The arguments in favour of recertification have been made cogently. Doctors in the UK on the whole continue to enjoy the trust and respect of their patients and the general public, but the Shipman enquiry led by Dame Janet Smith questioned the validity of the existing system. Following a lengthy discussion, the Chief Medical Officer of England published his proposal for professional regulation : Trust, assurance and safety – the regulation of health professionals in the 21 st century was published in February 2007. This document laid out the principles of revalidation for all doctors practising in the United Kingdom. The purpose of revalidation is principally to ensure that doctors update their knowledge and skills, and that they are fit to practise. This mechanism of revalidation will ensure that health professionals will be able to demonstrate their continued fitness to practise by collecting supporting data. The medical revalidation has two components: relicensure and specialist recertification. From 16 November 2009 all doctors are expected to have a licence to practise to enable them to remain on the Medical Register, and this licence must be renewed every year. This process will be managed by the General Medical Council (GMC). Recertification will apply to all specialist doctors, including general practitioners, requiring them to demonstrate that they meet the standards that apply to their particular medical specialty. The Royal Colleges have been delegated to set these standards, and approved by the GMC. Recertification will take place every five years. Recertification will be underpinned by enhanced appraisal, multi source feedback, and a robust continuing professional development programme.
Introduction
The arguments in favour of Recertification have been made cogently. Doctors in the UK on the whole continue to enjoy the trust and respect of their patients and general public, but the Shipman enquiry led by Dame Janet Smith questioned the validity of the existing system. Following a lengthy discussion, the Chief Medical Officer of England published his proposal for professional regulation: Trust , assurance and safety – the regulation of health professionals in the 21 st century was published in February 2007. This document laid out the principles of revalidation for all doctors practising in the United Kingdom. The purpose of revalidation is principally to ensure that doctors update their knowledge, skills, and fitness to practise. This mechanism of revalidation will ensure that health professionals are able to demonstrate their continued fitness to practise by collecting supporting data. Medical revalidation has two components: relicensure and specialist recertification. With effect from 16 November 2009 all doctors are expected to have a licence to practise which will enable them to remain on the medical register, and this licence must be renewed every year. This process will be managed by the General Medical Council (GMC). Recertification will apply to all specialist doctors, including general practitioners, requiring them to demonstrate that they meet the standards that apply to their particular medical specialty. The Royal Colleges have been delegated to set these standards, and approved by the GMC. Recertification will take place every five years. This article describes the approach adopted by the Royal College of Obstetricians and Gynaecologists (RCOG) to support the recertification of obstetricians and gynaecologists.
Current system of postgraduate training in the United Kingdom
Under the auspices of the Postgraduate Medical Education and Training Board (PMETB), radical changes have led to the streamlining of training, regular on-site assessments, and the development of special skills for certification as a specialist. During these years of training, doctors have to demonstrate that they have acquired the necessary skills and competences which are judged by using workplace-based assessments, 360 degree feedback, and their annual review of competence progression (ARCP). Finally, they have to pass the final examination of the “Membership of the Royal College of Obstetricians & Gynaecologists (MRCOG)”.
In the UK, certification is the only method of gaining specialist registration in order to take up a consultant post. Certification can be acquired by presenting either a certificate of completion of training (CCT) or, for doctors trained overseas, a certificate of eligibility for specialist registration (CESR).
Current system of postgraduate training in the United Kingdom
Under the auspices of the Postgraduate Medical Education and Training Board (PMETB), radical changes have led to the streamlining of training, regular on-site assessments, and the development of special skills for certification as a specialist. During these years of training, doctors have to demonstrate that they have acquired the necessary skills and competences which are judged by using workplace-based assessments, 360 degree feedback, and their annual review of competence progression (ARCP). Finally, they have to pass the final examination of the “Membership of the Royal College of Obstetricians & Gynaecologists (MRCOG)”.
