Would you visit a doctor who has, next to his or her name in the public register, a mention of a court proceeding or tribunal hearing?
Or would you prefer to see another doctor, even if the small print on the register stated ‘allegations not proven’?
I often find the legalese speak on AHPRA’s website difficult to understand. A recent report recommended that the register should include web links to published disciplinary decisions and court rulings – which AHPRA has been implementing.
However, and this is not immediately clear from the explanation on the website, apparently proceedings will also be published when a doctor or other health practitioner was found not guilty.
Complaints that have been dismissed in a tribunal as without merit will still be listed with a link to the relevant court or tribunal ruling, according to this article on DoctorPortal. The issue was also flagged at the national AMA Conference last month.
This measure is meant to ‘build trust between doctors and patients’. I’m not sure it is protecting the public but I can imagine that publishing complaints that have been dismissed is confusing for the public – and can also be misinterpreted.
It has the potential to not only affect the reputation of health professionals unfairly, but also their mental health and general wellbeing.
We need to have another long hard look at this.
“The Medical Board of Australia (the Board) has decided to publish links to serious disciplinary decisions by courts and tribunals on the public register of practitioners only when there has been an adverse finding against the doctor.
The Board will not publish links from an individual doctor’s entry on the register to public court and tribunal decisions when no adverse finding against the doctor has been made.
The Board has removed links to tribunal decisions in which there was no adverse finding about the doctor that had been published on the register since March 2018.”
If you are an Australian health professional and you have a health problem, there is a risk that your job is on the line if you seek medical assistance. But help is on its way…
As a result of mandatory reporting obligations under the National Law doctors and other health professionals may avoid seeking help or treatment for fear of being reported to the Australian Health Practitioners Regulation Agency (AHPRA) by their treating practitioner.
The reporting requirements were originally developed to protect the public against practitioners who have e.g. a health problem, an impairment or engage in serious misconduct.
Concerns have been raised repeatedly that health professionals are not seeking help and this has been flagged as a risk to the public in itself. Practitioners have also argued that their treatment should be kept confidential, just like every other Australian who seeks care.
Western Australia is the only state where these mandatory reporting guidelines are not applicable. Sadly, there is anecdotal evidence that this has created interstate traffic by practitioners in need of medical assistance.
This is the least favourable option as it would mean no change. This option would treat impairment matters and other notifiable conduct identically, requiring treating practitioners to report any notifiable conduct as is currently the case.
This is likely the most favourable option from the perspective of health practitioners as it provides a complete exemption for treating practitioners from the requirement to report notifiable conduct in respect of their practitioner patients – similar to the Western Australian model.
Practitioners would have the same rights as any other Australian to seek care, without fear of being reported by their treating practitioner and recognising the importance of confidentiality.
This option would entrust the treating practitioner to make a voluntary notification in accordance with their professional and ethical obligations to protect the health and safety of the public.
When a patient poses a serious risk to the public, professional and ethical obligations require treating practitioners to report (even in the absence of a requirement to do so) and to encourage the practitioner that they are treating to self-report.
Other practitioners including colleagues and employers remain under a mandatory obligation to report impairment and other forms of notifiable conduct.
This option would only exempt treating practitioners from the requirement to report an impairment matter if it will not place the public at substantial risk of harm.
All other types of notifiable conduct, current or past, must be reported by a treating practitioner. This means that practitioners with for example a mental health or addiction problem may not disclose issues to their treating practitioner, or may avoid seeking help.
This option would exempt treating practitioners from reporting impairment matters and to only require reporting of other forms of notifiable conduct where there is a current or future assessment that the notifiable conduct is likely to occur.
This option creates problems with regards to for example risk assessment which is often based on past conduct. Health practitioners may not fully disclose health matters and avoid seeking help under this option.
The WA model
I expect that most practitioners will prefer option 2. This option allows full disclosure of health issues, facilitating diagnosis and treatment. It respects the confidentiality of the patient-doctor relationship which is the basis of a successful road to recovery.
The COAG discussion paper reports that an independent review found no evidence that the WA model impacted on notification rates, further supporting option 2 as the preferred nationwide solution.
