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 Table of Contents  
INVITED EDITORIAL
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 12-15

Revalidation or recertification: What does it all mean?


Department of General Medicine and Infectious Diseases, John Hunter Hospital; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia

Date of Web Publication11-Jun-2018

Correspondence Address:
Dr. Robert Pickles
Department of Infectious Diseases, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW 2305
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_132_17

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How to cite this article:
Pickles R. Revalidation or recertification: What does it all mean?. Arch Med Health Sci 2018;6:12-5

How to cite this URL:
Pickles R. Revalidation or recertification: What does it all mean?. Arch Med Health Sci [serial online] 2018 [cited 2018 Jun 18];6:12-5. Available from: http://www.amhsjournal.org/text.asp?2018/6/1/12/234092




  Introduction Top


On entering medical school, students are introduced to the concept of lifelong learning which is reinforced during each phase of their career. Evidence suggests that the vast majority of practicing physicians do spend significant amounts of time and money to maintain their clinical knowledge and skills. The enormous explosion of medical technology and information over the past few decades has meant that it is increasingly challenging to keep up with these advances as well as maintain and fine tune and revise the foundation knowledge acquired during training. Research has shown that over time, the clinical skills of physicians do decline.[1] In addition, there is good evidence to suggest that we are not reliable when it comes diagnosing our own learning needs.[2]

The concepts of continuing medical education (CME) and continuing professional development (CPD) are well established worldwide. The idea of time-limited certification dates from 1969 when the American Board of Family Medicine issued 7-year-limited certificates. Simultaneously, other American boards introduced time-limited certification. Since 2000, the standard generally in the US has been to adopt the so-called “maintenance of certification (MOC)” programs which have included a 10 yearly, four-part recertification assessment of medical knowledge, clinical competence, and communication skills.[3] Throughout the Western world, there has been vigorous debate about the necessity for as well as the form recertification should take. This includes the US [4] and Australia.[5] In an editorial addressing the debate between recertification and mandatory CME in 1979, Relman stated that “CME alone, without some kind of test, cannot possibly assure competence.”[6] Further, he warned it would be a mistake for the profession to abandon the idea of recertification, implying that if the profession did not engage with the concept, there would be a risk of external imposition of a system.

The terms CME and CPD are often used interchangeably although typically, CME refers to lectures, presentations, reading, and conference attendance. CPD more often refers to a broader range of CME activities that allow practitioners to broaden their knowledge, expertise, and competence, as well as the personal qualities required in their day-to-day professional lives. Documentation of CPD is compulsory in Australia, New Zealand, and most Canadian Provinces in order for a practitioner to renew their registration annually.


  What Constitutes Optimal Continuing Professional Development? Top


In addition to assessing a doctor's original qualifications, assessment as to whether a doctor is practising at an accepted standard should include an assessment of what they do in their everyday practice.[7] Up to the point of graduating from medical school and during vocational training, significant assessment of student and graduate competence occurs before commencement of independent practice. This has resulted in the current concepts of longitudinal multimodal assessment programs which are now well established in the field of graduate medical education. The concept of continuing postgraduate education has been well established since the 1970s, and in addition to didactic lectures, a broad range of educational models has been employed based on clinician practice. Adult learning principles including self-directed learning and reflection have been employed to support practitioners. Key points relating to adult learning include the following:[8]

  1. Adults are independent, self-directed learners
  2. Accumulation of significant experience, which is a potent source of learning
  3. Valuing learning that integrates with their daily practice
  4. Interest in problem-centered approaches rather than subject-centered ones
  5. Motivation to learn by internal rather than external drivers.


Current thinking about medical CPD includes the following:

  1. The learner should be an active contributor to the educational process
  2. Learning relates to real-life problems
  3. The learners' current knowledge and experience are taken into account in new learning situations
  4. Learners are given the opportunity and support to use self-direction in their learning
  5. Learners are given opportunities and support for practice, as well as self-assessment and constructive feedback from teachers and peers
  6. Learners have opportunities for self-reflection including analyzing and assessing their own performance.


What does the literature tell us about various methods of CME? Bloom evaluated eight educational methods' effects on physician performance – didactic teaching, reading printed matter, lectures from opinion leaders, academic detailing, clinical practice guidelines, engaging in interactive education with audit and feedback on results, and reminders.[9] The most valuable methods were interactive and included audit of patient data along with feedback, interactive educational seminars, academic detailing, and reminders. These were all shown to have a positive impact on both clinical performance and patient outcomes. Conversely, didactic lectures and printed materials had little benefit on either clinical performance or patient outcomes whereas clinical practice guidelines and opinion leaders had modest effects. Similar findings have been reported by other authors.[10] It is clear, therefore, that the ability of CPD to impact on clinician performance and health outcomes depends on its design and presentation to participating clinicians.


