Accompanying this are some sixty generic standards, complemented in separate booklets by more detailed guidance on particular aspects of practice, for example, confidentiality. Good Medical Practice is underpinned by careful research on patients’ expectations of doctors. It is the template for the specialty-specific versions now published by most of the UK medical royal colleges.
Good Medical Practice was designed to guide doctors in their everyday practice. It was first used by the GMC as the benchmark against which UK doctors’ fitness to practice should be assessed when complaints are made against them. Today, it underpins licensure, certification, and revalidation. It is the foundation of all medical curricula in the United Kingdom.
Every year, on convocation day, the new doctors who have just graduated from Cambridge University stand to commit themselves publically to uphold Duties of a Doctor throughout their practicing lives. The students initiated this moving ceremony fifteen years ago. It would be good if other universities in the United Kingdom followed their example.
The licensing authorities in Australia34 and New Zealand35 have introduced their own versions of Good Medical Practice.
United States
In 2002, distinguished physicians, under the auspices of the ABIM Foundation, the American College of Physicians, and the European Federation of Internal Medicine, published the statement Medical Professionalism in the New Millennium: A Physician’s Charter.36 The Charter explains the underlying rationale, against the background of their heartfelt concern that the principles of medical professionalism were being eroded or even lost in today’s managerially driven healthcare.
The authors described three core principles of professionalism, namely, the primacy of patient welfare, patient autonomy, and social justice. They then listed ten commitments that doctors have, including, for example, commitments to professional competence, honesty with patients, patient confidentiality, and maintaining appropriate relations with patients. The Physician’s Charter has been seen as a very valuable reminder to doctors of the essentials of contemporary medical professionalism and their central relevance to modern medical practice, and in that sense has been widely appreciated. However, the Charter is a statement of a set of principles; unlike Good Medical Practice, it was not designed to be an operational code.
Perhaps recognizing this, in 2005, the U.S. Federation of State Medical Boards (FSMB) started informal consultations with other interested organizations to promote effective medical regulation. One result was the creation of the National Alliance for Physician Competence, charged with producing a U.S. version of Good Medical Practice. The various bodies responsible for educating, licensing, certifying, and credentialing U.S. doctors all recognized that they had no common language or framework for fulfilling their responsibilities in a consistent way, and that they needed one. GMP-USA was intended to present an agreed statement of professional responsibilities for both U.S. and Canadian doctors, for use in everyday practice. It was published online in 200937 but was not adopted by the constituting bodies because of unresolved differences among them about content and purpose. As an exercise in collective self-regulation, the attempt failed – a bridge too far. It seems that unresolved issues about professional identity and responsibility were the problem.
Meanwhile, in 1999, the U.S. Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) together began the Outcome Project to define competencies that would be used in accrediting graduate medical programs.38 This project identified six general competencies that are widely and successfully used in the United States and elsewhere today. The competencies are the following: professionalism; patient care and procedural skills; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; and systems-based practice. The competencies have provided a durable framework for assessing practice at all levels.
Canada
In 2005, the Royal College of Physicians and Surgeons of Canada created their CanMEDS document around the competencies for training in patient-centered practice.39 Although not a code of practice, it has nevertheless provided the basis for guiding and tracking doctors’ participation in continuing medical education (CME) and in their professional development and is the basis for maintenance of certification by the College – Canadian MOC. A version of the CanMEDS framework is used by the College of Family Physicians of Canada, bringing consistency of purpose across all of Canadian medicine. Interestingly, the CanMEDS and ACGME competencies complement each other.
Holding doctors to account: maintenance of licensure and certification
Having a code of practice is the beginning. Making sure that all doctors observe it conscientiously throughout their active practicing lives is the critical next step. In many countries, professional bodies and employers encourage and support CME and continuing professional development (CPD). However, as with any voluntary undertakings, the uptake over the years has been patchy. For example, a study of twenty-four countries in the Western world has shown that at present, none have completely satisfactory arrangements for ensuring ongoing competence.40 To try to achieve better results, regulators have therefore started to link the codes directly with evidence-based maintenance of licensure and certification. The three countries that led these developments offer somewhat different approaches.
