Posted by: Nicholas Ramscar27 January 2014
Appraisal and revalidation are not popular with doctors. This is hardly surprising – nobody in any job likes this kind of scrutiny. So do we have a case for complaint, given that regular review of doctors’ capabilities will strike most members of the public as a reasonable and long-overdue step?
Perhaps the easiest way to show that we do is to consider the value of revalidation within the framework of evidence-based medicine. This is the kind of judgment we are expected to make every day, in selecting investigations and treatments, and it is the driving ethos of a modern and cost-effective health service. We should re-label the revalidation process for what it is – a screening test – and see whether it stands up to accepted criteria.
There is a good case for considering revalidation as a screening test. A large population – every doctor – is being investigated for a condition, namely unsuitability to practice medicine. The test is being applied to asymptomatic members of the population, those without the warning symptoms of patient complaints, colleague concerns, criminal convictions and so on. It uses taxpayers’ money, and takes doctors out of their consulting rooms. And interventions are planned on the basis of its findings, for those found to be harbouring the condition.
This screening test comes with attached costs. There is a very concrete and quantifiable cost in the time and money taken up with the interview itself. There is a slightly more hazy cost in the time taken to prepare for the process, which will vary between subjects. And then there is a completely unknown cost in terms of overall impact on the population. Anecdotally, there is a cohort of older GPs who are being pushed towards retirement by the imposition of this process, when they otherwise might have stayed in practice. Perhaps anecdote is all it is, perhaps not. But these are the doctors that a cost-effective health service can least afford to lose, the ones that younger GPs like myself can learn most from. In accordance with the law of unintended consequences, this huge attempt to enforce ongoing professional development may stunt it by removing the very people who could best train the up-and-coming generation. We should at least treat these anecdotes as yellow cards, and take them as seriously as we would a potential side-effect from a drug or surgical procedure.
For this costly and potentially deleterious screening to be imposed, we should expect it to comply with accepted criteria for a good test. This is what the public have a right to expect from a healthcare system funded by them for their benefit. I was taught at medical school that the best assessment for a screening test was Wilson’s criteria, which are easily found at gpnotebook.com.
To be sure, revalidation passes some of the criteria with flying colours, notably the first and last. Doctors who aren’t fit to practise are indeed an important health problem, and case-finding would be a continuous process. It’s in the middle that things become murky. Is there a ‘recognisable latent stage’ for unsuitability to practise? Is the process ‘easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific’? I would suggest that this hasn’t yet been sufficiently demonstrated. Is it really possible to grade a doctor’s quality by the number of hours of teaching they attend in a year? I know I’ve learnt more from corridor conversations with colleagues, and from patients, than I have ever done in formal, quantifiable teaching. But the real learning, the stuff that stays with you for life, doesn’t come with a certificate.
The bottom line is this: appraisal and revalidation impose a blanket cost on all doctors, and on the taxpayer. The health service should only implement it if these costs procure clear gains; this is the basis of economical evidence-based practice. For most of us, the process is just a convoluted, demoralising, and time-consuming way of proving that we’re doing what we are already doing.
This will be a test replete with false positives and false negatives; I’m not convinced that doctors who truly have something to hide will find it difficult to gather the evidence needed for appraisal and revalidation. And attending fifty hours of lectures a year doesn’t prove you give a damn about your patients.
Dr Nick Ramscar is a GP in Bracknell, Berkshire