I am firm. You are obstinate. He is pig-headed. Is revalidation susceptible to prejudice? Of course it is.
Every process is, unless you specifically build in equality impact assessments to look for sources of bias and try to eliminate them.
However, if a camel is a horse designed by a committee, revalidation is a horse designed by lots and lots of committees, so it isn’t surprising that the end result looks more like a mutant octopus than a sleek thoroughbred. Nobody really knows whether this beast will even be able to get all the legs to go in the same direction – but nevertheless we are very soon expected to attempt to mount it and gallop off over the horizon to the Promised Land of ‘safer doctors, safer patients’.
One of the things that worries many doctors is how much weight the process will give to subjective measures such as colleague and patient feedback, which are entirely beyond our control. No matter how nice you are to your patients and charming to your staff, some people out there just won’t like you, and some of those won’t like you because of their beliefs about what the colour of your skin, your accent, your sex or your visible impairment mean about the kind of person you are, and the kind of doctor you are.
We all have prejudices. The best that can be hoped for is to be aware of them, and try to ensure when in the position of having to judge another person that you are not allowing yourself to be unduly influenced by them.
Anyone who has concerns about the impact of prejudice and bias might like to cast an eye over the case of Dr Ewa Michalak and ask themselves what her ‘colleague feedback’ might have looked like.
Dr Michalak is the Polish nephrologist who won a substantial settlement on the grounds of race and sex discrimination after her colleagues decided to hound her out of her job. The GMC’s own study of multi-source feedback has demonstrated that certain groups of doctors score less well, particularly locums and doctors trained overseas.
A study of multi-source feedback by Mount & Scullen reports that ‘only about 25% of the variance in MSF ratings reflects ratee performance. Although this amount is meaningful and useful, it is relatively small compared to that represented by the idiosyncratic tendencies of individual raters’.
In other words, MSF says more about the person doing the rating than the person being rated. A read of Hannah Cooke’s paper ‘Scapegoating and the Unpopular Nurse’ shows that good nurses who were seen as ‘not one of us’ were at risk for reasons that were nothing to do with competence.
Incorporating a measure into revalidation that will disadvantage some participants risks creating a self-fulfilling prophecy – namely, that certain subgroups in the profession will be more likely to fail than others.
BME doctors are already over-represented in GMC fitness-to-practise proceedings; sessional GPs are vociferously pointing out the difficulties they are already having in gathering evidence for appraisal to meet criteria devised for GP’s with fixed practice bases. And NCAS has reported that in 80% of cases of doctors referred with ‘performance problems’, their investigations revealed that when Trust management suggests that ‘the doctor is always the problem/the problem is always the doctor’, they haven’t always told the whole story.
Lay people who are aware that revalidation is happening at all tend to assume that it’s some kind of exam that tests clinical knowledge: objective, standardised, and capable of being blinded to remove sources of prejudice and bias.
You either know how to look after your patients to an acceptable standard – or you don’t, and you need some refresher training. It is entirely reasonable that we should have to demonstrate that we know what we’re doing clinically and are keeping up-to-date. But the tools used to assess competence need to be validated and evidence-based – not just based on somebody’s opinion of your practice.
Dr Catherine Harkin is a GP in Edinburgh and sits on the Equalityand Diversity Committee at British Medical Association