The practice of medicine has, of late, been the subject of intense scrutiny by regulators.
First it was cosmetic surgery, which resulted in the Medical Board of Australia issuing new Guidelines1 in tandem with the licensing of cosmetic surgery facilities in New South Wales.2
More recently, the Board has issued an Interim Report on the controversial issue of ‘revalidation’ of medical practitioners.3 Revalidation, otherwise known as relicensing, is somewhat opaquely defined by the Board as ‘a process that supports medical practitioners to maintain and enhance their professional skills and knowledge and to remain fit to practise medicine.’4 A more informative definition, we suggest, is that revalidation is a mandatory appraisal process requiring medical practitioners to demonstrate that they are fit to practice in order to maintain their registration. The stated purpose of revalidation is to ensure public safety.5
Summary of the Interim Report on revalidation
The Interim Report is informed by a research report jointly commissioned by the Board and the Australian Health Practitioner Regulation Agency (AHPRA) from the Collaboration for the Advancement of Medical Education Research Assessment (CAMERA), a research institute associated with Plymouth University.6 The appointment by Australian regulators of an English research centre to consider the issue of revalidation in a local context may seem unusual until it is understood that revalidation became mandatory in the United Kingdom in 2012.7
The Expert Advisory Group (EAG), appointed by the Board, has proposed the introduction of a revalidation scheme in Australia, based on two parts:
(a) strengthened continuing professional development (CPD); and
(b) proactive identification of ‘at risk’ and poorly performing practitioners.
The second part of the proposed scheme has, in particular, generated press coverage.8
The EAG is concerned that a strengthened CPD program, in isolation, would be insufficient to identify practitioners who may be putting the public at risk. The EAG has proposed that strategies be implemented to proactively identify poorly performing practitioners. This would entail ‘robust’ early detection.
It is estimated, based on international research, that about 6% of medical practitioners are poorly performing at any one time.9 According to the EAG, practitioners most likely to be ‘at risk’ share one or more of the following characteristics:
(a) age (from 35 years, increasing into middle and older age);
(b) male;
(c) number of prior complaints;
(d) passage of time since last complaint;
(e) primary medical qualification acquired in certain overseas countries of origin;
(f) speciality;
(g) lack of response to feedback;
(h) unrecognised cognitive impairment;
(i) practising in isolation;
(j) low levels of high-quality CPD activities; and
It is acknowledged by the EAG that not all members of these cohorts are underperforming or at risk to the public.
The EAG supports a tiered approach to the assessment of performance, proportionate to the level of potential risk. The first proposed level of assessment would be known as ‘multi-source feedback’ (also known as ‘360 degree’ appraisal), which would entail feedback being sought from ‘health stakeholders’, including the practitioner’s colleagues, co-workers and patients.11 Sensibly, it would appear that it is not proposed that patients assess practitioners on their perceived level of clinical competency.12
For practitioners who pose a more serious risk, a peer-mediation process is proposed, which would entail a review of medical records; peer review of performance practice; and feedback on practice or data.13
Many of the details surrounding identifying, assessing and ‘remediating’ poorly performing practitioners are still to be worked out. Specifically, some of the details that the EAG has raised for further consideration include:
(a) which ‘stakeholders’ should have a role in assessment (e.g. should it extend to insurers, employers and specialist colleges);
(b) the roles and responsibilities of relevant stakeholders;
(c) the thresholds for reporting practitioners to regulators for poor performance;
(d) how poor performance among practitioners who are outside colleges and work outside organisations with robust clinical governance structures is best able to be identified; and
According to the EAG, the existing regulatory role of the Board and AHPRA in investigating poorly performing practitioners, and in limiting their registration (where necessary), should be regarded as distinct from the identification of risk by stakeholders.15
Conclusion
While the purpose of revalidation is undoubtedly laudable, there are many issues that need to be worked out, prior to Australia having an operational (and workable) revalidation scheme. The devil may well end up being in the detail.
It is hoped by the Board that revalidation, if implemented, will result in better outcomes for patients, with decreased risk of them being exposed to low-quality care and malpractice; however, as acknowledged by the EAG, there is little research presently available about the long term effectiveness of ‘remediation’ programs for practitioners, which consequently pose challenges for regulators in adopting an evidence based approach to reform.16
Not surprisingly, revalidation has not been met with enthusiastic support by the medical profession. The AMA has expressed disquiet about the potential of revalidation to add to the administrative burden and costs of practitioners with little demonstrable gain.17
From the perspective of the insurance industry, it is expected that revalidation would result in medical defence organisations experiencing a modest increase in claim notifications, arising from referrals being made to the Board or AHPRA, which are the subject of investigation, both in terms of fitness to practice and alleged ethical or boundary violations.
The current consultative process is ongoing and closes on 30 November 2016. We will update you further, once that process has concluded.
[1] ‘Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures’, which will take effect from 1 October 2016
[2] Pursuant to the Private Health Facilities Amendment (Cosmetic Surgery) Regulations 2016 (NSW), which will take effect from 3 March 2017. Note that it has been reported that Victoria is considering the NSW regulations as part of its own evaluation of the cosmetic surgery industry: see www.theage.com.au/victoria/victorias-cosmetic-surgery-crackdown-to-take-its-lead-from-nsw-20160603-gpb93e.html
[3] Medical Board of Australia, ‘Expert Advisory Group on revalidation: Interim Report’, August 2016
[4] Terms of reference of the Consultative Committee on the revalidation of medical practitioners
[5] Interim Report, page 6
[6] J Archer et al, ‘The evidence and options for medical revalidation in the Australian context’, final report, CAMERA, 10 July 2015
[7] In the UK revalidation requires medical practitioners to engage in annual appraisals over a 5 year cycle, which are designed to assist them reflect and review on their current practice and future developments. See: http://www.gmc-uk.org/doctors/revalidation/9627.asp
[8] See, e.g. http://www.abc.net.au/news/2016-08-17/shonky-doctors-face-medical-board-crackdown/7749354
[9] Interim Report, page 11
[10] Ibid, pages 10 and 44-47
[11] Ibid, pages 11 and 29-33
[12] Ibid, page 30
[13] Ibid, page 11
[14] Ibid, page 12
[15] Ibid
[16] Ibid, pages 12 and 58
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