American College of Physicians: Internal Medicine — Doctors for Adults ®

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Heeding the public's call for better quality and safety

From the September ACP Observer, copyright 2004 by the American College of Physicians.

When I first heard the term "mural dyslexia" defined by Lloyd H. Smith, MACP, emeritus professor of medicine at the University of California, San Francisco, I immediately thought of the specialty of internal medicine.

As Dr. Smith explained it, the term refers to people's "inability to read the handwriting on the wall." With society's attitude toward doctors shifting from one of support to one of criticism, the entire medical profession should take a cue from Dr. Smith and take a hard look at public attitudes.

Patients and payers alike are insisting that we demonstrate ongoing clinical competency throughout our careers. It is no longer enough to show that we know the answers to questions of medical knowledge; we must now provide continuing evidence of the quality of our clinical performance.

This growing scrutiny is being driven by increasing public concern over medical errors and patient safety. Those concerns have produced doubts about our performance as clinicians, which in turn have led to questions as to how well we maintain our clinical skills.

That's why, as internists, we must "read the handwriting on the wall" and take action to show the public we are committed to the highest quality clinical care and the highest standards of our profession.

From knowledge to performance

Several reports from the Institute of Medicine (IOM) have underscored the public's concern over medical errors and patient safety. They have also called attention to the medical profession's failure to provide high quality health care.

Those reports have undermined the public's trust in the health care system and produced doubts about our performance as clinicians. The reports have also created a societal expectation that physicians will be motivated to actively confront safety and quality issues—and have led to questions as to how well we are maintaining our clinical skills. As a result, board certification and recertification are getting new attention as ways to ensure the ongoing clinical competence of the nation's physicians.

While the product of medical school is fundamental medical knowledge, board certification gives the public evidence that physicians have the requisite knowledge, attitudes, skills and experience to provide quality care in a given specialty.

Against the backdrop of changing public expectations, however, board certification and recertification have recently been reshaped by changes in educational and training standards, which are set by the Accreditation Council for Graduate Medical Education (ACGME) and the respective residency review committees. ACGME now places new emphasis in residency programs on care outcomes, basing a program's accreditation on how successfully it prepares residents to practice medicine.

The ACGME has identified six competencies as critical to the practice of medicine: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. Because physicians must complete an ACGME-accredited residency to sit for the boards in their specialty, the standards set by both the ACGME and the residency review committees have played a major role in the recent evolution of the certification and recertification standards.

The American Board of Medical Specialties (ABMS), the umbrella group representing certifying boards, has agreed that practicing specialists should be evaluated for the same general competencies as residents, not only for initial certification but also for recertification. The ABMS now is also requiring more emphasis on practice performance.

The American Board of Internal Medicine (ABIM) established several voluntary recertification programs between 1974 and 1986 and launched a new recertification program, Continuous Professional Development (CPD), in 1995.

By 1998, all the ABMS-member boards had proposed time-limited certificates requiring physicians to recertify at seven- to 10-year intervals. By 2000, all the boards had agreed to issue time-limited certificates requiring recertification—and to transition from recertification to maintenance of certification. The four requirements for maintenance of certification, which are set by ABMS, are: evidence of professional standing; evidence of cognitive expertise; evidence of lifelong learning and improvement; and evidence of practice performance.

With the ABMS transitioning from recertification to maintenance of certification, the focus shifted from an assessment of knowledge to an evaluation of continuing clinical competence and the ability to deliver high quality health care.

Looming regulation?

Many board certification organizations have recognized the need for a more comprehensive program to assess continuing clinical competence and practice performance. Their rationale? That engaging in the process of practice evaluation leads to practice improvement—and that setting those standards within medicine is better than waiting for a regulatory quality inspection to be imposed upon us.

According to the ABMS, some state legislatures—which are concerned about patient safety—have begun to explore the possibility of requiring physicians to document maintenance of competence to renew their license.

In April 2004, for instance, the South Carolina legislature passed a law calling for physicians to demonstrate continued professional competency to renew their license. The bill spelled out several options physicians can use to do that. One of those options, according to the Federation of State Medical Boards, is recertification after examination by a national specialty board.

Physician anxiety

ACP and the ABIM have been involved in ongoing discussions about what role maintenance of certification can play in bridging what the IOM has called "the quality chasm." Because of the ABIM's historical focus on testing knowledge and the initial structure of its CPD modular format, the College and the ABIM believe that practicing physicians who need to recertify have felt anxious about CPD's self-evaluation process knowledge modules.

Both the ABIM and ACP now support the concept of allowing internists to use MKSAP to satisfy all, not just two, of the knowledge modules required by CPD. (For more information, see "College and ABIM outline ongoing evolution in recertification.")

While recertifying physicians have been anxious about the knowledge modules of the CPD and the secure exam, the handwriting on the wall suggests that the practice performance component of the maintenance of certification process will be the key criterion by which the public holds internists accountable in the future.

"Pay for performance" programs are being instituted in managed care organizations and by industry and are being pilot-tested by government. And there is growing public clamor for medicine to prove its commitment to practice improvement. It is time for us to read that handwriting on the wall and decide how we want to meet that challenge.

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