Life-long learning

With some 12,000 University Hospital medical staff currently on strike in Germany, issues of pay and working conditions are high on the agenda. However, amongst the long list of demands of their representatives is also a call for a comprehensive indenture governing postgraduate training. Here, few doctors are privileged to be signed up for the entire time of their higher specialist training. Training, certification and, thereafter, maintenance of standards are interrelated and key to the concept of quality management - a growing issue for healthcare providers and, ultimately, the general public. With reference to radiology, a recent insightful editorial by Forsting (Forsting M [2005] The future of radiology - from the necessity of a vision. Fortschr Röntgenstr 177: 1485-8) has highlighted the need to make structural changes to the German healthcare system. He proposes adoption of the Anglo-American concept of organ-based sub-specialisation. Such change may lead to individual consultants maintaining mastership of their chosen area of interest while providing more clinically relevant reporting. This approach could also impact positively upon scarce resources with a more efficient and economical use of expert opinion and hardware, thereby closing the circle of quality management.

Mors certa, hora incerta

However, a commentary immediately attached states that such presumed visionary considerations have been put forward frequently before and that the case for preserving the status quo is strong. The 28th President of the United States, Woodrow Wilson, is quoted as saying: ‘If you want to make enemies, try to change something’. Resistance to change somehow seems a natural approach. In contrast, actual change has often derived momentum from more emotional, headline-making issues that attracted people’s attention. Scandals have frequently triggered change. Healthcare reform may thus need to be public opinion- if not patient-driven. Calls for changes to Western healthcare systems date back to the 1980s in the US, when Arnold Relman, the then editor of The New England Journal of Medicine envisaged ‘a new era (of) assessment and accountability’. Specifically, he suggested that any medical activity should pass the test of ‘costs, safety and effectiveness’ to allow an informed argument of clinical management issues both with patients as well as healthcare providers. Further progressing from here, ‘the 21st century would be the era of resource constraints’ (Friedenberg).

But what is so wrong with our current system? The problem lies within medical self-regulation. Klemperer quotes BMJ editor Dr Richard Smith as saying in 1999 that the medical world has a culture of covering up mistakes and of forgiving those who made them (paraphrased). A US study of the same year found that at least 40,000, and perhaps as many as 98,000 people, die in hospitals annually as a result of preventable medical errors. Furthermore, a systematic review of the relationship between years in practice and quality of care found the performance of the majority of physicians evaluated to be decreasing with time. If such occurrences are indeed serious and widespread, they are considered by many as being immanent to the system rather than due to individual failures. However, failing individuals may still be key to the process in that we require ways of identifying and suggesting ways of dealing with problem doctors. Previously, as Smith asserts, the old way founded on the expectation that doctors would keep up-to-date professionally and would do something about colleagues who performed badly (paraphrased). Such half-hearted self-regulation appears to have failed, although there is perhaps no better way as replacing it with self-regulation: ‘The specialised knowledge and skill that form the basis of a profession (may) also make lay people largely unsuitable for regulating it’. While doctors primarily discharge their responsibilities to patients, they have special responsibilities to healthcare providers, i.e. funders of healthcare, which, ultimately, also represent the general public. If we accept the need for change to the way medical self-regulation is organised, ample best-practice examples have been drawn from the success story of quality management in civil aviation. In 1998 the International Civil Aviation Organisation initiated a cultural change by introducing regular and mandatory safety audits for all member states. Principally, the concept of revalidation for doctors has been modelled around those experiences.

In 2003 a Gallup poll established that over 80% of the general US public valued certification and regular certificate renewal to an extent that they would change physician if the attending doctor failed to maintain certification. A system of revalidation therefore has the potential to establish and maintain trust in the patient/doctor relationship. Revalidation aims to ensure that medical staff is up-to-date and fit to practice. To retain his licence, the obligation is on the practicing doctor to prove this is the case. The two elements of such proof are factual information regarding maintenance of standards of competence, care and conduct as well as evidence of reflection on the doctor’s performance. The instrument of the latter is regular formal appraisal, its outcome a personal development plan. Revalidation thereby takes continuous professional development beyond the mere certification of knowledge and competence to include performance, which also comprises social skills and, in particular, communication. More specifically, in addition to the backbone of a personal development plan and participation in appraisal, key evidence may include a description of an individual’s practice, results of benchmarking and medical audit, particularly relating to errors and other outcome measures, written knowledge tests, certification from an approved local person as well as results of validated questionnaires asking patients to rate a doctor’s performance. Irrespective of doctors’ likely natural trepidation when validated in this way, it is argued that could be gained from participating in such process. To this end, revalidation is only the final common pathway, the foundation of which could be laid down during postgraduate, or even undergraduate training. Indeed, there is no good reason why medical students should not be brought up in an environment that actively engages with clinical governance issues.

