The move towards revalidation for doctors is relentless, although progress is slow and fraught with problems that had not been envisaged. It will inevitably be costly and demanding in time if it is to be robust and reliable. But will patients be safer as a result?
I have in front of me a document entitled “Revalidation: Statement of Intent” co-authored by the representatives of the Department of Health, The General Medical Council, Healthier Scotland, the Welsh Assembly Government and the Department of Health, Social Services and Public Safety.
It is a résumé of progress made towards the intended regular revalidation of doctors. In it, the Rt Hon Andrew Lansley, MP, is quoted as saying:
‘Revalidation is something that the public expect their doctors to undertake and, if implemented sensitively and effectively, is something that will support all doctors in their innate professional desire to improve their practice still further.’
Now, I don’t have any issue with the notion that doctors need to keep up to date and to evaluate the development of their skills and knowledge and to determine such learning and personal development plans as will enable them to do so. But I do have issues with the motivation behind the introduction of revalidation and its proposed process. And whence came this statement that ‘Revalidation is something that the public expect their doctors to undertake’? No patient I ever asked or told about revalidation expressed this desire. Indeed, the great majority didn’t know anything about it. Pretty well without exception they appeared to think that doctors, being professional and trustworthy people, would make it their business to keep up to date and needed neither carrot nor stick to persuade or coerce them into doing so.
No. I think that the motive behind the drive toward revalidation comes from another direction entirely, and is two pronged: a desire by politicians to present themselves in a good light to those they hope will vote for them, and as a part of the ongoing move to push the blame for failures within the Health Service on to those who work at its sharp end. And also as a sop to the media.
I have worked with and taught doctors for decades. The genuinely lazy doctor who had no interest in giving the best he or she could, seldom if ever came my way. Personal development and improvement is very much a part of practice and a source of deep satisfaction for those privileged to work in the field of medicine. Medical science and the way in which medical care is delivered is constantly changing and developing. There is simply no way in which anyone can be a medical practitioner and not be engaged in serious learning. The truth is that revalidation, if it does what it seems to be intended to do, will be complex and costly in terms of time and money. And it will identify only a tiny minority of doctors who may not be coming up to the mark. We need to ask, too, how sensitive is this instrument: how accurate will it be in its objective? Will it really identify only those doctors who really are deficient, and will deficient doctors be identified with near 100% accuracy?
I have asked many times of those whom I thought to be well place to give a straight answer: What evidence is there that revalidation will do the job it purports to: to improve patient safety and to protect the public from failing, incompetent or dangerous doctors? I have never been given an answer and I suspect the reason for this is perfectly simple: there isn’t any.
Patients do not expect perfection from their doctors, and although some hold quite unrealistic expectations of the medical profession, the majority do not. My own questioning and experience of practice is that what matters most to patients is easy, early and unobstructed access to a doctor or their choice. And once in her or his presence to be treated kindly and courteously, to be listened to and heard, and not to be made to feel foolish. The best doctors, patients know well, don’t know everything and their skills are not all-encompassing. But they will acknowledge this, and either take steps to fill knowledge gaps or to pass the patient on to a colleague who has the skills to address their needs. It is this attitude and this approach that mark out the best of doctors: those who can recognise and acknowledge their limits, and how best to address these limitations both in the immediacy of a situation, and in the longer term. I can illustrate this with an example of a learning experience of my own: it concerned my handling of children presenting with an acute wheeze in the GP surgery. In the interest of safety I used to refer on to hospital more than I might have needed to be had I been more confident and competent in their management. But hospitalisation can be a distressing experience for both child and parents. So I devised a learning programme for myself and was able to improve upon my own management in surgery. My referral rate for these children dropped.
Even so, to attribute all or even most medical failings to professional incompetence misses the point, even if it is convenient for our political masters to do so. Doctors work long hours. They get tired. Many work when they themselves are ill, often because there is just no-one else to take over a surgery at short notice. It is these deficiencies that result in clinical error, more than any notion of incompetence. And each patient is allotted just ten minutes of a doctor’s time. Now, doctors are masters at efficient use of time, even compensating for the laughably short time for each appointment. It is often the acute crises that are the most straightforward, not least because it is usually possible to gauge quickly that the patient is seriously unwell. Another example: A man patient I scarcely knew stood in the doorway of my consulting room, pale and sweaty with a fist clenched over his chest. Within two minutes he was lying on the couch having been given aspirin, within four minutes the practice nurse was standing by him, defibrillator at the ready, and within ten minutes he was on his way to the coronary care unit in an ambulance with sirens blaring and blue lights flashing. But much more difficult to unravel is the presentation by the patient who complains of vague, ongoing fatigue. These need painstaking and time consuming assessment. And for most such presentations, no organic disease will actually be identified.
No. Revalidation as it is proposed may well not meet the objectives it sets, other than that it will be looked upon with pride by its authors (if indeed it ever gets off the ground. But that is another story).
And something else: inevitably a small number of doctors will be judged to be so incompetent that they will be removed from practice. Conversely, revalidation may fail to identify a small number of doctors who are seriously incompetent, even dangerous, and these will continue to practise. But many more will be lost to Health Service and patients simply because they are not prepared to go through the onerous and time demanding revalidation process that will be required of them.
I know of at least one such doctor. He is one of the most highly qualifed GPs I know, and at the age of 60 re-sat the tough membership examination, which he first passed thirty years previously, in order to be appointed a clinical skills examiner for that same examination. He passed it without difficulty.
That doctor is about to finish writing this blog for you. Well, I will be 65 this year and I think I am entitled, after over 40 years at coal face medical practice, to finally hang up the stethoscope for good. But I’ve had enough of the nonsense. I was a doctor, not a data gatherer, box ticker or navel gazer. I pity my colleagues I am leaving behind in the morass, and I pity the patients who are misled into thinking that having their doctors “revalidated” will do anything other than take them out of the surgery for no good purpose so that it will be even more difficult to get to see them.