Ensuring — and Tracking — Physician Competence
June 2008
By Bonnie Darves
Editor’s Note: There is now a concerted effort by regulators and healthcare institutions to ensure the sustained competency of practicing physicians and those who are in training. No longer is the accumulation of CME hours the metric by which the competency of practicing physicians is measured. CME providers are now required to conduct a needs assessment for gaps in the knowledge and skill of their learners and to develop programs to enhance performance and clinical outcomes. On the institutional level, standardized and longitudinal methods for assessing performance are now being utilized. These include the evaluation of patient outcomes by data analysis from case reviews and performance indicators, physician accomplishments, patient and peer feedback, as well as maintenance of up-to-date certification. Physician leadership and involvement in competency efforts promote patient safety.
— John A. Fromson, M.D., Chairman of the Department of Psychiatry at MetroWest Medical Center
Major initiatives by professional organizations and oversight bodies will change the way physicians maintain certification and licensure throughout their careers.
Physicians coming out of training today expect that their performance will be measured from a variety of perspectives, from how they treat patients with chronic disease, to how patients and coworkers rate their interpersonal skills in delivering care. Despite the push for performance measurement issuing from every conceivable quarter — the federal government, health plans and purchasers, and more recently, patients — little has been done on a broad scale to ensure physicians’ continuing competence as they move through their careers.
In a development some say is long overdue, organizations involved in physician licensure, board certification, and continuing education are moving ahead with initiatives that raise the bar for evaluating physician competence. The American Board of Medical Specialties (ABMS), the American Board of Internal Medicine (ABIM), the Federation of State Medical Boards (FSMB), and organizations that accredit graduate medical and continuing medical education have all embarked on ambitious competence-evaluation initiatives. Those initiatives, individually and collectively, are intended to address the time interval between when physicians obtain licenses or certification and when they reapply or recertify.
“It’s about public accountability and having a way to hold on to our commitment to be an accountable profession — and part of being a profession is regularly measuring what we do and reporting that to those to whom we are accountable,” said Daniel Duffy, MD, the senior advisor to the president of the American Board of Internal Medicine who frequently writes on the topic of physician competence. “Accountability does not mean ‘I intend to do a good job. Trust me, I’m good.’ It’s like Ronald Reagan used to say: ‘Trust, but verify.’”
The movement toward verifying not only physicians’ credentials but also their knowledge and competence on a more continual, rather than periodic, basis has become a “hot button” for several reasons. For one, rapidly evolving developments in medical science mean that keeping up is hard to do, even for the most diligent. In addition, widely recognized problems in patient safety, along with poor knowledge-deficit recognition and medical-licensure gaps that enable incompetent physicians to continue practicing, have combined to create a call for more demonstrable competence.
“It is a time of incredibly rapid scientific discovery and great complexity in the practice of medicine — and a time in which the public expects their physicians to be competent and accountable,” said James N. Thompson, MD, president and chief executive officer of the Federation of State Medical Boards in Dallas, Texas. “The generation of physicians coming in now will ‘grow up’ with the expectation that they need to demonstrate continued competency throughout their practice lifetime.”
Presumably, most practicing physicians have a vested interest in maintaining their skills and expanding their knowledge — and most profess to do so. The problem is that few
reliable, standardized mechanisms, beyond initial boards and licensing exams, have existed for assessing continuing competence. Individuals and organizations involved in that assessment, including specialty boards themselves, concur that the traditional process of recertifying physicians is faulty at best. Intervals between certification exams vary, from six years in some specialties to a full decade in others, and a few boards still do not require recertification. More important, perhaps, few specialties to date have required evidence of competence between exams.
“A number of studies have shown that only about half of patients are [treated] according to best practices, and there have been several studies about degradation in physician performance over time,” said Sheldon Horowitz, MD, special advisor to the president of the ABMS in Evanston, Illinois. “That is why boards are moving toward a more continuous process in which physicians learn and improve and assess their practice in a more CQI [continuous quality improvement] approach.”
The CQI approach to ensuring competence is well illustrated by ABMS’ evolving maintenance of certification (MOC) initiative. This undertaking requires recertifying physicians to provide evidence of continuous learning, self-assessment, and practice performance and improvement on a three- to five-year cycle. MOC employs a framework similar to the one that the Accreditation Council for Graduate Medical Education (ACGME) developed for evaluating residents’ competency in a range of areas (See descriptions in sidebar.).
