Revalidation of Canadian physicians

We commend Wendy Levinson for her provocative suggestions regarding revalidation of Canadian physicians.1 We also applaud CMAJ for publishing views that are more demanding and supportive of meaningful external verification of Canadian physicians' ongoing competence than those of the Canadian Medical Association.

We agree with much of what Levinson has advocated, specifically the call for a revalidation process for all physicians implemented by the provincial medical regulatory bodies and the call for an external assessment of physician performance. Indeed, valid methodology to measure the actual performance of physicians in practice is the Holy Grail sought by medical regulators.

As noted in the editorial, a number of jurisdictions have mandated or will mandate participation in 1 of the 2 national maintenance of certification programs. Two jurisdictions, Alberta and Nova Scotia, also require all physicians to undergo regular multisource feedback reviews from patients (if applicable), colleagues and coworkers. Rather than an “alternative approach,” as suggested by Levinson, Alberta's Physician Achievement Review program is an integral component of the Alberta college's revalidation strategy. Although it is a quality-improvement program, 20% of physicians undergoing this review will be flagged for follow-up, and 1 out of 5 of those (about 4% of the total) will undergo a formal peer review of their practice.

In addition, Levinson argues that the process is “only feasible for primary care and larger specialties” when in fact Physician Achievement Review tools have been created, used and validated for primary care, medical specialties, surgical specialties, episodic care (e.g., emergency and walk-in practices), anesthesia, laboratory medicine and diagnostic imaging. Very few physicians are not captured by the Physician Achievement Review process. Results from our implementation of each set of Physician Achievement Review tools have been published in peer-reviewed journals.2^,3

In other jurisdictions, peer review of physician practice is a prominent component of quality assurance. Many provincial medical regulators operate accreditation programs for laboratories, diagnostic imaging and other diagnostic modalities. These programs not only capture and review the policies and procedures but also involve direct inspection of the facilities where physicians provide services as well as review outcomes.

In addition, many medical regulators either operate, or have access to, prescribing or dispensing information on a limited or broader scale. Such information can prove useful as a screen into what physicians are doing in practice. The Collège des Médecins du Québec has used prescribing data very effectively in monitoring, intervening in and improving the practices of physicians in that province. We look upon the analysis of databases, such as those for prescribing, as offering a real opportunity to create affordable, proactive, valid and reliable tools to assist in providing the kind of external oversight that Levinson recommends.

Notwithstanding the many activities we employ to ensure that our members are performing to an acceptable standard, we recognize that the currently available tools are not sufficient to ensure that every physician remains competent. We therefore heartily support Levinson's call for more research to understand the relation between revalidation and quality of care in practice and to explore the most effective methods to assess physician performance.

Although examinations can measure a physician's knowledge base, they do not measure how a physician actually performs in practice. Thus, although we are less sure of the value of examinations in pursuit of this goal (and nor are physicians in our jurisdictions), we strongly support adding methods to our toolbox that have been proven successful. Evidence-based regulation should be our mantra as we move to achieve the very important ends that Levinson advocates and that our public demands.