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Revalidation in obstetrics and gynaecology—the story so far
Current Obstetrics & Gynaecology (2000) 10, 168–169 © 2000 Harcourt Publishers. Ltd doi:10.1054/cuog.2000.0111, available online at http://www.idealibrary.com on
Medico-legal/education/admin
Revalidation in obstetrics and gynaecology—the story so far
J. Drife
specialty-specific standards. As well as general professional attributes such as honesty and confidentiality, the public will expect assessment of a doctor’s clinical performance within his or her specialty. In ours this means that revalidation will involve the Royal College of Obstetricians and Gynaecologists (RCOG). Neither the GMC nor the RCOG, however, gathers information on the performance of individual specialists. Data such as rates of complications or readmissions, or information about patient satisfaction will have to be collected by hospitals or by doctors themselves. Thus, the revalidation process will involve cooperation between the GMC, the RCOG, individual doctors and NHS trusts. For doctors practising wholly or partly in the private sector, information will have to be provided by private hospitals.
INTRODUCTION Revalidation is making headlines in the medical press. In February 1999 the General Medical Council (GMC) resolved to introduce revalidation of registration and to have a fully worked up model ready by February 2001. The purpose of this article is to summarize the present position and possible future developments. THE NEED FOR REVALIDATION Doctors undergo rigorous selection procedures and examinations before graduating but once on the medical register our names remain there unless we remove them, default on our GMC subscription or commit serious professional misconduct. As with our driving licences, no checks are made unless problems occur. The public, however, wants to treat us like airline pilots, with regular assessments rather than waiting for an accident or a near miss. It is easy to accept the principle of regular checks but it is more difficult to decide what should be checked, and who should do the checking.
THE STANDARDS REQUIRED Failure to meet the GMC’s standards means losing the right to practise in any capacity, even that of a trainee. Therefore the GMC’s standards of clinical practice are unlikely to cause difficulty to consultants or other career grade doctors. Nevertheless, the GMC sets high standards for the generic skills expected of all doctors. These are set out in its booklet ‘Good Medical Practice’ and can be grouped under eight headings:
GENERAL PRINCIPLES The profession and the public seem agreed that examinations are not appropriate for revalidation. The ability to pass exams is not closely enough related to a doctor’s performance in day-to-day work. It is also agreed that the GMC should oversee revalidation, not only because it is the body that maintains the medical register but also because it has a broad view of what the public expects from doctors. It does not, however, have expertise in setting
• Good clinical care • Treatment in emergencies • Maintaining good medical practice (i.e. keeping up to date) • Teaching and training • Maintaining trust (including good relationships with patients) • Working with colleagues • Probity in professional performance • Health
J. Drife, Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, London NW1 4RG, UK.
168
Revalidation in obstetrics and gynaecology The GMC wants the criteria for revalidation to reflect these headings. Some of them imply a culture change. In the past, an inability to work with medical or nonmedical colleagues has sometimes been tolerated as eccentricity, but not in the future. Standards specific to obstetrics and gynaecology are likely to be set by the RCOG. This already happens for trainees. ‘Setting standards to improve women’s health’ is the College’s business, but at present this means standards to which members should aspire. Standards for revalidation are different, as failure to meet them could involve doctors losing their livelihood. Subspecialization presents another problem. Should the College set broad standards that will apply across the whole specialty, or should subspecialists be required to meet higher standards in their areas of expertise?
LOG BOOKS The number of complications or complaints that a doctor has must be assessed in relation to the amount and type of work undertaken. For example, if audit shows that a particular surgeon has three cases of unintended urinary tract damage in a year it will be important to know whether his or her workload involves several major cancer cases every week or one straightforward hysterectomy every month. Some consultants already keep a log of their activity, having started the habit during training. Others may be content to rely on figures produced by their trust, but this may be a risky strategy, as hospital statistics are not always reliable. For example, operating lists may not differentiate operations performed by the consultant from those performed by trainees.