United Kingdom: maintenance of licensure through revalidation
Revalidation was initially a professional initiative that acquired the backing of Parliament and the National Health Service (NHS). Support for it was strengthened by the recommendations of the three public inquiries mentioned earlier.12,28,29 The law now requires all British doctors regularly to demonstrate to the GMC that they are currently up to date and fit to practice in their chosen field and are able to provide a good standard of patient care. The license to practice has therefore ceased to be limited to the recognition of a doctor’s qualifications on graduation and the attainment of specialist certification at early moments in a doctor’s career. Instead, it defines the current status of doctors’ practice.41,42
Revalidation is the process supporting maintenance of licensure. Through revalidation, doctors must demonstrate their continuing compliance with the standards of Good Medical Practice. It is based on a portfolio of evidence covering CPD, quality improvement activity, significant events, feedback from colleagues and patients, and a summary of complaints and compliments. The updated portfolio is reviewed in an annual workplace appraisal. At the end of the five-year revalidation cycle, a legally designated Responsible Officer at the doctor’s workplace submits a recommendation based on the summated results of both the evidence and appraisals. The Responsible Officer decides whether there is sufficient evidence to recommend revalidation. In situations in which there are concerns about a doctor’s practice, the GMC will investigate and ultimately decide what to do through its established fitness to practice procedures.
Revalidation is still new. Three big questions remain unanswered. First, will the GMC settle eventually for an optimal standard of practice or accept something less? Second, will the evidence of performance offered by doctors be sufficiently robust to demonstrate compliance convincingly? And third, will the processes for assessing and judging the evidence be equally robust in demonstrating continuing compliance? The answers to these questions should become clearer from the evaluation of the first revalidation cycle.
Incidentally, following the recommendation of the most recent public inquiry,29 the UK Nursing and Midwifery Council (NMC) is piloting a revalidation scheme for nurses in 2015.43
United States: maintenance of certification – MOC
The American Board of Medical Specialties uses a common framework for professional development and assessment based on the ACGME competencies. Following a rigorous review of the existing program, new standards for ABMS Programs for MOC will be implemented in 2015.44 Each of the twenty-four ABMS specialty boards has adopted the framework. There are four parts:
Part 1. Professionalism and professional standing – the doctor should hold a valid, unrestricted license to practice in a state in the United States, or in Canada. MOC Programs must incorporate professionalism learning and assessment activities.
Part 2. Life-long learning and self-assessment – the doctor should take part in educational and self-assessment programs that meet specialty-specific standards set by the Member Board;
Part 3. Assessment of knowledge, judgment, and skills – showing by the results of examination that the doctor has the necessary knowledge to provide quality care in his or her specialty.
Part 4. Improvement in medical practice – requiring physicians to engage in performance-in-practice assessment (at the individual or system level) with ongoing improvement activities.
To give some idea of performance in MOC, it is helpful to look at the American Board of Internal Medicine (ABIM) MOC requirements as an example. ABIM says that, as of October 2014, of more than 200,000 ABIM professionally active Board-Certified physicians, more than 150,000 are currently enrolled in MOC.45 The minimum passing score set by ABIM is an absolute standard based on the examination content. Physician subject-matter experts determine how much of that content an examinee must get right to be deemed certified. On average, a physician must answer approximately sixty-five percent of items correctly to achieve a passing score. The Internal Medicine MOC first-taker pass rate in 2013 was seventy-eight percent.46
Diplomats in any specialty under the auspices of ABIM who do not pass the exam within the required period are not allowed to describe themselves as “Board Certified” in that discipline.