The Medical Board of Australia is well aware of the daunting revalidation dilemma: how to identify underperforming doctors without subjecting the rest to time-consuming and needless procedures?
The percentage of underperforming doctors is low. Nevertheless, in the UKall doctors undergo regular appraisals and are ‘revalidated’ every five years if they are deemed up to date and fit to practice.
The UK revalidation system has received its fair share of criticism. A common complaint is that the collegiate appraisal process has been ‘dumbed down’ as it changed from a formative to a summative process.
Other criticism includes the heavy time burden and paperwork, the negative impact on doctors’ wellbeing (while the profession already works in a highly stressful environment), the creation of a tick-box mentality, and a situation where some doctors are avoiding complicated situations and high-risk patients that could get them into trouble.
The good news is that the Australian Medical Board does not seem to want to copy the UK model and instead appears to be looking at countries like Canada or New Zealand, where the focus lies more on self-regulation as opposed to external regulation.
Expect the introduction of some sort of revalidation model in the next two to five years. The question is of course: are we heading in the right direction?
Interestingly, there is still discussion about the purpose of revalidation of doctors (see picture). The overarching principle seems to be improving patient care, but whether it’s about ensuring public safety, ‘catching dodgy doctors’ or making good doctors better, is not always clear.
Some say it’s a bit of everything, which may be true but the problem is: how are we going to develop a revalidation system that does ‘a bit of everything’?
According to the Medical Board of Australia the fundamental purpose of revalidation is to ensure public safety. The Board has proposed a two-pronged approach to achieve this, namely improving continuous professional development (CPD) and identifying at risk doctors:
To maintain and enhance the performance of doctors practising in Australia through efficient, effective, contemporary, evidence- based CPD relevant to their scope of practice.
To proactively identify doctors who are either performing poorly or are at risk of performing poorly, assess their performance and when appropriate support their remediation of their practice.
To be fair, I agree our CPD model could be a lot better, focusing more on where we need to improve instead of what we want to improve.
At the same time there are concerns about the Medical Board proposal, especially with regards to the method of finding the underperformers. The Medical Board has recognised many of the issues and is currently consulting with the profession.
The overarching problem is that there is little evidence to show that revalidation improves patient outcomes. I can see at least two other major issues:
Externally enforced actions have less impact than internally-driven change in a collegiate, supportive environment. The colleges, rather than the Medical Board, AHPRA, employers or other parties, should be supported with data and resources to provide skilled remediation.
The proposed profiling of doctors (e.g. over the of 35, male, trained overseas, previous complaints) appears to be a blunt approach. The tools should be sharpened, focusing more on behaviour and performance. To identify underperforming doctors we need a good screening tool. As Wilson and Jungner outlined fifty years ago, there are several criteria to be met first, to make sure we’re not doing more harm than good, especially as the percentage of underperforming doctors is low and at this stage we’re not 100 percent sure what kind of doctors we are looking for. We should also be careful not to confuse screening and assessment tools.
The way forward
The starting point should be a supportive, non punitive solution. Only when the desired outcomes through collegiate processes are not achieved, should regulators become involved. Any model must be fair, evidence-based and not create large amounts of paperwork.
Here are seven principles I believe are important when moving forward:
The focus of revalidation should be heavily weighted towards self-regulation and strengthening collegiate education and remediation processes;
Self-initiated gap and learning needs analysis are effective tools to direct life-long learning, supported by evidence;
Peer review, performance review and outcome measurement could be used to strengthen QI&CPD but will require further evaluation;
Data exchange between agencies and organisations, keeping in mind confidentiality and privacy, could identify underperformers earlier;
Under performing doctors must be supported, not only via remediation but also looking after the wellbeing of the doctor involved;
There needs to be clarity and transparency about potential medicolegal use of data collected during the revalidation process;
The costs involved should not be carried by the profession alone.
And lastly, we really need a less punitive term instead of revalidation.
Australian doctors are kept on a short leash. I recently renewed my registration with the Australian Health Practitioner Regulation Agency (AHPRA). This annual ritual is always interesting.