169
Appraisal should occur annually. Its main purpose is to assist the doctor to develop his/her career to its full potential. It will involve review of the doctor’s job plan, personal development plan and educational activity. It should be carried out by the Clinical Director or deputy. Assessment should occur at regular intervals, for example every 5 years, and its main purpose is to ensure that the doctor is maintaining his/her standards of clinical practice. It should be carried out by three people—the Medical Director or deputy, a non-executive director or other lay person, and an appropriate specialist. It will involve reviewing: • a log of the doctor’s activity (self- or hospital-generated); • audit data; • third party questionnaires (obtained from 10–12 colleagues); • a patient satisfaction survey; • reports from private institutions in which the doctor works. Trusts will notify the GMC and the College of the names of doctors who have completed the process satisfactorily, WHEN THINGS GO WRONG The annual appraisal will inevitably involve an element of assessment which should flag up problems well before the 5-year review. The College should have a panel of senior fellows ready to advise trusts or doctors if asked. Some problems can be addressed by retraining, which will require cooperation between trusts and probably supervision by the RCOG. If, despite these mechanisms, concerns emerge at the assessment stage, the GMC will be notified and the doctor may be required to undergo further assessment under the GMC’s performance procedures.
THE RCOG WORKING PARTY In 1999 the RCOG formed a working party to discuss revalidation, with the aim of suggesting a mechanism that would be both thorough and practical. Its report, in the form of a discussion document,1 was published early in 2000, and its recommendations can be summarized as follows: • Individual doctors have the final responsibility for their own revalidation. • The College should define the process, check that it is occurring and ensure uniform standards across the country. • Trusts should have three mechanisms in place to underpin revalidation: Audit requires systematic collection of data relating to incidents (including operative complications), complaints and litigation.
THE FUTURE The process outlined here will require years to refine. For example, very little published evidence is available on complication rates, and minimum standards for specialist practice will be defined only when audit is in place across the country. The revalidation process, however, is likely to have a beneficial effect from the outset, by focussing attention on quality of care, rather than on health economics. For most doctors it will for the first time provide objective evidence of the high standards to which they already practise. REFERENCES 1.
Royal College of Obstetricians & Gynaecologists. Revalidation in Obstetrics & Gynaecology. London: RCOG, 2000.
Medico-legal/education/admin
Revalidation in obstetrics and gynaecology—the story so far
J. Drife
specialty-specific standards. As well as general professional attributes such as honesty and confidentiality, the public will expect assessment of a doctor’s clinical performance within his or her specialty. In ours this means that revalidation will involve the Royal College of Obstetricians and Gynaecologists (RCOG). Neither the GMC nor the RCOG, however, gathers information on the performance of individual specialists. Data such as rates of complications or readmissions, or information about patient satisfaction will have to be collected by hospitals or by doctors themselves. Thus, the revalidation process will involve cooperation between the GMC, the RCOG, individual doctors and NHS trusts. For doctors practising wholly or partly in the private sector, information will have to be provided by private hospitals.
INTRODUCTION Revalidation is making headlines in the medical press. In February 1999 the General Medical Council (GMC) resolved to introduce revalidation of registration and to have a fully worked up model ready by February 2001. The purpose of this article is to summarize the present position and possible future developments. THE NEED FOR REVALIDATION Doctors undergo rigorous selection procedures and examinations before graduating but once on the medical register our names remain there unless we remove them, default on our GMC subscription or commit serious professional misconduct. As with our driving licences, no checks are made unless problems occur. The public, however, wants to treat us like airline pilots, with regular assessments rather than waiting for an accident or a near miss. It is easy to accept the principle of regular checks but it is more difficult to decide what should be checked, and who should do the checking.