“When the competencies are meaningfully implemented through their educational experiences, new physicians will be better prepared for practice,” said Susan Swing, PhD, ACGME’s vice president of research and education.
All 24 of ABMS’ member boards have submitted their MOC plans, but some — particularly internal medicine, family practice and pediatrics — are “a bit ahead of the others,” Dr. Horowitz reported, in implementing their new requirements and developing associated assessment tools. He also cites the American College of Surgeons’ development of a practice-based learning system that allows surgeons to track their surgical cases and outcomes, as ahead of the curve.
“The main thrust is that all of the boards are moving from a largely episodic system to a more continuous one,” Dr. Horowitz said, while decreasing the relative importance of and reliance upon the traditional written exam.
More recently, the ACGME, working with ABMS, has begun identifying and developing measurement tools programs that can use to assess educational outcomes. Although nascent, the tools-chart-stimulated oral exams, 360-degree evaluation, checklist evaluation of trainees’ lives or recorded performance and patient surveys, among others — are being incorporated in training programs.
The next phase of ACGME’s initiative includes final development and dissemination of the Learning Portfolio, an interactive, Web-based development tool that will enable residents to record and organize their learning and track their progress. Use of the Learning Portfolio will not be mandatory, according to Pam Derstine, PhD, senior project manager in ACGME’s department of research and education.
“What’s new, and important about all of this is that physicians have an opportunity on a recurring basis to participate in standardized measures of their performance in practice, and of knowledge and of lifelong learning,” said Dr. Duffy. That will not only provide physicians with a valid and reliable tool for demonstrating, to patients and others, their professional competence and commitment to improvement, he added, but also a means of logically directing their CME.
“This is a better arrangement because right now patients have absolutely no objective evidence about any physician,” Dr. Duffy said. “MOC will allow physicians to distinguish themselves and to differentiate themselves — that’s one reason for the certification movement in the first place — and it will give the patients better information. Thirdly, and most important, it will actually give physicians a navigation system throughout their professional careers — like a GPS system.”
Dr. Horowitz concurs, suggesting that physicians heading into practice should view MOC as a boon, not an additional burden. “What’s exciting to me — of course, not all the doctors in practice are excited at this point — is that with MOC we’re getting a process that should be very meaningful to help physicians deliver the best care,” he said. “And as the process gets better, this should be a win-win for everyone.”
CME Sees Big Changes, Too
In tandem with the movement toward verifying physician competence over time, the continuing medical education (CME) realm is raising the bar as well. A decade ago, CME activities varied substantially in their rigor and, hence, in their value in improving physician performance. The variability was once so great, in fact, that some in the field have likened it to a free-for-all — especially given the lax requirements regarding the activities’ direct practice applicability.
“In years past, a physician could just attend any CME program regardless of whether it had any reference to their particular practice,” explained Dr. Thompson, “but now some very dramatic changes are occurring.” For example, in 2006 the Accreditation Council for Continuing Medical Education (ACCME) released new standards for accrediting CME providers that require providers to ensure programs focus on improving physician performance and competence in practice, as well as patient outcomes.
The council is also pushing CME providers to include more comprehensive self-assessment and practice-implementation components in their programs. That is a far cry, Dr. Thompson and others note, from the inherently passive and sometimes casual structures of programs that have been offered essentially as add-ons to recreational activities.
By requiring more practice-based CME, Dr. Thompson observes, ACCME is attempting to play a pivotal role in underpinning the continuous-improvement efforts occurring in certification-maintenance and relicensure realms.
Reducing Duplication, Redundancy Key Objectives
Physicians who already feel overwhelmed by numerous, often disparate reporting requirements being levied upon them by entities ranging from national accrediting bodies to local health plans, may be understandably concerned that additional requirements from specialty boards and licensing organizations will increase their workload.
Fortunately, for physicians and the organizations themselves, plans are underway to streamline and coordinate the competence-assessment initiatives of the ABMS, ACGME and others, to reduce overlap and duplication.
“One goal of this entire effort is to support physicians in their lifelong learning and continuous improvement rather than to burden them with more paperwork,” Dr. Thompson said. “For the physician who is board certified, he or she will likely, by process of maintaining their certification, have fulfilled all or nearly all of the requirements to maintain their licensure.”