Like thousands of other doctors, I first had to fill out an online questionnaire. As usual, AHPRA wanted to know if I had a physical or mental impairment, disability, condition or disorder – including substance abuse or dependence – that would detrimentally affect my capacity to work as a doctor. I was reminded that I’m required by law to declare any impairments.
There were questions about criminal records, compliance with the law, continuous professional development, indemnity insurance, work history and immigration status. I was advised that if I did not give the required information, I could lose my registration.
Finally I dutifully transferred the required $724 into AHPRA’s bank account.
High professional standards
The yearly AHPRA registration procedure symbolises the way doctors are controlled in Australia. Contrary to common belief, doctors allowed little freedom.
Before doctors can prescribe certain medications, they have to call Medicare to get approval. Prescribing habits are monitored. Doctors are audited randomly to make sure billing practices are not out of line with peers. They may be prosecuted if there is a deviation from the average. In most states, doctors have to report colleagues who are not performing optimally.
At the same time, professional medical standards in Australia are high. Take the accreditation standards of the Royal Australian College of General Practitioners, or the CPD requirements. Both quality assurance programs have become more robust over the years and are continuously being reviewed and improved by the College.
QI&CPD programs recognise ongoing education to improve the quality of everyday clinical practice by promoting the development and maintenance of medical skills and lifelong learning.
Is there a problem?
Why is there still talk about revalidation of doctors? Is the public concerned about the quality of Australian doctors?
The national AMA patient survey indicated that GPs are considered by the public to be trustworthy, knowledgeable and experienced. A large patient satisfaction survey endorsed by the RACGP found there was a very high level of satisfaction with General Practice in Australia.
Another study published in the MJA also showed that patients reported high levels of satisfaction with GP care, and for many years Australian doctors have been in the top three most trusted professions in the annual Roy Morgan research.
Based on numbers from Canada, AHPRA estimates that 1.5 per cent of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5 per cent of unsatisfactory performers in any group is low. It appears that any potential problem lies with a significantly small minority of doctors.
Carpet-bombing the profession
There are many revalidation models – from strengthening CPD to targeting those at high risk of complaints, to the full- bore version rolled out in the UK. But if the AHPRA tries to identify substandard doctors, carpet-bombing the whole profession is problematic.
Dr Steve Wilson, Chair of the AMA (WA) Council of General Practice, questioned in Medicus magazine whether revalidation would address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or lack of time, training, experience or adequate remuneration?
Competency checks of doctors may sound appealing to the public. I’m sure some politicians will love the rhetoric. But simply copying the UK’s revalidation system would be a mistake.
About 5,000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.
Existing quality systems
In recent years, our healthcare system has seen several unsuccessful concepts not supported by evidence. Think for example about the super clinics program and some of the accompanying cost blowouts, delays and disappointing results.
It will be easier and cheaper to build on existing quality assurance systems.
This article has previously been published in Medicus, the AMA(WA) magazine.
The Medical Board of Australia could be about to make a costly mistake. Regular testing of competency being introduced is not a matter of if, but when, said the new boss of the NSW Medical Council, Dr Greg Kesby, in an interview with Australian Doctor magazine.Dr Kesby also said there needed to be a process to instil confidence within the community that all doctors’ knowledge was up-to-date.
On the face of it, competency checks of doctors sounds appealing. I’m sure some politicians will love the rhetoric. But at the same time, alarm bells were going off when I read the interview.
Does Dr Kesby imply that the Australian public has lost confidence in its health practitioners? Are there concerns about the quality of Australian healthcare? There are many other unanswered questions too.
Is there any evidence that the current quality assurance systems, such as accreditation and CPD, are insufficient? Is recertification or revalidation — such as has been implemented in the UK — an efficient way to improve the quality of healthcare? Is it possible to design a system that reliably differentiates between good and bad practitioners? And how do we define competency?
Based on numbers from Canada, AHPRA estimates that 1.5% of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5% of unsatisfactory performers in any group is low. There are numerous models: from strengthening CPD to targeting those at high risk of complaints, to the full-bore version rolled out in the UK. But if the board tries to identify these substandard doctors, carpet-bombing the whole profession is problematic.
