Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Take control and responsibility as Professionals
- David Levine (26 June 2005)
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Re: Take control and responsibility as Professionals
- Brian J Penney (27 June 2005)
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Breathtaking
- David Levine (29 June 2005)
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The smart money
- Graeme M Mackenzie (29 June 2005)
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Re: Re: Take control and responsibility as Professionals
- Graeme M Mackenzie (1 July 2005)
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Revalidation and the Educational Potential of Peer Review
- Murray Lough (7 July 2005)
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The nurses, of course !
- Oliver R Dearlove (4 September 2005)
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Nurses' Revalidation
- Oliver R Dearlove (16 October 2005)
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David Levine, Consultant Physician West Cornwall Hospital TR18 2PF
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As ever John Norcini's is the voice of reason and deep understanding of this issue. No more time can be wasted on pointless debates about the need for revalidation but all our efforts must go into making it useful, effective and fair. The distribution of performance in a medical population and the relevance of this to the two uses of revalidation are keys to progress. The need to start soon, even in a small way, and learn as we go, is the only way to maintain our professional self-respect and the trust of the public as a whole. We don't need to waste our time squabbling with other professions who like to be seen as wise after events; they have to sort out their own problems. Competing interests: None declared |
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Brian J Penney, Family Physician Ontario, Canada
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David Levines simplistic acceptance of the Norcini oracle and abandonment of critical appraisal is breathtaking. Norcini is not a physician but has made himself an "expert" The obsession that some physicians have with being "holier than thou" now is accompanied by the need to have been proven "Holier than thou" by revalidation. Physicians should have the same rights, restrictions and privileges of other professions whose practice may affect the life or limb of citizens. I cannot imagine any Administrator, hospital manager or politician being revalidated on an annual basis on his knowledge or indeed the outcome of his cases. These professions are as culpable as any physician if a patient is denied or delayed access to any life preserving treatment. Why should physicians be unique? I am aware of studies indicating potential for deterioration in physician performance. However, the same potential exists in every profession. Can you imagine My Lord Judge being subject to annual scrutiny of his knowledge or performance? Yet arguably, he has more influence over the lives of people before him than most physicians ever do. We have done enough self flagellation following Bristol, Shipman, Alder Hey & Ledward et al. It is time to re-examine the need for revalidation and if for physicians then for all professionals. Competing interests: Physician subject to revalidation |
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David Levine, Consultant Physician West Cornwall Hospital TR18 2PF
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I'm sorry if I've angered Dr Penney. All I would say in reply is that professions exist and practice only insofar as the public wishes them to do so. This actually gives the public responsibilities as well as rights! Rightly or wrongly I believe that the public now want to see some evidence that members of the medical profession remain up to date and fit to practice. I entirely agree with Dr Penney that other professions can expect to do the same. I can indeed imagine that 'My Lord Judge' should be subject to annual scrutiny of his (or her) knowledge or performance. I suspect that something, albeit covert, of the sort happens now and if the public demand better scrutiny it will happen. My responsibility is however for myself and I simply wish to have some professional control of the way I manage this responsibility. I don't need a judge to tell me how best to revalidate; I can work it out for myself and I don't regard John Norcini as an enemy because he's not a Physician. I'm afraid the comments about , 'abandonment of critical appraisal' and 'holier than thou' are incomprehensible, and possibly just rude, so I'll ignore them. Competing interests: None declared |
