The Evolving Paradigm -Tying Physician Demonstration of Continuing Competency to Maintenance of Licensure

Does the emperor have any clothes?

Linda Van Etta, M.D., FACPMarch 7, 2009

Concerns about poor quality of healthcare in U.S. IOM reports- 1999, To Err is Human

followed by Crossing the Quality Chasm

consumer groups-Consumers Union, public reporting

TJC-national patient safety initiatives Is the problem due to physician incompetence?

Increasing “concerns” about physician competency Perception of decreased physician skills

and knowledge during practice life Perceived need for physicians to

provide enhanced demonstration of competency periodically during their careers-CME not enough

Perception that current state medical board requirements for MOL are inadequate to assure competence

What is physician competence? The ability to answer knowledge

questions on a secure exam? or The ability to diagnose patients

and prescribe appropriate treatment?

History/evolution of physician training and certification 1840s-physician “trade schools” 1845-Nathan Davis, NY, proposed

nationwide professional association 1847-AMA founded 1876-AAMC 1889-Johns Hopkins Hospital,

Osler’s textbook, medical school-first “residency”

History/evolution of physician training and certification 1910-Abraham Flexner, Carnegie

Foundation on quality of medical education-only 5 found acceptable

1912-FSMB created 1914-AMA Council on Medical

Education-institutes program of hospital internships, approved facilities

1915-NBME

History/evolution of physician training and certification 1916-board of ophthamology 1924-board of otolaryngology 1930-board of OB/Gyn 1932-board of dermatology and

syphiliology 1933-boards unite to form ABMS

History/evolution of physician training and certification 1937-AHA created 1940’s-1970’s-evolving councils regarding

graduate medical education (GME) 1965-Medicare Bill, GME now public policy 1981-ACGME formed 2000-2002-ACGME endorses six general

competencies to assess residents (also adopted by ABMS)

Six core competencies Patient care Medical knowledge Interpersonal and communication

skills Professionalism Systems-based practice Practice-based learning and

improvement

ABMS (American Board of Medical Specialties) Founded 1933 24 member boards 38 specialty, 108 subspecialty

certificates Certify “85%” of licensed U.S.

physicians 1970’s- moved towards time-

limited certificates

ABMS ~ 850,000 certificates 5-100% of certificates time-limited,

depending on specialty ~ 60% of total are time limited at present Life-time (non-time limited) certificate

holders can volunteer to recertify, but most have not

cannot legally break the life-time certificates

ABMS-Maintenance of certification (MOC) program January, 1998- “white paper”, David

Hahrwold, M.D. for exec committee March, 1998-taskforce on

competence formed-MOC proposed All 24 board started MOC as of 2008

with full implementation by 2016 Replaced the single, secure exam

for recertification

ABMS/MOC-4 parts Professional standing Lifelong learning and self-

assessment Cognitive expertise (secure exam) Practice performance assessment

Horowitz article-Neurology, 2008 Sheldon Horowitz, M.D.-ABMS executive

for MOC “linkages of participation in MOC to

improved physician performance and patients outcomes are not yet available”

“all four parts of MOC are essential, but Part 4 is the heart and soul of the program as it involves looking directly at patient care and patient outcomes”

Horowitz article “As MOC establishes links to other

programs, such as maintenance of licensure, pay-for-performance, and recognition programs, diplomates with non time-limited certificates will be more likely to participate in MOC.”

Horowitz article “A number of efforts to accomplish

this coordination are under way. ABMS and its Member Boards are working to tie physician participation in Medicare and other government-controlled health care programs to MOC.”

Horowitz article “ABMS also is working with the

Federation of State Medical Boards so that participation in MOC may eventually fulfill some new, more stringent requirements for renewing a state medical license.”

FSMB-MOC/MOL 70 member state medical boards Presently, state medical boards require

payment of a fee and most require CME to renew a state medical license

FSMB board of directors and the CEO, Jim Thompson, M.D. launched 2 national initiatives regarding maintenance of competency and the possibility of tying MOC to maintenance of licensure (MOL)

2 FSMB MOC/MOL initiatives Special FSMB committee on MOL- formed in

2003 with report to HOD at annual meeting in May, 2008

Physician Alliance for Physician Competency (PAPC)-now renamed the National Alliance for Physician Competency- members include the FSMB, member medical boards, ABMS, AMA, AARP, NBME, etc- has held periodic summits, meeting since March, 2005

“burning platform”

Minnesota BMP-MOC/MOL taskforce Meeting since August, 2006 Stakeholders on taskforce-BMP, U of M,

MMA, ACP, MAFP, MHA, BCBS, ABMS Data mining of MN licensees-discovered

only 70% are board certified Presentations by ABMS, FSMB, Canadian

MOC/performance review program, etc

Goals of the MBMP MOC/MOL taskforce conclude that the current

requirement of 25 CME credits per year is an adequate demonstration of continuing competency, if not

recommend an alternative way for licensees to demonstrate continuing competency

Any new requirements should Be available to all licensed physicians

and osteopaths, all eligible Acceptable to the public, regulators,

and physicians Practice relevant, fair, and validated Non-punitive Not onerous or duplicative Not dissuade physicians from practicing

in Minnesota

Minnesota Primary vs Non-Primary Care PhysicianCertification Term by Age Group

0 3

777

1,1541,092

996

804

1

340264

314193

169225

562

574

06 24

17553

480

59

294235

447

536

453

222

10711

492

52576

225

550496

364

30

200

400

600

800

1000

1200

1400

25-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71above

Age Group

# of

Min

neso

ta P

hysi

cian

s

Primary Care Lifetime Certification Primary Care Time Limited CertificationNon-Primary Care Lifetime Certification Non-Primary Care Time Limited Certification

