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In the brave new world of medical regulation, there are many questions to be answered

Some of the complex and pressing issues facing medical regulators around the world are profiled in Marie McInerney’s final report below from the recent 12th International Medical Regulation Conference in Melbourne.


Marie McInerney writes:

Four years ago, former Radio National broadcaster Julie McCrossin was working together with senior federal health department executives at an international health forum in Canberra that she was helping to facilitate.

Two days later, she found herself unable to speak. This was due to a traumatic intubation during a biopsy that confirmed she had stage four throat cancer.

Now in remission, McCrossin shared her story with conference delegates to make the point to regulators and others involved in the health system that it is “absurd” to talk about “them” and “us”.

“Any one of us can slip through that membrane (to become the patient),” she said, launching an intense interactive session challenging regulators to say what action would be needed, where they lived, to ensure they would get safe, quality health care if they were the patient.

It was a session designed to ask as many questions as it answered, but it prompted the ready admission from UK General Medical Council chair Dr Terence Stephenson that most doctors know “who they wouldn’t want to be treated by” – who they wouldn’t let treat family or their dog.

“I’ve always been troubled that the public doesn’t know that,” he said.

For many of the delegates, it was access to information about the practitioner and the treatment that they would be after.

But even if we did have more transparency of data and health information, McCrossin asked, how do we ensure the very vulnerable are “deadset safe”? What about those with low health literacy, who aren’t fluent in the main language where they live, who lack a sense that they have any agency or power, who live in more remote areas, and are often very sick, she asked.

And, said New Zealand GP Dr Jonathan Fox, the value of information about quality health care is predicated on the patient having a choice of medical practitioner – which is not available for many, especially those living in rural and regional places.

He asked: “What about the patient who doesn’t have choice?”

Improving complaint processes

At the start of the three-day conference, organisers polled the nearly 500 delegates at the conference on what keeps them awake at night.

The results were reported back on the final day.

Over half of those who responded said they worried whether or not regulation was protecting the public adequately. About a quarter worried about “things I don’t know”, practices and behaviours of doctors that they didn’t know about, or not having enough “intelligence” to be effective.

One in five worried about making the wrong decision – either failing to protect a patient or harming a doctor by putting them through an unnecessary complaints process.

The findings underlined what one presenter described as a “weakness in the current system” – that the process can be a negative experience for both the practitioner, who feels stressed, and unfairly or unjustly subjected to a notification, and the patient, equally often very vulnerable and stressed, who feels the regulator “protects its own”.

The conference heard about new approaches put in place by the General Medical Council in the UK to balance public safety with the needs of ill or vulnerable doctors, after a review of cases found that up to 28 doctors had died by suicide between 2005 and 2013 while being investigated by the GMC.

The review showed that many of the doctors who suicided suffered from a recognised mental disorder, most commonly depressive illness, bipolar disorder and personality disorder, while a number also had drug and/or alcohol addictions.

The GMC’s Anna Rowland told the conference that mental health specialist Professor Louis Appleby had been enlisted to identify what changes could be made to GMC processes. Croakey readers can find out more here about those changes, including recognition of the need to act earlier, more sensitively and to focus better on treatment.

Rowland said the aim was to provide “sensitive handling” while ensuring patient protection.

There were also many discussions on how to make the system work better for patients and other complainants, including adopting restorative justice processes that put patient and practitioner in the same room to come to an understanding and response – “a move from a reporting system to a learning system”, as one presenter put it.

Currently regulators in Australia are restricted in what they can tell patients about an investigation but one session discussed whether even just warmer communications, thanking them for their complaint and saying that it may not have resulted in punishment but that it would help to improve practice or systems, might make a big difference.

More voices in the room?

US regulator Kathleen Haley, CEO of the Oregon Medical Board, told a plenary session that one issue that “snaps my mind awake at 3am” is the makeup of her board, which she thinks of as “a big dinner party”.

She worries: Are they the right people at the table? Do they come from diverse backgrounds of experience and geographic place? Do we have the right tools? Do we mentor members who are brand new?

Most regulatory boards now have public and consumer representatives, but one speaker recalled a leading regulator being aghast not so long ago at the very notion, before being slightly mollified by the thought that it would be acceptable, “perhaps if they had a PhD”.

