The issue of whether and how licensed physicians should be required to demonstrate continuing competence has been debated for decades. In the early years of the 21st century, though, maintenance of competence is emerging as a hot button topic at state medical boards across the country. Some boards are considering requiring periodic retesting for license renewal. Others are trying to shore up existing means of documenting competence, such as strengthening the requirements for continuing education. This article examines how several states are addressing the issue.

TEXAS TAKES THE LEAD

In August 2002, the Texas State Board of Medical Examiners made a bold move. It became the first state medical board to formally endorse a program that would require all physicians to show continuing proficiency through periodic retesting. New legislation would be required to actually implement the program. The board expects to propose such a statutory change to the legislature in early 2003. If it is enacted, implementation would begin no sooner than 2005.

Like other boards, the Texas board currently is reactive. It usually identifies and addresses problems caused by physician incompetence only after patients or peers have filed a complaint. The Texas board’s goal is to assume a more proactive position. “Patient safety would be better served if we could actively identify practitioners at risk of poor performance,” says Donald W. Patrick, MD, JD, the board’s executive director. “Physicians who have passed a monitored exam, like a board certification exam, have demonstrated current knowledge and cognitive ability.”

Out-of-state physicians who move into Texas already have to demonstrate proficiency to get a license there. To do this, they are required to have passed a nationally recognized exam within the past 10 years. “If we require it of out-of-state doctors, it should be effective for ensuring proficiency among in-state doctors as well,” says Patrick. Following this reasoning, the board’s proposed plan would require all physicians to pass a monitored exam every 10 years. For many physicians, this requirement would be met by passing their specialty board recertification exam. For some physicians, however, another option would need to be available. This includes physicians whose board certification does not require taking a monitored exam and those who are not board certified. These physicians would have to pass an exam such as the Special Purpose Examination (SPEX), a standardized test of general medical knowledge.

Other assessment options are being considered as well. One possibility is the Clinical Skills Examination (CSE), a new component now being developed for the United States Medical Licensing Examination. The CSE, is expected to be introduced in mid-2004. It will be a one-day test in which examinees are asked to demonstrate hands-on clinical skills in simulated cases involving “standardized patients,” laypersons who have been trained to act like real patients in a doctor’s office. Another possibility is several proposed modules for the SPEX that would focus on specific areas of competence.

The Texas board plans to give physicians three chances to pass a test such as the SPEX. After the third failed attempt, a physician might be referred for more comprehensive assessment and remediation through an organization such as the Center for Personalized Education for Physicians in Colorado. Patrick believes this is more than fair: “If you can’t pass a relatively simple test like the SPEX after studying and taking it three times, you probably don’t have the intellectual capability to be a doctor. In the practice of medicine, you have to carry a lot of information in your head. If you can’t do that, we don’t see how you can possibly practice medicine in a safe fashion.”

The financial impact on the board of implementing the program is expected to be minimal, since the testing would be administered by outside organizations. Any expenses might be offset by converting to biennial, rather than annual, registration, which would reduce staff time. Physicians who already take board recertification exams would incur no additional costs. The cost to other physicians would be $63 per year, based on the current SPEX fee of $630 averaged over 10 years.

HIGH NOON IN TEXAS

It is still unclear, however, whether the Texas legislature will follow the board’s lead. Atthis point, the board’s plan is facing strong opposition from the Texas Medical Association (TMA). “Our goal, like that of the Board of Medical Examiners, is to ensure quality medical care provided by quality physicians,” says Ladon Homer, MD, chair of the TMA Board of Trustees. “We just don’t believe that there is any scientific evidence that this particular process will weed out the bad-acting physicians. Most of these folks are poor practitioners because of their ethics or their negligence — not necessarily because of a deficiency in their knowledge base.” Homer’s concern is that a test designed to measure knowledge wouldn’t detect such problems.

A second concern is that requiring physicians to take a generalized medical test, such as the SPEX, would be unfair to specialists. Of course, this obstacle could be overcome by offering specialty tests as an alternative. A third concern that may prove harder to surmount is the contention that no written test, no matter what its orientation, can really gauge a physician’s clinical competence. “The key issue is how physicians behave, what their practice patterns are, and what they do on a daily basis,” says Susan Strate, MD, chair of the TMA Patient-Physician Advocacy Committee. “These are very difficult things to measure, and they’re especially hard to measure by a single exam.”

