Revalidation of Canadian physicians

The author responds:

There is general agreement that any system of revalidation should ideally measure the competence of physicians in each of the CanMEDS roles and the actual performance of physicians in their daily practice. As suggested by Trevor Theman and colleagues, Craig Campbell, and Robert Ouellet, a robust revalidation system should incorporate multiple assessment tools: self-assessment of knowledge, practice reviews done by peers, simulation testing of skills and feedback from patients and peers. We all agree that a broad array of tools is needed to assess physicians' competence; ideally, each tool would measure a different aspect of physicians' skills. However, all of the letter writers are against the use of an examination.

How then can we measure physicians' knowledge? Patients want a physician who is up to date on the most recent advances in their field and they think that physicians should periodically take a test. However, physicians argue vehemently that they do not need a test for a variety of reasons: they keep up to date through continuing medical education, examination preparation would take too much time, and tests do not measure what physicians do in practice. My suspicion is that fear of failure may be a factor in the resistance to an examination. I experienced that fear when I recently wrote the American Board of Internal Medicine's recertification examination. However, as with all examinations, it provided the impetus for me to undertake a comprehensive study program to update my knowledge. The preparation for the examination was an excellent learning experience.

An examination is a reasonable mechanism by which to assess knowledge with an external standard. Studies indicate that physicians are poor at judging their own competence1 and that they are unlikely to be able to accurately assess their knowledge in the absence of such an external standard.

I continue to believe that a comprehensive system of revalidation needs to incorporate methods to assess both knowledge and performance in practice.2 For example, practice assessments can review how I manage essential hypertension, but they cannot capture whether I will recognize that a patient has a pheochromocytoma as the underlying cause of their symptoms: an examination serves this purpose better than a practice assessment. Specialty-specific examinations have been used effectively in the United States for the last 2 decades to measure knowledge. In Canada, we must hold ourselves to a high standard to ensure that we provide the best possible care to our patients.