The front pages of medical textbooks frequently contain a disclaimer, stating that medicine as a science is evolving and that certain statements made in the publication should be checked against other, usually more up-to-date information. Considering learning as a process in today’s medicine thus cannot be done in isolation. Much theory evolves around the question of how we acquire knowledge. It is not feasible to briefly summarise this multi-facetted issue. What unites articles concerned with medical learning is the context of clinical training in which learning takes place. This defines a relation with the level of patient care as well as outcomes. So, to achieve excellence, i.e. to practice well, one must first be an effective life-long learner. Subjects of learning are as plentiful as demanded for the revalidation process and include knowledge and reflection on performance, i.e. identification of gaps and critical appraisal. Given that communication has been shown to affect patient outcomes, improvement of social skills and communication in particular are part of the enterprise. Learning should further be evidence-based, with feedback as the most available and influential measure at its centre. Wood concludes that ‘Without a system of constructive feedback, we are in danger of producing uncertain and overconfident physicians without adequate self-checks to regulate their activities and decisions.’ She also asserts that feedback, as a form of information sharing, is much desired by learners and it facilitates a communal sense of responsibility for learning.

To illustrate the application of these considerations for radiological training, UK practice may serve as an example: Following several years at senior house officer level, UK radiologists receive five years of structured, higher professional training before board examination and certification. Apart from providing a curriculum, The Royal College of Radiologists’ Structured Training document lays down the basic principles of training, namely the apprenticeship system, definition of core competencies, log book recording, annual appraisal and, finally, the testing of knowledge and competence, leading to board certification. There is particular emphasis on evidence-based practice, audit and research activities. More recently, instructional technology with web-based tools, telemedicine etc. has been put forward as a timely addition to the evolution of this textbook and apprenticeship-based model. With the establishment of three radiology academies, the UK has already implemented this development. Applicably, the Health Minister, Lord Warner, spoke at the launch via video link. Radiology as a technology-intensive specialty in many ways lends itself to the application of such strategies. A recent symposium in Frankfurt regarding the present situation and opportunities that arise through
> e-learning for general practice concluded that the development of
> e-learning activities is both sensible and urgent.

However, few international societies or regulatory bodies have adopted the concept of board certification built upon structured training. As an investigative and, in a lesser part therapeutic speciality, radiology already holds a high degree of transparency of work processes, making it an ideal candidate to pilot the introduction of structured training. Aiming for a high and consistent level of performance, a very large number of standardised routine procedures can be defined in standard operation procedures, a key tool in quality management. As long as examination numbers are sufficiently high enough locally, a very good standard of organ-based speciality training could be given. As with consultants, it seems legitimate to ask how then to assess what residents are capable of doing. This is easier to answer than how to identify those individuals who lack ‘the necessary humanistic qualities required of a physician’. It is certain that ‘putting effort into teaching and the challenging of residents coupled with supervision at a local level (paraphrased)’ may allow residents to be ‘the best that he or she can be’ (Friedenberg RM [2000] An endangered art: teaching. Radiology 214: 317-9). What does that mean for German radiology practice? Forsting suggests there has been little regarding necessary structural change in this country. This is supported by a search of the online database of the German publishing house Springer on 20/4/06, using the key words in this article’s title: it yielded no hits within radiology journals. German radiology needs to build upon its many and internationally envied advantages with respect to state-of-the-art infrastructure, healthcare spending and high level of clinical care given. Much work has already been done elsewhere. It takes no genius to consider it. 

Practicing medicine is at the heart of the human condition. Empathy towards one’s fellowman, whether patient, colleague or oneself, demands careful consideration of the path, if changes to the German healthcare system are being considered. If the case for structural change is acknowledged, the belief that lifelong learning supports quality in healthcare is, in my opinion, key to the approach. The move from loose self-regulation through variable compliance with continuous medical education towards a transparent system of regular revalidation with lay involvement remains an emotional one. Just as learning must be sought, change must come from inside. The methods required to carry out meaningful performance assessments are still being evaluated, but that should not necessarily hold back measures to improve on current regulations governing training, certification and maintenance of excellence as well as continuous improvement in healthcare provision.

*a referenced version of this article is available upon request by contacting the author at jlarsenmd@hotmail.com

01.05.2006

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