Maintenance of licensure
The Federation of State Medical Boards (FSMB) has adopted the principle of the maintenance of licensure (MOL) as a condition for license renewal.47 Physicians will be expected to demonstrate their commitment to lifelong learning that is relevant to their area of practice and contributes to improved healthcare. In 2010, the FSMB’s House of Delegates adopted a framework for putting MOL into action, but implementation is estimated to be still several years away. Meanwhile, there is an expectation that participation in MOC will be accepted as representing substantial compliance with MOL, while not a requirement for MOL.
Canada
The Royal College of Physicians and Surgeons of Canada has adopted MOC for Canadian specialists and the Canadian College of Family Medicine has done the same for family physicians. A new version of MOC, CanMEDS 2015 is about to come into use following a meticulous process of development and consultation.48
Completion of an RCPSC Fellowship, the mark of certification as a specialist, is dependent upon a physician’s commitment to take part in MOC regularly. Fellows who choose not to honor this commitment lose their entitlement to the use of letters FRCP(C), on the grounds that they can no longer demonstrate that they are up to date and fit to practice. A form of collegial fellowship exists for those who are retired from practice but wish to retain their affiliation with the College and the ethical principles it stands for.
In 2006, the Federation of Medical Regulatory Authorities brought the thirteen Canadian jurisdictions together to agree to a set of principles for a Canadian revalidation process.23 The authorities agreed that “all licensed physicians in Canada must participate in a recognized revalidation process in which they demonstrate their commitment to continued competent performance in a framework that is fair, relevant, inclusive, transferable and formative.” Since then, participation in CPD has been adopted as a condition of continued licensure by most jurisdictions. Progress other than this has been slow.
The battle for hearts and minds
Securing agreement to some form of time-limited licensure and certification has been opposed on both sides of the Atlantic, especially when the question of mandated accountability for standards of practice was introduced. The UK and U.S. experiences illustrate the point.
The revalidation decision in 1998 divided the British medical profession. Much has been written about the frantic process of achieving implementation between 1998 and 2012. It is important to understand the nature of the resistance if progress is to be made. Readers wanting to better understand the arguments, and the passion behind them, will find two publications helpful. Sir Donald Irvine, GMC President when revalidation was first proposed, recorded the early argument in detail, and submitted this in 2003 as part of his witness statement to the public inquiry into the practice of a murderous family doctor, Harold Shipman.49 The other is the report itself, written by a High Court Judge, Dame Janet Smith.12
Essentially, the loose coalition of reformers held together by the GMC was the key driver. The profession split between reformers – the GMC, medical royal colleges, and patients’ organizations, who wanted a robust, evidence-based, national process with public participation and external scrutiny; and the conservative doctors, led by the British Medical Association (BMA), who wanted to do as little as possible. In particular, the conservatives objected to the linkage of individual performance review with licensure because of the implications for the continuing right to practice of doctors whose performance was an issue. As the battle swayed this way and that, there was a dramatic intervention in 2004 when Dame Janet said in no uncertain terms that the adoption of watered-down assessments by doctors opposed to revalidation would not comply with the evaluation of practice required by the recently amended Medical Act governing medical practice, which the profession itself had asked for. It was largely as a result of her intervention that the form of revalidation in use today does comply with the law – just barely.
There are parallels in the U.S. experience. The implementation of MOC seemed to have been somewhat uncontentious, while it remained a strictly voluntary undertaking. However, some U.S. physicians are now expressing similar anxieties to their conservative British colleagues, primarily regarding any possible linkage between MOC and MOL, the very idea of MOL itself and in the potential use of MOC by employers, insurers, and other agencies as a lever to influence physicians’ behavior and employment conditions. There are other concerns too, particularly, for example, about cost to the physician, the time taken from patients, and the relevance of some of the knowledge testing. Some U.S. physicians are just angry at now being held to account for their current practice. The strength of feeling may be gauged in the views expressed by the Association of American Physicians and Surgeons,50 the recently formed pressure group Change Board Recertification,51 and the debate at the time of writing provoked by two papers in the New England Journal of Medicine,52,53 setting out both sides of the argument.
