Mandatory revalidation of medical licences will likely be introduced across Canada within 5 years in response to the demands for improved patient safety, regulatory officials say.
Figure. Photo by: Art Explosion
“It's coming. It's just a question of how it's going to be done and when. There's a tremendous will to do it,” says Dr. Bernard Marlow, director of CPD/CME (continuing professional development / continuing medical education) at the College of Family Physicians of Canada (CFPC).
About a dozen nations and 37 US states have already moved to implement revalidation. It's clear there's an increased societal “expectation” that doctors regularly demonstrate fitness to practice, says Dr. Bob Burns, president of the Federation of Medical Regulatory Authorities of Canada (FMRAC). “And as a self-regulating profession, we have a professional obligation to demonstrate continuing competence.”
It's equally apparent that if professional organizations fail to step up to the plate, provincial governments will fill the void, says Royal College of Physicians and Surgeons of Canada (RCPSC) Director of Professional Development, Dr. Craig Campbell.
A revalidation bill has already been introduced in Manitoba but died on the order paper, while several other provinces, including Ontario, Saskatchewan and BC are contemplating regulation.
Revalidation is expected to be high on the agenda of this summer's intergovernmental health ministers meeting, fuelled by the 2004 CMAJ study by Ross Baker, Peter Norton, et al. (170[11]: 1678-86) and the Health Care in Canada 2004 report by the Canadian Institute for Health Information. The latter indicated as many as 23 750 deaths, 1.1 million added days in hospital and $750 million in spending could be annually attributable to medical errors by doctors, hospitals and pharmacists.
The validity of linking revalidation to ongoing CME was the focus of a special educational session of the annual FMRAC meeting in Saskatoon. Although no consensus was reached, “we have to begin to connect the dots,” Burns says.
Most models of revalidation propose some measure of ongoing CME, as well as some means of periodic practice review, such as the Physician Achievement Review (PAR) program adopted in Alberta and Nova Scotia, wherein all doctors are assessed every 5 years.
But PAR is aimed at quality assessment rather than summative measurement of whether a physician is competent, Burns adds. “That requires a different sort of tool, like testing.”
It's arguable whether CPD/ CME alone provides a basis for revalidation, Burns notes. “The link between CME and actual performance is tenuous at best.”
“It's a bit of stretch” to assert that CME necessarily changes performance and practice, Campbell adds.
Nevertheless, the colleges want their maintenance of certification programs (for continued membership) to be including in any revalidation schemes. About 50% of FPs belong to the CFPC, while an estimated 80% of specialists belong to the RCPSC.
Implementing revalidation will also require overcoming several systemic barriers, argues CMA President Dr. Sunil Patel. Those include providing the money to conduct physician reviews, bolster CPD/CME and providing remedial training for doctors who fail to make the grade.
“It makes sense that in a rapidly evolving world, where standards have to be maintained, certain types of revalidation are necessary [for example, for immigrating physicians],” Patel says. “But a wholesale revalidation process would require a tremendous amount of resources, both from the federal and provincial governments, and from the universities and the licensing authorities. It could cause a serious problem in the delivery of health care because you already are stretched to the limit in terms of human resources.”
Another unresolved issue centres around portability. With each province having jurisdiction over licensing, 10 different systems may emerge, making it difficult for doctors to move between provinces, Burns notes. “Yet, the ideal, and the desire, is to have something that's consistent through all the provinces.”
Marlow says achieving that objective will be altogether problematic.. “From the looks of it, we could have 10 different ways of re-licensure, and with different fees. It doesn't look like they're all going to embrace the same method.” — Wayne Kondro, Ottawa