During the mid to latter part of the 1990s, the Pew Health Professions Commission’s Taskforce on Health Care Workforce Regulation released a series of reports aimed at improving the health care profession’s responsiveness to consumer needs and safety. The reports also focused on the regulation of health care providers as a means of ensuring high-quality health care services. In particular, in its report entitled Reforming Healthcare Workforce Regulation, the Taskforce recommended that states “require each licensing board to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals.”1
In November 1999, the Institute of Medicine (IOM) released a report entitled To Err is Human: Building a Safer Health System, which focused mainly on systems-based errors within the medical community and provided recommendations to improve patient safety within health care organizations. However, recognizing the responsibility of licensing bodies to document the competence and skills of physicians, the report also recommended that medical licensing bodies periodically re-examine and relicense physicians “based on both competence and knowledge of safety practices.”2
In the midst of such overwhelming focus on patient safety and ongoing practitioner competence, many medical regulatory agencies began to critically evaluate how their organizations monitor practitioner competence. Some professions, such as pharmacy, attempted to implement continuing competence measures only to have them fail due to lack of practitioner support for (and trust in) the measures proposed and those proposing them.3
As discussed in the following pages, while a few organizations either already have or are close to implementing programs to assess practitioners’ ongoing competence, most continue to struggle with how to effectively ensure the continuing competence of its health care practitioners. This report provides the following information:
Recent examples of state medical board interest in maintenance of licensure;
An overview of methods currently utilized by state medical boards to assess physicians’ competence;
A discussion of the implications of maintenance of licensure initiatives on the medical regulatory system;
A review of how several international licensing authorities document physician continued competence;
A review of initiatives by organizations focused on lifelong learning; and
A review of how other health care professions ensure the continued competence of their practitioners.
STATE MEDICAL BOARD INTEREST IN MAINTENANCE OF LICENSURE
In 1997 the Federation of State Medical Boards (FSMB) commissioned a study of public awareness and attitudes about state medical boards. Results indicated that physician retesting was emerging as a “hot button.” The periodic retesting of physicians was the second most-cited responsibility for state medical boards, with 9.3% of the public mentioning it “top-of-mind.” A 10% top-of-mind mention signifies a national issue (Federation of State Medical Boards, unpublished data, 1997).
At the same time, the Medical Board of California began discussing the need for recertification of physicians’ licenses. However, early discussions were politically tenuous, and the board recognized that development of an examination for recertification purposes would be costly. Therefore, further discussions were tabled. In 2002, however, the board established the Committee on Recertification to review “continuing competency and requalification for physicians and surgeons.”4
In 2000, the Nevada State Board of Medical Examiners formed a study group to consider the issue of “requalification” of its licensees based on a demonstration of clinical competence. In early 2001 the FSMB, NBME and the Nevada board informally discussed collaborating on a pilot study for implementing time-limited licensure in Nevada. Although initial interest in utilizing a modular examination system seemed strong, the board stepped back from actively pursuing the issue of re-qualification in mid-2001 after a change in board membership. Despite this, a subgroup of the board has continued to discuss the issue and has held several roundtable meetings to brainstorm. According to a September 2002 conversation with the board’s executive director, there is a strong possibility the board will adopt a regulation in early 2003 requiring all physicians to demonstrate competence as a requirement for relicensure.
In September 2000 the Federation hosted a symposium in Washington, D.C., to discuss the role of medical licensure in the next century and priorities facing state medical boards. The audience was comprised of representatives from state medical boards and other interested organizations. Among other issues, maintenance of physician competence was identified as an important priority.
The Texas State Board of Medical Examiners (TSBME) recently took steps to require periodic retesting of its licensees. On August 16, 2002, the board formally endorsed “implementation of a program requiring periodic demonstration of current proficiency by all physicians.”5 Although the board must pursue the matter legislatively before such a program can be implemented, a current draft proposal of the initiative would require physicians to “provide evidence of either certification, recertification, or successful completion of an approved assessment completed at least once every 10 years as a condition for active licensure in Texas.”5 The FSMB has engaged in informal discussions with representatives from the board about examinations that could be utilized for retesting purposes.
