Dr Joanna Flynn, chair of the Medical Board of Australia, talks about CPD reform and the vexed question of identifying doctors who are performing below accepted standards …
MJA: There’s international evidence that about 6% of the medical workforce are not performing up to the standard they should be. You’ve also said [in a Perspective published in this issue of the MJA] that there was no data for the Australian context. Why do we need revalidation when we don’t have the evidence saying we need it?
Dr Joanna Flynn (JF): What the Medical Board of Australia (the Board) has proposed are two things. One is strengthening continuing professional development (CPD) for all doctors, and the other is seeing what we can do to identify doctors who are at risk of performing poorly earlier, before they cause harm to the public and to themselves.
The issue about strengthening CPD is reasonably straightforward, in that all doctors are required, as a condition of their registration … to do continuing professional development and we have some standards about what that means.
If there’s a body evidence – strong evidence – as there is, about some forms of CPD being more effective than others, then the Board believes that we should be setting a framework where the CPD that doctors do is at the effective end of the spectrum … we know that if you want to improve patient safety, and change doctors’ behaviour, then they need to be looking at things that help them reflect on their own practice, interact with their peers, and look at patient outcomes where they can.
So, what are we saying about poor performance? There’s a good body of evidence that says that there are some doctors already on the radar who are performing poorly, and there are doctors who are slipping off the curve, and we know that when they end up in trouble it’s very stressful and traumatic for them, and it’s damaging for their patients.
There are markers that have been recognised in some communities, of doctors more likely to be in those categories.
MJA: Whose job is it going to be to identify those doctors who are at risk? And how do we then manage them and who does that?
JF: They are key questions to which there are not yet any clear answers.
It’s important that the profession, collectively, engages in and owns whatever the outcome of this process is. It ought to be something that happens locally, and where there are concerns about someone’s performance, or obvious markers of risk, [there ought to be] a plan in place, locally, to help that doctor maintain high standards.
One of the interesting things about what happens for [airline] pilots is they get as much training on giving and receiving feedback as they do on the technical aspects of the aircraft.
We have a culture where we’re not very good at that. We can see things going on around us that we’re uncomfortable with in our colleagues’ behaviour, but as often as not we don’t say anything to the person in front of us. We might talk to somebody else in the team, or we might go home and talk to our partner about it, but that’s really doing people a disservice.
How can we reframe our expectations about feedback, and make sure people are getting feedback about their performance? If they start to display things which potentially mean that they’re not going to be performing as well as they need to be, or they themselves would want to be, [are there] pathways for identifying that and giving them support, putting them back on to the right path before things get to a stage where they’re not remediable or something bad happens?
MJA: Do you think that the risk factors that have been identified – over 35 males, solo or small practice scenarios – is there a danger that certain doctors are targeted more than others? Rural GPs, for example.
JF: We can’t have a model that means that people who are in rural practice are not able to be part of whatever the processes are. People have raised concerns about that.
They’ve certainly said, doctors are already stressed and doing too much and now you’re putting a whole lot more burdens on them. And I’m very conscious that if you put a whole lot more burdens on people it doesn’t help their performance. It doesn’t help their morale. It doesn’t help their mental health. And it doesn’t, ultimately, help the communities they’re serving. We’re very committed to not doing that.
So, there are a lot more questions in this space than there are answers.
MJA: Do you see the Medical Board as having an active role in this, once it’s up and running?
JF: In terms of the models for doctors at risk, we haven’t got a clear handle on that yet. As I said earlier there’s lots of evidence that if problems are identified early and dealt with locally that leads to the best outcomes. I don’t want the Board to be involved in that sort of process. The Board should only have a role where there’s a clear risk to the public emerging – if there’s a doctor who’s not taking part in the processes at all, or having been identified in the processes as potentially being underperforming, won’t engage in whatever the next steps are in terms of further assessment or remediation, further educational support, or where something is identified in those processes that current, present, real risk to the public.
Clearly there’s a threshold that you need to be across before you ought to be in the Board’s regulatory space.
CS: Do you think there’s a gap between what the public thinks doctors should go through in terms of review and what doctors believe they need?
JF: Yes, there is, and we’ve published some social research which shows that gap. It shows that the public believe that doctors ought to be, and in fact are being reviewed … more often than they are. In general, doctors think it should only happen if there’s a problem, whereas patients think it should happen on a [regular] basis.
Doctors generally think that they do know what they need to keep them up to date and they generally think that they’re doing it, and I think they’re probably right. But we want to make sure that continues to be the case into the future. Medicine’s getting more complex. Society’s getting more complex.
CS: There seems to be some paranoia out there. And the paranoia seems to [say] once AHPRA and the MBA have got their hands on it, it’s just going to get rammed through.
JF: I understand the profession at large views AHPRA and the Medical Board as a big bureaucratic, slow, unfriendly process. We’re doing our best on lots of fronts to try and address that. The boundary between the Board and AHPRA is blurry in doctors’ understanding and because we’re so inextricably linked to some degree that doesn’t matter too much. But this [process] is the Board, as the body responsible for setting standards and regulating standards in the profession, really saying to the profession, and to the community, okay, so what do we need to do, into the future.
We know that there are very high levels of trust for doctors in Australia. That’s so precious. We need to make sure we preserve that.
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