New Zealand Society of Anaesthetists Recertification in New Zealand Philip Pigou July 2017

The Lancet view 1897 New Zealand described as … “… a happy home for every kind of unfeathered quack.” Lancet 1897 (1): 490 So this was a challenge for the profession and regulators in the late nineteenth century and early twentieth century. Whilst I don’t believe it would be accurate today (or even in 1897), what is accurate is that there are still doctors who are not performing adequately; there are doctors who are not competent; and the public has a increased expectation of high quality performance and professionalism – and this expectation can only continue to increase. The Council as regulator does need to consider all of these factors when establishing policy about recertification or any other intervention.

Of course we have to be careful that we don’t take regulation too far – it is a fine balance in deciding the best approach to take – understanding the areas of risk is crucial in our policy development and decision-making.

Our strategy – self and independent regulation Setting the framework for recertification and promoting competence Collaborating with the profession/stakeholders on developing standards Ensuring competence and fitness to practise Over the last ten years, we have built our strategy on the principle that both self regulation and independent regulation are important. Self regulation in that standards of practice, the knowledge required and implementation of this policy should be profession-led. Independent regulation in that the regulator does represent the public, not the profession – and we must establish policies that reflect this role. We have undertaken this role in these four areas. Establishing multilateral relationships to share information and manage risk Assessing and investigating competence, health and conduct of individual doctors

Principles for recertification Quality recertification activities are: Evidence-based Formative in nature Informed by relevant data Based in the doctor’s actual work and workplace setting Profession-led Informed by public input and referenced to the Code of Consumers’ Rights Supported by employers Our principles for recertification were consulted and finalised in 2016. Evidence to support what we do is important – however we don’t always have evidence. Something that is innovative is unlikely to have much evidence behind it. Data – about performance and outcomes is important – as is data from colleagues and the public about performance. I have already touched on profession-led. And the Code of Consumers Rights – they are legally rights of patients which means that the other side of the same coin is a duty on doctors and other health practitioners. A duty is the highest form of legal responsibility.

Performance and outcome data Council proposed that each doctor uses performance and outcome data to inform their professional development General support for this, particularly for data from own practice Concerns about who would collect the data, its interpretation, contextual factors such as team & individual Role of Ministry of Health and HQSC to establish how data can be collected and used for quality improvement General agreement that performance and outcome data, multisource feedback and external peer review that is drawn from a doctor’s own practice, should be used to identify professional development needs and inform CPD planning. some concerns were raised about what data would be collected, who would be responsible for collecting and collating data, and whether good quality data would be available to draw on. Some emphasised the need for care to be taken, given contextual factors such as clinical resources and team performance that contribute to individual doctor outcomes, and that it is often difficult to identify what is attributable to an individual doctor. Ministry of Health and the Health Quality and Safety Commission have been charged with establishing how patient outcome data can be meaningfully collected and utilised for quality improvement.

Multisource feedback Council proposed that data from MSF should inform professional development – from colleagues and patients Supported as valid and reliable, with appropriate number and breadth of participants important Used by colleges and in prevocational training Need for a trained adviser to give feedback ‘Multisource feedback is increasingly popular but problematic. Selection of sources, anonymity, formulating feedback and delivering feedback are all challenging. Multisource feedback done well requires expertise, time and resources.’ The use of multisource feedback was supported in principle by many submitters as a valid and reliable way of informing professional development and assessing clinical performance, however it needed to include an appropriate number and breadth of participants Several colleges are already implementing MSF It is also being introduced for Interns “A debrief of a candidate’s MSF report by a trained ‘advisor’ has been identified in College trials as an essential element in its effectiveness.” “Multisource feedback is increasingly popular but problematic. Selection of feedback sources, maintaining anonymity, formulating the feedback obtained and delivering the feedback in the right context are all challenging. Multisource feedback done well requires expertise, time and resources which don’t exist within financially challenged DHBs.”