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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I assume the survivalists of the profession will get into revalidation. Better to be reporting on people than being reported on. On a serious note, the authorities need to look at practice in terms of how much daily on going evidenced based peer review in going on in a team. In our medium sized practice (non training)we have Jounral articles sent around the E mail every day for discussion. The excellent On Medica site automatically send around scores of articles every month which are disseminated for discussion. Any interesting articles result in an e mail to our audit clerk to search on our patients to see how we are performing with reference to the article. The results are sent around and practice influenced as a result. The audits are collected up and presented at the weekly pracice meeting for further action. Many clincial cases and much experience is shared via e mail to ensure that one doctors experience is disseminated. Using our computer record all clinicians can automatically tract interesting and signficant cases if prompted to do so by the clinician in charge. Significant and interesting hospital information is sent round via e mail using cutting and pasting of letter sections. We have an electronic signficant event system disseminated via e mail. Using our computer database we could show that a certain percentage of cases of one doctor are seen by another doctor within 3 months. In a similar practice I worked in, I could show that 46 % of my patients were seen by a colleague in 3 months. The moral of all that is that we rarely have set meetings for education and peer review because so much is going on all the time. Although we do automatically save our e mailed Journal articles and interesting cases (using the Outlook Rules) and associated discussions for a face to face meeting once a month. Indeed with desktop internet access and all the experience sharing of primary and secondary care patient involvement that goes on, I find the idea of attending an evening didactic lecture as quaint and socially attractive but not an efficient use of my time for staying up to date. The authorities must recognise that this patient based education and peer review is actually far more effective and valid that a walletful of certificates of meetings attended. It means that I can do a full 8 session patient contact week and still be home for tea and family while in many ways being better informed and educated than ever. It is not rocket science, what we do, and actually costs nothing. In my view it is a revolutionary way of staying up to date and well informed in a way which directly influences practice. I can demonstrate that it is happening and think that as evidence of being effective, up to date and open to peer review and learning is worth far more than the cosy confidential chat of reappraisal where mendacity is always tempting, or an exam which can be studied for and will never represent patient focussed learning. Competing interests: None declared |
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Graeme M Mackenzie, gp CA28 7RG
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Hear Hear for Brian Penney. In my 20 years as a GP, in three practices, and when it comes to patient care, almost all my colleagues have been highly motivated, generally altruistic individuals with the normal human failings. This current round of the debate on revalidation reminds of the old joke: save police time, beat yourself up. Change this to: save government time, confess that you are a useless doctor (especially if you are old) and do something about it. Competing interests: None declared |
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Murray Lough, Assistant Director NHS Education for Scotland, 2 Central Quay, 89 Hydepark Street, Glasgow G3 8BW
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REVALIDATION AND THE EDUCATIONAL POTENTIAL OF PEER REVIEW In his editorial “Where next with Revalidation?” Norcini highlights the role that education “must offer” in addition to performance review1. One crucial element as part of both the appraisal and revalidation processes which has consistently avoided clarification by the GMC and Dame Janet is the method whereby evidence being included in a doctor’s portfolio is quality assured to ensure a consistent standard is being achieved appropriate for both formative i.e. educational assessment and summative i.e. good enough assessment. Since 1996 throughout the United Kingdom all GP registrars have had to submit a video, a written piece of practical work, usually an audit, a completed trainer’s report and an MCQ of factual knowledge2. Experience through peer review of this process over the past nearly 10 years has shown the variation in the quality and therefore competence of those submitting a video or an audit despite being in a training environment3. Using the same trained peer review assessors, additional data from the west of Scotland have shown even wider variation among GP principals (in both training and non training practices) and SHOs vocationally training for general practice4. It would not be impossible to extend this national quality assurance infrastructure already in place to include each bit of evidence required for revalidation thus assuring both the public and the profession that doctors are being assessed equally and fairly. The system could be applied in both general practice and hospital and although on the surface may appear bureaucratic and costly, it would begin to address the many educational needs which have already become apparent in the early stages of the appraisal process as judged by the material being submitted as part of a personal development plan. To critics of this system, what is the alternative? If self-regulation is to mean anything, we must take charge of our own education as a means to both professional self-development and revalidation. REFERENCES 1. Norcini JJ Where next with revalidation? BMJ 2005;330:1458-9 2. National Health Service (Vocational Training for General Medical Services) Regulation 9(2) Statutory Instrument 3150, 1997, London HMSO 3. Murray T S, Attwood M, Lough M, Kelly M, Kelly D Summative Assessment of the competence of General Practice Registrars 1996 -2001. Reasons for and implications of failure Education for Primary Care 2004;15:169-174 4. McKay J Bowie P Lough M Variations in the ability of general practice to apply two methods of clinical audit:: a 5-year study of assessment by peer review. Journal of Evaluation in Clinical Practice (In Press) Competing interests: None declared |
