Should you be forced to keep up to date?

Mandatory recertification: now's the time to speak out

By Julia Cyboran

Is the profession ready for this?

Dr Mark Frobb, a Vancouver GP/pain management specialist, thinks it is. "In an ideal world mandatory physician recertification would be the perfect thing to do," he says. "Information is moving at such a fast pace, you have to make sure that doctors are current with the latest tools and are up to date on the latest clinical advances."

On the other side of the fence, Alberta GP David Yue isn't so sure. "In theory, it's a good idea for physicians to 'prove' that we're proficient in what we do," he says. But he's quick to observe that doctors are being singled out. "Lawyers, dentists and accountants, to name a few, have no compulsory recertification once they've passed all their requirements."

The CMAJ editorialist argues that it's time to act because "failure to move ahead [with recertification] will lead to increasing public distrust" and "contribute to patient and public dissatisfaction, adverse events and poorer outcomes of care." This sense of urgency is most likely a reaction to the much-publicized Canadian Institute on Health Information study, which reported that of 185,000 medical errors annually, 70,000 were preventable.

A LIFETIME TO FORGET
Those at the CMAJ aren't the only ones with a recertification bee in their bonnet. The College of Family Physicians of Canada (CFPC) has also been busy looking at options. "I think the concept of physicians being licensed for life isn't good for the Canadian doctor," says Dr Bernard Marlow, director of CME. "I think we need to develop a process for the average citizen to determine if physicians are competent."

That said, he makes it clear he's at variance with the CMA's position. "The editorial in the CMAJ, which challenged the colleges, missed the whole point," says Dr Marlow. He explains that only half the doctors in Canada are part of the CFPC and that its members are required to take part in regular certified CME programs to remain members in good standing. He wonders, "How do we reach the other 50%?"

WHO'S RESPONSIBLE
Dr Marlow and the CMAJ editorial do agree on one thing: the benefit of having a single system from coast to coast. Some provinces are already going it alone. Ontario is looking to have a recertification, or 'revalidation,' program in place within the next two years, and Manitoba was working on a program which it only recently put on hold.

Dr Rocco Gerace of the College of Physicians and Surgeons of Ontario explains the Ontario initiative this way: "The basis for [revalidation] is the feeling of the College that every physician should have an assessment every five years." The College has been involved in an ongoing peer assessment for years but is now funnelling resources into a larger revalidation program. "We want our revalidation program to be tailored and relevant to the doctor," he says.

In Dr Gerace's view, the provincial colleges ought to take on the responsibility for recertification. "I don't think that this in any way should be represented as turf battle," he says. "We should all work together. This is not a debate between licensing bodies and colleges."

GETTING DOCS ON PAR
Mr John Swiniarski, assistant-registrar with the College of Physicians and Surgeons of Alberta agrees. "I think that because every province has a college, it's responsible for the process," he says. "It's a program that is better managed at a provincial level." He's been working with Alberta's Physician Achievement Review (PAR) for five years. Although not a mandatory recertification program, PAR has made a name for itself as a highly effective peer-review system.

"We started PAR out as a quality improvement practice," says Mr Swiniarski. PAR was initially met with apprehension. Many physicians were afraid that the results would affect the complaints process. "Most doctors look at this performance review with a little trepidation," he admits. That's not the case today. "Doctors are much more accepting," he says. "They see it as an opportunity to have feedback."

But PAR is very different from recertification. "This focuses on 'do you do it?'" says Mr Swiniarski, "not 'how you do it.'"

WHAT TO MEASURE
Many of the review programs in place are only measuring the 'do' and not the 'how.' Getting to the root of clinical competency is easier said than done. Dr Marlow points to three ways it could be accomplished: certified CME, peer-review, or examination.

But the question of putting docs to the test raises apprehension. "I'm not sure that the default position of asking clinicians to memorize ever-increasing amounts of details so that we know they have a "basic-knowledge" of medical problems is acceptable," says Dr Emmett Francoeur, a Montreal pediatrician. "What to measure remains a great challenge."

Alberta dermatologist Dr Gordon Searles agrees. "An examination is either too simple to be effective or tests only esoteric things thought relevant by academic physicians," he says.

WHAT A TURN OFF
Although the debate over responsibility and measurement continues, Dr Marlow reminds us of another more pressing issue. "The timing is not good right now," he says. "We're facing a huge doctor shortage in this country. The province that brings in recertification may be at a disadvantage because it might turn off physicians."

Have your say. What do you think about mandatory recertification? What have your experiences been with provincial peer review? Send us a letter with your comments. Email us at [email protected].