METHODS CURRENTLY UTILIZED BY MEDICAL BOARDS TO DOCUMENT PHYSICIAN COMPETENCE
Currently, medical licensing authorities utilize a variety of information sources to document and verify the current competence of licensure applicants. Among them are:
While such information assists boards in making decisions about the fitness of licensure applicants and sheds light on the competence of physicians that are already licensed, it falls short of the comprehensive, ongoing documentation of physician competence called for in the IOM and the Pew Commission’s reports.
Additionally, while most licensing authorities require continuing education for relicensure, the lack of research evidencing the effectiveness of continuing education on practitioner performance has led to discussion about whether more stringent requirements to protect the public. As a result, some have argued for an overhaul of the continuing education system to make organizers more accountable for the content and practitioners more accountable for the retention and application of what is learned.8
IMPLICATIONS OF CONTINUED COMPETENCE INITIATIVES
A number of issues are central to a discussion about continued competence programs:
Gaining consensus on the definition of competence. What does it mean to say a physician is competent?
Determining whether the assessment should focus on general medical knowledge/skills or specialty-specific knowledge/skills
Determining what areas of physician practice/knowledge will be measured
Re-evaluating and restructuring the continuing (medical) education system, such as implementing interactive sessions, post-testing, demonstration by attendees of what was learned during sessions, and future practice performance evaluations
Deciding who is responsible for initiating and implementing such programs — should they be legislatively mandated or should the profession take a proactive approach?
Deciding who pays for the program — should the costs be borne solely by the practitioner?
Deciding how often the practitioner should be evaluated
Obtaining buy-in from the profession
Deciding what types of assessment tools will be used
Evaluating outcomes of such initiatives
Perhaps the most practical concern to medical licensing authorities is determining what areas and skills should be assessed in order for a physician to demonstrate current competence. Potential areas for physician assessment include:
Clinical and communication skills
Technical skills (tends to be more specialty-specific)
Organizational skills/management of information (ability to integrate technological advances into the practice environment)
Ability to function in a group environment (teamwork)
Questions that merit discussion include: What tools do medical licensing authorities have at their disposal to measure these competencies and what tools are most effective? Should physicians be required to demonstrate competence in all areas of their practice or only in those areas that constitute core knowledge? How is core knowledge defined and what are the skills of which it consists?
In a recent JAMA article, Epstein and Hundert defined competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.”9 Although the article is aimed at assessing the professional competence of medical students and residents, Epstein and Hundert’s definition of competence is a good starting point for identifying elements that medical licensing authorities may want to assess in licensed, practicing physicians.
Likewise, in a response to the Pew Taskforce report Reforming Healthcare Workforce Regulation, the American Nurses Association (ANA) stated, “We oppose attempts to weaken educational standards for nursing or to construe competence in such a way as to reduce professional practice to the performance of a series of tasks. Professional nursing practice must rest on a solid educational basis covering a broad range of physical, psychosocial, spiritual, and cultural competencies.”10
It is unclear whether medical boards should be solely responsible for evaluating all areas of physician competence. One could argue it is a responsibility best accomplished through collaboration. But this approach raises questions about how medical boards might work with other medical organizations — such as the American Board of Medical Specialties (ABMS), professional organizations, and physician employers (hospitals, managed care organizations, etc.) – to ensure ongoing physician competence. In a presentation at the December, 2001 Albert Schweitzer Conference regarding The Role of Professional Associations in Licensing and Re-Validating Physicians, Ian Gilmore of the Royal College of Physicians of the United Kingdom spoke to the efficacy and feasibility of multiple organizations working together to assess physician competence. “It seems that the UK has moved in five years from a lax control of physician competence by a single agency,” said Gilmore, “to tight control by a plethora of agencies that have yet to demonstrate how they will work harmoniously together in the interests of patients.”11 Therefore, the role and responsibility of each organization in assuring physician competence must be reviewed and clarified.