Interesting questions were raised in other sessions about consumer representation – such as whether community board members agree with the public or their fellow regulators in an outcry over perceived regulator failure, and whether growing level of public representation was producing different judgments on cases and/or having an impact on public confidence.

Such questions also highlighted for Croakey some gaps in the program. While there were many consumer representatives of regulatory bodies speaking and presenting, some of these issues could have been more deeply explored with a dedicated patient voice and/or session, at least an opportunity for complainants to highlight ‘best’ and ‘worst’ practice in regulation.

Interestingly, this article – Nothing about us without us”—patient partnership in medical conferences was published in the British Medical Journal just before the conference, saying that involvement in academic medical conferences “is an important step to bring patients closer to the conversations driving the future of healthcare” and to widen research agendas.

Given the strong presence there of regulators from Canada, the US, New Zealand and Australia, it would also have been interesting to hear, from regulators and from Indigenous organisations and patients, about the role of medical regulation in cultural competence and safety.

Talking about what keeps him awake at night, outgoing IAMRA chair Niall Dickson referred to the UK’s Mid Staffs scandal where he said it was not the professions, community organisations, or hospital board that were making enough noise about the problems – but the families of patients who were the “canaries in the coalmine”.

“A bad doctor is better than no doctor at all”

For Dr Gyikua Plange-Rhule from the Medical and Dental Council of Ghana, it was a revelation to come to the conference and discover that other regulators are as unpopular as she sometimes is.

“We get told ‘all you care about is attacking doctors’,” she told Croakey. While she said it is good in some ways that Ghana is not as “quick to pounce” on complaints as are Western regulators and media, there are problems when workforce shortages and cultural attitudes to doctors still produce the view that “a bad doctor is better than no doctor”.

She often hears criticism of sanctions against doctors, even if it’s resulted in the death of a patient, that it “won’t bring them back”.

From Africa to rural New Zealand and Australia, this was a big issue across the conference – where patients, communities and health administrations overlook poor performance and behaviour because a doctor or other practitioner will be too difficult to replace. (Uganda, for example, has just 5,000 doctors for 40 million people, compared to around 100,000 for half that many people in Australia)

While most regulatory systems have clear ways to act when something is definitely wrong (assaulting a patient, prescribing the wrong drug), there are also questions about what to do with general negligence or under-performance (such as not suggesting a relevant test/screen, not using the latest evidence-based treatment guidelines, not addressing co-morbidities etc).

A Northern Territory study presented to the conference of regulatory cases that did not lead to sanctions or other action found that most were about clinical care, were not frivolous, and involved harm or poor outcomes for patients. But they found that while the treatment was “not ideal, not perfect”, it still usually fell “within reasonable standard”.

Some regulators see the answer in peer review, common practice in the UK and New Zealand, where doctors in clinical groups get together – in a supportive, non-punitive environment – to discuss relevant details of their practice (for example, GPs in the same region get together and review each others’ prescribing rates), to help the poorer doctors to improve their practice.

It’s what the UK’s GMC hopes its controversial new revalidation system will help address, particularly by getting “360 degree feedback” on doctors from a mixture of medical and non-medical colleagues. (Critics of revalidation say it is a cumbersome tick-box exercise, that was introduced without evidence of effectiveness and only highlighted lack of accountability by regulators themselves. A review is underway.)

But the issue also raises international reporting issues. One Zambian delegate called for international reporting of bad doctors. “If they are a bad doctor in New Zealand, they are a bad doctor in Zambia,” he said.

Finally, incoming IAMRA chair Dr Humayun (Hank) Chaudhry, who has a public health background, sounded a warning on the “dangers of unintended consequences” in regulation.

He cited the case of cardiac surgeons in New York State whose ‘death rates’ for coronary bypass surgery were released to the public annually, in a bid by health officials to stamp out poor performance. It famously saw mortality rates fall, but prompted concerns that some surgeons were turning away severely ill patients for fear a death would hurt their rankings.

Reflections from some participants

  1. What was the most important takeaway message from the conference? Why was it the most important?

Dr Margaret Mungherera, Vice Chair of the Uganda Medical and Dental Practitioners Council, former President of the World Medical Association, IAMRA chair elect

The most important message I took away is the need to build public trust and confidence in the regulatory system. This is because access to health services depends on the quality of the health services. The quality of a service is measured by how efficient, effective, patient centered and to what degree patient safety is assured. So the building of public trust and confidence in the services is therefore important.

