Elusive Continuing Competence by Anne Paxton

Since the American Board of Family Practice issued its first time-limited certificate 30 years ago, cosmic amounts of ink and forest products have been lost to the subject of continuing competence across the professions, with little more than token progress. Several recent news stories from abroad suggest that England, Ireland, and Australia are also confronting, or avoiding, the same issues so familiar to Americans. They have the same scandals, the same levels of controversy, and the same scarcity of truly pro-active programs to assure continuing competence, but they also have a few new ideas.

A key debate in England concerns the private General Medical Council’s proposal to strike doctors off the register if they fail regularly to prove their fitness to practice, a plan hatched amid growing hints from the government that if doctors do not put strong sanctions for poor performance in place, the GMC might be replaced by a state disciplinary body. A counter-proposal from the British Medical Association avoids the concept of revalidating physician competence. Called the "Surest Way Forward," it claims that such an idea could be open to legal challenge, especially from doctors who qualified in the European Union.

Rather than periodic checks, a constant watch on doctor’s performance would be preferable, this proposal maintains. The physician’s work would be always under review by senior doctors and managers who have on hand records of in-service training and achievements compared with peers in the same specialty, in the form of a clinical audit.

The scandal that put continuing competence on the front burner occurred at Bristol Royal Infirmary. For Steve Bolsin, a cardiac anesthetist there, peer review was a dismal failure. Noticing that open-heart surgery operations at the hospital were taking four hours instead of the normal one hour, and that the death rates for babies having such operations were up to three times those at other British Hospitals, Bolsin complained for six years, to no avail.

Authorities finally did move to address the problem, and now the cardiac surgeons involved face charges of serious professional misconduct. But Bolsin was hounded out of the country for having broken ranks with his colleagues.

Merrilyn Walton, health-care complaints commissioner in New South Wales, Australia, cites the Bolsin case as an example of why fellow professionals are not a reliable corrective for individual failings.

"Peer review is talked about as if it means something, but when you actually peel it back, it means 100 different things to 100 different people and a lot of people are practicing with no peer review at all."

The quiet verdict in the United States is that it’s expensive too. Without much fanfare, in 1996 members of the American Board of Medical Specialties discontinued on-site review of practice, which was costing up to $10,500 for a two-day on-site visit.

Echoing a familiar complaint about state licensing for physicians here, which stops at basic medical education, then turns over governance of specialties to private boards, Walton says Australians mistakenly assume that any surgeon who performs a specific procedure is properly trained to do so. "There are no laws requiring doctors to have surgical training before they perform operations. They train on the job. Some doctors think that watching a video of a doctor performing the procedure is sufficient preparation for them to operate on patients. Some practice on inanimate objects, such as kiwi fruit."

In Ireland, the Medical Council which regulates physicians, also cited the Bolsin case as raising "disturbing questions about the extent to which the profession monitors its activities." The Medical Council’s "Discussion Paper on Competence Assurance Structures 1998" is proposing a "huge shake-up" of the profession, says the Irish Times.

Under its plan, doctors would be required to accumulate a total of 250 points over a five year period. Sixty percent of the points would be awarded for continuing medical education or continuing professional development, based on specific education and validation structures. Twenty percent of the points would be awarded through peer review, probably via small groups of peers undertaking practice visits, review of protocols, and case review. The final 20% of points would be awarded for performance review, including some systematic audit of practice with peer comparison.

Despite peer review’s many failings, it remains a central mechanism in reform proposals, and there is some reason to believe it has more effect than re-testing anyway, simply because a key factor in incompetent performance may be isolation.

That was abundantly clear in one of the top US health scandals so far this year: the case of the Palo Alto blood technician who was discovered to be reusing disposable needles for blood draws, contrary to the most basic principles of laboratory safety. An employee of SmithKline Beecham Clinical Laboratories, the technician, known as a phlebotomist, had received her training in 1994, and should have known that rewashing needles in a solution of hydrogen peroxide was ineffective in killing viruses like hepatitis and HIV.

Some 3,600 patients who had blood taken at her draw station were notified to come in to be tested for exposure to blood-borne diseases, several class action suits are now in progress, and stricter regulation of phlebotomy is in the works.

But the phlebotomist, who worked alone at the draw station, may have had a rationale for her admittedly bizarre behavior. Although no specific motive has been publicly described, there were several reports that she was rewashing "butterfly" needles, which are easier to use on patients than safety needles but cost up to 20 times as much, in order to keep them available without having to report the extra cost.

Whether this was her private reasoning or not, the key issue here was perceptively described by one quality assurance expert. "You train people, and you think they’re going to follow all the rules and understand them, and somebody who’s out by themselves, or even with a couple of people, may change the way they do things and not inform you. It’s just a human issue: people who are isolated tend to purposely or inadvertently reinterpret the rules, unless you’re constantly reinforcing them on some periodic basis."