Dr. Horowitz added that all of the organizations, to a large extent, and certain payers are communicating with one another precisely to avoid the problem Dr. Thompson cites.
“There’s a focused effort to ensure, for example, that physicians won’t have to [document] diabetes care 10 different times — once for each insurer, once for the government, once for their health care organization and once for MOC,” he said. “We are all working on that.”
Shortly before his retirement in December 2007, Dennis O’Leary, MD, then president of the Joint Commission, the nation’s longest standing healthcare accrediting body, described the movement toward individual-physician competence evaluation on a continuous basis as a key step toward improving patient safety.
“At some point, the biggest challenge lies in changing organizations’’ cultures of safety—but the core is health professional competency,” Dr. O’Leary said, “and the efforts to measure competence in more concrete terms as part of maintenance of certification is a step in the right direction.”
Professional Organizations Raise the Competence, Performance Bar
In recent years, all of the U.S. entities involved in assessing physician knowledge — from specialty boards to licensing entities and accrediting bodies — have launched initiatives to support continuous learning and ensure competence.
Those efforts, individually and collectively, are changing the way physicians pursue lifelong learning and demonstrate their commitment to keeping up with developments in their respective fields. Following is a summary of several key initiatives:
American Board of Medical Specialties (ABMS), at www.abms.org or (847) 491-9091. The ABMS’ still-evolving maintenance of certification (MOC) program, since adopted by all 24 member boards, requires as a condition of recertification that physicians demonstrate they have met the following four-part criteria: professional standing, commitment to lifelong learning and participation in self-assessment activities, cognitive expertise in their field, and evaluation of practice performance.
Generally, ABMS member boards are employing the six general competencies originally adopted by the Accreditation Council for Graduate Medical Education (see entry below).
ABMS also has developed a 20-credit Web-based Patient Safety Improvement Program for physicians and other health care professionals.
Accreditation Council for Graduate Medical Education (ACGME), at www.acgme.org or (312) 755-5000. The ACGME has undertaken a multi-phase initiative to improve physician learning and assessment in medical training programs, to provide a better platform for continuous learning throughout the career. The key component is the Outcome Project, designed to evaluate training programs’ accomplishments based on the extent to which participants demonstrate competency in six areas. These include medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
More recently, the ACGME, working with ABMS, has begun developing measurement tools programs to assess educational outcomes. The ACGME’s Learning Portfolio, an interactive, Web-based development tool for residents, enters beta testing in 2008.
Bureau of Osteopathic Specialists (BOS), at www.do-online.org or (312) 202-8000. The BOS, in concert with its 18 approved specialty boards, is progressing toward employing continuous rather than periodic evaluation of physicians’ competence. Like the ABMS, ABIM and ACGME, the BOS has adopted a core-competencies approach, and is moving toward a more standardized recertification process among member boards.
Federation of State Medical Boards (FSMB), at www.fsmb.org or (817) 868-4000. In response to both the public push for greater accountability by physician licensure boards and numerous studies pointing to the failure of state relicensure programs to guarantee physician competence, the FSMB is substantially expanding its licensure-maintenance policy and moving toward greater uniformity in physician licensure. The organization recently developed a common license application form, which is now used by only a handful of states but is expected to gain more widespread adoption.
In early 2008, FSMB proposed principles for strengthening licensure-maintenance requirements and outlined theoretical standards for demonstrating physician competence. These include physician-provided evidence of self-evaluation and self-assessment; passage of an exam at least every 10 years to demonstrate competence within the individual physician’s scope of practice; and demonstrated accountability for practice performance.
Joint Commission (JC), at www.jointcommission.org or (630) 792-5000. The Commission has moved beyond its initial focus on hospitals’ credentialing and privileging standards to push for more proactive evaluation of physicians’ competence and clinical skills. New standards, enacted in 2007 and 2008, seek to make the granting of hospital privileges and the credentialing process more objective, by requiring organizations to conduct focused professional practice evaluations of physicians seeking new privileges, and requiring organizations to evaluate physicians’ performance on a continuous rather than periodic basis. |
Note: The author, Bonnie Darves, is an independent health care writer based in Lake Oswego, Oregon.
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