From a practical standpoint, medical licensing authorities must grapple with issues of how to implement ongoing competence programs in a manageable fashion, to avoid having to simultaneously assess the entire physician population. Also requiring consideration are questions about how to handle physicians who want to re-enter practice or who have time-limited licenses, and how such a system might impact the practice of telemedicine. Most significantly, boards must decide what the implications are to a physician’s license if that physician is unable to meet the board’s criteria for demonstrating current competence.
The impact of such programs on medical regulation as a whole also must be evaluated. Medical licensing authorities in the United States issue licenses that allow physicians to engage in the general, undifferentiated practice of medicine. Of particular interest to licensing authorities, then, is whether the evaluation of a physician’s ongoing competence should occur at the general or specialty-specific level. At issue is the effect that assessing specialty-specific skills would have on the current system of medical licensure. Would such a system move licensing authorities toward licensure by specialty? What are the implications of granting a physician an initial license based on general medical knowledge and skills but then requiring the same physician to maintain that license based on specialty-specific knowledge and/or skills?
Additionally, although specialty-board certification and recertification are currently accepted by most medical boards for licensure by endorsement, would specialty-specific maintenance of licensure programs receive the same status? In other words, if a physician were licensed in a state that utilized specialty-specific assessment tools for ongoing competence assessment, would that physician be able to obtain licensure in another state that assesses ongoing competence at the general level? Furthermore, if a physician’s license was suspended, restricted, or revoked due to inability to perform adequately in a specialty-specific program, could that physician then obtain licensure from another board that utilizes a general practice program?
According to the 1999–2000 volume of the Federation of State Medical Boards’ The Exchange, 12 medical and nine osteopathic licensing authorities require applicants for licensure by endorsement who have not passed a national medical licensing examination within 10 years of the date of application to pass the SPEX.12,13 Nine medical boards and nine osteopathic boards accept primary certification or recertification by the ABMS for such applicants. 12,13
If licensing authorities require endorsement licensure applicants to demonstrate some level of competency prior to issuing a license, should they not also require the same periodic demonstration of competence by current licensees (whose fitness to practice is currently only assessed at one point in time) prior to initial licensure? In its report To Err is Human: Building a Safer Health System, the IOM recommended that “professional licensing bodies consider continuing qualifications over a lifetime of practice, not just at initial licensure.”2 Clearly, while medical licensing authorities recognize that implementing maintenance of licensure programs is compatible with their mission and duty to protect the public (and is perhaps long overdue from a public safety perspective), implementation of an effective system of assessing physicians’ ongoing competence will require boards to discuss and resolve these and other equally important questions.
AN INTERNATIONAL PERSPECTIVE
College of Physicians and Surgeons, Ontario, Canada14
The College of Physicians and Surgeons of Ontario has engaged in regular, periodic evaluation of its physician population since 1981, when it began its Peer Assessment Program. While the program initially focused on family physicians, in 2000 the College began assessing specialist physicians as well. The goal of the program is to evaluate every physician once every 10 years.
The assessment takes place in the physician’s office and focuses on office facilities, medical records and quality of care. To facilitate acceptance of the program, the college utilizes physicians who have previously been assessed to conduct the evaluations. While the majority of physicians meet the required standards, those found to have concerns participate in one of two programs developed by the college to evaluate physician practice deficiencies: the Physician Review Program (PREP) and the Specialists Assessment Program (SAP).
PREP is a one-day program established in 1987 to evaluate the knowledge, skill and judgment of family physicians. The program consists of a multiple-choice examination, chart stimulated recall, and standardized patients. SAP is a one- to three-day program established in 1985 and assesses the knowledge, skill and judgment of medical and surgical specialists. The program consists of direct observation of the physician in the practice environment, chart stimulated recall, and interviews with colleagues and staff. Following assessment by PREP or SAP, remedial education and training (such as individualized courses, training programs, and supervised practice settings) are prescribed if necessary.
As of 2001, the college performed 500 Peer Assessments each year, along with 50 PREP/SAP evaluations. Each Peer Assessment costs the college $1,400. The total cost for each individualized PREP or SAP program is $6,000; the physician is charged $3,700; and the college underwrites the rest. All costs to the college are borne through physician membership dues. While this has not met with unanimous approval, the college feels that the vast majority of physicians understand it is the price for self-regulation.