In the UK, certification is the only method of gaining specialist registration in order to take up a consultant post. Certification can be acquired by presenting either a certificate of completion of training (CCT) or, for doctors trained overseas, a certificate of eligibility for specialist registration (CESR).
Why do we need recertification?
Although our current system of training doctors to be specialists is now heavily regulated, this is not matched by the current systematic assessments of performance during the course of specialists’ careers. All obstetricians and gynaecologists practising in the UK are expected to take part in continuing professional development (CPD) activities. However, concerns have been expressed about the effectiveness of various types of learning supporting the CPD activities. It has also been suggested that the thresholds of optimum performance are set by each individual’s personal qualities such as abilities, mental capacity, and innate talents. In one review, 62 out of 63 studies showed that physicians’ performance deteriorated over time making continuous focused learning important in medical practice. This issue of relatively poor performance became relevant following the publication of the reports of inquiries into underperforming and errant doctors (Shipman, Ayling, Neale and Kerr/Haslam Inquiries). For this reason professional regulation is now perceived as a vehicle for identifying and dealing with such doctors. In order to optimise the benefits of recertification, the underlying rationale should be not only to identify the small number of doctors who pose a risk to their patients but also to support the large number of doctors who are committed to the goals of lifelong learning and continuous improvement that are the hallmarks of professionalism. The huge expansion of knowledge and rapid pace of technological development in modern times have challenged clinicians to keep up to date, and have led to a “quality gap” between the standards that can and should be delivered and what is actually delivered in health care. If appropriate action is not taken now, this gap could continue to widen, and in turn erode the trust which the public has in the medical profession. This emphasises the need for continuing education.
Recertification will provide opportunities for specialists to maintain their competence throughout their career and maintain public trust in their profession.
Professional benefits of revalidation
Research evidence from the USA supports the notion that specialist certification has a positive impact on patients’ health outcomes. Three decades ago, the majority of participants in a voluntary recertification programme in obstetrics and gynaecology in the United States found it to be an educational experience which was worth their time and effort provided the procedures did not become too cumbersome. In surgery, certification had a higher correlation with reduced mortality. In patients treated for acute myocardial infarction, certified doctors provided better overall quality of care and prescribed fewer inappropriate drugs than non-certified doctors.
International models of certification
There are existing models of recertification in obstetrics and gynaecology in other countries. For two decades, the certificates issued by the American Board of Obstetricians and Gynaecologists for obstetrics and gynaecology and for the sub-specialties of maternal-fetal medicine, reproductive medicine, and oncology have been time-limited, and since 2001 recertification has been required every six years. This recertification can be obtained in one of three ways: either an oral or a written examination every six years; alternatively, sitting an annual certification examination; starting as early as two years before the specialty certificate is due to expire. The American Board of Radiology considers four distinct areas for recertification; the individual clinician’s professional standing, their having demonstrated ongoing learning and periodic self assessment, the demonstration of competence in their day-to-day approach, and the evaluation of their practical performance. In order to assess practical performance, each clinician needs to complete three practice quality improvement (PQI) exercises within a ten-year cycle. Each of these PQIs is designed to assess the clinician’s medical knowledge, their patient care, communication skills, professionalism, practice-based learning, and systems-based practice.
The American Board of Emergency Medicine invites each clinician to submit a series of charts. These charts are then scrutinised and a number are used to form an oral examination which focuses on clinical management and decision making.
The Royal College of Physicians and Surgeons of Canada established a CPD programme in 2000 and this programme forms the basis for mandating the maintenance of certification and fellowship in the College post-2005. In this model, practitioners define not only the areas of competence that they see as relevant to their practical needs but other areas such as doctor-patient communication, interdisciplinary team skills and risk management. Fellows are required to accumulate 400 credits during five years by participating in one of six types of educational activities ranging from self-directed learning, understanding audits, teaching, and taking part in accredited self assessment programmes to publishing research papers. The College places strong emphasis on reflective learning in practice.
