towards placing new emphasis on maintaining standards in practice.
In the United Kingdom and Canada there is increased interest in the accountability of medical practitioners
Regulating bodies are adopting proactive methods, and emphasis is placed on maintaining standards for registered practitioners
Identification of seriously deficient performance rests initially on peer review of actual practice
Programmes to maintain standards must include opportunities for remedial education; successful outcomes will follow only if there is identified professional, educational, and financial support The safety of patients is the primary consideration
One prominent phenomenon is that the increasing role of lay members on the governing boards of regulatory bodies has opened the self governance of the profession to wider scrutiny. For example, in Britain the General Medical Council recently increased its lay representation to 25%, at the same time reducing representation from universities and medical royal colleges. But perhaps the most powerful influence has come from the need to control healthcare costs while maintaining quality, shown in government cutbacks to healthcare budgets in Canada and the wave of managed care sweeping the United States.4 As part of their need to be more cost effective, funding bodies are documenting practitioners' performance on a regular basis.5 For example, the publication of report cards on the performances of individual doctors is not unheard of in the United States. 6 7 Health reforms in the United Kingdom which emphasise cost effectiveness, clinical effectiveness, and evidence based medicine have also contributed to a focus on the performance of doctors in clinical practice,8 matched by the professional support for the introduction of the professional performance procedures by the GMC.9
Professional regulation and maintenance of practice standards
In the United Kingdom the GMC maintains the medical register and regulates the entry of practitioners to it. The education committee of the council (by statute an independent body) inspects and accredits medical schools awarding the basic medical degree, and over recent years the GMC has had a profound effect on the undergraduate curriculum through its publication Tomorrow's Doctors.10 A national standard for medical graduates is maintained by this mechanism, underpinned by the system of external examiners, which operates between the universities. In 1997 the GMC has issued guidance about the attributes expected of new doctors by the end of the preregistration house year and in so doing has signalled its intention to require improvements in the learning experience provided for new medical graduates before they achieve full registration.11 The guidance also includes an indication of the ways in which the progress of medical graduates should be assessed so that problems of poor performance, which may become intractable during the later stages of the doctor's career, can be identified and remedied early.
Once a practitioner is registered he or she must maintain good standing and practice in accordance with the guidance set out in Duties of a Doctor: Good Medical Practice.12 This important text, which includes sections on relationships with patients and colleagues as well as on clinical method, describes the boundaries and standards for modern medical practice and by implication maps out the territory wherein the council's legitimate regulatory activities will be exercised in relation to individual clinical practice.
The GMC has powers to impose conditions on practice and to suspend practitioners or to remove them from the register on grounds of ill health or conduct. Since 1 September 1997 it also has direct powers within the Medical (Professional Performance) Act 1995 to assess poorly performing practitioners and to limit or suspend their practice if their performance is found to be seriously deficient. The introduction of a national standard to identify seriously deficient performance across all medical disciplines and at any stage of a doctor's career will have a profound effect on local governance and self regulation throughout the profession and should reinforce public confidence in standards of medical practice in the United Kingdom.13
The approach to standards for licensure (registration) and the approach to maintenance of standards of practice are similar in Canada and the United States. After receiving the medical degree, all graduates must pass licensing examinations such as the qualifying examinations of the Medical Council of Canada, or the medical licensing examination in the United States. The existence of a national standard by examination for entry to the register is in direct contrast with Britain, where the function is delegated to the universities. The examination process is conducted in two (Canada) or three (United States) parts over time and serves as the basis of general licensure by the licensing authorities in the individual provinces or states. In both countries, licensure and maintenance of licensure are responsibilities of the province or state.
In common with the British GMC, Canadian licensing bodies are responsible for ongoing maintenance of standards for practitioners. Several provincial licensing authorities have developed physician review and enhancement of performance programmes (PREPP) which are designed to assess the knowledge and skills of practitioners who are referred after being identified by the complaint process, through self referral, or from referral by colleagues.14 More recently the Federation of Medical Licensing Authorities of Canada has developed a two component model by which it intends to monitor and enhance the performance of all practising physicians in Canada, referred to as the Canadian Model for the Monitoring and Enhancement of Physician Performance (MEPP). Three national workshops of all stakeholders in the Canadian medical community established a consensus about the mechanisms for monitoring and the approaches to enhancement and remediation.15-18 Pilot projects were carried out to assess various approaches to the monitoring aspects of the new programme. The MEPP model has three monitoring steps and three dimensions for enhancement that run in parallel and association with them (box).
The Canadian approach will in effect sample the entire register of practitioners. A different procedure has been adopted in the United Kingdom. Identification of serious deficiency of performance within the performance procedures of the GMC is triggered by a complaint to the council. Medical and lay screeners then decide whether there is a case that the doctor is dysfunctional and whether the dysfunction is best addressed within the performance procedures rather than through the health or conduct routes. With the GMC dealing with the issue of very poor performance in practice, the need for regular testing of all career doctors is reduced, particularly if individual, local, and national professional standards are maintained by self assessment, local peer review, and external review by the national professional bodies.3
Identifying doctors who are performing badly
Similar methods for assessing clinical performance for practitioners at risk have been adopted by the licensing bodies in Britain and Canada. Performance is initially assessed by peer review in the setting of actual practice. Tests of competence follow for those few practitioners whose standard of performance remains in doubt.