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Oliver R Dearlove, Consultant Anaesthestist Royal Manchester Childrens Hospital
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I have been following the case of Nurse Grigg Booth (Daily Telegraph 30 Aug 2005) who was indicted for the murder of three patients but has recently died herself. I ask myself, will there be the same demands for a huge, bloated and expensive bureaucracy to monitor ‘revalidation’ in nurses, as occurred after the death of Harold Shipman ? Will we see Dr Fiona Godlee selflessly fling herself behind half- rehearsed measures to monitor nurses in case there should be many more Angels of Death lurking on the wards stalking the young and old, without thought of her own personal preferment in Honours lists if it becomes government policy ? She could entitle her editorials “Revalidation of Nurses: GMC shows the way.” I could write the script if she wants. Everyone who has witnessed a nurse’s compulsion to fill out nursing process forms, will have a heart that sinks to hear of further paperwork measures that get in the way of nurses and their patients. Everyone loves a good nurse and we could completely confuse the situation as they have in revalidation – having a good nurse and not having someone like Grigg or Beverly Allitt. What is the answer ? I know ! Let’s start off by calling every nurse bad and insisting that they show us they are good ! We could have patients filling out the nursing process forms and countersigning whether or not the auxiliaries have carried out any health care procedure. This would be patient appraisal. We could make nurse revalidation worse – or better – by insisting on time-consuming collection of data which can be shown to have no bearing on skills or competences of personnel. There are around 700 000 registered nurses with the NMC, and even if the classification is in error at a rate 1%, a ludicrously optimistic estimate, then only 7000 nurses are mistakenly called bad when they are good, just to reassure the public. However, if there is no call for further intrusive and useless monitoring, then we can conclude that the impetus for revalidation in medicine is not patient-centred but politician-centred. This love of controlling anyone in health care delivery, would certainly explain demands that revalidation in medicine go forward despite lack of evidence the measures will achieve their goals and in spite of quite a lot of evidence that the measures will not. Oliver R Dearlove FRCA Conflict of interests ORD has been nominated as a candidate contesting the GMC by election. Competing interests: as script |
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Oliver R Dearlove, Consultant Anaesthetist Royal Manchester Children's Hospital
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Nurses revalidation I see another nurse has been indicted for murder (1). But from no- one, displaced civil servants, lay members, patient advocates, under- employed regulatory apparatchiks looking for work, do I hear strident proposals for Shipman-like checks on all 700 000 nurses. Think of all the work for the regulators ! Why are they so silent? The evidence is out there. There seems to be more than one Sr Shipman ( Grigg Allitt ) poisoning patients on the not so Q T. The revalidators’ day will come, so let us discuss what form it will take. I can already see in my mind’s eye, the General Nursing Council trumpeting half-assed proposals foisted on them by lay members and civil servants and claiming they are leading the world. Moreover we will be told that this enormously expensive regulations untried and untested, is the envy of the world. Apparatchiks from the regulator will flock to Eastern Europe. Where will the expenses paid gravy train stop? Perhaps at Sofia or Belgrade to tell the stunned Slavs how to do nurses’ revalidation the English way. A cloying self-congratulatory House journal will carry photographs of clutches of them, from all parts of the globe, Zimbabwe perhaps, all of them simpering into the camera. On thing is clear through all this. Evidence under pinning nurses’ revalidation will have to be externally confirmed and not by nurses as they cannot be trusted. So my question is this: will doctors, who everyone knows are not to be trusted to validate their own evidence of good practice be allowed to validate the evidence of the nurses ? Or will this be a cue for more lay regulators ? Millions of regulatory pounds could be diverted to lawyers’ pockets – in fact anywhere except Health Care, to decide these and other important regulatory issues. The possibilities are endless and stretch out in the imagination but always at the tax payers’ expense. Has anyone costed the likely impact of revalidation ? Oliver Dearlove FRCA Conflicts – None Reference Daily Telegraph Male Nurse is Indicted for murder Thursday 13 October 2005 Competing interests: None declared |
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