To some extent, Patrick concurs with this view. This is why the Texas board has changed its focus from “continuing competence” to “continuing proficiency.” The American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education have developed a list of six broad aspects of competence that are thought to be critical for physicians to possess and maintain: medical knowledge, patient care, interpersonal and communicative skills, professionalism, practice-based learning and improvement, and systems-based-practice. In an ideal world, a board might periodically assess all of these areas in all physicians, but Patrick considers that impractical. Proficiency is a more vague concept. As defined by the Texas board, it seems to tap mainly the domain of medical knowledge. “It’s a watered-down version of competency,” admits Patrick. “We felt there was no way we could check overall competency, but the next best thing would be to check proficiency with a written test.”

Not everyone agrees, of course. TMA president Fred Merian, MD, for one, believes that observation by peers is a better option. “Peer review is done in hospitals by a peer review committee that looks at a certain number of cases from every physician who has privileges in that hospital,” Merian says. He believes this offers the best way to assess how well a physician performs in the real world. On the downside, not all physicians currently are subject to such scrutiny, and the task of extending peer observation to every doctor in the state could be quite complicated and expensive.

The debate, then, is not so much over whether physicians should demonstrate continuing competence as over how. When it comes to periodic retesting, Patrick says that the response from physicians so far has run the gamut from very negative to very positive: “There are some people who say, ‘Hell, no, I took the last test I’m going to take 40 years ago, and I’m not ever taking another test in my life.’ But there are others who say, ‘Hey, I need to be tested on a periodic basis, because I need to make sure that I can still cut the mustard.’” The challenge for the Texas board will be bringing these two sides together under a plan that is acceptable to most.

NEVADA MOVES AHEAD

Other boards around the country are watching the Texas showdown closely. None is watching with a keener eye than the Nevada State Board of Medical Examiners, where maintenance of competence has been much discussed. In 2000 the Nevada board formed a study group to look into the issue. In 2001 the board even informally considered teaming up with the Federation of State Medical Boards and the National Board of Medical Examiners on a pilot study of time-limited licensure. That plan ultimately was scrapped after a change in board membership. However, the issue has remained alive in committee discussions and roundtable meetings.

“We’ve arrived at a point where we have a tentative recommendation,” says Donald Baepler, PhD, DSc, chair of the committee investigating the subject. “I can’t emphasize too much the word ‘tentative,’ however. We still need to hold public meetings with the medical societies and another board hearing. But I suspect that our final recommendation will be rather similar to what we have drafted now.” The committee will report to the full board in March 2003. The board’s executive director expects that the board will take dispositive action on the matter then.

The preliminary draft of the recommendation would require that all physicians show continuing competence every 10 years in one of five ways:

  • by obtaining primary certification or recertification by a specialty board.

  • for board-certified physicians who are not subject to recertification, by maintaining hospital privileges at a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – certified hospital and treating an average of at least 25 inpatient cases at that hospital per year.

  • for physicians who are not board-certified, by maintaining hospital privileges at two JCAHO-certified hospitals and treating an average of at least 25 inpatient cases at each hospital per year.

  • for physicians who are not board-certified and who practice in rural areas where only one JCAHO-certified hospital is available, by maintaining hospital privileges at one JCAHO-certified hospital, treating an average of at least one in-patient case there per month, and completing 20 hours of continuing medical education related to rural practice. The latter is in addition to other continuing education requirements.

  • for other physicians, by passing the SPEX with a minimum score of 70% or completing another formal examination that has been approved by the board.

The Nevada plan seems designed to avoid some of the roadblocks encountered in Texas. Specifically, it offers hospital credentialing and peer review as an alternative to taking a written test. Nevertheless, it remains to be seen how the medical community in Nevada will react to the proposed requirements.