One thing is for sure: UK-style revalidation is expensive. The process takes 1-2 working days per practitioner. Imagine thousands of Australian doctors having to take a couple of days off work to fulfil revalidation requirements.
Imagine the enormous effort it will take to manage this process. Think about the additional cost of the training, time and wages of the appraisers — who, I assume, will be doctors too — and the admin staff, extra regulation, log books, documents, IT etc.
According to the UK’s Pulse magazine, the revalidation of doctors has become a colossal enterprise, costing taxpayers £97 million (about $207 million) a year. This figure does not include revalidation of other health practitioners. Critics of the UK system have said it will not detect poor doctors, as its main purpose is to gain patients’ trust. Others feel it mainly serves to demonstrate what good practice looks like.
Policing the profession
A former UK GP-appraiser, now working in Australia, mentioned on the GPs Down Under Facebook group that appraisals used to be fun, interesting and mainly pastoral. Under revalidation, they became a form of policing the profession, he said.
Professor Kerry Breen, adjunct professor in the department of forensic medicine at Monash University, wrote in the Medical Journal of Australia last year that there was little evidence to support the idea of transposing the UK system to Australia.
He said that despite some local failures of medical regulation and hospital governance, the community had not lost faith either in its doctors or regulatory system. Indeed, it appears the public is largely content with its healthcare practitioners: Australian doctors, nurses and pharmacists have been in the top three most trusted professions for many years in the annual Roy Morgan research.
More recently, Dr Steve Wilson, an AMA WA representative, questioned in the AMA’s magazine whether revalidation would be able to address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or a lack of time, training, experience or adequate remuneration?
Don’t follow the UK
About 5000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. Simply copying the UK’s revalidation system would be a big mistake. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.
In recent years, our healthcare system has seen enough unsuccessful concepts not supported by evidence. Think about the super clinics program or the PCEHR, and the accompanying cost blowouts, delays and disappointing results.
It will be easier and cheaper to build on existing quality assurance systems.
Let’s look, for example, at refining CPD and accreditation. As they say, the main difference between a wise man and a fool is that a fool’s mistakes never teach him anything.
Developing an expensive new system with little or no supportive evidence failed in the case of super clinics and e-health, and it will fail with revalidation too.
This article was originally published in Australian Doctor Magazine.
Wouldn’t it be great if we could spot the bad apples before we consume them? Or even better: before they become bad? In recent years medical regulators around the world have been exploring ways to identify doctors who are performing poorly.
In the UK all apples are tested once a year via a process called revalidation. But some have said it will not detect poor doctors; its main purpose is to gain patients’ trust. Others say it is meant to demonstrate what good apples look like. But one thing is for sure: Revalidation is labour-intensive and expensive.
“There is indeed an additional time cost,” said GP Dr Paresh Dawda in Australian Family Physican. “The appraisal meeting was usually 3 hours in length, and on average it took another 5 or 6 hours to collate the evidence and complete the forms, which is in keeping with an average of 9 hours found in the revalidation pilots.”
Then there are the training, time and wages of the appraisers, usually doctors too, the administrative staff, extra regulation, log books, documents, IT… Revalidation has become an enormous enterprise, costing £97M ($186M) a year, mainly because of added pressures on doctors’ time.
It seems logical that, before a country embarks on an operation like this, the problem it is trying to solve has been defined and the solution is effective.
So what’s the problem?
According to the Medical Board of Australia, evidence from Canada shows that 1.5% of doctors are not good enough. The Board has translated this figure to Australia, and thinks that over 1,350 doctors could be performing unsatisfactorily. Other research indicates that just 3% of doctors are the source of 49% of complaints.
“Where is the evidence that further regulation is needed?
Several safety mechanisms are already in place: At the moment Australian doctors must meet the Medical Board’s mandatory registration standards, including for recency of practice and continuing professional development. Doctors can be subjected to random compliance audits.
Although a majority of Australian doctors seems to support competence checks, there are serious questions about the UK-style revalidation process.