In 2000, in an effort to decrease costs, the college implemented a Mini-Peer Assessment, in which the physician completes and submits a questionnaire and medical records to an assessor, who then determines whether an on-site visit is necessary. Early results indicate that offsite review correlates to onsite review.
Further information about the college’s Peer Assessment Program is available at: http://www.cpso.on.ca.
General Medical Council, United Kingdom
In the United Kingdom, physicians must register with the General Medical Council (GMC) and have their names placed in the Medical Register. In 1999, the GMC began developing a system for doctors to regularly demonstrate competence through a process called revalidation.15 In addition to changes in physician behavior, potential benefits of the revalidation initiative include “the identification of currently dysfunctional doctors and the encouragement of the provision of early assistance to doctors who have problems which if not tackled might lead to a referral to the GMC.”16 The Council intends to gradually introduce the revalidation process to avoid simultaneous revalidation of all physicians.
Note: In a presentation at the December 2001 Albert Schweitzer Institute Conference referenced earlier, Ian Gilmore of the Royal College of Physicians, United Kingdom, noted other efforts in the United Kingdom to assess physician competence: “In the last five years, the GMC has brought in complex, well-validated tests of competence so that doctors could be also removed from the general register if there was evidence of poor clinical practice; but this has been only on the basis of ‘exception reporting,’ rather than a review of practice for all.”11
Revalidation will be required of all practicing physicians; physicians who are retired, working abroad, or do not have to exercise the privileges of registration to perform their jobs may be allowed to transfer to a non-revalidating list. Doctors who have been out of practice for some time and who wish to return to practice will have to provide evidence of fitness to practice, and may then have their practice temporarily supervised.15
There are three stages to the revalidation process, the first two of which will undergo external quality assurance: collection of information and yearly appraisal, five-year assessment, and the GMC’s decision on the physician’s registration.17
COLLECTION OF INFORMATION AND YEARLY APPRAISAL
All physicians will be required to collect a folder of information describing their job functions and their ability to perform those functions. Physicians will be required to provide documentation of their performance in the following areas: good clinical care, maintaining good medical practice (keeping up to date), relationships with patients, working with colleagues, teaching and training, probity, and health.18
Each year physicians will undergo an appraisal of information contained in their folders and an appraisal of their performance during the prior year. If serious concerns arise about the doctor’s fitness to practice safely, the doctor will be reported to the General Medical Council.15
Every five years, each physician will be responsible for submitting his folder to a local revalidation group for review. Following review of the folder, the group will recommend to the GMC whether or not the physician should be allowed to continue practicing. Physicians who fail to provide sufficient information for a determination to be made could face removal from the Medical Register. If a physician has problems but does not pose a threat to public safety, the revalidation group can give the physician the opportunity to correct his/her practice without review by the GMC. In such instances, any problems and solutions identified by the revalidation group will be reviewed during the next revalidation cycle.15
General Medical Council decision on physician’s registration
If the revalidation group recommends that the doctor be allowed to continue practicing, the GMC will revalidate the doctor’s registration. This information will be available to the medical community and the public. The GMC will investigate cases in which the group recommends that the doctor not be allowed to continue practicing. If the GMC decides that the physician is a threat to public safety, it has the authority to suspend or revoke the physician’s registration or require the physician to undergo retraining or practice supervision.15
OTHER INTERNATIONAL INITIATIVES
The December 2001 Albert Schweitzer Institute conference in Budapest, Hungary, The Role of Professional Associations in Licensing and Re-Validating Physicians, brought together medical educators and regulators from the United States, the United Kingdom, Russia, and Latvia to discuss the roles of professional and government associations in licensing and revalidating physicians, and in continuing medical education. Full details of the conference can be found at: http://www.schweitzerinstitute.org/programs/health care/conference_materials/2001/professional_associations/english/prof_assoc_eng_agenda.htm.
