Medical Education Feature - March 2008
By Ken Ortolon
The Federation of State Medical Boards (FSMB) likely will vote in May to recommend that state medical boards across the country require physicians seeking relicensure to demonstrate their competence through testing or other mechanisms.
FSMB officials say the recommendation, which its House of Delegates will debate on May 3, follows a trend established by national medical specialty boards to require periodic recertification by physicians. But initial reaction from both Texas Medical Association leaders and rank-and-file Texas physicians again is as negative as it was in 2002, when the Texas Medical Board (TMB) voted to seek legislative authority to require physicians to demonstrate their continued competence every 10 years.
TMA President William W. Hinchey, MD, of San Antonio, questions whether there are any data to prove that periodic competency testing improves quality of care.
Still Got It?
In its report, released in December, the FSMB Special Committee on Maintenance of Licensure said state medical boards devote few resources to prospectively ensuring licensees' ongoing competency.
"In contrast to the rigorous standards for initial licensure, state medical boards have few requirements in place to ensure licensed physicians maintain their competence throughout their professional careers," the FSMB committee report states. "In virtually every state, it is possible for a physician to practice medicine for a lifetime without having to demonstrate to the state medical board that he or she has maintained an acceptable level of continuing qualifications or competence."
To remedy that, the committee recommended state medical boards require physicians seeking relicensure to demonstrate competence in their daily practice. The committee says competence could be demonstrated through ongoing reflective self-evaluation, self-assessment, and practice assessment, with subsequent successful completion of educational activities tailored to correct deficiencies identified by the assessment.
The committee also suggested evidence of self-evaluation, self-assessment, and practice assessment could include self-evaluation exercises or modules, such as self-review tests, home study courses, and Web-based materials, "or passage of a state medical board approved examination in the physician's current practice area."
The report goes on to recommend that physicians demonstrate continued competence in the areas of medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, system-based practice, and, if applicable, osteopathic philosophy and osteopathic manipulative medicine. This criterion should be met, in part, by passage of a "valid, secure, proctored examination in the physician's current practice area not more than every 10 years."
The report was to be presented for approval to the FSMB Board of Directors in February and then to the FSMB House of Delegates at its meeting on May 3.
James N. Thompson, MD, FSMB president and chief executive officer, says the recommendations are part of a national movement within the medical profession to assure quality improvement in patient care. The recommendations are intended to guide licensing boards in implementing a resolution the FSMB House of Delegates passed in 2004 that urged state boards to begin ensuring physician competence at the time of relicensure.
"What we are doing is a quality initiative that encourages physicians to keep current," Dr. Thompson said. "We believe that it is consistent with what is going on nationally, and our policy is the beginning of a process to help the state boards in this movement."
In fact, all 24 national medical specialty boards that are part of the American Board of Medical Specialties (ABMS) now require their board-certified physicians to recertify through examination or other measures at least once every 10 years.
Eagle Lake family physician R. Russell Thomas Jr., DO, is a consultant to the FSMB special committee. He says the committee envisions specialty board recertification as a way state licensing agencies would obtain their proof of a physician's continued competence.
"So it's not an additional test above and beyond what the specialty boards would require," said Dr. Thomas, who also chairs the Accreditation Council on Continuing Medical Education.
Dr. Thompson says most physicians already are board certified. In 2002, TMB estimated that some 80 percent of Texas physicians were board certified. ABMS estimates that 85 percent of physicians nationally are now board certified.
"We believe in most circumstances, physicians who maintain their board certification will likely fully meet all the requirements of maintaining their licensure, which would avoid unnecessary duplication in this process," Dr. Thompson said.
But many of those board-certified physicians - particularly those certified before the mid-1980s - received lifetime certification and therefore are not subject to recertification by their boards. Internal medicine diplomates boarded before 1990, for example, are grandfathered and not subject to recertification. The same is true for orthopedic surgery diplomates certified before 1986, neurological surgery diplomates certified before 1999, and plastic surgery diplomates certified before 1995.
Dr. Thomas says competency testing would impact a significant number of grandfathered physicians. But, he adds, many of those grandfathered physicians already voluntarily undergo the recertification process. Most specialty boards offer that option, he says.
In fact, Dr. Thompson says he took the recertification exam in otolaryngology even though he holds a lifetime certificate.
Test or Not?
If the FSMB House of Delegates approves the committee's recommendations, none of the 70 licensing boards will be required to implement testing for maintenance of licensure. Dr. Thompson says the federation enjoys considerable influence on its member boards, but has no authority of its own.
"What we're hoping for is that if the boards do move forward with a maintenance of licensure initiative, there will be some uniformity nationally by virtue of our having policy," he said.
Donald Patrick, MD, JD, TMB executive director, says the Texas board has not revisited the testing issue since it dropped its 2002 proposal. He says, however, that he still supports a demonstration of competency requirement and would expect the board to be part of a group of state licensing agencies that might move in that direction.
"The Texas Medical Board would look at what other medical boards are planning and, of course, we would work very closely with TMA and TOMA [Texas Osteopathic Medical Association] to come up with a solution that we could phase in over time and that would be a feather in the cap of doctors to show their patients that we are keeping up," said Dr. Patrick, who also serves on the FSMB special committee.
FSMB officials hope physicians will react more positively to competency testing this time around, but Texas physicians are still skeptical.
Susan M. Strate, MD, a Wichita Falls pathologist, chaired both the TMA Ad Hoc Committee on Patient Safety and the TMA Patient-Physician Advocacy Committee, which looked at the TMB proposal in 2002. She says her opinion of competency testing hasn't changed.
"The problem is that competency testing simply hasn't been proven to be effective," she said. "There's no proof that taking some sort of exam will adequately test the physicians' knowledge or their abilities in their day-to-day work."
A number of physicians contacted by Texas Medicine also questioned whether more testing would truly improve quality of care.
"Does more bureaucracy really make better doctors?" asked Victoria family physician Joseph C. Perkinson III, MD.
A recent study published online in Circulation , however, did find that the time elapsed since a primary care physician's last board certification correlates with a decline in the quality of care provided to patients.
Dr. Hinchey says board-certified physicians with lifetime certification should continue to be grandfathered unless state medical boards can "clearly demonstrate" that quality issues exist. Dr. Hinchey, a board-certified pathologist, voluntarily has recertified twice in recent years despite holding lifetime certification.
Still, Dr. Thompson hopes physicians ultimately will embrace maintenance of licensure requirements.
"There is an opportunity for physicians to demonstrate to the public that they're maintaining competence," he said. "I believe that when physicians, particularly board-certified physicians, realize that what they are doing to maintain their board certification will for the most part, if not fully, meet their requirements for maintaining their licensure, they will be very satisfied with this proposal."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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