AMA(WA)’s GP Dr Steve Wilson in this blog post: “Where is the evidence that further regulation is needed, which will be preventative and ultimately beneficial to the profession and the community?”
“Will it address those who fail to practise to agreed levels, and is that a sign of ‘impairment’ or more about personal style, lack of time, adequate remuneration, or lack of care, training, experience, sheer demand and workforce numbers?”
At a conference in 2013 Medical Board of Australia Chair, Dr Flynn admitted that ‘the problem that a revalidation-style system would help solve was not yet defined’.
But Dr Flynn questioned the current continuous professional education system: “Can you assure me that everyone who has done your CPD program is actually competent and practising at a reasonable standard? (…) My sense is that, for most CPD programs, they don’t do that, or at least, not to a high enough level of certainty.”
After meeting Dr Flynn in 2013, the RACGP stated in Australian Doctor magazine: “The meeting provided an opportunity for the college to discuss the strength of our current QI & CPD program, and the necessity of adding yet another mechanism to identify underperforming doctors, when processes are already in place – such as the medical boards, health quality and complaints boards and indemnity insurers.”
What’s the Medical Board up to?
“We started a conversation about revalidation in Australia in 2012,” said Dr Joanna Flynn in last week’s media release, “as part of our commitment to making sure doctors in Australia maintain the skills to provide safe and ethical care to patients throughout their working lives.”
The board has asked the University of Plymouth to answer some questions on revalidation. At first glance this seems a sensible approach.
Dr Flynn: “We have commissioned this research to find out what is working well internationally, what is in place in comparable health care systems, and what principles the Board should consider in developing revalidation in Australia. (…) this research will help make sure that the decisions the Board makes in future about revalidation are effective, evidence-based and practical.”
The aim of the project is to:
establish the existing evidence base for the validity of revalidation or similar in countries comparable to Australia
identify best practice and any gaps in knowledge for revalidation processes
establish the validity evidence for revalidation’s effectiveness in supporting safe practice
develop a range of models for the Australian context for the Board to consider.
It seems to me the research questions are broad and several steps are taken at once. For example: ‘Establishing the evidence for revalidation’ and ‘developing a range of revalidation models’ are entirely separate processes.
It appears the Medical Board has already made up its mind. The research findings will be considered by the Board in the second half of 2015. I am certainly looking forward to the results and conclusions, as well details about cost and setup of the study.
The Camera revalidation research website of the University of Plymouth doesn’t give any answers away: “The research team is currently undertaking an ambitious programme of research involving three interlinking studies to explore and understand revalidation in all its complexity.”
Putting the cart before the horse
The question is of course: Is revalidation the right solution? Are there other options? One could argue that this should have been considered before spending tax dollars on an overseas research project.
Professor Breen, from the Department of Forensic Medicine at the Monash University in Melbourne, said in the Medical Journal of Australia: “There is little to support the idea of simply transposing the UK system to Australia. Despite some local failures of medical regulation and hospital governance, there has been no widespread loss of faith of the community either in its doctors or in the regulatory system.”
“Is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?
“The Medical Board of Australia would be wiser to start afresh by asking and answering two questions — namely, is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?
“The medical profession in the UK appears to have accepted revalidation, albeit reluctantly, as representing the price to be paid for maintaining the existence of the GMC and for regaining public trust after a series of regulatory failures.”
“It has been claimed that revalidation will not reliably detect poorly performing doctors, and many commentators have pointed out that revalidation would not have identified Dr Harold Shipman.”
Immediate past president of the AMA, GP Dr Steve Hambleton had second thoughts too. In MJA Insight he said: “We need to make sure we maintain our currency and continue to improve health outcomes, but in terms of value for money, making everybody go through a 5-yearly process of 360-degree evaluation is not needed in the Australian health system.”
Both Professor Breen and Dr Hambleton suggested there are better ways to deal with the bad apples. Database analysis could be one solution. Other options are targeted revalidation and a revamp of the existing CPD program and accreditation. Some have argued that the focus should be on the workplace, not just on health professionals.