In New Zealand, the CPD programme is compulsory as there is a three-year time limit applied to the award of FRANZCOG. The New Zealand Medical Council requires doctors to complete 150 hours of CPD in three years. CPD must include one audit of individual performance per year. A minimum of 25 of these points must be in the practice review and clinical risk management area. Clinicians are encouraged to take part in a voluntary practice visit programme and it is not linked to any regulatory authority/requirement. The focus of this practice visit is collegiality and identification of areas of vulnerability. All aspects of practice are reviewed, including surgical technique, communication, records, office procedures etc.
In Australia, each state/territory has a separate Medical Board and each of these have different requirements for registration. All require evidence of participation in a CPD programme.
What should be assessed?
A review of the literature essentially supports a strong commitment from the clinicians that their practice is up to date by providing evidence of “good quality care supported by clinical outcome indicators”, that they are up to date with current knowledge, and that their CPD activity is relevant to their day-to-day clinical work. The public wants an assurance from the regulators that the doctors are judgement safe. Although recertification by examination has been found to be useful, it is now being advocated that the evidence for continuing certification should be based around six general areas of competence that all specialists should maintain: medical knowledge, patient care, interpersonal and communicative skills, professionalism, practice-based learning and improvement, and systems-based practice.
The contribution of the RCOG to setting standards of care and performance monitoring
The RCOG’s commitment to setting standards as its core activity is captured by its strapline, “ Setting standards to improve women’s health ”. The RCOG was the first College to instigate a CME/CPD programme in 1994. It has a long tradition of disseminating best practice guidance in clinical and professional arenas through its green-top and national evidence-based guidelines and the clinical governance series. The zenith of this commitment to the development and maintenance of national standards was reached with the recent publication of Standards for Maternity Care and Standards for Gynaecology , both of which are intended to enable the provision of safe and satisfying care and the best possible clinical outcomes.
The College has well-established programmes of activity in education as well as in professional and clinical standards. These will inform the recertification programme. ( Fig. 1 )
How to assess a practitioner’s competence for a recertification programme
There is considerable interest in doctors’ performance and the tools required to assess this. Dame Janet Smith’s review found that among the high risk organisations of the aviation, nuclear, and offshore oil industries, the assessment of competence was carried out against defined standards of competence, that the interval between assessments ranged from six months to three years, and that repeated failures were an exception rather than the rule. Costs are high in the aviation industry, with far fewer pilots than there are doctors, the annual budget for safety amounts to £70 million. Although politically highly desirable, the cash-strapped NHS cannot possibly afford to invest in this model of assessment.
To make recertification credible, the medical profession needs to use reliable, evidence-based and valid instruments to assess competence. There must be backed up by educational events, suitable for an adult learner to promote skills-based learning. It must be recognised that during the formative years of medical training, learning is very much based on acquiring theoretical knowledge and on the model of serving as an apprentice. Once a doctor is in a consultant post, there is a fundamental shift in learning methods: the emphasis is more on self-directed acquisition of content knowledge and on reflective learning. There is evidence to suggest that a decline in age-related diagnostic performance is heavily mitigated by active engagement in CPD, particularly in areas relevant to clinical practice; CPD also improves the results of recertification examinations.
Various tools and mechanisms to assess competence
A wide variety of tools and mechanisms could potentially be employed in recertification, and some of these tools are discussed below. It is important to establish some guiding principles at the outset as these will determine which of the array of options is adopted. These simple but important principles will constitute the reference point for evaluating the proposed recertification programme as it goes through the process of consultation. Broadly speaking, these tools should support the following elements of reassurance.
- 1.
Evidence of professional standing – that the individual’s practice is safe and quality assured and is comparable to his/her peers;
- 2.
Evidence of commitment to lifelong learning and involvement in a periodic self assessment process, supported by a participation in the CPD: the tangible benefits of CPD have been shown in Fig. 2 .
