Views & Reviews From the Frontline

The revalidation question

BMJ 2008; 337 doi: (Published 20 August 2008) Cite this as: BMJ 2008;337:a1353
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

    It was 1995, and I had smoothed down my hair, flattened my John Major suit, and adjusted my silk tie—this was my viva examination for membership of the royal college. This was a time of Russian roulette examinations, and everything depended on the examiners. My goal was to be just like them, such is the power of peer pressure. A hot question then, as now, was revalidation, and I had my response learnt, though without the pain of experience.

    The ideas behind revalidation seem like common sense: ensuring quality and protecting patients from the mistakes of the past. The question is not whether but how these aims are to be achieved. Much has already changed in the past decade; the professional scars of Bristol, Alder Hey, and Shipman are deep and still tender. The new mantra is, quite rightly, to protect patients above all else. And this new generation of doctors is increasingly literate in communication skills and medical ethics. So any new plans for revalidation must not be a belated overreaction to the mistakes of the past. They should acknowledge that our profession is multicultural and diverse, requiring clinicians with a range of attitudes and skills, and must not seek to impose a clumsy photofit caricature of what we should be.

    The greatest concern, however, is the call for yet more involvement of the public. Clearly we need to respond to patients, but involving the public is already fraught with difficulties. Firstly, vociferous special interest groups who ignore the views of the silent contented majority may distort the public voice, skewing care. Secondly, biased “patient satisfaction” feedback (which is often anonymous and not validated) has become the single yardstick of quality of care. Regrettably, this feedback focuses almost exclusively on the negative and is already destroying NHS morale. Anyway, sometimes denying patients “what they want” is a fundamental professional duty of care (so long as it is properly explained). Distant government quangos should appreciate that doctors are not selling toasters and that the customer is not always right. The pursuit of consumerist health care is the single greatest threat to our society’s wellbeing.

    Lastly, the medical authorities already know which doctors are failing and that resources should be targeted at supporting these doctors. Revalidation has to be a realistic process, and we should accept that it will not prevent the determinedly deceitful doctor. Revalidation must be simple, be based on knowledge, use statements of support from peers, and, above all be free of fickle political interference. If not, practising medicine won’t just be difficult but nigh impossible.


    Cite this as: BMJ 2008;337:a1353

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