American Board of Medical Specialties
In March 1998, the ABMS created the Task Force on Competence to develop methods to document and demonstrate the competence of specialist physicians throughout their careers. In response to concerns about the inadequacy of the recertification process to document a physician’s ongoing competence, the task force developed a description of the competent physician, six general competencies, and the Maintenance of Certification program for all specialty boards to use. The six general competencies developed by the task force are: medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.19
As part of the Maintenance of Certification program, physicians must be able to provide evidence of the following criteria on a continual basis in order to maintain their certification:
Professional standing: maintenance of an unlimited, unrestricted medical license19
Commitment to lifelong learning and involvement in periodic self-assessment: CME “tailored to individual needs and that includes documentation of skill enhancement and behavior change rather than simply accumulated hours”3
Cognitive expertise: a practice-based examination19
Evaluation of performance in practice will include “assessments of process, assessments of outcomes, patient and peer assessment, and assessments to document the efficient and appropriate use of resources.”19
The Accreditation Council for Graduate Medical Education
As part of its mission to ensure and improve the quality of graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) began the Outcome Project. While the accreditation process traditionally focuses on the potential of a program to educate residents, the Outcome Project focuses on the actual accomplishments of a program through an assessment of its outcomes.20
Utilizing a list of general competencies developed by the Outcome Project, residency programs are required to provide educational experiences that enable their residents to obtain competencies in six areas “to the level expected of a new practitioner.”21 Illustrating the lifelong learning engaged in by all physicians, these same competencies form the core of the ABMS Maintenance of Certification program cited above.
Residency programs also must demonstrate a plan to assess residents’ performance and to utilize the results to improve performance. Consequently, the Outcome Project is involved in the “identification and development of measurement tools for programs to use as part of an overall evaluation system.”20 The ACGME, in collaboration with the ABMS, developed a “toolbox” of instruments that programs can use for educational outcomes assessment. In September 2000 the ACGME and ABMS released a report entitled Toolbox of Assessment Methods that provides descriptions, psychometric qualities, and feasibility of assessment tools for evaluating residents.22 Included in these tools are instruments such as a 360-degree evaluation, chart stimulated recall oral examinations, checklist evaluation of live or recorded performance, patient surveys and written examinations.
Full details about these tools and the Outcome Project are located on the ACGME Web site at www.acgme.org.
OTHER HEALTH CARE PROFESSIONALS
The American Nurses Credentialing Center (ANCC) ensures that nurse practitioners have the competence and ability to practice safely, both at the entry level and upon recertification at the five-year point.23 The ANCC offers several recertification options, including a practice component, an examination, and continuing education options (contact hours, academic credit, presentations and lectures, research and publications, and preceptorships). In 1996 to 1997, in response to the lack of evidence supporting continuing education or other methods for assessing maintenance of competence, the ANCC initiated research on competency assessment for recertification. Employing computer-simulated case studies, the research is specifically targeted to measure the competence of nurse practitioners every five years.3
In 1999, following identification by the American Nurses Association (ANA) of continuing competence as a major focus issue, the ANCC research group began working with the ANA to test its portfolio model, which allows nurses to document individual ongoing continued competence activities. Nurses re-evaluate the portfolio yearly or upon a change in practice roles. The portfolio consists of professional credentials, workplace evaluations, continuing education, leadership activities and narrative self-reflection.3
The National Council of State Boards of Nursing (NCSBN) also utilizes a portfolio model as part of the Continued Competency Accountability Profile (CCAP) developed by its Nursing Practice and Education Continued Competence Subcommittee. The CCAP involves “assessing strengths, weaknesses and identification of learning needs; planning strategies to maintain/attain/regain competence; implementing strategies needed by the individual nurse to assure competence within the nurse’s role and current practice setting; and conducting an evaluation to determine if learning objectives have been met.”24
In 2001 the NCSBN announced plans to undertake a longitudinal study “to discover how safe nursing practice evolves over the first five years following initial licensure.”25 The study will be implemented in two phases. Phase I will survey a cross-section of nurses at various intervals in their career (from six to 60 months post-entry) to determine the characteristics and evolution of practice. During Phase II, the practice characteristics of these nurses will be examined at set intervals during the next five years. In addition to gaining valuable information about how the practice and competencies of nurses evolve over time, the study will assist in determining which competencies are crucial for safe practice and how they are most effectively measured.25
