August 1999 Bulletin

ABMS seeks career-long evaluations

Explores ways to assure public specialists are providing quality care

By Sandra Lee Breisch

To assure medical professionals are maintaining competence throughout their careers, the American Board of Medical Specialties (ABMS), an umbrella organization comprised of 24 medical specialty boards, has formed a task force to formulate plans on ways to continually scrutinize diplomates' knowledge and assess their performance.

"We're looking to refine the meaning of certification and suggesting that the concept of recertification is limited," explains Stephen H. Miller, MD, executive vice president of ABMS. "So, we're looking at the maintenance of certification. The physician's knowledge base and performance will be evaluated on a continual basis.

"In general, it's to ensure that physicians are maintaining competence throughout their professional careers."

The public's demand for accountability is the impetus behind the ABMS initiative, says David L. Nahrwold, MD, who heads a special ABMS task force on competence and is chairman of the Strategic Initiatives Committee for the Accreditation Council for Graduate Medical Education (ACGME). "It's a general expectation of society that we, as a profession, need to be responsive because the public's demands for competence is escalating," explains Dr. Nahrwold. "None of us tolerate incompetency in anything anymore whether it's having your automobile repaired or any service you receive. We expect that when we pay the bill, the job's been done competently. Needless to say, the medical profession is not immune to this."

"There's nothing really new that's being done here," stresses Dr. Miller. "We're just looking into a more codified and more measurable way of determining competence to assure the public that physician specialists are providing quality of care."

Dr. Nahrwold acknowledges that the initial certification process is "quite good" because it consists of one or more examinations that test medical knowledge, medical judgment, medical decision-making and can even test an individual's ethics. "In order to be admitted to a board examination, the board requires evidence from a training program director that the individual has successfully completed training," he explains. "And, in the procedural specialties such as orthopaedics, the board can require that a certain number and type of procedures had been performed during the residency program. So, there are other criteria that enter into the examination."

But where the process seems to be "not as rigorous," points out Dr. Nahrwold, is in recertification, because of the time-limited certificates that have seven- to 10-year guarantees. "The time limit is a very long gap," stresses Dr. Nahrwold, "And not all boards have implemented their recertification processes. More importantly, even the boards that have recertification, base it on medical knowledge-in other words, an exam for medical knowledge and to some extent judgment. But there is not testing for whether an individual knows how to perform a particular procedure that was developed after he or she was certified for the first time. Given the fact that technology is moving so rapidly and medicine is so intertwined with new technology, clearly recertification every 10 years means that we're not as thorough as we were for initial certification."

Thus, Dr. Nahrwold believes it's not possible to certify to the public at this time that physicians are competent, even with the certification/recertification process. "Competency has gradations," explains Dr. Nahrwold. "Some might view competency as absolutely perfect and needless to say, we can't achieve that. So, it's not as if this is imminently feasible and possible."

To refine the definition of competence and expand the recertification process, the ABMS is working closely with the ACGME. Both groups have six general competencies goals for residents and physicians to achieve: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. ABMS also will be looking at competency in outcomes. "By the time residents enter a training program, they'll know that they will be expected to display these competencies throughout their residencies and their practicing lifetimes," says Dr. Miller.

To get this project off to a good start, Dr. Nahrwold noted that it's going to require a great deal of collaborative effort. "The boards can't do this alone," he says. "The specialty societies are going to have to be involved in this as well. Each board is going to have to work within its own specialty, involve the appropriate specialty societies and work on this concept of maintenance of certification.

"For instance, the Academy has hands-on courses on how to perform new procedures in their facility [Orthopaedic Learning Center]. So, the board might look at the procedures and processes the Academy uses to say, 'doctor so and so has demonstrated this.' And that could be part of maintaining certification."

Dr. Miller said the ABMS also is developing relationships with the Council of Medical Specialty Societies (CMSS) to look at ways to evaluate clinical practice.

One of the biggest concerns practicing physicians might have with maintaining certification, says Dr. Nahrwold, "is that they'd view this as, 'I've got more hassle.' And they feel they already got that. . ."

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