2008-intersection of the MBMP/taskforce and FSMB Nov 2007-FSMB special committee on

MOL issued draft report for comment (30 days)

Jan 2008-MBMP spent majority of meeting discussing the draft report and forwarded comments to the FSMB

Feb 6, 2008-taskforce had presentation from Carol Clothier, FSMB, on the now “restructured” report

MOL proposed standards for demonstrating competency-FSMB Participation in an ongoing process of

reflective self-evaluation, self assessment, and practice assessment including learning modules, CME, etc.

Demonstration of medical knowledge thru a secure exam at least once every 10 years

Accountability for performance on practice thru 360 evaluations, patient satisfaction surveys and collection and analysis of practice data

MOL proposed standards-FSMB State medical licensing boards would need

to monitor the compliance of their licensees, and discipline any physician out of compliance regardless of their competency

At present only 36% of members boards are supportive of requiring physicians to provide enhanced demonstration of competence as a condition of license renewal/reregistration (FSMB survey, 2008)

MBMP and FSMB-MOC/MOL May 2008- FSMB annual meeting and HOD Members of the MBMP contributed

significant dialogue about the MOL report HOD adopted the recommendations of the

report, but recommended no implementation at this time but rather study of the implications of implementation. Report due to HOD, May 2009

2008-intersection of the MBMP/taskforce and the FSMB June 5, 2008- taskforce reviewed the

FSMB BOD and HOD report on MOL July 2008- Dr. Rebecca Hafter-Fogarty

and Dr. Linda Van Etta were invited by the FSMB to participate in the 6th summit meeting of the NAPC. Draft of the Guide to Good Medical Practice-USA, version 1.0 reviewed and released

NAPC-”Guide to Good Medical Practice” Mimics the core competencies of the

ACGME and ABMS Recommends a MOC program for all

physicians 270 bullet points a physician must

uphold covering many aspects of care delivery

“aspirational versus attainable” at present

2008-intersection of the MBMP/taskforce and the FSMB Oct 9-10, 2008- Dr. Linda Van Etta

attended the FSMB MOL taskforce meeting on models for MOL implementation-representatives of 13 state medical boards invited.

Oct 13, 2008- MBMP taskforce discussed Guide to Good Medical Practice document and forwarded feedback to the FSMB

2008- the FSMB October 11, 2008- Dr. Regina

Benjamin, chair of the FSMB board of directors, accepts the resignation of CEO, Jim Thompson, M.D., effective October 31, 2008

Barbara Schneidman, M.D.- leaves the AMA to become the interim CEO of the FSMB

The future of MOC/MOL Will we continue down the current

path outlined by the FSMB? Will the process be slowed or

changed by the new leadership at the FSMB?

Is this the right path?

Recommendations of the MBMP taskforce no changes to the MOL requirements

should be made at this time MBMP should closely monitor and influence

the ongoing MOL initiatives at the FSMB Eventually all physicians will have time

limited board certifications from the ABMS or AOA and will be enrolled in MOC programs resulting in enhanced demonstration of “competency”

Is the chosen surrogate valid? ABMS MOC programs have been

“chosen” as the way for physicians to demonstrate maintenance of competency, but does

MOC = MOC ?

Circulation-February 5, 2008 Retrospective study of 8,127

diabetic patients treated for hypertension

301 internists at primary care clinics affiliated with MGH and B&WH in Boston

“treatment intensification”

Circulation- Boston studyBetter care (optimal hypertension

control) by internists recently board certified:

26.7% -recently board certified 6.9% -last certified 31 years

previously

Circulation –Boston studyFirst study that “analyzed a

quantitative relationship between the length of time since the last board certification and quality of care”

Is 26.7% the level of quality we want to achieve?

“Does the emperor have any clothes?” Will requiring physicians to

participate in MOC programs as currently structured and tying that to MOL result in improved quality of care and patient outcomes?

Or, will it simply result in increased burdens on physicians?

A “better path” for MOC/MOL programs the changes should be “evolutionary, not revolutionary” do away with the requirement for a “secure, high

stakes” exam and focus on quality improvement and education modules (ABMS components 2 and 4)

focus on system errors and system solutions, with feed back loops to physicians

Harness EHR technology to help physicians improve episodes of care

Allow multiple organizations to develop learning modules that fulfill the MOL requirements, not just the ABMS

Recommended reading

Guide to Good Medical Practice-USA, version 1.0 (National Alliance for Physician Competency)

FSMB-MOL committee report to HOD, May 2008

Horowitz, Sheldon-Maintenance of certification: The next phase in assessing and improving physician performance. Neurology 2008; 71;605-609.