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AUSTRALIAN MEDICAL ASSOCIATION (WA)
ISSUE AND PROCESS
Under the title of Managing Performance, AMA CoGP has been asked to provide comments for consideration by the AMA’s Ethics and Medico-Legal Committee (EMLC) and the Economics and Workforce Committee (EWC) for Federal Council and the later AMA contribution to the Medical Board of Australia (MBA) conversation on revalidation. In November last year, the MBA announced it would begin the discussion of revalidation for medical practitioners in Australia, particularly as to “how it can support patient safety”.
There is an international framework through which the highest regulating body, International Association of Medical Regulatory Authorities (IAMRA) defines revalidation (a.k.a. ‘Recertification’) as “…the process by which doctors have to regularly show that they are up to date and fit to practise medicine allowing retention of license to practise’. MBA expects to develop an initial discussion paper later this year and to consult widely with all stakeholders as the ‘conversation’ develops.
In January this year, the AMA Executive Council requested EMLC and EWC to:
• Identify the gaps (if any) in existing processes for identifying and addressing risky behaviour
• Develop a working definition of revalidation in that context
• Identify and address the compliance and opportunity costs; and
• Introduce the concept of professional responsibility for addressing risky behaviour directly with colleagues, on the basis of avoiding the need to make a mandatory report.
The fact is that Australian General Practice is already a heavily regulated environment. We have an internationally-acclaimed Accreditation system, Recognised Training Pathways, Vocational Registration and a fairly rigorous Continuous Professional Development requirement. However, certain limitations prevail – e.g. self-assessment can be poor, old(er) doctors are slower and can be overall less safe, and that manual skills such as surgical dexterity decline from around 55-60 years old. Doctors also rate quite highly on stress and mental disorders scales.
Further, I believe many of the ‘safety nets’ of the past have been largely crisis based – i.e. once you are seriously in trouble, are not prevention/education orientated and Mandatory Reporting has done nothing to help the situation in all states bar WA. The analogy often drawn for doctors is pilots. However commercial pilots especially, have rigorous annual health check-ups, rigid substance and alcohol restrictions and are mandated to fly long-haul no more than a certain numbers of hours a week for fatigue reasons. Meanwhile we still bang on about Safe Hours practice yet see it summarily breached every day. Will this be addressed as part of the process?
Secretariat, as always, prepared an excellent paper which posed such timely questions as:
• Does the medical profession have confidence that the regulatory framework is working to identify and address risky behaviour?
• Are there gaps or deficiencies in the current regulatory framework or processes that could be filled or improved to identify and address risky behaviours?
• Is the regulatory framework adequately addressing the issues to manage poor performance?
• Is the regulatory framework adequately informing activity to avoid future adverse events?
Fundamental questions need to be asked. 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? For me, some of the immediate issues are:
• We must show the evidence for need?
• Costs will have to rise if a revalidation process is introduced. Who pays?
• Will yet more layers of bureaucracy and an ‘industry’ grow around it?
• What is it we are trying to address? Risky behaviour? ‘Safe to Practice’? Competence versus doing a quality job?
• Why validate every doctor to catch the sub-competent or dangerous minority?
• It may cause attrition of medical numbers, both overall and in certain craft groups especially ‘riskier’ areas of practice
• Encourage earlier retirement of older doctors who are not ‘hypo-competent’ (a new term) but feel under threat by this process
• Any process should be profession owned
• Have the MDOs called for it as a risk mitigation strategy to date? No
• We need a better system to address near misses, substandard care and protection for any whistle-blowers.
The next moves include an MBA forum in Melbourne on revalidation for medical practitioners; MBA Chair Dr Joanna Flynn in discussion with Federal Council; and a policy session on revalidation at the AMA National Conference in May.
Dr Flynn of the MBA will present and the President of the British Medical Association has been invited to share the UK experiences to date.
The document will be further refined after each of these meetings to keep the AMA’s position up-to-date and to shape any formal AMA submission to the MBA.
To share your thoughts, please email me