This week the UK regulator of doctors, the General Medical Council (GMC), has launched a consultation over the Continuing Professional Development (CPD) of qualified, practising doctors. This subject is of immense importance because the pace of medical advances is such that patients cannot expect to receive the best treatment if doctors are not up to date.
The GMC believes that individual doctors should carry primary responsibility for their own CPD and that no specific material should be mandatory. A system of annual appraisals has been in force for UK doctors since 2002, mainly to identify personal and professional development needs. These appraisals are often arranged by a doctor’s employer if he has one but they can be carried out by a number of appropriate organisations. As part of the annual appraisal process each doctor’s personal CPD arrangements are reviewed and recorded but doctors are not legally obliged to follow any advice given. A new system is scheduled to be rolled out from late 2012 onwards under which the licence of doctors to practise will require to be revalidated every five years. As part of the revalidation procedure the adequacy of each doctor’s CPD will have to be demonstrated by examining the records from past appraisals.
In general, there is much to be said for every doctor managing his own affairs with limited bureaucratic interference, regulatory burden or political pressure. However, lessons from other countries, particularly the USA, teach us that even doctors are not immune from pursuing their own self interests. Some members of the medical profession are financially or commercially motivated and do not voluntarily keep abreast of new developments as they should. Doctors can also share the same biases as one another. In such circumstances they may unwittingly fail to put the public interest first.
Most doctors are general practitioners. Their role is a very broad one to which no brief description can do justice. However, the cornerstones of general practice are diagnosis, lifestyle advice and pharmaceuticals. If action other than drug treatment or lifestyle adjustment is needed or if the diagnosis is uncertain, the patient will generally be referred to a hospital or specialist. If general practitioners are to provide the best medical care, they absolutely have to be on top of the latest drugs and diagnostic tests suitable for use in a general practice setting. The UK medical profession is one of the best in the world but there is evidence that patient outcomes in some illnesses are being compromised by poor uptake of new drugs in the UK . Part of the reason is economic or political, for example the past policies of NICE regarding the affordability and value of drugs. Another part of the reason is that doctors may have a good case for not prescribing a new drug unnecessarily until it has been around long enough for unexpected, important side effects to be ruled out. However, the third part of the reason is that many UK doctors have a bias against learning about new medicines and diagnostic techniques. To doctors it can always seem more pressing to see one more patient in the waiting room, to visit one more really ill patient or to go off duty on time rather than to be learning about new products.
The need for doctors to study drugs and for high-quality independent reviews has risen for three reasons:
- Pharmaceutical companies have been responding to mergers, difficult times in the industry and growing centralisation of prescribing decisions by cutting back on salesmen visiting doctors. These people were never very popular with many doctors but did help to generate interest in medical advances.
- The growing global trend towards increased regulation, the rising complexity of medicine and the heightened financial pressures on the pharmaceutical industry have combined to raise the demand for independent expert views and understanding.
- The way forward is not for organisations like NICE to issue rigid prescribing edicts. Such bodies have their role but tend to be slow and ponderous and to lag behind leading medical opinion. In addition, the circumstances of each patient often vary too much to make simple, inflexible guidelines appropriate.
Learning about new drugs, diagnostic tests and the latest evidence on existing drugs is too important to be left for general practitioners to take or leave as they wish. The GMC is well placed to work out the details over how to move forward. Possibilities include an explicit requirement or a strong suggestion that the matter will carry a high profile when decisions are taken over the revalidation of individual doctors’ right to practice. The consultation opened this week by the GMC invites views from all interested parties. The lay public and politicians should lobby the GMC forcefully to make sure that general practitioners really do keep up to date with the latest drugs and diagnostic tests. At the same time the public and doctors should continue to remind politicians about the importance of medical advances being available quickly to patients.
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I don’t really see why a reasearch fellow in pharmaceuticals can comment on revalidation for the whole medical profession and I find most of the above article naive, unfounded and rather simplistic.
As a practising GP I have a duty to keep up with revalidation, otherwise I will lose my license to practise and fall behind with the latest evidence based research causing my patients to suffer poor quality care.
Financial reasons and self interest do not play a part in preventing me keeping up to date here, but volume of NHS caseload does limit energy and time for further study(however as revalidation and CPD accreditation is mandatory all GPs are given a week of study leave a year to compensate for study time so really the caseload does not limit our ability to attend such events) ; my self interest here only drives me to keep practising evidence based medicine and staying up to date with NHS targets; so I really don’t know what financially motivated self interest activities the author is describing which are preventing GPs from keeping up to date with revalidation?
Unlike in the USA where doctors are paid by patients and are inextricably biased and linked to the pharmaceutical and insurance industry, NHS doctors have little influence over what new medications they are allowed to prescribe and the PCT/local guidelines along with national guidance from NICE is what controls our prescribing habits; most “new” durgs are more expensive and are pioneered by secondary care consultant specialists NOT GPs!
