Patients, professionalism, and revalidation
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7502.1265 (Published 26 May 2005) Cite this as: BMJ 2005;330:1265
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Having read this article, the concept of transition from primacy of
the doctor to the primacy of the patient stuck in my mind as I got into my
car to set out for work. It may be because I was reminded of a line from
Tennyson that I had learnt in childhood, “the old order changeth yielding
place to new”. It also reminded me of what Sir Liam Donaldson had said in
his call for ideas, that the interests of the patient and the wider public
are put before the practitioner’s own interests. Just as it should be I
said to myself as I drove off. I soon started to think of what was to be
my theme for the morning tutorial and I was trying to recollect some
examples how evidence based practice would apply not only to the
clinicians but also to the radiologists.
My thoughts for some unknown reason swung back to the primacy of the
patient and revalidation. It is one thing I thought to uphold the primacy
of the patient but what was the evidence to believe that the patient
wanted revalidation through establishing the doctor’s fitness to practice
(FTP) or wanting proof of their knowledge and skills which was on offer. I
was listening to Radio 4 and would you believe it the presenter said “how
often do you ask for the qualifications of the lawyer, plumber or the
electrician you engage?” How do you make sure that you are not dealing
with a cowboy? Do you check whether he is a registered plumber or
electrician?
Why did revalidation via FTP enter into the statute books? Did anyone
obtain the patients views? I could not help the feeling, yes the primacy
of the patient is very important, but there still is that attitude of ‘we
know what you want and what is good for you’. Not to be too unkind I could
not help the thought that a lot of this came about because the politicians
and the administration wanted to be seen to discharge their
responsibility. They were being blamed for not having done enough to
prevent the medical disasters that were being reported and some thing had
to be done and done quickly. The GMC in particular was under great
pressure and its credibility was at stake. Revalidation and assessment of
FTP seemed a reasonable enough solution. Solving the complexities of
administering the scheme was left for a later date - the familiar cart
before the horse situation.
I have not conducted a survey either but most of us know how we set
about set about finding a plumber or an electrician. I do not think that
patients opt for a more complex procedure to find a doctor. Patients
hardly ever get into the details of the doctors skill and knowledge but
quite often rely on the recommendation of other patients and by and large
register with a doctor with a ‘good reputation’. How does one come to be
known as a good doctor. In addition to personal qualities the quality of
service provided probably figures high on the list. Well then would it not
make sense to device a scheme by which a doctor may be held responsible
for and assessed to ensure the provision of high quality healthcare and
maintenance of the means to provide it as a means for revalidation
I doubt if this message would get to the review body but would they
ascertain by a questionnaire or some other means that any means they
propose would meet with patient approval. A consultation document perhaps
prior to finalisation? My response to the CMO’s call for ideas of
revalidation through quality of care (QOC) and not FTP was based on real
life situation after all.
Competing interests:
None declared
Competing interests: No competing interests
The article as also the revalidation and licensure enterprise seem to
skim over the point of clinical competence with amazing simplicity.The
idea of 'doctor taking responsibility for his own training' appears
deceivingly righteous but is far from being practical in a universal way
and thus defeats it's purpose.
Probably,a little illustration will help.The Royal college of
Physicians lays down competence in putting in central venous lines,trans-
venous pacing and chest drains as part of SHO training syllabus.However,at
a recent audit in a DGH,it was found that less than ten percent of SHOs
felt confident in above procedures and trans-venous pacing by an SHO was a
little humourous idea.Self directed learning in practical procedures can
at best be as vague as an SHO requesting a registrarto bleep him/her when
he is about to perform one of these procedures and anybody working at SHO
level in a busy DGH would know that the probability of tutor and the
taught being free and available for the rendezvous in the maze of
nights,ward cover,ward rounds,on calls etc is not strong.Furtheron,you go
through the stages of observing,assisting,doing it under supervision and
then finally doing it independently.It would be revealing to look at
Junior doctors' appraisal folders in the practical skills column and
seeing how often the 'need to acquire skills' keep repeating themselves.
The idea is not to contest the current guidelines on licensure and
revalidation but to find ways for it's successful implementation in key
areas and doctors' training should certainly be one of these.A patient-
centric model of healthcare does not have to guard itself from including
doctors' training needs.Doctors in training often attend practical courses
or even take up short term jobs in more practical oriented specialties in
order to equip themselves.Have we accepted that these are the recommended
and universally(for NHS) practicable ways of 'self directed learning'?In
any case,constant upgradation of licensure criteria without inclusion of
care givers' training needs may help identify incompetent or dangerous
doctors at it's best but will not be able to prevent the production of
such doctors in the first place nor would it seek to elevate the standards
expected of a 'good doctor'.It may well be said that the final exam at
medical school most comprehensively allows only the competent to enter the
profession and it is the subsequent professional years that make some of
them incompetent.So,why ignore what happens in all these years when
seeking to raise the standards of care?
Competing interests:
None declared
Competing interests: No competing interests
It is unfortunate that Donald Irvine (Sir) uncritically accepts the
pronouncements of Janet Smith (Dame) to be of any relevance to the
revalidation mechanism in preventing further outbreaks of Harold Shipman.
As my good colleague (Mr ) with whom I regularly work quotes, "If all you
have is a hammer, everything looks like a nail": Harold Shipman was not a
GMC revalidation issue, but one for the police.