OTHER STATES STEP UP

Nebraska

In several other states, the maintenance of competence issue is in the active discussion stage. In Nebraska, the legislature passed a law in early 2002 requiring all professional boards to establish requirements for ensuring continuing competence. A short deadline for implementation was set for January 1, 2003. The law spelled out numerous possible options, including continuing education, clinical privileging at an ambulatory surgery center or hospital, specialty board certification, professional certification, self-assessment, peer review or evaluation, professional portfolio, practical demonstration, audit, exit interviews with consumers, outcome documentation, testing, refresher courses, or in-service training. The Nebraska Board of Medicine and Surgery responded by considering all of the various options and ultimately decided to implement continuing education requirements. However, a representative of the Nebraska Regulation and Licensure Credentialing Division says that the other options for assessing continuing competence may be explored at a later date.

Missouri

In Missouri, too, broad concerns about maintenance of competence have so far led to relatively narrow changes in continuing education requirements. The state already mandated 50 hours of continuing education every two years. Recently, the Missouri State Board of Registration for the Healing Arts amended the rule to allow physicians to take only 40 hours of continuing education every two years if the courses include a post test. “The board felt that, if there is a post test, we at least can be sure that physicians are attending the courses and getting something out of them,” says Tina Steinman, executive director of the board. However, she also notes that “this is just the first step. It is part of an ongoing discussion about physician competency.”

The board has discussed other options, such as requiring periodic retesting. For things to move beyond the discussion stage, however, some sticky issues will have to be resolved. Says Steinman, “If you’re a great clinical physician, but you don’t take written tests well, what are we going to do? Take your license — and your livelihood — away? These are the types of questions we’ll have to deal with.”

California

In California, interest in maintenance of competence has waxed and waned in recent years. Lately, though, it has moved back to the front burner at the Medical Board of California. “My staff are working and contacting both Texas and Nevada to see what their plans are,” says Neal Kohatsu, MD, board medical director. The board also has hosted presentations by the American Board of Medical Specialties and the Federation of State Medical Boards, and more presentations are planned for the near future.

“It’s hard to say when the board will feel that they have gathered enough information and are ready to move ahead,” says Kohatsu. “There seems to be a continuing flow of new information at the Federation and specialty board level. There always is something new that we need to learn about and consider before making a proposal.” Despite the challenges, though, Kohatsu says he feels that this is an issue whose time has come: “The whole pace of medicine has increased, so the need to ensure that physicians are staying up with the frontiers of medicine has become more urgent. Today, you can’t just learn a body of knowledge and skills in residency, then be prepared to practice for the next 30 years. You have to be continually growing, developing new skills, and enhancing your knowledge base.”

STATE OF THE STATES

Several boards are at an even earlier stage of exploration. At the Arizona Medical Board, for example, policy analyst Ron Lockaby says he will be researching periodic retesting this year. However, no information has been presented to the board yet, nor has the topic been placed on the agenda. “We’re looking at the Texas model and would most likely follow their example in some fashion,” says Lockaby.

Many other boards have not even begun to address this critical issue, and so far those that have are faced with more questions than answers. Opposition to periodic retesting, in particular, also is starting to rise. The Texas Medical Association has taken a strong stance against the practice. Likewise, the American Osteopathic Association has adopted a statement opposing “any attempt by federal or state agencies to mandate recertification or retesting, either as a condition of relicensure, or as a requirement for receiving payment under a health benefits program.”

In addition, some professional societies have expressed concern about requiring specialists to pass tests of general medical knowledge. “There easily could be questions on a general test like the SPEX that would probably not be answerable for any specialist,” says William Hartmann, MD, executive vice president of the American Board of Pathology. “On the other hand, there are probably questions that any specialist could answer that a graduating medical student could not.”

Despite these reservations, however, most observers agree that maintenance of competence is an issue that is here to stay. “Medical practice changes quite rapidly today,” says Kohatsu of the California board. “Hopefully, physicians are staying abreast of developments in their field. As a board, though, it’s important for us to see what our role might be in ensuring that continuing competency.”

Many people believe that written tests have a place in this process. The challenge is finding the best tests for assessing specialized expertise. Some people believe that appropriate alternatives also should be available for physicians who are better at hands-on medicine than at taking tests. However, the bottom line is that any physician needs to have a large store of up-to-date knowledge and a high degree of cognitive ability in order to practice safely. Says Patrick of the Texas board, “Seeing patients and doing procedures are tests that a doctor has to pass every day.”