In Canada, in those provinces with existing physician review and enhancement of performance programmes, practitioners have been identified by self referral, referral by colleagues, random office audits, and investigation of patients' complaints. Under the first step of the monitoring component of the MEPP model, the performance of all physicians will be screened through fee for service billing patterns, peer assessment questionnaires, and patient satisfaction questionnaires.16 These components of the monitoring mechanisms are being piloted in Alberta and Quebec by the local licensing authorities. 19 20 It is expected that the cost will be low, under £20 per physician. The vast majority of practitioners will “pass” this first cut without a problem and enhancement steps will be feedback, primarily for reassurance.
At the second step of monitoring, about 10% of practitioners could be identified from the first screen as at risk or in need and will move to a second level of assessment such as hospital audit, office audit, and structured interview of the physician. Enhancement will focus on continuing education programmes for individuals or groups.
Individually oriented monitoring and enhancement will apply to very few doctors (1-2%) and requires an objective assessment of need. The majority of the components for the third step are embodied in the existing physician review and enhancement programmes and consist of written tests of practice related knowledge, assessment of basic clinical skills by objective structured examinations, oral examinations that may include role play, and detailed interviews in order to set out a specific remedial programme for that individual.18
In Britain, once a doctor on the register enters the assessment stage of the professional performance procedures, the approach taken by the GMC assessors has much in common with the second and third steps in the Canadian model. The assessment will be in two phases: a peer review visit to the practice, rapidly followed by tests of competence if serious deficiency of performance cannot be ruled out by the assessors during phase one. The assessment methods, which derive their overall validity from the content of practice set out in Good Medical Practice, have been endorsed by the council and were implemented in September 1997.21
In phase one, the assessment consists of a peer review of performance conducted by a team of two medical and one lay assessor from the GMC. They will review the performance of the doctor in the setting of actual practice using equivalent methods, standards, and documentation for all disciplines (box).
Assessment by GMC during peer review visit
Assessment of medical record keeping
Discussion of the management of the doctor's own cases and clinical work
Observation of aspects of actual practice
Audit of clinical outcomes
Interviews with third parties
Structured interview with the doctor
Site tour to determine the circumstances of practice
In phase two the assessments take the form of tests of competence designed to assess the knowledge, skills and attitudes necessary for the practice in which the doctor is engaged. By this stage the assessors have not been able to rule out serious deficiency of performance and they will be seeking further evidence on which to come to a conclusion. The relation between competence (can do) and performance (does do) is complex, in that the first does not always predict the second. But here, performance is in doubt. By testing competence the assessors can discover, when serious deficiency is found, whether poor performance is because the doctor cannot or will not practise at an acceptable standard. This has major implications for the recommendations for remedial education and training.
Peer support and peer managed learning
The current approach in Canada is to design a learning package for the needs of the poorly performing doctor, based on the assessment at either step 2 or step 3. It is key that members of the profession have ownership in this process by functioning as evaluators and assisting in developing the remedial learning programmes. The extent of this feeling was shown at the third MEPP workshop in 1996, where the profession identified key characteristics needed for the programme to succeed:
A peer to peer approach
An educational contract with one to one traineeship or mentorship
Willingness of doctors to participate in the enhancement process
Support from the various medical organisations.
There was also strong support for feedback that was as immediate as possible and non-judgmental.17
In Britain the primary purpose of the assessments within the performance procedures is to describe the performance of the doctor in practice in a degree of detail which gives a sound basis for the decisions that must be taken within the GMC about the doctor's fitness to practise. The intention is to restore the doctor to effective clinical practice, providing patients or the public are not placed in jeopardy.13 The report from the assessors will be available to the doctor, who will be able to use it to plan a programme of remedial education and training with the help of the regional postgraduate dean or the regional director of postgraduate general practice education.
Nature of remedial education
In Canada it is proposed that remedial education be individually oriented, based on the assessment and degree of risk, and that it be one to one and non-judgmental. The real question, which is not yet solved, is who will pay and whether the universities and their affiliated teaching institutions will be able to accept the challenge on these terms.
Similar approaches will be adopted in Britain, where the situation is still fluid, with wide recognition of the problems associated with remedial education and training at this standard. Not least, the ethical and legal framework within which these doctors can see and treat patients under supervision needs further clarification and the educational support, NHS management, and financial support for the clinical teams who undertake to receive them must be identified. The cost of the assessment will be borne by the GMC, and financial support for the doctor to undertake a remedial programme may be available from NHS trusts and health authorities. What is clear in both Britain and Canada is that a successful outcome is possible only if the individual doctor accepts the responsibility both for undertaking the remedial programme and for achieving an improvement in clinical performance.
Continued poor performance
In both the Canada and Britain the licensing authorities take the responsibility for doctors who remain below the acceptable level of performance after a remedial programme. In the current Canadian enhancement programmes in certain provinces, this paradigm is well established and tested. Results in some programmes indicate that a matter of fact but non-judgmental approach will work for most practitioners with deficits, but a very small number will represent too high a risk to their patients. For that group the judgment of the licensing authorities becomes operative, as it does for doctors who are unable to raise their level of performance after the remedial programme. The experience in Ontario has shown that some individuals are too far down the scale to recover because of poor cognition or deteriorated knowledge and skills.22 For them the solution is negotiated retirement, knowing full well that the licensing authorities have the responsibility and mandate to act.
Experience in Britain will build up and be made public in the years after the introduction of the performance procedures. At this stage it is impossible to predict the outcome of remediation and reassessment, although the Canadian experience seems relevant.