Where next with revalidation?
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《英国医生杂志》
Self regulation should survive, but revalidation must offer education as well as performance review
A century ago, Cornford described how a conservative faculty at Cambridge University, England, struggled to deflect the pressure to reform.1 Some aspects of that treatise have been reprised in the BMJ series on the United Kingdom General Medical Council, which ends this week, as regulators take on the public's need for a mechanism to ensure that doctors provide good care for patients throughout their careers.2-8 Three themes emerge from this series and from the broader debate: revalidation is necessary; revalidation must be comprehensive; and medicine should be self regulated.
In his article, Irvine espouses the view that doctors are personally responsible for their own ability to provide good care and that they share in the collective responsibility for their colleagues.4 In this context, revalidation is an essential expression of professionalism and a means of establishing accountability to patients and the public.
Overwhelmingly, patients also feel that revalidation is necessary. Cain, Benjamin, and Thompson report that, in 1997, periodic retesting of doctors was an emerging issue in the United States.8 By 2003 a Gallup poll found that more that 80% of adults believed that it was important or very important for doctors to be re-evaluated periodically regarding their qualifications; to have high success rates for the conditions they treat most often; periodically pass a written test of medical knowledge; and to receive high ratings from their patients.9
Unfortunately, despite both professional obligation and patients' expectations, the performance of doctors declines over time. A recent systematic review found that, compared with their younger colleagues, older doctors and those in practice for more years had less factual knowledge; they were less likely to adhere to standards for diagnosis, screening, prevention, and treatment; and their patients had poorer outcomes.10 This review has limitations, but it remains clear that doctors who have been in practice longer are at increased risk for providing lower quality care. Professionalism, patients' expectations, and the declining performance of doctors over time converge to make revalidation a necessity.
The authors of this BMJ series disagreed over whether revalidation should encourage professional development or weed out those unfit to practise.2 3 5 As Irvine says, it needs to do both.3 If it only affirms the positive, revalidation will allow those few who are unfit to continue to practise. If it only eliminates the unfit, revalidation will permit an unabated decline in the performance of all other doctors. Both outcomes could cause harm to patients, so a revalidation programme must include both assessment and education.
Authors of the series agree that revalidation should focus on performance in practice. The assessment methods needed to support performance review are in their infancy, and much remains to be done.11 At the same time, tests of knowledge and clinical skill as well as ratings by patients and peers have considerable potential as tools to screen for poor performance, given their positive associations with the quality of care.9 A revalidation programme should not be delayed while awaiting an ideal method, but its implementation should be accompanied by a rigorous evaluation of the assessment methods used.
In contrast, this series has been largely silent on the role of education. This may reflect doubts about the effectiveness of such education or the view that it is beyond the remit of regulators. None the less, evidence is increasing that practice based learning improves the quality of care and its inclusion is especially important given the decline in the performance of doctors over time.12
The specialised knowledge and skills that form the basis of a profession also make lay people largely unsuitable for regulating it. As Dauphinee argues, self regulation is the best option.7 However, the absence of the patients' voice in the regulation of medicine is one of the primary reasons that a robust programme of revalidation is not in place. Without outside pressure, it is difficult for any group to submit its members voluntarily to ongoing scrutiny that could lead to loss of their livelihoods.
The articles in this series bring forward several good ideas for ensuring that revalidation gives patients a voice and responds to their needs, and that there is genuine effort to deal with the obstacles raised by Cain, Benjamin, and Thompson.8 Walshe and Benson recommend harmonising the regulation of all the health professions,6 Lakhani cites the importance of using lay people in the revalidation process,5 and Dauphinee stresses the importance of substantive skill and independence.7
Good as they are, however, these ideas alone will not deter the increasing involvement of governments, payers, and patients in the regulation of doctors. The medical profession has to resist the temptation to deflect the pressure to reform. Doctors should take control of the situation through institutions such as the General Medical Council, and move forward urgently with a robust programme of revalidation. Doctors and patients have no other good alternative.
John J Norcini, president
Foundation for Advancement of International Medical Education and Research, 3624 Market Street, 4th Floor, Philadelphia, PA 19104, USA
(jnorcini@faimer.org)
Education and debate p 1504 and Personal view p 1515
Competing interests: None declared.
References
Johnson G. University politics: F.M. Cornford's Cambridge and his advice to the young academic politician. Cambridge University Press, 1994.
Esmail A. GMC and the future of revalidation: failure to act on good intentions. BMJ 2005;330: 1144-7.
Catto G. GMC and the future of revalidation: building on the GMC's achievements. BMJ 2005;330: 1205-7.
Irvine D. GMC and the future of revalidation: patients, professionalism, and revalidation. BMJ 2005;330: 1265-8.
Lakhani M. GMC and the future of revalidation: a way forward. BMJ 2005;330: 1326-8.
Walshe K, Benson L. GMC and the future of revalidation: time for radical reform. BMJ 2005;330: 1504-6.
Dauphinee WD. GMC and the future of revalidation: revalidation in 2005: Progress and maybe some lessons learned? BMJ 2005;330: 1385-7.
Cain FE, Benjamin RM, Thompson JN. GMC and the future of revalidation: obstacles to maintenance of licensure in the United States. BMJ 2005;330: 1443-5.
Brennan TA, Horwitz RA, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA 2004;292: 1038-43.
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Int Med 2005;142: 260-73.
Norcini JJ. Current perspectives in assessment: The assessment of performance at work. Med Educ (in press).
Robertson MK, Umble KE, Cervero RM. Impact studies in continuing education for health professions: Update. J Contin Educ Health Prof 2003;23: 146-56.
