The effect of revalidation

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.

Changing behaviour

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

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.

Perceptions Reval

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 ReynoldsToby 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 .

4 responses to “The effect of revalidation

  1. There seems to be some simplistic thinking behind these ideas.
    Apparently appraisal is expected to identify ‘under performing’ doctors. I am not sure that this is the official GMC view but it is helpful to know that these ideas are prevalent – knowing that they are prevalent however will not increase trust between appraises and their appraisers, nor will it increase the value of the appraisal process as a developmental exercise.
    Apparently we are all to be encouraged to share learning from (presumably our own) mistakes. Exactly how this is to be done without risking victimisation or worse as an ‘under performing doctor’ is not at all clear. An effective anonymised system for sharing learning has been suggested before but does not at present exist. Does the GMC intend to create one?
    I will finish this post by pointing out the apparent conflict between ‘treating sepsis promptly’ and avoiding ‘overuse of antibiotics’. I presume that there is not some other method of treating sepsis of which I am unaware? What doctors need is helpful information that enables them to make effective decisions; not hectoring, abuse, victimisation, or bullying.

    Best wishes to all

    Tony Kelpie
    GP; 21 years as trainer 1989-2010; 8 years as appraiser 2003-2011

  2. Thanks for replying. This is very much appreciated. I am not certain however that you are replying to my comments; the part in inverted commas isn’t part of my submission so perhaps there are crossed wires, or perhaps there is some background to the original post of which I am unaware.
    My reason for being sufficiently concerned to respond is that the use of phrases such as ‘underperforming doctors’ engenders apprehension in me. I think we as a profession and the GMC as an organisation would do well to accept that we are all underperforming, compared to the high standards to which we aspire. This avoids us falling into the trap of thinking that improvement is needed by others, but not by ourselves. It is only a few steps from thinking of ‘underperforming doctors’ as a group to be ‘identified’ before one arrives at the view that it is the GMC’s duty to pursue or persecute these doctors out of existence. I hope that I know that this is not the official position of the GMC but I do perceive that these attitudes are not absent form everything that the GMC does. The initial position expressed in a recent consultation by the GMC did betray a lack of humanity in the approach to dealing with doctors; I don’t recall the precise thrust of the consultation but I do recall that I was not alone in pointing out the lack of balance in the GMC (initial) position, especially where it applied to doctors with health problems – the views expressed could be summarised as ‘we should do alll we can to look after patients compassionately – but not if that patient also happens to be a doctor’.
    It is unfortunate that you have not put your name to your reply. I am always made uncomfortable by this and especially where the word ‘we’ is used to imply that there is a considered and obvious position on a difficult issue, when this is not in fact the case. For the moment I will,presume that this lapse is an oversight on your part – whoever you are!
    Best wishes
    Tony (never anonymous) Kelpie

    • Tony,

      Many apologies- that reply was left in error on the wrong comment thread hence have now deleted it. Yours, James (moderator)

  3. Pingback: Do I need a licence to practise if I no longer see patients? | General Medical Council·

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s