Board recertification gets tougher

Concerned about patient safety and physician competence, specialty boards are imposing new requirements. Many doctors are balking.

By Ken Terry
Senior Editor

Specialty boards are raising the bar for recertification by imposing stringent new performance measures. The boards say the changes are essential to guarantee physician competency and reduce medical errors. But many physicians are already grumbling that the requirements won't make anyone a better doctor or improve patient outcomes. In their view, the mandatory chart reviews and surveys of patients and colleagues that will be demanded are an unnecessary and burdensome intrusion into their practices.

The new process will be "a lot more hassle for very little to be gained," complains Scott R. Helmers, a family physician in Sibley, IA.

Like it or not, however, the new approach to evaluating your clinical skills appears to be here to stay. Most doctors who don't have permanent certification will have no choice but to comply if they want to remain in good standing with insurers and hospitals that refuse to deal with non-board-certified physicians.

Assuring the public that doctors are competent

Why have the boards adopted these new standards? Although recertification exams that test clinical knowledge are rigorous now, they don't show how physicians apply their knowledge in practice, says FP Joseph W. Tollison, deputy executive director of the American Board of Family Practice.

"Certification alone isn't a surrogate for competency tests," says FP Martha Illige, medical director of the Denver-based Center for Personalized Education of Physicians, a remedial program for doctors with clinical skills deficits. "You can pass boards and still have problems with the practice of medicine."

Some specialty boards were already grappling with this problem when the Institute of Medicine issued its report on medical errors in 1999. But the public concern over errors, along with studies showing wide variations in practice and gaps in patient care, created a new sense of urgency among the boards and their umbrella organization, the American Board of Medical Specialties.

The Accreditation Council for Graduate Medical Education had been addressing this issue, too. To avoid duplication of effort, ACGME and the ABMS agreed on a set of six areas in which physicians should demonstrate competency: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

"Practice-based learning and improvement" requires the ability to find and assimilate the best new medical evidence into one's daily practice. "Systems-based practice" measures the ability to use the resources of the local healthcare delivery system effectively. This can include maintaining close communications with consultants, knowing how to formulate an effective discharge plan, or being able to work with health plans to get what patients need.

In July, ACGME began requiring all residency programs to evaluate these competencies, although they have 10 years to implement their new assessment methods. The specialty boards, too, are introducing these competencies in their new requirements for recertification. The requirements will be phased in over several years, but some physicians are already facing them, and many more will, starting in January.

By the end of this year, all 24 specialty boards must have plans to help doctors assess their own knowledge and their ability to keep up with the medical field. Practice performance measures that evaluate the other competencies must be submitted to the ABMS by December 2004.

Initial board certification won't be affected by the new rules, because boards will rely on the residency programs to provide them with the new evaluations mandated by ACGME. So if a physician is recommended by his residency program director, a specialty board will presume he's ready to take the certification exam.

Family doctors take a high-tech approach

How exactly will the new recertification process work? Currently, the American Board of Family Practice requires all board-certified FPs to take recertification exams at seven-year intervals. Beginning next year, they'll have to perform six self-assessment tests before they're allowed to sit for the recertification exam. The first two available modules will enable doctors to measure their knowledge of diabetes and hypertension. Eventually, they'll be able to select from a menu of 20 modules covering the conditions identified by the Institute of Medicine as needing improvement in the quality of care.

The self-assessment exams will be built on evidence-based guidelines, and physicians will take them online. If their answers show they need help in certain areas, "we'll provide links to materials that will help them expand their knowledge," says Joseph Tollison of the ABFP. Then they can retake the exam. When they pass it, they'll be allowed to enter a clinical simulation program designed to show how they apply knowledge in realistic situations.

This program, which requires an online tutorial, is expected to be ready in January. The simulator creates a patient of a particular age, gender, and race and assigns a condition with a particular degree of severity. "Once we have that 'patient,' the candidate has a chance to ask the simulator questions to get responses back about symptoms, and he can conduct lab tests and physical exams and procedures," says FP Michael D. Hagen, associate executive director of the ABFP. "On the basis of those results, he can initiate therapy and have the patient come back after whatever amount of time he wants."

To measure doctors' communication skills, the ABFP will have each of them give questionnaires to 50 real patients, who'll be asked to respond to the board via the Web or a telephone voice-response system. The ABIM, which uses a similar approach, has found that about half of the patients respond to its survey. The 12,000 family physicians who'll enter the new recertification program in January comprise about a fifth of ABFP diplomates; by 2010, all FPs who wish to keep their board certification will be involved.

Although the ABFP already requires some chart reviews for recertification, the board won't introduce new practice performance measures for a year or two.

The AAFP wants the quality improvement modules—which will include the performance measures—to focus on specific conditions. For a diabetes module, for instance, a physician would pull 15 to 20 charts of his patients with diabetes.

"He'd answer evidence-based questions about those charts, report the data confidentially via the Web, and receive immediate feedback on how his performance compared with expected norms as well as that of peers who were taking the same module," says AAFP Executive Vice President Douglas E. Henley. "Then he'd be directed to initiate a quality improvement program. After three months, the physician would be required to reassess the charts to see if there'd been an improvement in the way those patients were being managed."

The internal medicine board takes a leadership role

ABIM introduced recertification in 1990—20 years after ABFP did—and its diplomates need to extend their certificates only once a decade. Internists who were certified before 1990 are permanently boarded—a source of discontent among their younger colleagues.