Regular Practice Review Council proposed that all colleges provide RPR as an option for their doctors to undertake on a voluntary basis Some colleges already have RPR as an option – some feedback suggested it should be mandatory Already a requirement for doctors on a general scope ‘Most host and visiting doctors find this a very worthwhile process … it is the most tangible and useful component of recertification’ ‘…we see great value in RPR. It provides an opportunity for external assessment of doctors’ practice and would enrich the data and feedback on which to develop effective PDPs’. RPR is a tool increasingly used through the medical profession – it is compulsory every three years for doctors on a general scope of practice. Also several colleges or associations are using RPR – Orthopaedic surgeons; O&G There were positive comments

Regular Practice Review – some issues ‘Resources and costs involved in RPR for doctors would need to be considered. Any costs and resources incurred by medical colleges in development and delivery of a RPR model would likely be reflected in increased college fees and in the case of DHB employed doctors, contractual arrangements will mean this increased cost will ultimately be covered by DHBs. Depending on the extent of the RPR model, these costs may be significant for DHBs.’ ‘RPR should be used only when issues of poor performance had been identified.’ And there were issues raised Resources and costs are a factor, however there is increasing evidence that RPR is cost-effective. Council is evaluating The RPR model for general scope doctors and the results are generally positive. RPR isn’t a tool for assessing poor performance – it is a formative tool for identifying areas a doctor is doing well and areas for potential improvement.

Professional Development Plans Council proposed that each doctor develops a PDP, targeted to identify and address their professional development A PDP is a plan of a doctors recertification over time Many colleges believed a PDP should form a central part of recertification ‘We support the requirement that doctors review their own PDP each year, with input from an external reviewer.’ ‘… a PDP will benefit a doctor to target CME for areas of improvement which may be identified …’ Several colleges already have a form of PDP – requiring Fellows to record their CPD – what they have done for the year. Council’s idea is that each doctor will have at least some idea of what their CPD will entail at the start of the year – that they will think about what they need to do, what they want to do, and record it. A small number of colleges and DHBs felt the development and use of the PDP should be managed by the employer, rather than as part of the recertification process.

Career management and planning Council proposed colleges provide around career planning for all doctors and consideration given to recertification activities that would support doctors over their whole career, then as they age and work towards retirement Most controversial proposal Some misunderstanding about the aging doctor – there was and is no suggestion of a compulsory retirement age or other requirement Many objected to any requirement to limit career options or clinical work. GP’s were vehement in opposing any required age-specific activities, citing concerns about the negative impact on the primary health workforce

By comparison ‘It would be helpful to mandate reviews from a specific age – suggest 70 years old.’ DHB CMO and ‘… above the age of 55 a plan should be made around on-call commitments and retirement planning.’ DHB CMO

Aging and cognitive decline ‘Research shows that between ages 40 and 75 years, the mean cognitive ability declines by more than 20%, but there is significant variability from one person to another, indicating that while some older physicians are profoundly impaired, others retain their ability and skills. ‘As physicians age, a required cognitive evaluation combined with a confidential, anonymous feedback evaluation by peers and coworkers regarding wellness and competence would be beneficial both to physicians and their patients… Absent robust professional initiatives in this area, regulators and legislators may impose more draconian measures.’ The Aging Physician and the Medical Profession: A Review The JAMA Network: JAMA Surgery E. Patchen Dellinger, MD; Carlos A. Pellegrini, MD; Thomas H. Gallagher, MD This raises the whole question of aging and cognitive decline – a risk factor that needs to be considered by the profession. This is a recent article from the USA

Increasing evidence of concern ‘…while age alone may not be associated with reduced competence, the substantial increase in variation around cognitive skills as physicians age suggests the issue cannot be ignored. A significant number of physicians who are referred to formal evaluation programs owing to concerns about performance demonstrate cognitive decline.’ Ibid ‘… doctors’ high education levels give them cognitive reserve, which tends to delay onset of cognitive decline.’ This is an important area for ongoing research. We can’t just make assumptions about age and cognitive decline – we need to understand the true impact and take time in getting it right. And we need to ask the public what they think – you can’t speak for me if I haven’t had a say.

Your practising certificate A PC is not a tax receipt We issue practising certificates to doctors who have maintained their competence to continue practising medicine

Where to from here?