Revalidation of Canadian physicians/The author responds

Canadian Medical Association. Journal; CMAJ, Mar 3, 2009 by Theman, Trevor W, Oetter, Heidi M, Kendel, Dennis A, Campbell, Craig M, Ouellet, Robert, Levinson, Wendy

We commend Wendy Levinson for her provocative suggestions regarding revalidation of Canadian physicians.1 We also applaud CMAJ for publishing views that are more demanding and supportive of meaningful external verification of Canadian physicians' ongoing competence than those of the Canadian Medical Association.

We agree with much of what Levinson has advocated, specifically the call for a revalidation process for all physicians implemented by the provincial medical regulatory bodies and the call for an external assessment of physician performance. Indeed, valid methodology to measure the actual performance of physicians in practice is the Holy Grail sought by medical regulators.

As noted in the editorial, a number of jurisdictions have mandated or will mandate participation in 1 of the 2 national maintenance of certification programs. Two jurisdictions, Alberta and Nova Scotia, also require all physicians to undergo regular multisource feedback reviews from patients (if applicable), colleagues and coworkers. Rather than an "alternative approach," as suggested by Levinson, Alberta's Physician Achievement Review program is an integral component of the Alberta college's revalidation strategy. Although it is a quality-improvement program, 20% of physicians undergoing this review will be flagged for follow-up, and 1 out of 5 of those (about 4% of the total) will undergo a formal peer review of their practice.

In addition, Levinson argues that the process is "only feasible for primary care and larger specialties" when in fact Physician Achievement Review tools have been created, used and validated for primary care, medical specialties, surgical specialties, episodic care (e.g., emergency and walk-in practices), anesthesia, laboratory medicine and diagnostic imaging. Very few physicians are not captured by the Physician Achievement Review process. Results from our implementation of each set of Physician Achievement Review tools have been published in peer-reviewed journals.2,3

In other jurisdictions, peer review of physician practice is a prominent component of quality assurance. Many provincial medical regulators operate accreditation programs for laboratories, diagnostic imaging and other diagnostic modalities. These programs not only capture and review the policies and procedures but also involve direct inspection of the facilities where physicians provide services as well as review outcomes.

In addition, many medical regulators either operate, or have access to, prescribing or dispensing information on a limited or broader scale. Such information can prove useful as a screen into what physicians are doing in practice. The Coll�ge des M�decins du Qu�bec has used prescribing data very effectively in monitoring, intervening in and improving the practices of physicians in that province. We look upon the analysis of databases, such as those for prescribing, as offering a real opportunity to create affordable, proactive, valid and reliable tools to assist in providing the kind of external oversight that Levinson recommends.

Notwithstanding the many activities we employ to ensure that our members are performing to an acceptable standard, we recognize that the currently available tools are not sufficient to ensure that every physician remains competent. We therefore heartily support Levinson's call for more research to understand the relation between revalidation and quality of care in practice and to explore the most effective methods to assess physician performance.

Although examinations can measure a physician's knowledge base, they do not measure how a physician actually performs in practice. Thus, although we are less sure of the value of examinations in pursuit of this goal (and nor are physicians in our jurisdictions), we strongly support adding methods to our toolbox that have been proven successful. Evidence-based regulation should be our mantra as we move to achieve the very important ends that Levinson advocates and that our public demands.

Trevor W. Theman MD

Registrar, College of Physicians

and Surgeons of Alberta, Edmonton, Alta.

Heidi M. Oetter MD

Registrar, College of Physicians

and Surgeons of British Columbia,

Vancouver, BC

Dennis A. Kendel MD

Registrar, College of Physicians

and Surgeons of Saskatchewan,

Saskatoon, Sask.

Competing interests: None declared.

REFERENCES

1. Levinson W. Revalidation of physicians in Canada: Are we passing the test? [editorial] CMAJ 2008;179:979-80.

2. Hall W, Violato C, Lewkonia R, et al. Assessment of physician performance in Alberta: the physician achievement review. CMAJ 1999;161:52-7.

3. Lockyer J, Violato C, Fidler H. What multi source feedback factors influence physician self assessments? A five-year longitudinal study. Acad Med 2007;82(10 Suppl):S77-80.

DOI:10.1503/cmaj.1080121

We thank Wendy Levinson for promoting the principle that physicians individually and the medical profession collectively must be accountable for sustaining and enhancing physicians' knowledge, skills, attitudes and competencies over a lifetime of practice and that these processes must be transparent. 1 In 2005, the Council of the Royal College of Physicians and Surgeons of Canada established lifelong learning as the professional ethic for all fellows. The Maintenance of Certification program has promoted and supported this mandate by establishing high standards for group learning, self-learning and practice and performance assessment strategies and by requiring fellows to plan, implement, document and defend, where required, their process of learning and the outcomes achieved that contributed to the quality of their professional practice. Participation in continuing professional development activities alone is an inadequate marker of learning, and learning divorced from improvements in competence, performance and health outcomes is an inadequate metric for any continuing professional development system committed to improving the quality of professional practice.