Utopia, El Dorado, The Holy Grail and all that Excellence in emergency medicine

Abstract

Emergency MedicineVolume 3, Issue 4 p. 239-242 Free Access Utopia, El Dorado, The Holy Grail and all that Excellence in emergency medicine First published: December 1991 https://doi.org/10.1111/j.1442-2026.1991.tb00571.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat The following represents the text of the 1991. Tom Hamilton Lecture delivered to the Annual Scientific Meeting of the Australasian College for Emergency Medicine by Associate Professor Garry Phillips on 3rd November, 1991 Mr Chairman, Mr Hamilton, Ladies and Gentlemen. I am very honoured to have been asked by the Society to deliver the first Tom Hamilton Lecture following the inaugural address by Tom Hamilton himself. Why me? If one looks at the trend in Tom Hamilton lecturers, one sees restless people, rebels even. I was an anaesthetist turned intensivist when Emergency Medicine began in this country. I was not one of the original men and women who discovered it, but an opportunity arose to help the new specialty on its way and I took it, despite the raising of eyebrows and more by some of my colleagues. What of the title of this lecture: ‘Utopia, El Dorado, The Holy Grail and all that’? The origins of all three terms are known to you: Utopia “A place or state of ideal perfection. A visionary system of political or social perfections” El Dorado “A legendary treasure city; a place of reputed fabulous wealth” The Holy Grail “The symbol of a less pure kind of Christianity. The object of a legendary quest for mystical union with God” But none of these really express what I wanted. Perhaps the closest analogy of the search for excellence in Emergency Medicine is found in ancient stories like the twelve labours of Heracles, or Jason's search for the Golden Fleece, or the trials of Odysseus returning home from the siege of Troy. Perhaps Odysseus is the prototype emergency physician. He was described as a man of outstanding wisdom, eloquence, resourcefulness, courage and endurance. With a talent for ruses and deceptions, he was unscrupulous, but wise and honourable. For Emergency Medicine to develop, there must be a dedication to the pursuit of excellence by each individual, by each department, and by the Society and College. At an individual level, the way has been shown by those who began the specialty. The recently published excellent history of the Society outlines many of these achievements. I confess I must have been the worst contributor to that history, and I publicly apologise to Paul Gaudry and George Jelinek for the long delays in answering correspondence and for the gaps in my memory. The Society, like Heracles and Odysseus and others has not been without its problems. In his chapter on the Society, Paul Gaudry makes reference to “Formation of the Society”, “Society rethinks its goals”, “Controversy and realignment of goals”, “Rebuilding the Society”. Tom Hamilton in his President's Report enthuses about the future and quotes Shakespeare in support. Tony Harrison speaks of his concern for the future of the Society after formation of the College, and Richard Cockington rallied others to the cause of “resurrecting the Society” which has clearly been achieved. The road to the future has been laid by George Jelinek and his supporting cast. When you read the history, think of two aspects; the current situation, and the people who sustain it and will create the future, and the founders, who are old and tired, but won't go away a until they are certain of the future. In their memory I would like to quote from a poem by Mary Gilmore: “I am he Who paved the way That you might walk At your case to-day; I was the conscript Sent to hell To make the desert The living well; I bore the heat I blazed the track— Furrowed and bloody Upon my back. I split the rock; I felled the tree; The nation was— Because of me!”. The College has established a training and examination system which matches that of any College. A specialist emerging from this system is not a surgeon or a physician, or an anaesthetist, but an expert in the management of patients and problems presenting to the emergency department. Certainly he or she possesses skills also possessed by other specialists, some to a higher degree, and some to a lesser degree. However, one cannot demand respect for one's knowledge or skills, one must earn it by exhibiting the knowledge and skills at a level and with an attitude which cannot be criticised. And there is a time commitment. To control a situation, and to brook no interference, one must be there, all the time, if not personally, then in spirit through the person of one's staff. But there is more required. Joe Epstein, in his recent President's report, drew attention to the achievements of Emergency Medicine in seven years, while at the same time expressing concern at the paucity of our intellectual productivity. He repeatedly made one point, emergency medicine will only realise its full potential and obtain the acknowledgement it deserves when emergency physicians are positioned in every major contemporary debate of our time. We have to learn to resist the magnetism of the immediate, the obligation to fix now rather than to think and write. We must realise that in the world of medical politics, intellectual productivity is “the only game in town”. But more than personal respect and acknowledgement is required. The department must be acknowledged as having expertise 24 hours a day, and this depends on a team approach which is so good that the boss can be absent and not noticed because the department functions just as well in his or her absence. More than individuals and departments, the specialty must be acknowledged for the role it plays in present day health care. Health is a public debate and we are under public scrutiny. Read the Health Strategy documents and reports like those originating from the National Office of Overseas Skills Recognition and you will see where the future lies. Emergency Medicine has an advantage over all other disciplines; it is continuously open to public scrutiny. It is young, dedicated and enthusiastic. Support is there for the asking (or taking). I would like now to move on to a subject in which I have a particular interest, the question of continued demonstration of competence (alias “recertification”), perhaps best addressed by asking the following questions. What is