The National Commission on Certification of Physician Assistants (NCCPA) is responsible for certifying and ensuring the competence of physician assistants (PAs). To receive certification by the NCCPA, PAs must pass the Physician Assistant National Certifying Examination (PANCE), a multiple-choice question exam that assesses basic medical and surgical knowledge.26
After initial certification, a six-year certification maintenance cycle begins. By the end of the second and fourth year of the certification maintenance cycle, PAs must submit proof of completion of a minimum of 100 CME hours to the NCCPA. By the end of the sixth and final year of the certification cycle, PAs must pass one of two recertification examinations: the Physician Assistant National Recertifying Examination (PANRE) or the Pathway II examination, the latter of which was developed for specialized physician assistants.27
The PANRE and the Pathway II are multiple-choice examinations constructed to assess general medical and surgical knowledge; however, the PANRE is a 5-hour computer-based examination that is administered only at Sylvan Technology Centers, whereas the Pathway II is a paper and pencil take-home (open-book) examination. PAs are given six weeks to complete and return the Pathway II exam. PAs who opt to take the Pathway II exam must also complete an elective component28 that consists of an additional 100 hours of continuing medical education. While the 100 hours can be taken at any point during the six-year certification cycle, the PA cannot use any of the same hours to fulfill the CME requirement for years two or four of the certification cycle.28
Additional information about PA recertification can be found on the NCCPA Web site at http://www.nccpa.net.
Emergency Medical Technicians
The National Registry of Emergency Medical Technicians (NREMT) certifies the competency of individuals to practice as emergency medical technicians (EMTs). One of the purposes of the NREMT is “to develop guidelines and programs to assist individuals who have completed Emergency Medical Technician programs to raise their level of competence to assure the provision of improved Emergency Medical Services.”29
EMTs can be certified in one of three areas: Basic, Intermediate and Paramedic. While the standards for certification vary by area, all EMTs are required to meet specific recertification requirements biennially in order to maintain their certification. Following is a review of the certification and recertification requirements for paramedics. Information concerning the NREMT-Basic and NREMT-Intermediate certification and recertification can be found at the NREMT Web site at http://www.nremt.org.
Requirements for NREMT-Paramedic registration include, in part:
Current National Registry or state certification at the EMT-Basic or EMT-Intermediate level
Current approved CPR credential for the professional rescuer
Signature of the EMT-Paramedic Education Program Director or the service director of training/operations verifying competence in the EMT-Basic skills as listed on the NREMTParamedic application
Successful completion of the NREMT-Paramedic written and practical examinations
The EMT-Paramedic Written Examination is a three-hour, 180-question, multiple-choice exam. The practical examination “consists of twelve skills presented in a scenario-type format to approximate the abilities of the EMT-Paramedic to function in the out-of-hospital setting.”30
Reregistration is awarded on a biennial basis. To renew their EMT registration, paramedics are required to be working “within an emergency medical service, rescue service or patient/health care setting, performing ALS skills under the direction of the Physician Director.”31 They also must meet certain criteria, including refresher training, current CPR and Advanced Cardiac Life Support (ACLS) certification, continuing education, and a statement by their physician director that they are competent in their skills.31
In November 2001 the NREMT Board of Directors approved a change in the NREMT-Paramedic refresher courses, as recommended by the NREMT Continued Competency Committee. Beginning in March 2004, refresher education for NREMT-Intermediate and NREMT-paramedics will be divided into two areas:
Following the release of several high-profile reports in the mid- to late-1990s regarding systems-based errors and patient safety, many medical licensing and regulatory agencies in the United States began to review their role in assuring the ongoing ability of their health care practitioners to practice safely. Consequently, a few health care professions and entities have made great strides in developing programs to assess the competency of practitioners on an ongoing, periodic basis.
As the focus on patient safety initiatives continues and public pressure for physician accountability grows, medical licensing authorities will see increasing demand for programs and systems to ensure physicians are able to practice medicine safely not just at the point of initial licensure, but throughout their careers. Therefore, state medical boards will need to engage in extensive, in-depth discussions regarding not only the need for such programs and the tools necessary to implement them, but the potential repercussions on medical regulation as a whole.