Chris Lancelot on... ensuring revalidation is right

I have no problem with the principle of revalidation: it is patently obvious that the nation needs to ensure its doctors are competent. But can revalidation be carried out accurately? It's not as simple as you might think.

For example, I have no worries about the operational side of our practice. We hit most targets and score well in patient surveys. But knowledge testing is a different matter.  

How would a knowledge test be performed? Many GPs over 50 have never taken a multiple-choice paper. Judging by the numbers considering retiring if asked to undergo revalidation, I suspect this is a widespread and valid concern.  

What is to be tested? The origin, insertion and innervation of sartorius? The microscopic findings in Hirschsprung’s disease? Knowledge testing is more difficult in primary care than the specialties, because of the vast array of subjects we cover. There is no way I can remember everything: but when faced with something I don’t know, or may not be up to date on, I have a foolproof remedy — I look it up. How do we test for that?  

Crucially, much GP medicine is currently devolved to other health professionals. Asthma was once one of my specialisms: I’m almost de-skilled now, because my nurses run the clinics.  

Finally, practices are surprisingly different. GPs in the affluent suburbs will seldom see chronic schizophrenia; rural GPs may have few ethnic patients; some practices have little or no HIV. A ‘one-size-fits-all’ GP knowledge exam — with questions on how to treat hypertension in an Afro-Caribbean, the next step in the control of a particular diabetic, or how to section a patient when no social worker is available — will not necessarily be an appropriate test of the individual GP in their current practice.  

Designing a knowledge exam to revalidate all GPs fairly will be a nightmare. It has to test adequately, yet not discriminate against GPs who for legitimate reasons have become deskilled in certain areas. The DoH will first have to validate revalidation, to ensure that it really does identify solely the poor performers. A doctor must fail revalidation, rather than the revalidation process failing the doctor.  

Dr Lancelot is a GP from Lancashire.

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