Rapid responses to the front page story
Should you be forced to keep up to date?

POINTS TO COVER
In principle I think it's a good idea to have some sort of mandatory recertification but there are a number of issues that would need to be addressed before you would see doctors agreeing with such a plan. Some of these are:

•Cost and time of doing recertification shouldn't be a barrier to practice and physicians should be reimbursed

•Material that doctors are tested on should be relevant to their practices and not a medical school type exam which is mostly memorization of meaningless facts and figures.

•Doctor's practices are varied and the knowledge and skills they are required to have varies greatly. Designing a recertification exam would need to address these issues.

Dr Sanjeev Goel
Brampton, ON

GREY AREA
Regarding mandatory recertification I see both positive and negative sides as well as a whole bunch of grey in the middle.

On the positive side, it would be preferable to have our professional organizations administer any evaluations of competency rather than the provincial governments. I think by far the majority of us realize that when we 'signed up' to be doctors we were entering a life-long learning program. It's extremely naive to think that leaving a residency means leaving exams, as every patient and every problem or issue we deal with is the real test. The idea of recertification is good if it's appropriate, ie testing what it's meant to be testing. Judging competency is tough, as being competent is more than just having knowledge or skills, it's also about professional integrity, knowing when to get help, when to say 'I don't know,' ability to communicate with your patient and listen, and to be compassionate and ethical.

On the negative side, I'm fresh out of my second residency and the idea of preparing for a prescribed exam makes me shudder. My last set of 'exams' cost me precious family time, evenings with my children, loss of income, tons of stress, etc. So again, an exam for the sake of an exam is not useful, it has to be a validated tool to assess competency.

In the grey zone, there are a lot of unanswered questions. The driver for mandatory revalidation is the demand for improved patient safety. But what is the expected improvement in patient safety with mandatory revalidation? Is this more of a mechanism to satisfy public pressure? Patient safety is very important and every reasonable attempt should be met to provide competent care; but have our societal expectations of care-providers become impossible to meet? People want a faultless system of healthcare with faultless humans providing the care, but with the freedom to make all the potentially reckless individual decisions they want (ie driving without seat belts, smoking, etc). It would be terrific if we as care-providers could make the most competent decisions possible with patients who exercised equal good judgment.

Dr Charmaine Enns
Cumberland, BC

INITIAL CONCERN
As I prepare for my certification exam in developmental behavioral pediatrics in the US (it just became a subspecialty in the States, and thus exams have just become available), this question is even more salient. My initial reaction is one of concern given that my experience with the exam process in the Royal College was not a good one. What to measure remains a great challenge, for all the reasons mentioned in the CMAJ editorial. For example, if a physician can't remember all the details of ECG interpretation in a child who has just undergone a cardiovascular operation, but does recognize the severity of the presenting complaint and appropriately asks for help from a team member, how do you measure that clinical process? Should he fail because he doesn't know ECG interpretation or should he be commended because he knows how to work in a multidisciplinary fashion? In a hospital setting, many programs depend on smooth and skilled communication between multiple professional groups, especially I might add in child development. How does one measure that? How do you measure empathy for parents and children, another essential ingredient of excellent care? Either we value this newfound insight into what a professional does or we don't. I must also add that the present system of maintenance of certification does have an impact on my clinical decision-making. Constant exposure to teaching will change behaviours in clinicians committed to excellent care and professional development.

Dr Emmett Francoeur
Montreal, QC