Competing interests:
Employee of the State
Competing interests: No competing interests
The cardiac surgeons have indeed done well to show that it is
possible to establish baseline good practice across a specialty, but
paradoxically that is because it is acceptable for some of their patients
to die, and that single criterion has great importance. It is more
difficult for those of us who work in specialties where the outcomes are
more nebulous. I am not afraid of assessment, but I honestly do not know
what that assessment should consist of.
Competing interests:
None declared
Competing interests: No competing interests
Sir Donald Irvine's call for a combined Lords and Commons select
committee is very sensible but its role would have to be limited to
looking at certain areas such as standards, safety, complaints and
litigation. The Health Select Committee could be left to concentrate on
other areas related to health. It is important that the work of
"independent" regulators - such as the Healthcare Commission and Monitor -
is scrutined and that such organisations can be held to account directly
by representatives of the public and not via the indirect route of the
Secretary of State for Health and the Department of Health. As Sir Donald
indicates, accountability does include a duty to expain and that should
apply to the regulators as well.
Competing interests:
Interest in safety and regulation of managers
Competing interests: No competing interests
With presidents like this, the future is bleak
This article is written by a past president of the GMC and so in part
lets us glimpse thinking about regulation that was in the forefront of
attempts by our leaders to reform regulation in the last five years. The
essay suffers from the usual defects in argument that are now being
identified as common highlights in debates concerning doctors’ regulation.
These are:
1.Donald Irvine identifies a new composite quality and gives it a new
name - goodness – without checking to see if it exists. It could after
all be like phlogiston an eighteenth century combustibility function. It
could be like a ‘good try’ in rugby or football. Perhaps it is like ‘well
done’ in athletics or cookery. A defence – ‘I can think of it and
therefore it exists’ is not enough for something as important as patient
safety and doctors’ regulation. There is no evidence in his essay that
doctors’ goodness as a function exists other than he says it does.
2.There is an assumption that doctors’ goodness can be measured. I am
more concerned that measurement should be fair and equitable. That is the
measure for a general practitioner in some way are related to those for a
psychiatrist. I agree that there are attributes of doctors that one can
measure –surgical output or number of anaesthetics, spring to my mind –
but I would like to see evidence that these measures if they are to be
used to assess doctors’ goodness, do actually do so.
3. I am concerned that any measures actually measure some sort of
competence and skill across the board. That is, surgeons – whose output
can be measured are not unfairly disadvantaged when it comes to
psychiatrists, whose output may be more difficult to measure. I am
concerned that there is no evidence for this given in the essay. I note
Donald Irvine’s background is general practice.
4. I want those doctors that score low, actually to be bad doctors.
This means, of course, that there is a countermeasure – doctors’ badness,
which can also be measured. I am not at all sure that this is the case and
would like to be shown evidence for such. It is obvious to me that if one
scores well as a good doctor and high as a bad doctor, then there is
something wrong with the measurement scheme and says nothing about the
doctor. Reader will immediately remember that Harold Shipman was thought
for a long time by his patients to be a good doctor whereas we all know
now that he was killing them. This means that asking patient whether they
think their doctor is good or not will not pick up mass-murderers, if that
is what you think ‘goodness’ should measure.
There is an implication that the ‘goodness’ measure can be ordered
[put into an order, best -> worst]. We know this because
Donald Irvine was reported in the Daily Telegraph (1) as saying that 5% of
doctors were not fit to practise or in the ideas of this article, ‘bad’. I
can’t imagine that he is talking about a random 5%. It can only mean that
the worst 5% are unfit to practise. And to identify the worst 5%, you have
to have an ordered set. There is no evidence at all, that the goodness of
a doctor can be measured let alone put into an order.
For my own purpose of appraisal, I have over the last five years kept
details and outcomes of all arterial lines, all central lines, all
caudals, all epidurals, all children I have anaesthetised under 5 kg and
all children I have anaesthetised under four weeks of age. I also have all
palates I have anaesthetised and all burns patients – these seem to be
particularly troublesome. These are compiled prospectively from day to day
and needless to say is time consuming. I have kept details of these
because I am afraid my Hospital might secretly audit one of these, shred
the audit and imply something else at an inquiry as they did in the past.
Opportunities for publication do occur but are limited. (2,3). I appraise
my colleagues and they keep similar records. The Hospital computer records
are not efficient at retrieving these details.
I am all for measurable functions because I have a mathematical
background but I am not sure if Donald Irvine’s ideas will get up and run
in the field of medical regulation. The only problem with a conclusion
such as this, and it is something Liam Donaldson will have to grapple
with, is that we have been wasting our time and vast amounts of tax
payers’ money in the last five years. It is as though we are setting up a
system. whereby another Harold Shipman could wave a sheaf of patient
questionnaires at television cameras and exclaim, “Look! I can’t have
murdered anyone, all my patients think I am wonderful!” Both the taxpayer
and GMC subscriber can ask a relevant question; are we getting value for
money in medical regulation and the answer is clearly no.
In its cloying self-admiring now defunct house journal, [GMC news],
the GMC previously trumpeted its attempts to export medical regulation to
Eastern European counties who would join the European Union and move their
medical staff west. They should now warn those countries that took up the
challenge that the systems they were championing are defective and time
consuming and not worth the expensive effort. In short there is no sign
that they or their successors will be fit for their purpose: regulation.
Oliver R Dearlove
Refs.1 Burleigh J Three million have doctors who are not up to job.
Daily Telegraph December 2004
2 Dearlove OR. CVP lines in children Br Jl Anaes 2005 93…..136
3. Dearlove OR PerkinsRP Cleft palate repair Anaesthesia 2004 59
1032
Competing interests:
These views are personal and not held by anyone else
Competing interests: No competing interests