Towards a pedagogy for patient and public involvement in medical education.

CONTEXT: This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement (PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education. METHODS: The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives. RESULTS: As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts. CONCLUSION: The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process.

The McDonaldization of appraisal? Doctors' views of the early impacts of medical revalidation in the United Kingdom.

INTRODUCTION: Medical regulation is rapidly changing with claims that systems such as revalidation/relicensing will reassure the public. Yet the impact of such initiatives is unknown. METHODS: Using the principles of efficiency, calculability, predictability and control through technology, identified by Ritzer, and exampled by the McDonalds business model, we analyzed interviews with doctors between May 2012-Dec 2013 which focused on doctor experiences of appraisal and revalidation in SW England. RESULTS: The research found significant changes in appraisals since the launch of revalidation in December 2012. Appraisal has been standardized with a list of supporting information that must be collected by doctors. The success of implementation is measured in the numbers of appraisals completed but less is known about the quality of the appraisal itself. Such efficiencies have been supported by IT systems that themselves might be at risk of driving the process. DISCUSSION: There are potential advantages to McDonaldization including appraisals available to all, not just for doctors working in the NHS, and a potentially more appetizing recipe for their completion. As yet a state of McAppraisal has not been reached; with a complete transfer of trust in the doctor to trust in the appraisal process within revalidation. However policymakers will need to continue to ensure that regulatory initiatives, such as revalidation, are not just a process for their own sake.

"No one has yet properly articulated what we are trying to achieve": a discourse analysis of interviews with revalidation policy leaders in the United Kingdom.

PURPOSE: To analyze prevailing definitions of revalidation (i.e., a recently instituted system of ongoing review for all physicians in the United Kingdom), the circumstances of their origin, and proposed applications, after a protracted and sometimes difficult decade in development. This was to support a more consensual approach to revalidation policy before its launch in 2012. METHOD: In 2010 and 2011, the authors carried out a critical discourse analysis of interviews with 31 medical and legal revalidation policy makers. These individuals represented the main stakeholder bodies, including the General Medical Council, Academy of Medical Royal Colleges, British Medical Association, National Health Service Employers, and the departments of health from across the United Kingdom. RESULTS: The authors identified two overarching discourses: regulation and professionalism, held together by patients as "discursive glue." Regulation frames revalidation as a way to identify "bad apples," requiring a summative approach and minimum standards. Professionalism looks to revalidation as a process by which all doctors improve, requiring evolving standards and a developmental model. CONCLUSIONS: These two discourses were not mutually exclusive; indeed, most interviewees used them interchangeably. However, they are in some regards at odds. Their coexistence has been supported by a shared discursive formation around patients. Yet the authors found little patient-centered policy in revalidation in its current form. The authors concluded that patients need to be recognized, making them present with an active voice. They also stressed the importance of established and ongoing evaluation of medical regulation as a policy and process.

Revalidation: Patients or process? Analysis using visual data.

Revalidation is a significant recent regulatory policy reform from the UK General Medical Council and being considered elsewhere around the world. The policy aims to regulate licensed doctors to ensure that they are 'up-to-date and fit-to practise'. Fundamental to the policy is that the revalidation of doctors should benefit patients and improve doctor-patient relationships. As part of an evaluation of the development of revalidation, 31 policy makers involved in its development were interviewed in 2010-2011 and were asked to draw what revalidation meant to them. From this, 29 drawings were produced and this article focuses on their analysis. The drawings emphasised abstract systems and processes, with a distinct lack of interpersonal interactions or representation of individual patients and doctors. Only 3 of the 29 images included individual patients and doctors. This depersonalisation of policy is examined with respect to the purported key objective of revalidation to benefit patients. Using a distinctively different modality, the drawings serve to confirm the two key discourses of regulation and professionalism prevalent in the interview data, while highlighting the notable absence of the patient. The benefits and limitations of using drawings as a research method are discussed for a health policy context.