it? Continued demonstration of competence means that we must show on an ongoing basis, that we retain the competence we had when we received our Fellowship. It is more than voluntary participation in CME. Why do it? Because it is part of continuing education, and because it demonstrates to ourselves, our colleagues, the public and government that we are competent. There is also a threat that if we don't do it, others will. The Department of Employment Education and Training is well down the track of reviewing what professionals do, including the setting of standards and the assessment of performance. Who needs it? We all do, but especially those who are practising outside the mainstream, or practising part-time. What is competence? Many things Competence implies possession of knowledge and technical skills, but it also implies the ability to gather data, to synthesize and organise data, to judge and to plan management. Competence implies a range of character attributes and skills including honesty, reliability conscientiousness, the ability to learn from experience, to react appropriately, to communicate effectively, to teach and to engage in continuing education. How is it tested? An ideal programme should contain three elements:— a) competence in practice, tested perhaps by outcome studies, by chart stimulated recall, or by practice visits b) ability to respond appropriately to a range of problems, which are important, new, or infrequently encountered, tested perhaps by simulations, patient based MCQs, or oral exams c) warranty of interpersonal and moral characteristics There is a discipline which studies whether examinations can test competence, and I will mention some recent work. a) Ramsey examined the prediction of three measures in the practice examined by the written American Board of Internal Medicine (ABIM) certification examination; a comprehensive peer rating instrument, a patient satisfaction questionnaire, and a structured chart review of primary care problems. He found a correlation of 0.39–0.44 (disattenuated 0.53–0.59) between components of the peer rating and the certification score obtained 5–10 years earlier. However, the certification score was uncorrelated with either patient satisfaction or quality of care methods. He also reported correlation between the oral component of certification 10 years earlier and case simulated recall (CSR) of 0.37 (0.5) and between a concurrent oral and CSR of 0.54 as a recertification exam. He found no relationship between peer rating, chart audit and patient satisfaction. b) Solomon examined the ability of the two part Emergency Medicine certification examination to predict actual clinical performance. He found a correlation of 0.45 (disattenuated 0.6) between written certification 10 years earlier and a CSR assessment. He also reported a correlation between the oral component of the certification 10 years earlier and the CSR of 0.37 (0.5); and between a concurrent oral and the CSR of 0.54, administered as a recertification examination.1 c) Norman compared 20 general practitioners selected randomly with a second sample identified by peer review as having deficiencies in competence. All took an MCQ/oral/simulated patient and CSR exam. He found a correlation of 0.42 (0.481 between MCQ and CSR administered concurrently. He also found a correlation between standardised patients and CSR of 0.69 (0.74) between oral and CSR of 0.6 (0.67) and between an objective structured clinical examination (OSCE) and CSR of 0.57 (0.64). Conclusions drawn from these reports by Norman were that all the studies indicated mid-range correlations between a written objective MCQ and measures of performance in practice, and that there was no evidence for large differences in standards of care in the test and actual clinical setting2. However, despite there being a clear relationship from these studies between scores on certification examinations and performance in practice, there was no relationship between patient satisfaction and the certification measures. How often? The process needs to be ongoing with verification at intervals of 5–7 years. Will this detect all incompetent practitioners? No. Many incompetent practitioners are “morally incompetent”, but can pass any tests set. The process which detects “bad apples” is related to, but different from the process which keeps “good apples” good. Is it new? Actually it is not. Reference to the need for ongoing education is made in the Hippocratic Oath. Sir William Osler was quoted by Tom Hamilton in his lecture “on the Educational Value of the Medical Society”. Sir William Osler wrote the following in another of his lectures in 1904. “The practitioner requires at least three things with which to stimulate and maintain his education, a notebook, a library, and a quinquennial brain-dusting. Every fifth year, back to the hospital, back to the laboratory, for renovation, rehabilitation, rejuvenation, reintegration, resuscitation etc”. What are the implications? Before establishing such a system, we need to have agreed upon a number of matters. • What are the components of the system? • What are the standards to be met? • What are the pass/fail criteria? • What happens to a failure? • Does it apply to all Fellows or new Fellows? • Is time-limited certification an option? How do we go about it? Carefully, The ultimate decision rests with the certifying body the College. But the Society could be involved. There needs to be planning, data gathering, communication, even before a decision is made on what route to pursue. Returning to the beginning, in the search of Emergency Medicine excellence, in the pursuit of Utopia, El Dorado and the Holy Grail, you are in a prime position in medicine. All that is required is the hard work of all Fellows of the College and all members of the Society in whatever areas they have talents Odysseus did not get home from by himself; he had a team which accepted bus leadership. Tom Hamilton did not establish what you have today by himself; he had a team which accepted his leadership. Associate Professor Garry Phillips References 1 Ramsey PG et al. Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med 1989;(7): 719– 726. Google Scholar 2 Norman G. ‘Can an examination predict competence?’ The role of recertification in maintenance of competence. Annals RCPSC 1991; 249 (1): 121– 124. Google Scholar Volume3, Issue4December 1991Pages 239-242 ReferencesRelatedInformation