  How Can We Strengthen Continuing Professional Development? Top


Accepting that in order for CPD to achieve the desired aims of improving clinician performance and patient outcomes, what needs to be done? Clearly, passive reading and didactic lectures by themselves are of limited use. High-impact activities incorporate formative assessment of clinician performance and measurement of patient outcomes, with some degree of self-reflection. These include recording of critical incidents, specific patient outcomes such as immunization rates, chronic disease indicators, timely access to care, morbidity and mortality reports, and patient complaints to name a few. Audit and feedback in peer-review sessions are commonly used to assess patient outcomes and are especially effective in the setting of an underperforming practitioner or unit.[11] However, barriers to the effectiveness of audit in improving care include poor management, lack of organizational support, excessive workload, and time constraints.


  Revalidation or Recertification – What Are They? How Do They Differ from Continuing Professional Development? Top


The term “revalidation” was coined by the General Medical Council (GMC) of the United Kingdom in the 1990s and is very similar to “recertification” as used in the United States. It has been defined by the International Association of Medical Regulatory Authorities as the process by which doctors show that they are up to date and fit to practice medicine. The process of revalidation in the UK commenced formally in 2012 and has become a mandatory component of medical license renewal. Its introduction was intended to address several highly publicized concerns about the quality of healthcare, including the case of Dr. Harold Shipman, a GP, who murdered dozens of his patients over many years, along with the Bristol cardiac surgical scandal which resulted in the deaths of a number of pediatric cardiac surgical patients.

In addition to elements of CPD outlined above, it involves participation in an annual appraisal along with a more detailed assessment every 5 years. This includes multisource feedback from multiple health practitioners (only half of whom are doctors) as well as patients. The system is decentralized and involves designated bodies supporting and administering the full appraisal process. The system has been criticized as being cumbersome, labor intensive, and very costly.[12],[13] A recent survey of responsible officers of the designated bodies reporting to the GMC found that while there were improvements noted in certain areas, these mostly related to identifying poor performance, and that the “one size fits all” process didn't appear to achieve anything positive for those already performing well.[14]

Robust forms of revalidation are now well established in most Canadian Provinces, where participation is mandatory and involves a combination of enhanced CPD, including practice audit, multisource feedback, and formative assessment, aligned with the CanMEDS framework that promotes self-reflection and practice improvement. Similarly, in New Zealand, Germany, and the Netherlands forms of mandatory revalidation exist.

In the US, recertification has been required for doctors who have completed a training pathway under the auspices of the American Board of Medical Specialties for over 20 years, and the terminology has moved toward “MOC.” Different specialties have differing requirements, but these can vary from combinations of open-book examinations, CME points, completion of a practice improvement program, and a high-stakes secured examination every 10 years. However, at present, this process remains voluntary and subject to continuing debate, and is not yet mandated for registration renewal, although the registration renewal processes also differ between states. There is some evidence from within the US that recertification is associated with higher standards of care.[15]

The Medical Board of Australia is considering the implementation of revalidation for the 100,000-plus registered medical practitioners in Australia. This is in addition to the already mandatory requirement that medical practitioners are engaged in a CPD program. The rationales for proceeding with a process of revalidation include strengthening and formalizing CPD, as well as the early identification of doctors at risk of poor performance, as well as those already performing poorly. A major factor appears to center around how to identify poorly performing doctors without subjecting the vast majority to time-consuming and needless procedures. Furthermore, the risk in a society with high levels of fee-for-service medicine, such as Australia and the United States, is that the costs of cumbersome system will passed on to consumers and third-party payers, serving to add to already increasing health-care expenditure. Mindful of this, the Medical Board of Australia has stated that such a system should be “smarter not harder: strengthened CPD should increase effectiveness but not require more time and resources for participants.”[16]


  Identification of the Poorly Performing Practitioner Top


Data from the UK and US suggest that a small number of doctors are not practising at an adequate standard at any one time, estimated at between 6% and 12%.[17],[18] These issues can vary from behavioral, lack of commitment to duties, poor skills and knowledge, dishonesty, sexual matters, and poor communication with colleagues. Two areas of concern identified by the United States Federation of State Medical Boards include a doctor failing to maintain acceptable professional standards and when a doctor lacks cognitive and noncognitive abilities to perform effectively in their scope of practice.

Analyses of disciplinary data in the US and UK have shown that age has an effect on the frequency of complaints. The UK GMC reported that those doctors who had two or more complaints registered against them from 2007 to 2012 were 7 times more likely to receive a complaint in 2013. Furthermore, the higher risks were found in male doctors in general, males over 50 years who were non-UK graduates, and male GPs aged 30–50 who were non-UK graduates.

