The GMC’s recent Perceptions study shows that a third of doctors are now reflecting more on their practice than a year ago. That might not sound like a lot, but by comparison to other interventions aimed at changing behaviour, it is remarkably effective
In my work as a doctor, I try to make sure I wash my hands, prescribe appropriate antibiotics and treat sepsis quickly (amongst other things). I know that it is important to concentrate on these because research shows that we doctors aren’t as thorough in performing these tasks as we want and ought to be.
Perhaps this shouldn’t be surprising. We all know from out personal lives that there is an imperfect conversion between thinking something is a good idea and getting around to doing it.
The fact that we are still trying to raise hand washing rates 150 years after the realisation that poor hand hygiene led to infections supports this point.
Studies show that changing prescribing behaviour is also difficult: complex interventions to reduce antibiotic prescribing for respiratory tract infections in children and to improve antibiotic prescribing for inpatients in general both show it is hard to change the behaviour of more than a minority of prescribers. Efforts to improve compliance with key sepsis guideline recommendations show similar results.One conclusion is that doctors just need to pull their socks up and make these changes. While this is a popular initial response, it is not one that is likely to drive the improvement we are looking for.
There is plenty of evidence that even large scale interventions, in these specific areas and more widely, can realistically aim to achieve only a relatively small behavioural change.
This is well known to those leading change among the public [PDF], patients and within the NHS [PDF], and has supported the popularity of theories that manage expectations around change. The “nudge” theory that has been credited with influencing public policy in the UK in the last few years is a prominent example of this.
Revalidation for doctors was introduced by the GMC at the end of 2012. In what was probably the largest change to medical regulation in the UK in 150 years, a legal obligation was introduced for all doctors to demonstrate that they were keeping up to date within the scope of their practice. Part of the reason revalidation was introduced was to satisfy public expectations – pilots and other professionals in safety critical industries all have to demonstrate they are keeping up to date, so why not doctors? But the vast majority of doctors were already undergoing appraisal, and for them revalidation brought in a framework to structure this.
Although appraisal should help to identify underperforming doctors, for most people the aim is to help promote good practice and to raise standards, through reflection on a doctor’s work. Appraisal and reflection help professionals develop, and it shouldn’t be surprising that good appraisal is associated with good patient care.
In this context it is heartening to review the results of the GMC’s tracking survey, which asked more than 2700 doctors about their experiences of revalidation, amongst other things.
Of the more than 800 respondents who had been revalidated, 37% said they were collecting more information about their practice than a year ago, and 34% said they were reflecting more on their practice.
Nearly a quarter said they felt more part of a governed structure that supported their professional development, although 14% said they felt this was less true. Perhaps unsurprisingly, doctors with less positive views about the medical profession and the GMC were more likely to report that they felt less part of a governed structure.
I’m a trainee, so my revalidation and appraisal is done through my annual training review (Annual Review of Competency Progression), which is a formal, structured process. Nonetheless, the introduction of revalidation brought about an important change for me.
Learning from mistakes
One of my main interests, and something I have been trying to think more about while working at the GMC this year, is the question of how we as a profession can get better at learning from mistakes and incidents: our own, and those of others.
Before we can learn from errors, we need to acknowledge that they happen, and before we can learn from the mistakes of others, they have to share them.
At a recent workshop on patient safety teaching that I helped organise at this year’s GMC conference, we heard from delegates that a lack of an open safety culture was the main obstacle to patient safety teaching. So although many doctors are open about error, adverse events and near misses, there is a clear need to do more in this area.
Revalidation mandates discussion of serious incidents. For me, this helps normalise a discussion that can otherwise be a difficult one to start. When I started having appraisal discussion at ARCPs, there was no routine discussion of such incidents, and now there is. For me, this is progress however you look at it.
Toby Reynolds is a trainee in anaesthesia from North East London, currently placed at the GMC for a year through the National Medical Director’s Clinical Fellow Scheme. He is writing this blog in his personal capacity, rather than as a representative of the GMC .