A century ago, Cornford described how a conservative faculty at Cambridge University, England, struggled to deflect the pressure to reform.1 Some aspects of that treatise have been reprised in the BMJ series on the United Kingdom General Medical Council, which ends this week, as regulators take on the public's need for a mechanism to ensure that doctors provide good care for patients throughout their careers.2-8 Three themes emerge from this series and from the broader debate: revalidation is necessary; revalidation must be comprehensive; and medicine should be self regulated.
In his article, Irvine espouses the view that doctors are personally responsible for their own ability to provide good care and that they share in the collective responsibility for their colleagues.4 In this context, revalidation is an essential expression of professionalism and a means of establishing accountability to patients and the public.
Overwhelmingly, patients also feel that revalidation is necessary. Cain, Benjamin, and Thompson report that, in 1997, periodic retesting of doctors was an emerging issue in the United States.8 By 2003 a Gallup poll found that more that 80% of adults believed that it was important or very important for doctors to be re-evaluated periodically regarding their qualifications; to have high success rates for the conditions they treat most often; periodically pass a written test of medical knowledge; and to receive high ratings from their patients.9
Unfortunately, despite both professional obligation and patients' expectations, the performance of doctors declines over time. A recent systematic review found that, compared with their younger colleagues, older doctors and those in practice for more years had less factual knowledge; they were less likely to adhere to standards for diagnosis, screening, prevention, and treatment; and their patients had poorer outcomes.10 This review has limitations, but it remains clear that doctors who have been in practice longer are at increased risk for providing lower quality care. Professionalism, patients' expectations, and the declining performance of doctors over time converge to make revalidation a necessity.
The authors of this BMJ series disagreed over whether revalidation should encourage professional development or weed out those unfit to practise.2 3 5 As Irvine says, it needs to do both.3 If it only affirms the positive, revalidation will allow those few who are unfit to continue to practise. If it only eliminates the unfit, revalidation will permit an unabated decline in the performance of all other doctors. Both outcomes could cause harm to patients, so a revalidation programme must include both assessment and education.
Authors of the series agree that revalidation should focus on performance in practice. The assessment methods needed to support performance review are in their infancy, and much remains to be done.11 At the same time, tests of knowledge and clinical skill as well as ratings by patients and peers have considerable potential as tools to screen for poor performance, given their positive associations with the quality of care.9 A revalidation programme should not be delayed while awaiting an ideal method, but its implementation should be accompanied by a rigorous evaluation of the assessment methods used.
In contrast, this series has been largely silent on the role of education. This may reflect doubts about the effectiveness of such education or the view that it is beyond the remit of regulators. None the less, evidence is increasing that practice based learning improves the quality of care and its inclusion is especially important given the decline in the performance of doctors over time.12
The specialised knowledge and skills that form the basis of a profession also make lay people largely unsuitable for regulating it. As Dauphinee argues, self regulation is the best option.7 However, the absence of the patients' voice in the regulation of medicine is one of the primary reasons that a robust programme of revalidation is not in place. Without outside pressure, it is difficult for any group to submit its members voluntarily to ongoing scrutiny that could lead to loss of their livelihoods.
The articles in this series bring forward several good ideas for ensuring that revalidation gives patients a voice and responds to their needs, and that there is genuine effort to deal with the obstacles raised by Cain, Benjamin, and Thompson.8 Walshe and Benson recommend harmonising the regulation of all the health professions,6 Lakhani cites the importance of using lay people in the revalidation process,5 and Dauphinee stresses the importance of substantive skill and independence.7
Good as they are, however, these ideas alone will not deter the increasing involvement of governments, payers, and patients in the regulation of doctors. The medical profession has to resist the temptation to deflect the pressure to reform. Doctors should take control of the situation through institutions such as the General Medical Council, and move forward urgently with a robust programme of revalidation. Doctors and patients have no other good alternative.
John J Norcini, president
Foundation for Advancement of International Medical Education and Research, 3624 Market Street, 4th Floor, Philadelphia, PA 19104, USA
(jnorcini@faimer.org)
Education and debate p 1504 and Personal view p 1515
Competing interests: None declared.
References
Johnson G. University politics: F.M. Cornford's Cambridge and his advice to the young academic politician. Cambridge University Press, 1994.
Esmail A. GMC and the future of revalidation: failure to act on good intentions. BMJ 2005;330: 1144-7.
Catto G. GMC and the future of revalidation: building on the GMC's achievements. BMJ 2005;330: 1205-7.
Irvine D. GMC and the future of revalidation: patients, professionalism, and revalidation. BMJ 2005;330: 1265-8.
Lakhani M. GMC and the future of revalidation: a way forward. BMJ 2005;330: 1326-8.
Walshe K, Benson L. GMC and the future of revalidation: time for radical reform. BMJ 2005;330: 1504-6.
Dauphinee WD. GMC and the future of revalidation: revalidation in 2005: Progress and maybe some lessons learned? BMJ 2005;330: 1385-7.
Cain FE, Benjamin RM, Thompson JN. GMC and the future of revalidation: obstacles to maintenance of licensure in the United States. BMJ 2005;330: 1443-5.
Brennan TA, Horwitz RA, Duffy FD, Cassel CK, Goode LD, Lipner RS. The role of physician specialty board certification status in the quality movement. JAMA 2004;292: 1038-43.
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Int Med 2005;142: 260-73.
Norcini JJ. Current perspectives in assessment: The assessment of performance at work. Med Educ (in press).
Robertson MK, Umble KE, Cervero RM. Impact studies in continuing education for health professions: Update. J Contin Educ Health Prof 2003;23: 146-56.