Anyone who has recently worked as a GP would understand that prescribing new treatments really isn’t as simple a decision as the author would like to suggest and is subject to far more complex and less naive pressures than the desire to finish the job on time. We have to work untill the job is done; ill people will deteriorate and die if left untreated and no private company will whisk them up and care for them – the buck stops with the community GP.
Lastly I would like to challenge your sweeping theory “that many UK doctors have a bias against learning about new medicines and diagnostic techniques” – what a load of unfounded rubbish – where is your evidence for this other than GP’s sensibly deciding not to waste precious time seeing drug reps peddling expensive treatments justified with biased research?
Surely you can see that the hard pressed GP is saving this time for revalidation and evidence based education?
I think really the author started off mixing two subjects – revalidation and pharmaceuticals; actually revalidation is far greater than just the area of pharmacy. GPs act as gatekeepers and are experts at efficiency measures whilst providing a high standard of care with limited resources – no other country in the world can lay claim to that as our system is unique and cost effective compared to many other countries – the inadequacies in treatment and diagnostics dont come from GPs but from political will to avoid spending more money.
I would like to see the Author advise parliament on her view of the role of NICE and see how it goes down in a time of austerity – really you are living in a dream
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From the Author in reply to Ben Sinclair (@MensHealthTips)
Thank you for your comment. To my mind you and I seem to be in broad agreement and so I am confused by the tone of what you have written. I have taken the liberty of reproducing your comments in upper case below and adding my remarks in normal type.
I DON’T REALLY SEE WHY A RESEARCH FELLOW IN PHARMACEUTICALS CAN COMMENT ON REVALIDATION FOR THE WHOLE MEDICAL PROFESSION AND I FIND MOST OF THE ABOVE ARTICLE NAIVE, UNFOUNDED AND RATHER SIMPLISTIC. Nothing in my article represents a medical opinion. The main recommendation is that the GMC should make sure that general practitioners really do keep up to date with the latest drugs and diagnostic tests. As regards how this should be done I said that the “GMC is well placed to work out the details over how to move forward”. For the record my professional work has not been confined to pharmaceuticals and none of the work of which I have been an author in medical journals relates to pharmaceuticals. I consider myself to be independent of both the pharmaceutical industry and the medical profession.
AS A PRACTISING GP I HAVE A DUTY TO KEEP UP WITH REVALIDATION, OTHERWISE I WILL LOSE MY LICENSE TO PRACTISE AND FALL BEHIND WITH THE LATEST EVIDENCE BASED RESEARCH CAUSING MY PATIENTS TO SUFFER POOR QUALITY CARE. FINANCIAL REASONS AND SELF INTEREST DO NOT PLAY A PART IN PREVENTING ME KEEPING UP TO DATE HERE, BUT VOLUME OF NHS CASELOAD DOES LIMIT ENERGY AND TIME FOR FURTHER STUDY(HOWEVER AS REVALIDATION AND CPD ACCREDITATION IS MANDATORY ALL GPS ARE GIVEN A WEEK OF STUDY LEAVE A YEAR TO COMPENSATE FOR STUDY TIME SO REALLY THE CASELOAD DOES NOT LIMIT OUR ABILITY TO ATTEND SUCH EVENTS) ; MY SELF INTEREST HERE ONLY DRIVES ME TO KEEP PRACTISING EVIDENCE BASED MEDICINE AND STAYING UP TO DATE WITH NHS TARGETS; SO I REALLY DON’T KNOW WHAT FINANCIALLY MOTIVATED SELF INTEREST ACTIVITIES THE AUTHOR IS DESCRIBING WHICH ARE PREVENTING GPS FROM KEEPING UP TO DATE WITH REVALIDATION? The comment about being financially or commercially motivated was specifically said to apply to “some doctors”. There was no implication that it applied to most GPs and certainly not to any specific individual. Some doctors, hopefully a small minority, do sometimes put earning money ahead of the interests of patients. Doctors are often more likely to follow courses of action if they are given a financial incentive to do so. Sadly regulations do not only have to cover the most conscientious doctors but also to make certain that differently motivated doctors are really doing the CPD that they claim and that the necessary material to suit their role is included. I am sure that we have all met doctors who remain licensed but are clearly not up to date in the way that they should be. The GMC rightly wishes to make this rarer.
UNLIKE IN THE USA WHERE DOCTORS ARE PAID BY PATIENTS AND ARE INEXTRICABLY BIASED AND LINKED TO THE PHARMACEUTICAL AND INSURANCE INDUSTRY, NHS DOCTORS HAVE LITTLE INFLUENCE OVER WHAT NEW MEDICATIONS THEY ARE ALLOWED TO PRESCRIBE AND THE PCT/LOCAL GUIDELINES ALONG WITH NATIONAL GUIDANCE FROM NICE IS WHAT CONTROLS OUR PRESCRIBING HABITS; MOST “NEW” DRUGS ARE MORE EXPENSIVE AND ARE PIONEERED BY SECONDARY CARE CONSULTANT SPECIALISTS NOT GPS! Somewhere along the line American doctors typically become more financially or commercially orientated than their UK counterparts. Some hard-nosed American doctors were once idealistic medical students who were just as altruistic as those in the UK. People who become doctors may have very noble intentions but a proportion will end up letting their profession down. The GMC needs to beware of increasing the burden on doctors but needs from time to time to update its regulations and procedures to improve medical practice.