THE STANDARDS REQUIRED Failure to meet the GMC’s standards means losing the right to practise in any capacity, even that of a trainee. Therefore the GMC’s standards of clinical practice are unlikely to cause difficulty to consultants or other career grade doctors. Nevertheless, the GMC sets high standards for the generic skills expected of all doctors. These are set out in its booklet ‘Good Medical Practice’ and can be grouped under eight headings:
GENERAL PRINCIPLES The profession and the public seem agreed that examinations are not appropriate for revalidation. The ability to pass exams is not closely enough related to a doctor’s performance in day-to-day work. It is also agreed that the GMC should oversee revalidation, not only because it is the body that maintains the medical register but also because it has a broad view of what the public expects from doctors. It does not, however, have expertise in setting
• Good clinical care • Treatment in emergencies • Maintaining good medical practice (i.e. keeping up to date) • Teaching and training • Maintaining trust (including good relationships with patients) • Working with colleagues • Probity in professional performance • Health
J. Drife, Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, London NW1 4RG, UK.
168
Revalidation in obstetrics and gynaecology The GMC wants the criteria for revalidation to reflect these headings. Some of them imply a culture change. In the past, an inability to work with medical or nonmedical colleagues has sometimes been tolerated as eccentricity, but not in the future. Standards specific to obstetrics and gynaecology are likely to be set by the RCOG. This already happens for trainees. ‘Setting standards to improve women’s health’ is the College’s business, but at present this means standards to which members should aspire. Standards for revalidation are different, as failure to meet them could involve doctors losing their livelihood. Subspecialization presents another problem. Should the College set broad standards that will apply across the whole specialty, or should subspecialists be required to meet higher standards in their areas of expertise?
LOG BOOKS The number of complications or complaints that a doctor has must be assessed in relation to the amount and type of work undertaken. For example, if audit shows that a particular surgeon has three cases of unintended urinary tract damage in a year it will be important to know whether his or her workload involves several major cancer cases every week or one straightforward hysterectomy every month. Some consultants already keep a log of their activity, having started the habit during training. Others may be content to rely on figures produced by their trust, but this may be a risky strategy, as hospital statistics are not always reliable. For example, operating lists may not differentiate operations performed by the consultant from those performed by trainees.
169
Appraisal should occur annually. Its main purpose is to assist the doctor to develop his/her career to its full potential. It will involve review of the doctor’s job plan, personal development plan and educational activity. It should be carried out by the Clinical Director or deputy. Assessment should occur at regular intervals, for example every 5 years, and its main purpose is to ensure that the doctor is maintaining his/her standards of clinical practice. It should be carried out by three people—the Medical Director or deputy, a non-executive director or other lay person, and an appropriate specialist. It will involve reviewing: • a log of the doctor’s activity (self- or hospital-generated); • audit data; • third party questionnaires (obtained from 10–12 colleagues); • a patient satisfaction survey; • reports from private institutions in which the doctor works. Trusts will notify the GMC and the College of the names of doctors who have completed the process satisfactorily, WHEN THINGS GO WRONG The annual appraisal will inevitably involve an element of assessment which should flag up problems well before the 5-year review. The College should have a panel of senior fellows ready to advise trusts or doctors if asked. Some problems can be addressed by retraining, which will require cooperation between trusts and probably supervision by the RCOG. If, despite these mechanisms, concerns emerge at the assessment stage, the GMC will be notified and the doctor may be required to undergo further assessment under the GMC’s performance procedures.
THE RCOG WORKING PARTY In 1999 the RCOG formed a working party to discuss revalidation, with the aim of suggesting a mechanism that would be both thorough and practical. Its report, in the form of a discussion document,1 was published early in 2000, and its recommendations can be summarized as follows: • Individual doctors have the final responsibility for their own revalidation. • The College should define the process, check that it is occurring and ensure uniform standards across the country. • Trusts should have three mechanisms in place to underpin revalidation: Audit requires systematic collection of data relating to incidents (including operative complications), complaints and litigation.
THE FUTURE The process outlined here will require years to refine. For example, very little published evidence is available on complication rates, and minimum standards for specialist practice will be defined only when audit is in place across the country. The revalidation process, however, is likely to have a beneficial effect from the outset, by focussing attention on quality of care, rather than on health economics. For most doctors it will for the first time provide objective evidence of the high standards to which they already practise. REFERENCES 1.
Royal College of Obstetricians & Gynaecologists. Revalidation in Obstetrics & Gynaecology. London: RCOG, 2000.