Talk of revalidation disturbs the sometimes brittle detente between clinicians and regulators, partly because revalidation seems to have become conflated into a single thing – intent and mechanism, question and answer all in one.This doesn’t help comments Dr Janice Bell, CEO of WAGPET and chair of the RACGP Expert Committee – Post fellowship Education […]
Talk of revalidation disturbs the sometimes brittle detente between clinicians and regulators, partly because revalidation seems to have become conflated into a single thing – intent and mechanism, question and answer all in one.This doesn’t help comments Dr Janice Bell, CEO of WAGPET and chair of the RACGP Expert Committee – Post fellowship Education
Having been stung many times by the nefarious nettle, I’ve learned it’s better to grasp one firmly when it’s in sight. Nettles can be nutritional and delicious as long as you know how to harvest, prepare and serve them.
And so it is with revalidation, which edged closer this month, with multiple options laid before us by the medical board. Avoidance is futile.
Hardly anyone would challenge the intent of revalidation. The community puts enormous trust in relative strangers bearing the doctor prefix, and that trust needs to be reliably honoured in every encounter. Rather, I suspect it’s the process, or mechanism, of revalidation, that remains both elusive and controversial, and too often the distinction between intention and mechanism is lost.
In terms of mechanisms, Australian general practice already has many that could serve the purpose of revalidation affordably, effectively, and efficiently. We have continuing professional development, quality improvement requirements, clinical audits, practice accreditation, evidence-based guidelines, and special interest credentialing. We get regular reports on our prescribing behaviour, billing and clinical cohorts. We get patient surveys and patients, where they can, vote with their feet. You’ll think of more.
Yet we still have evidence of mismanaged care, unintended health outcomes, cost blowouts, duplication, vacuums, avoidable complications, and the rare but devastating rat bag story. For clinicians who are outliers, there are legal levers and sanctions, but by then it’s late in the day, long and protracted for all involved. And while sometimes substandard care is about a clinician’s ability, attitude or aptitude, most times it’s more about context and systems.
We are not seeking, in a complex adaptive system like health, a holy grail, some lost chord, that will deliver quality care from all practitioners all of the time. It doesn’t exist, and history shows us the folly of the search. But neither are we powerless or bereft of solutions.
The solution in this case lies in transparently connecting and improving our existing mechanisms, linking them better to the intent of revalidation, and testing the outcomes. Unlike the amateur chess player who relies too much to his peril on the peripatetic queen piece, we can use the many mechanisms we already have, with all the unique and synchronous strategies they offer.
I’ve learnt that the best place to act is close to where there is most impact, where there can be ownership, accountability and responsibility. The greater distance from this place, the greater the bureaucracy, with its perverse incentives and unintended consequences. Every patient-clinician interaction, every clinician-clinician contact, every clinician-clinic staff conversation is an indicator of our capacity, capability, competency, and credibility – an answer from the moment, the context, the partners in the conversation. An answer that is transparent, accurate and actionable.
Big data has the potential to encourage quality practice and help prevent harm, but at present our systems are too clumsy, slow and disconnected to achieve this goal. Going forward, though, data analytics will increasingly identify quality issues we miss in the ebb and flow of our busy days. This data will provide more grist for our conversations; crucial peer-to-peer conversations drive our lifelong education and improve our services.
The good news for all of us is that while avoiding this particular nettle is not an option, we don’t grasp it alone. I’ve listened, with lots more to hear from groups like GPs Down Under, the RACGP expert committees including the Post Fellowship Education Committee which I chair, patients and clinicians everywhere. The Medical Republic provides another platform dedicated to debating the controversial, so we together may more directly design our future.
The question always has more power than its answer. Every clinician knows that for every complex problem there’s a solution that’s simple, neat and wrong. HG Mencken said it first, but I’m pretty sure day-one medical school addressed this topic. Something like, no real patients can be found in textbooks that test us. The territory is not the map that guides us. Be careful drawing straight lines where none exist in real life.
I’d much rather that as a profession we grasped the nettle than allow it to be grasped for us, harvested and prepared, served on a cold white platter, nutritious or otherwise.
Dr Janice Bell BA B Ed (Hons) MBBS Grad Dip Int Med Grad Cert CHM GAICD FRACGP
Chief Executive Officer
WAGPET
Western Australian General Practice Education and Training Limited
Chair of the RACGP Expert Committee – Post Fellowship Education