Journalist Paul Smith from Australian Doctor magazine was, as usual, spot on when he wrote: “(Doctors) may argue that targeted revalidation has greater merit than what they may see as carpet-bombing the entire profession.”
“Recently I cried at work,” posted Dr Adrienne Garner on the BMA blog. “Why? Because the evening before I’d been notified that my appraisal, submitted after hours of work, had been unsubmitted by my appraiser as it was ‘not sufficient for revalidation.”
“I was gutted. My mind churned with a mixture of thoughts ranging from anger to fear, through frustration and disappointment. Sleep had been impossible.”
“Under revalidation appraisals became a form of policing the profession.
Many studies show that doctors are more likely to experience psychological distress and suicidal thoughts than the general community, and there is a high rate of burnout. Pastoral care and self-reflection are important. But when they are part of a policed regulatory framework, they become a stressor in itself – which defeats the purpose.
Former Coventry GP Dr Gaurev Tewary, now working in Australia, posted on a social media platform: “I was an appraiser in the UK. My overall impression is this: Appraisals used to be fun and interesting and mainly pastoral. You did them to help people and I enjoyed supporting the profession. Under revalidation it became a form of policing the profession.”
About 5,000 doctors a year are considering to leave the UK, and many come to Australia. Bureaucracy is one of the reasons they emigrate. We must become better at dealing with bad apples, but healthcare is already a highly regulated industry and the last thing we need here in Australia is more regulation, red tape and stressed-out doctors.
I hope the Medical Board will work with the colleges and the AMA to explore better options.
The Australian Health Practitioner Regulation Agency now says in its new guidelines that practitioners can be fined if patients post online testimonials praising the clinical care they received.
Last Friday, it seemed as if AHPRA had backed down on the harsh regulation. But is this really the case?
What does AHPRA say?
First of all, here’s a quote from the current guidelines:
a review (…) that states ‘Practitioner was quick to diagnose my illness and gave excellent treatment’, is a testimonial which references clinical care and is considered in breach of the National Law.
The guidelines also state that health practitioners must take steps to remove unsolicited testimonials appearing on any (social media) website not under their control. However, last Friday the medical board put out a media statement on the AHPRA website saying this:
The advertising guidelines apply to testimonials in the context of advertising (…) there is a clear difference between advertising – which requires an intent to promote the health services – and unsolicited online comment over which practitioners do not usually have control (…). The Board recognises that practitioners are unable to control what is written about them in a public forum.
Indeed, this sounds a lot better than the official advertising guidelines – the medical press have used the words ‘backflip‘ and ‘backdown‘. However, the guidelines have not been updated, which leaves the following three questions unanswered:
1. If a patient posts a comment on my Facebook page stating that I gave excellent treatment, this is still considered in breach of the National Law according to AHPRA’s guidelines and I may be up for a fine if I don’t delete this friendly post. Will I be able to defend myself by referring to the media statement posted on the AHPRA website on 7 March 2014? If AHPRA is serious, the guidelines should be changed in accordance to their statement.
2. Health professionals need to know why our feedback about exactly this issue has not been taken on board in an earlier stage. The first draft guidelines appeared in 2012 and health practitioners were not impressed. The rules were already clear: we knew that testimonials in advertising are a no-go (and I don’t mean unsolicited Facebook comments from patients) – and of course this applies to websites, social media, the classroom, the elevator and anywhere else.
In AHPRA’s udated draft guidelines (2013) the issue of patient feedback vs testimonials had not been addressed, which again led to a storm of online comments as well as another lot of official submissions. See also this post (April 2013). As we know, the final version was published last month and positive patient feedback is not allowed, but then again on Friday the board seemed to think that patient comments are not advertising.
3. As the advertising guidelines are common to all national boards (e.g. dental, nursing & midwifery, psychology etc) we need to know if and how the statement by the medical board will be applied to the other 13 disciplines.
I’m happy with the clarification by medical board chair, Dr Joanna Flynn, and I agree it is a step in the right direction. But it still seems unnecessary government interference, and, after three revisions, the guidelines leave important questions unanswered.