INTRODUCTION
The imminent introduction of revalidation, ‘the process by which doctors will, in future, demonstrate to the General Medical Council (GMC) on a regular basis that they remain up to date and fit to practise’,1 obliges us to ask what guiding principles should be addressed as we implement revalidation? Seven years ago Good Medical Practice (GMP) for GPs stated, ‘the unacceptable GP has little knowledge of developments in clinical practice; has limited insight into the current state of his or her knowledge or performance; selects educational opportunities which do not reflect his or her learning needs; does not audit care in his or her practice, or does not feed it back into practice,’ and ‘is hostile to external audit or advice.’2,3
The five characteristics of the acceptable GP are the converse of the unacceptable one, but in our experience are not applicable to the complete breadth of a doctor's work. As we have assessed GPs whose performance has raised serious concerns4 we have found repeatedly that basic failures in diagnosis, poor management and haphazard follow-up are clear to assessors. It is clear that such doctors lack insight into their deficiencies and are often isolated from peers who may reveal and help correct them. Indeed GMC reports of GPs whose names have been erased from the medical register frequently cite a lack of insight as the root of their negligent performance. This leads us to propose that isolation and insight be two pillars upon which revalidation is practically based. In short, for a GP to be revalidated there would have to be convincing evidence that they were neither isolated nor lacking insight.
ISOLATION
GPs may be isolated by virtue of being single handed or a locum or by the dysfunctional working of their professional or group practice. Ill health is a significant factor in about 20%5 to 27%4 of cases of underperformance. Furthermore, doctors commonly face systematic barriers to accessing health care, and good management of their health should not be assumed.6
Isolation ought to be lessened by relationships within the primary healthcare team, especially fellow GPs who should share the daily interest, frustrations, and serendipity of the job. Outside the boundaries of individual practices ‘collegiality’ may also lessen isolation, for instance young and old principals groups. Surveys in the Mersey region in 1989 and 1998 showed 35% of principals attended a professional small group at any one time, ‘a self-motivated commitment to professional development often unrecognised by formal systems’.7 We do not know how many GPs currently participate in professional small groups and the future may involve seeing federations of practices or practice-based commissioning consortia taking their place.8
Professional contact with one's peers should help maintain and develop knowledge through formal events and small group or practice-learning sessions. Although we consider that there is no substitute for reading professional journals, it is critical discussion with peers which particularly enables new learning to be understood and placed in context. A single-handed GP or locum could become isolated through the absence of networking and support, but a substantial review of their work did not show that they underperform clinically.9
Professional isolation is indefensible10 and although appraisal has potentially lessened the isolation of some, appraisal may still run the risk of gaming, collusion and ‘playing the system’.11 Role models can powerfully shape behaviour and attitudes in students, which may persist throughout professional life,12 and contact with peers should reinforce good models. Mentoring can also positively influence doctors, ‘improve healthcare standards and services’13 and reduce isolation. It has been reported that benefits reported by doctors includes an increased sense of collegiality.14
INSIGHT
Long-standing mediocre performance is often difficult to manage and remedy due to a lack of insight,15 which is perhaps the most crucial attribute of the ‘acceptable GP’. The 1990s were a decade of professional self-audit when the insight gained through examining one's own performance should have led to deficiencies being corrected.16 Insight can develop through both systematic clinical and Significant Event Audit. The Quality and Outcomes Framework (QOF) has succeeded because the rapid electronic feedback of data has given awareness of deficient performance that can be remedied.
Unfortunately, for a minority of doctors, arrogance leads them to being hostile to external audit or advice.2 Since in many healthcare activities serious harm is ‘but a few unguarded moments away’17 clinicians, including GPs, remain the primary defence, not least for the insight they should bring to the possibility that wrong assumptions are harming, or could harm, a patient. One of the recognised early signs of the doctor in difficulty is ‘insight failure: rejection of constructive criticism; defensiveness; counter-challenge’.15
It is also difficult to gain insight without feedback from patients and colleagues. Feedback from consultations and discussions with informed peers are often necessary to see the larger picture and turn anecdotes into information. Perhaps the greatest difficulty GPs face is in acknowledging both the limits to their competence, or whether they are being too cautious in over-referring patients to services that will manage them less well than themselves. Furthermore, we must practice the medicine of uncertainty, ambiguity and complexity,18 balancing conflicting priorities and working beyond even the best clinical guidelines, which NICE considers unlikely to be able to accommodate more than around 80% of patients for whom it has been developed.19
CONCLUSION
For revalidation to succeed it will be necessary for the profession to agree that judgements that a doctor is ‘up-to-date and fit to practise’ are fair and valid. These difficult judgements must involve more than counting courses attended and hours spent listening to lectures. We believe isolation and insight are readily understandable to our profession and able to be stated in operational terms and we offer them as two pillars upon which these judgements could be based.
- © British Journal of General Practice, 2009.