Philosopher David Hume, in his book “A Treatise of Human Nature” describes how hard it is to derive ought directly from is – that is, how tricky it is to logically demonstrate why things should be done in a certain way. This is often referred to as “Hume’s Guillotine” as a way to demonstrate the severance of “is” statements from “ought” statements.
Now as you would all be aware, AHPRA is in the process of arguing that we (doctors) all should (in fact, be forced to) undergo revalidation on a regular basis. This entails going from the “is“ (concerns about medical practice) to the “ought“ (you must practice in a set way).
In this article I would like to critique AHPRA’s plan and show how the logic behind revalidation fails the “is” to “ought” argument (and thus validates Mr. Hume).
What are the reasons why AHPRA is wanting to force upon us a system of revalidation? A couple of years ago I read in “Aus Doc” magazine an article about this. The reasons put forward by Dr. Flynn were that other countries have revalidation, there is a concern about the safety of older solo doctors and the public is demanding that doctors get revalidated.
Firstly, there are other countries that have compulsory revalidation. However, there are other countries that have and do all sorts of things (the “is”) so how can this then become the “ought”? I fail to see this connection. Certainly we can learn how other countries deal with the issues that the Medical Board deal with but I am not aware of any law or socially accepted more that behooves someone or some group to act in a certain way just because another person/group does – particularly when the evidence behind revalidation is very poor (see below).
Secondly, the issue of older solo doctors appears to be of concern to AHPRA. In the article I read, these concerns were not spelled out, though allow me to quote Dr. Flynn; “there are concerns about older male doctors – those working in isolation, with little contact with their peers and little insight into their own practice. Often they are loved by their patients but that does not mean that they should still be working”. Now before I pull this apart, let me quote a recent survey (Oct 2012) by the Menzies Centre for Health Policy and the Nous Group: it found that there existed a high level of satisfaction with both GP and Specialist care (78% and 79% respectively) and over 85% expressed confidence in the quality and safety of their health care. So Dr. Flynn, given those numbers is there a crisis in the quality of health care in Australia? The numbers do not lead to that conclusion. And what about those older male doctors who are loved by their patients and so they should not practice? Interestingly the most important issue that needed improvement according to that those surveyed by the Menzies Centre, was access to medical and nursing staff! So may one conclude that AHPRA, in their wisdom, would like to take away access to those loved solo male doctors?
Now the reasons for revalidation have been dissected and shown to be scant, let us have a quick look at the evidence that supports introducing such a system. Well there seems to be very little and certainly not enough to make a case to introduce it here. In Plymouth University’s study ‘Evaluating the strategic impact of medical revalidation’ Dec 2013 this is what the last paragraph on page 17 says: “In conclusion, there have only been a limited number of small studies exploring the impact of appraisal on performance and patient outcomes. Relatively little empirical evidence of revalidation’s potential benefits exists, beyond opinions of its value from appraisers and appraisees.”
I am sure that many, if not most of you, if given such information would find it hard to then support making revalidation an obligatory part of our health system. If this was a drug company’s submission to the PBS it wouldn’t get in the door. Yet are we to accept that AHPRA knows best and so follow them blindly?
Finally it has been quoted by a number of people apart from Dr. Flynn that there is a public demand that we get revalidated. Now in my 20 years of practice I have yet to meet any patient who has said directly to me that we need revalidation of doctors. Nor have I seen any mention of this issue in the popular press. So without going to far out on a limb it seems that the “public demand” is not that public and perhaps reflects the agenda of the Medical Board?
So back to Mr Hume. The “is” is listed as “other countries”, “older solo male doctors” and “the public”. The “ought” is revalidation. And between them is a gulf as large as the Grand Canyon, which I have demonstrated above. It would seem that AHPRA on present evidence has fallen to “Hume’s Guillotine”.
Now I do not want to finish on a pessimistic note, so for what’s it’s worth, here are my thoughts about what AHPRA wants to do and another way to do it.
I am imagining that what AHPRA is wanting is no complaints about doctors and no adverse patient events (and that they are hoping that revalidation will help do this) – don’t we all. Why introduce a system that has lacks any support according to the available research and smacks of a paternalistic ideology when there is already an excellent and widely supported system which based on the most recent reviews, improves physician performance and has have some benefit to patient outcomes (Effectiveness of Continuing Medical Education, Cerveo R.M., Gaines J.K., July 2014 ACCME). May I suggest that in lieu of “revalidation” AHPRA engages with the colleges responsible for our CME , reviews what is offered and based on what evidence is available in regards to effective CME, suggest changes to the this system that reflects the evidence that gets the most benefit. This would have the support of the wider medical community, be easily incorporated into the existing CME structure and be a change owned across the profession.
Dr Nathan Kesteven,
(Published in GP Speak earlier this year)