Medical recertification: putting the walls back up?

May 1, 2009
Paul Dubbins, MBBS
Volume 25, Issue 3

Health tourism has never appealed to me much. I am privileged to live in a country where healthcare is considered a basic human right and where, while quality and access may not be perfect

Health tourism has never appealed to me much. I am privileged to live in a country where healthcare is considered a basic human right and where, while quality and access may not be perfect, the standard of care nonetheless remains high. If my hip needs resurfacing, I am not sure I would wish to travel even 200 miles up the motorway to Birmingham.

When I have my heart attack, I want to be in a hospital where I understand what the doctors and nurses are saying, my family is close by, and the quality of food is so poor that my greatest risk is malnutrition. But I delude myself. Over 30% of doctors practicing in the U.K. were born elsewhere. Happily, this does not concern the polyglot English. I will use linguistic skills to make myself understood, just as my compatriots do: I will speak more loudly than usual and with an even greater level of exasperation. That should do it!

I recognize the advantages of a pleasant environment for recuperation. My preference is a month convalescing in Mauritius after every attack of “man flu.” If I am to travel to deliver my professional skills, then there have to be certain attractions. I have always considered that practicing mammography in St. Tropez would be particularly intellectually challenging.

Doctors and patients have always traveled, either to gain more experience or a different outlook on healthcare, or to seek high-quality healthcare perhaps unavailable at home. The nature and volume of traffic has changed over the past few years, though. Much of the travel by professionals was previously between commonwealth countries, from the U.K. to the U.S., from France to Canada. Travel by patients was largely restricted to the wealthy few who could afford the cost of the journey and the high costs of private healthcare.

Travel within Europe did occur but to a lesser extent. The opening of European boundaries has changed the trickle of health tourists into something more approaching a flood. Now patients are seeking faster, better, safer, and/or cheaper treatment, wherever it may be found.

The U.K. has welcomed (if that is the right word) many new doctors from elsewhere in the European Union. Since 2003, more than 20% of new registrants for medical practice in the U.K. have come from continental Europe. Around 15% of these have come from Germany, making it inevitable that Germany will seek to fill its medical practitioner coffers from elsewhere. I imagine that the exodus of doctors from some areas in Europe will put a significant strain on the healthcare systems of those countries. In 2005, for example, nearly 50% of doctors in Ireland who had just finished their training left the country. Malta lost nearly 25% in a similar exodus.

In clinical radiology, neither the patient nor the radiologist actually has to travel. Image transfer and teleradiology have made national barriers almost irrelevant. The free movement of doctors throughout the EU, and the even freer movement of patient information, has much to commend it. There are also some very significant problems. The exchange of ideas, the ability to learn new skills, and greater workforce flexibility are all cited as advantageous, but, as already mentioned, this comes at the risk of draining specialist skills from certain countries and destabilizing healthcare systems. Some countries have expressed concern that while migrant doctors and those participating in teleradiology programs may have great
linguistic skills, they do not understand the finer nuances of the language they are reporting into or the complexities of the various healthcare systems.

LIFELONG LEARNING

The added complication of recertification has now entered into this mix. We have long assumed that fitness to practice medicine is a lifelong capability bestowed on receipt of a medical degree and that specialist practice similarly requires only a one-off qualification. From then on, you need only turn up for work every day, switch on the PACS (having remembered the password), and growl into a tape machine or voice-activated transcription device. This is enough to demonstrate that your specialist radiological skills remain intact. If you audit the things you know you are good at, the results are bound to show you in a good light. You return home happy in the knowledge that you can still cut it with the best.

Not any more. A number of high-profile cases in which the quality of patient care has been called into question-or worse, where a general practitioner was convicted of serial killing-have provided the impetus for a process of revalidation or recertification in the U.K. Radiologists will now be required to demonstrate diagnostic and therapeutic skills on a regular basis, based on peer review of practice and evaluation of audit outcomes. Potential personal problems, such as drug abuse, mental health issues, and alcohol usage, will be assessed as well.

The process of formal recertification might be peculiar to the U.K. within Europe, but it is already well established in the U.S. What will this mean for the free movement of radiologists or the wider availability of radiologists' expertise through teleradiology? Clearly, all radiologists practicing within the U.K. will be subject to the same constraints. There seems little doubt, however, that the potential for outsourcing reporting work to radiologists in other European countries will be compromised.

Directives from the European Commission that mandate the sharing of information about individuals' certification should ensure that information on fitness to practice is available to all EU member states. However, such initiatives have met with little support. Few countries have signed up for full collaboration and some countries have resolved not to participate at all.

We are a disparate group of nations with different cultures and a rich history that is at times inclusive and at other times particular to the nation state. We have a justifiable pride in our own institutions and educational systems. But we are, in many ways, a uniform group of specialists. We are all committed to providing the highest quality diagnostic skills and image-guided therapy for our patients.

Could we not agree that the standard by which we should be judged should be measured by the highest common denominator, drawing on the best aspects of education, training, and supervision from all of our nation states? If we fail to grasp this particular nettle, then all of the strides we have made toward greater pan-European understanding and professional cooperation could be compromised. If the U.K. border is closed to those who cannot demonstrate satisfactory recertification, will all borders then swiftly follow suit?

We could produce a suite of tools that would allow us to evaluate our practice continuously against a series of defined criteria. These criteria could be nation-specific if required. Those wishing to contribute to patient management outside their own national boundaries could take a pan-European “radiology baccalaureate,” to be renewed every five years. Such a qualification would reaffirm our skills, reassure patients across our union, cement our mutual collaboration, and potentially raise standards of education, training, and care for all.

In the more immediate future, I am happy to help anyone struggling with language difficulties by providing lessons in voice projection, irritated looks, and intolerant sighs!