ANYONE WHO HAS RECENTLY WORKED AS A GP WOULD UNDERSTAND THAT PRESCRIBING NEW TREATMENTS REALLY ISN’T AS SIMPLE A DECISION AS THE AUTHOR WOULD LIKE TO SUGGEST AND IS SUBJECT TO FAR MORE COMPLEX AND LESS NAIVE PRESSURES THAN THE DESIRE TO FINISH THE JOB ON TIME. WE HAVE TO WORK UNTIL THE JOB IS DONE; ILL PEOPLE WILL DETERIORATE AND DIE IF LEFT UNTREATED AND NO PRIVATE COMPANY WILL WHISK THEM UP AND CARE FOR THEM – THE BUCK STOPS WITH THE COMMUNITY GP. This latter sentiment is very laudable and is a view that I am sure the vast majority of GPs share. However, I have known cases of doctors not putting patients first and others have been reported in the Press or to the GMC. I accept that prescribing decisions are not simple; this is why doctors must remain up to date.
LASTLY I WOULD LIKE TO CHALLENGE YOUR SWEEPING THEORY “THAT MANY UK DOCTORS HAVE A BIAS AGAINST LEARNING ABOUT NEW MEDICINES AND DIAGNOSTIC TECHNIQUES” – WHAT A LOAD OF UNFOUNDED RUBBISH – WHERE IS YOUR EVIDENCE FOR THIS OTHER THAN GP’S SENSIBLY DECIDING NOT TO WASTE PRECIOUS TIME SEEING DRUG REPS PEDDLING EXPENSIVE TREATMENTS JUSTIFIED WITH BIASED RESEARCH? There is actually quite a lot of evidence. My article is a brief one where a full discussion of this complex subject was not possible. I gave a link to a relevant 95-page document in my article and repeat it here. I can provide further evidence on request. My article does not say that GPs should waste time on drug reps. In fact; I said that the need for doctors to study drugs and for high-quality independent reviews has risen. Drug reps are, as I said, unpopular with doctors but reps only exist because some doctors see them. They do help those doctors to learn about new drugs although I agree that there are much better ways.
SURELY YOU CAN SEE THAT THE HARD PRESSED GP IS SAVING THIS TIME FOR REVALIDATION AND EVIDENCE BASED EDUCATION? I totally agree that GPs are hard pressed, which is why I made my comments about seeing one more patient in the surgery or paying one more home visit. Certainly I prefer time to be spent on high-quality study than seeing reps. What I am stressing is the importance of the evidence-based study. I know that this is putting one more pressure on hard pressed GPs but to my mind CPD is tremendously important.
I THINK REALLY THE AUTHOR STARTED OFF MIXING TWO SUBJECTS – REVALIDATION AND PHARMACEUTICALS; ACTUALLY REVALIDATION IS FAR GREATER THAN JUST THE AREA OF PHARMACY. GPS ACT AS GATEKEEPERS AND ARE EXPERTS AT EFFICIENCY MEASURES WHILST PROVIDING A HIGH STANDARD OF CARE WITH LIMITED RESOURCES – NO OTHER COUNTRY IN THE WORLD CAN LAY CLAIM TO THAT AS OUR SYSTEM IS UNIQUE AND COST EFFECTIVE COMPARED TO MANY OTHER COUNTRIES – THE INADEQUACIES IN TREATMENT AND DIAGNOSTICS DON’T COME FROM GPS BUT FROM POLITICAL WILL TO AVOID SPENDING MORE MONEY. I said that the UK medical profession is one of the best in the world and that the role of GPs is a very broad one to which no brief description can do justice. The impact of spending constraints is important but it is not the whole story.
I WOULD LIKE TO SEE THE AUTHOR ADVISE PARLIAMENT ON HER VIEW OF THE ROLE OF NICE AND SEE HOW IT GOES DOWN IN A TIME OF AUSTERITY – REALLY YOU ARE LIVING IN A DREAM. The author has advised the Department of Health and senior politicians about her views on NICE. Extensive links to my blogs for 2020 health, published work, campaigns, submissions to Government departments and comments on Twitter can be found at http://www.researchideas.co.uk . All this work is purely voluntary and unpaid. I hope that this reply helps to reconcile our perceived differences.
Many thanks for your further explanation, which clarifies your points more fully and puts the article in a better context.
I agree broadly with your sentiment on reflection of your comments; but still feel that the US market and the UK medical profession are two very different beasts mainly because of the way the doctors are renumerated; therefore the UK medical profession is less open to financial bias as the US medics are. I have not had time to read your evidence of bias against new diagnostics/therapeutics but will do so with interest.