Lessons for the future
Across the Western world, the balance of power between the medical profession and the public is becoming more equal, more just, more right. We have learned that the change is unstoppable. Patient autonomy and all that it entails is here to stay. Achieving an optimal standard of practice and care from any doctor is the public’s defining expectation.
In these circumstances, the medical profession has a choice. It can get a grip, be positive, take the opportunity to redefine its social contract with the public,6 and paint a positive picture of how doctors see themselves and want to be seen by others, in the early twenty-first century. Or it can sulk, procrastinate, and do as little as possible in order to accommodate its weakest members, and watch the world outside make changes anyway.
In reality, the profession cannot go forward until it is prepared to acknowledge, confront, and deal with the elephant in the room, namely, the deep-seated belief among some doctors that they are entitled, by virtue of who and what they are, to near-total professional autonomy. They will resist any threat to such autonomy. Yet, we have also learned that such autonomy is not compatible with the delivery of optimal medical care for all patients. Moreover, other doctors positively welcome a new relationship with the public and patients and are determined to see this extend to the whole profession. The medical profession is thus divided; it has a crisis of identity.
We have learned that steps must be taken to seek resolution. The most important are described below.
On being a doctor: identity and codes of practice
We have learned from the experience with the ABIM Charter and Good Medical Practice that statements like these are essential for describing and communicating our core values, standards, and responsibilities. They are the outward visible expression of our identity, our professionalism. However, we have also learned that fine words are pointless unless we intend to put principles into practice. Indeed, without such intent, and the means to act on such intent, they could be interpreted at best as wishful thinking, at worst as almost a fraud on the public by promising what cannot be delivered across the practicing profession.
Good Medical Practice is evolving as the main code of professional practice in the English-speaking world. For the public everywhere, the case for a single code is compelling – call it International Good Medical Practice.
Honoring the promise: MOC, MOL, and clinical governance
We have learned that the reactive, complaints-driven approach to licensure and certification is being replaced by a quality-assuring model able to tell the public that all licensed and certificated doctors are currently good doctors, because doctors who have fallen short will have forfeited their practicing license or specialist certification. This new order of rigor, enhanced by a new order of transparency, is what the public is coming to expect from competent medical regulators.
As regulators learn from each other, we should expect more convergence on the kind of evidence and assessment methods to be used.54 For example, MOC is strong on the assessment of knowledge, whereas revalidation is not. Since knowledge is so important, the GMC needs to close this gap. On the other hand, revalidation is strong on the principle of workplace assessment, whereas MOC is just beginning to lean more in that direction, as evidenced, for example, by the discussions held recently at the Mayo Clinic by a group of high-performing, patient-centered U.S. hospitals.
As workplace clinical governance in health services everywhere becomes more patient centered and more sophisticated, and hospital boards insist on and support high performance from all their clinical staff, we should see both MOC and revalidation require rigorous formative and summative appraisal informed by high-quality data on doctors’ competence and personal performance. We should anticipate that much of the ongoing assessment process should merge with everyday practice as data generated through the electronic patient record becomes the norm.
Against this background, it is possible to envisage the kind of evidence that might go into a doctor’s MOC and revalidation portfolio in the future. For example, there would be evidence of clinical- and patient-reported outcomes, an assessment of knowledge relevant to the doctor’s current practice, multisource feedback from colleagues illuminating clinical judgment and the ability to work in a team effectively, evidence of attitudes to patients and the ability to communicate well drawn from patient-experience data, and evidence of honesty and general trustworthiness.
And so we can foresee a time when a common code of practice informs a common approach to the assessment of continuing fitness to practice. For the citizens of those countries involved, accustomed as they are to moving freely from one country to another, having that kind of guarantee about the quality of their doctors, wherever the patient happens to be, would be a huge step forward.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