Proactively screening for underperforming doctors is currently undertaken in both Ontario and Quebec in Canada. The College of Physicians and Surgeons of Ontario randomly selects members each year to undergo a “peer assessment” program. Physicians who have been in independent practice for at least 5 years and who are under 70 years of age are randomly selected. Members over the age of 70 are selected for mandatory peer review every 5 years. This assessment consists of a review of medical records, as well as a formal interview and discussion of the record review. Addition of multisource feedback is being considered. Approximately 10% of physicians are referred for further investigation, with activities such as direct observation of consultations being undertaken where necessary.

In Quebec, the process is termed “professional inspection visit” (PIV) and is a peer-assessment of the quality of practice involving random selection, as well as those who completed their medical degree >35 years ago, outliers on billing and prescribing data, those subject to complaints, and those performing only office-based work with no hospital appointment. The intention is to screen those at higher risk of performance issues.

A retrospective analysis of the PIV between 1998 and 2005 showed that the factors associated with a high quality of practice included hospital or community health center privileges and a greater number of CPD hours. Those factors associated with a poor quality of practice were advanced physician age, absence of institutional privileges, and more informal participation in CPD activities such as reading and nonaccredited activities.[19]


  Revalidation – What Does the Future Hold? Top


As discussed, revalidation exists in many forms in different parts of the world, and these processes are regularly being improved in response to research and feedback, to serve both public safety as well as the needs of the profession in this time of ever-evolving changes in medical knowledge and practice environment. It is clear that as a profession which has always enjoyed self-regulation, we must take ownership of the issue of enhanced CPD as well as revalidation, otherwise there is a risk that a system will be externally imposed. Professional bodies in partnership with educational institutions are uniquely placed to take the lead in this issue.

Acknowledgment

The author would like to acknowledge Professor Balakrishnan Nair, who commented on an early draft of this manuscript.



 
  References Top

1.
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73.  Back to cited text no. 1
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2.
Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L, et al. Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA 2006;296:1094-102.  Back to cited text no. 2
    
3.
Iglehart JK, Baron RB. Ensuring physicians' competence – Is maintenance of certification the answer? N Engl J Med 2012;367:2543-9.  Back to cited text no. 3
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4.
Baron RJ, Braddock CH 3rd. Knowing what we don't know – Improving maintenance of certification. N Engl J Med 2016;375:2516-7.  Back to cited text no. 4
    
5.
Breen KJ. Revalidation – what is the problem and what are the possible solutions? Med J Aust 2014;200:153-6.  Back to cited text no. 5
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6.
Relman AS. Recertification: Will we retreat? N Engl J Med 1979;301:778-9.  Back to cited text no. 6
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7.
Norcini JJ. Current perspectives in assessment: The assessment of performance at work. Med Educ 2005;39:880-9.  Back to cited text no. 7
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8.
Kaufman DM. Applying educational theory in practice. BMJ 2003;326:213-6.  Back to cited text no. 8
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9.
Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. Int J Technol Assess Health Care 2005;21:380-5.  Back to cited text no. 9
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10.
Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: An updated synthesis of systematic reviews. J Contin Educ Health Prof 2015;35:131-8.  Back to cited text no. 10
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11.
Trebble TM, Cruickshank L, Hockey PM, Heyworth N, Powell T, Clarke N, et al. Individual performance review in hospital practice: The development of a framework and evaluation of doctors' attitudes to its value and implementation. BMJ Qual Saf 2013;22:948-55.  Back to cited text no. 11
    
12.
Hawkes N. Revalidation seems to add little to the current appraisal process. BMJ 2012;345:e7375.  Back to cited text no. 12
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13.
Archer J, Regan de Bere S, Nunn S, Clark J, Corrigan O. “No one has yet properly articulated what we are trying to achieve”: A discourse analysis of interviews with revalidation policy leaders in the United Kingdom. Acad Med 2015;90:88-93.  Back to cited text no. 13
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14.
Walshe K, Boyd A, Bryce M, Luscombe K, Tazzyman A, Tredinnick-Rowe J, et al. Implementing medical revalidation in the united kingdom: Findings about organisational changes and impacts from a survey of responsible officers. J R Soc Med 2017;110:23-30.  Back to cited text no. 14
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15.
Sutherland K, Leatherman S. Does certification improve medical standards? BMJ 2006;333:439-41.  Back to cited text no. 15
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16.
Expert Advisory Group on Revalidation: Interim Report. Medical Board of Australia; August, 2016.  Back to cited text no. 16
    
17.
Donaldson LJ. Doctors with problems in an NHS workforce. BMJ 1994;308:1277-82.  Back to cited text no. 17
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Williams BW. The prevalence and special educational requirements of dyscompetent physicians. J Contin Educ Health Prof 2006;26:173-91.  Back to cited text no. 18
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19.
Goulet F, Hudon E, Gagnon R, Gauvin E, Lemire F, Arsenault I, et al. Effects of continuing professional development on clinical performance: Results of a study involving family practitioners in Quebec. Can Fam Physician 2013;59:518-25.  Back to cited text no. 19
    




 

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