Mark Bodycoat, Community member, Medical Board of Australia

There is a great deal of interest and energy in the medical profession and among medical regulators worldwide in setting, attaining and achieving high standards of practice and, by doing so, achieving the best possible outcomes for patient safety. Because there are significant differences in the scope and maturity of the regulatory systems represented at IAMRA, there are wide variations in the abilities of the regulators to establish and maintain the systems required to do this. Australia’s medical regulatory system is amongst the best in the world, and offers high standards of patient safety, but we need to continue to try to improve it.

juliemicJohn Stubbs, Community Member, New South Wales Board of the Medical Board of Australia

I was delighted to hear how well we do things here in Australia – and I was not aware of that before. We can continue to improve but from most of the overseas delegates I learnt we are really at the forefront of international regulation. In some ways I am not surprised as we ‘really punch well above our weight’ in the international health scene – and regulation is part of that.

  1. What would you have liked to hear more about? Why?

Dr Margaret Mungherera, Vice Chair of the Uganda Medical and Dental Practitioners Council, former President of the World Medical Association, IAMRA chair elect

I would have liked to hear more from experiences in resource-constrained countries in Africa, South America and Asia. How have they innovatively and creatively overcome the challenges in medical regulation?

I would have loved to hear more from members of the general public other than journalists (as well as the session led by Julie McCrossin, ABC TV and radio broadcaster Geraldine Doogue hosted a plenary session on ‘Shaping and old profession for a new society: what does the community need/want/expect’). And more presentations in the workshops from Africa and Asia.

Mark Bodycoat, Community member, Medical Board of Australia

There is a lot of work going on to maintain and improve standards of practice, but the public doesn’t always know much about it. Patients, the ultimate users and the intended beneficiaries of this work, tend to trust that there is a good system in place and that they are in fact protected from poor practice and its effects.

But they often don’t know what is actually going on, or HOW they are protected or what THEY can do if they get poor service or outcomes. Because they trusted “the system” they often feel let down, disempowered and angry in these circumstances. There is a substantial need for greater information for health consumers and for the continued and expanded inclusion of their voice in regulatory planning.

John Stubbs, Community Member, New South Wales Board of the Medical Board of Australia

Nothing more really – there were really interesting and engaging speakers, excellent plenaries and facilitators. Extremely well organised!

  1. How will what you heard there change the way you work?

Dr Margaret Mungherera, Vice Chair of the Uganda Medical and Dental Practitioners Council, former President of the World Medical Association, IAMRA chair elect

I intend to promote a dialogue between our medical regulatory body and the public. And to use the Melbourne presentations to promote discussions on assessing competency of doctors at different stages in their career.

Mark Bodycoat, Community member, Medical Board of Australia

I will continue to work with my colleagues on the Consumer Reference Group, on the Medical Board and in AHPRA to see that the work we do is as inclusive as is reasonably possible of the health consumer voice and to build on the healthy appetite for inclusion that already exists amongst those bodies.

John Stubbs, Community Member, New South Wales Board of the Medical Board of Australia

I will be really mindful of the practitioner – we do address the issue of public safety, but in a number of ways, clinicians bear the brunt. We must use good evidence, some rat cunning and our combined skills as a board or committee to achieve best outcomes for all.

* Croakey approached a number of other delegates for this Q&A but had not heard back from them in time for publication.

From the Twitterverse

juliemc2juliemcjuliemc3 juliemcintro

challenges

finalcommentsfeelsafe

maureenboontrust

leannewpatientexpecsvanekertmededfranbaum

usarepsregtheory

welcomewelcomedelegatesmanagers

newchair chaudhryclosesconfclosedicksoncloses

wordcloudfeatureimage

Thanks to all who helped share the #IAMRA2016 news

• More than 5.5 million Twitter impressions
• 279 participants on Twitter

finalanalyticsfinalparticipans• Read the Twitter transcript here.  See some of the @WePublicHealth coverage here.


• Journalist Marie McInerney covered #IAMRA2016 for the Croakey Conference News Service.

Bookmark this link for the coverage.

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