Yet ABIM is in the forefront of the drive to set more stringent requirements for recertification. It already requires diplomates who have three years or less before their recertification exams to perform some learning exercises. Between now and 2010, physicians will have to complete five take-home modules before taking the proctored exam. Starting in 2010, they must do two knowledge exams, two exercises involving chart reviews, and one exercise involving patient and peer feedback. Physicians are encouraged to do performance self-reviews now, and some are, says internist F. Daniel Duffy, ABIM's executive vice president.

The self-assessment exams can be taken on paper, on a computer using a program stored on a CD-ROM, or over the Internet. For general internists, the current modules cover broad areas like inpatient or outpatient general medicine or preventive care. But preventive cardiology is also available, and ABIM will soon offer modules on diabetes, asthma, and hypertension, as well.

The practice improvement modules are similar to the ones envisioned for family doctors, except that they include not only chart reviews but also questions about systems-based practice. This is supposed to help make physicians aware that they can improve the healthcare system and how they operate within it, says Duffy.

Physicians may select any patient population within a particular performance module. Then they give out surveys to the next 50 patients who meet those criteria and review 25 charts from that sample, says Duffy.

Internists, like family doctors, will also be evaluated by their peers. They'll have to ask 20 colleagues to fill out surveys with questions about their professionalism.

"We feel pretty comfortable that the six competencies are all addressed in our program," says Duffy. "Professionalism is addressed by evaluation by peers and patients, and by outside reviews such as hospital credentialing."

Resentment over the new requirements

The family physicians and internists we spoke with about the new requirements balk at the time-consuming new demands their specialty boards are placing on them. They feel that they're doing all they can to keep up with changes in medicine. It's unfair to ask them to do all this extra work, say some doctors, just to uncover the few bad apples in the profession.

"Physicians need ongoing education, but the problem is how to reach and educate the outliers—the people who haven't gained the knowledge or haven't kept up to date," says internist Gregory A. Hood of Lexington, KY. "This system lumps everybody together and makes them go through a very regimented process for the sake of the few."

Even physicians who see a more widespread need for quality improvement don't believe the boards are appropriate agents of change. Instead, they suggest, physician groups or hospitals should undertake this task. Internist Paul M. Reinbold, for instance, says his hospital in Cambridge, MD, is making a big effort to get physicians to follow guidelines because certain clinical measures affect the hospital's reimbursement.

"Nobody with coronary artery disease can get out of the hospital without aspirin—unless there's a reason next to it on the chart," he says. "That's what's going to fix the problem of practice variations. I don't think a board certifying me is going to make sure I put everyone on aspirin when they leave the hospital."

Physicians also dislike outside intervention in their practices. Notes FP David L. Boles of Nashville, "We've got insurance companies sending us letters saying, 'Here are our guidelines for the management of this chronic disease. Fill out this form and send it back to us, saying when you did this or did that.' If you want to spend the money to review my medical records, that's one thing. But if it's going to require more of me, I'm just kind of sick of it."

Other physicians point out that the recertification process can be gamed. "Doctors are smart individuals, and if they intend to keep doing things the way they're doing them, they'll find a way to keep their board certification," says Reinbold. "It doesn't necessarily mean it's going to change their behavior."

The boards are divided on how to deal with gaming. The American Board of Internal Medicine plans to do random audits of charts that physicians have reviewed themselves, at least in the testing phase. In contrast, the American Academy of Family Physicians—which will have input into the ABFP performance measures—doesn't feel it needs to audit physicians, since the purpose of reviewing one's own charts is not to pass a test but to improve care, says Henley.

The American Board of Pediatrics is more concerned about gaming but isn't relying on chart audits, either. Instead, it's working with the American Academy of Pediatrics to form local collaboratives of doctors. They'll deter gaming by having peers look at a doctor's chart data before it's submitted. And they'll encourage physicians to collaborate on quality improvement.

"Physicians don't like being told what to do," notes pediatrician Paul V. Miles, vice president for quality improvement and assessment in pediatric practice for the ABP. "But they do like working together to improve the health of kids."

Those physicians who feel they're being forced to jump through hoops to ferret out a few "bad apples," Miles adds, misunderstand the boards' concept. "The boards have adopted a quality improvement approach where the standard for practice performance is asking physicians to demonstrate that they can assess and systematically improve the quality of care they and their care team deliver. This is in contrast to an inspection approach that would have someone come into their practice to try to measure their quality of care. It changes the focus from trying to find 'bad apples' to developing tools and systems that help physicians improve care."

Henley feels physicians should view the new recertification process as a learning tool rather than a burden. "It allows doctors to assess where they are and compare their care to that of their peers, and show improvement as they move toward the expected norms. And when they go through that type of learning process, care will improve over time."

Regarding the extra work that family physicians are being asked to do, Henley says it's "likely" that their preparation for self-assessment exams and their practice-based learning projects will qualify for CME credit.

In the long run, the ABMS hopes the new recertification process will upgrade the level of medical practice by reducing practice variations, notes Sheldon D. Horowitz, the organization's associate vice president. "I think doctors want to do well and want to take good care of patients," he says. "If you show how they could do better, physicians would get closer to the standard of care."

 

Ken Terry. Board recertification gets tougher. Medical Economics Nov. 21, 2003;80:29.