Are You Competent?

TSBME Takes Step Toward Mandating Physician Proficiency Exams

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Medical Education Feature -- October 2002  

By Ken Ortolon 
Senior Editor  

Your patients assume you're competent. You know you're competent. But now the Texas State Board of Medical Examiners (TSBME) wants you to prove you're competent.

On Aug. 16, the board voted unanimously to move forward with a proposal to require periodic testing of physicians' "current proficiency." If all goes as planned, the first tests would be administered in 2005.

"The quality of patient care improves when the quality of physicians improves," said Donald Patrick, MD, JD, TSBME's executive director. "The Texas State Board of Medical Examiners proposes to improve the quality of physicians in Texas by requiring that doctors demonstrate current proficiency every 10 years."

Dr. Patrick says TSBME will ask the 2003 Texas Legislature to grant it authority to begin the testing. If that authority is granted, Texas would become the first state to require competency testing. The Texas Medical Association and the Texas Osteopathic Medical Association would be involved in developing rules for administering the tests, he says. 

Physicians greeted the board's proposal with considerable skepticism. The day after the board's vote, TMA's Ad Hoc Committee on Patient Safety, which has been studying clinical competency, recommended that lawmakers delay testing until an interim study can be conducted after next year's legislative session. Competency testing, the committee concluded, is an untried and unproven method of ensuring quality care.

"Physicians have to be accountable, there's no question about that," said Wichita Falls pathologist Susan Strate, MD, who chairs both the ad hoc committee and the TMA Patient-Physician Advocacy Committee. "But the proposed competency testing leaves open a whole array of questions, and there is no scientific basis that this will improve the quality of care to Texas patients."

Measuring Proficiency  

TSBME's proposal is still in the embryonic stages, but Dr. Patrick already has presented the concept of proficiency testing to legislative leaders. In an Aug. 5 letter to Lt. Gov. Bill Ratliff (R-Mount Pleasant), Dr. Patrick asked the legislature for aid in "improving public protection" under the Medical Practice Act.

"Changes in this act are needed to expand current statutory authority to suspend licensees determined to be sexual predators or whose actions pose a danger to their patients. Current authority is limited," Dr. Patrick wrote. "Also, legislation is needed to enable the agency to require and enforce continuing competency of its licensees by mandating a written, monitored test at least every 10 years."

As outlined by Dr. Patrick, the proposal would require physicians to obtain initial certification and recertification from their specialty board by taking a monitored examination at least every 10 years. Those who are not board certified would have to pass an approved assessment test. Officials at the Federation of State Medical Boards say about 90 percent of American physicians are board certified, but not all specialty boards require recertification or offer recertification exams that would meet the requirement.

 To allow agency staff to administer these new requirements, Dr. Patrick also proposes to switch from annual to biennial license renewal. Licensing fees would be doubled to continue to generate the same amount of revenue.

Proficiency tests being considered by TSBME are the Special Purpose Exam (SPEX), often given to medical students to measure general medical knowledge, and the Clinical Skills Exam, which will be required of all medical students beginning in 2004.

A third alternative would require physicians to take a portion of the SPEX exam, along with modules on ethics and communication, women's health, interpreting medical literature, mechanics of disease, and the musculoskeletal, gastrointestinal, and cardiovascular systems. "Other testing instruments could be developed by further research and implemented by 2005 when we want the testing cycle to begin," Dr. Patrick said.

Physicians would have three chances to pass. "Should the doctor fail the test on all three attempts, the physician would be required to participate in a remediation program approved by the board," he said.

SPEX, a multiple-choice exam, appears to be the most likely testing instrument at this time. A score of 75 is required to pass that exam.

TSBME President Lee Anderson, MD, a Fort Worth ophthalmologist, says he got "weak in the knees" when Dr. Patrick first proposed proficiency testing. "I was thinking, 'I don't want to take a test,'" he said. "But then the greater good began to chime in my brain for several reasons."

The first, he says, is the public good, followed by physicians' own professionalism. The third, he says, is the upcoming battle for medical liability insurance reform.

"It's a difficult conundrum because we're saying that we need tort reform, which we do. But the only mechanism out there right now to pick up physicians who may have cognitive issues or physical problems is either a complaint to the board or the malpractice system. We should be able as a profession to go to the legislature and say we need tort reform and if you give us this then here's what we'll do: We will either recertify or take some type of examination every 10 years."

Unanswered Questions  

Dr. Strate says assuring physician competence is laudable but adds the board is rushing headlong into uncharted territory when it already is having trouble meeting its current responsibilities. In a series of articles over the past several months, the Dallas Morning News harshly criticized TSBME for failing to revoke the licenses of physicians who have sexually abused patients, or to aggressively discipline doctors who have committed serious medical mistakes, even when they caused death. Competency testing will not identify sex offenders, substance abusers, or even many of those who have committed serious medical mistakes, she says.

The board has admitted that its investigative process is too slow, and it recently received emergency funds from Gov. Rick Perry's office to hire more investigators.

In his letter to Lieutenant Governor Ratliff, Dr. Patrick said the common thread of the media attention is to focus on sensational -- but old -- cases. "We can't change history," he said, "but we can move forward with a vigorous commitment to assure that only proficient physicians provide medical care in Texas." He added that the agency has been historically underfunded to provide the strong regulatory system expected by the people of Texas. The board is asking for about $900,000 per year for enhanced investigation and litigation activities.

The TMA ad hoc committee also recommended that lawmakers explore competency testing in an interim study because it did not feel TSBME had answered numerous serious questions: What happens to physicians who fail the exam? Will adequate programs for remediation be available? What standards will be used to measure if remediation has been successful? Who will approve and monitor remediation programs? How much will all of that cost? Dr. Patrick has said physicians who fail the test will be offered remediation but many of the ad hoc committee's other questions may not be answered until a more comprehensive proposal is presented to the legislature next year.

But the real problem, Dr. Strate says, is that competency testing simply has not been proven effective. "Basically, this is an untested concept. No other state in the country at this time is using competency testing for physicians," Dr. Strate said. Even if testing was effective in ensuring proficiency, SPEX is not adequate to test a physician's knowledge of the type of medicine he or she practices, she adds, and no test assesses a physician's judgment.

"SPEX is a medical school type of test," she said. "It's primary care-based and does not accurately assess the knowledge that many physicians use in real everyday practice."

Even exams used by medical specialty boards to assess physician knowledge during recertification do not always include material relevant to every physician in that specialty, says TMA President Fred Merian, MD, a Victoria family physician.

"I've taken the family practice boards once and I've recertified four times, and even though they've had 30 years of experience with this exam, I don't think that it particularly tests your competency," he said. "One year, there must have been 20 to 40 questions about frostbite. I get a few cold people every once in a while with hypothermia, but I don't really see a whole lot of frostbite in South Texas."

Dr. Merian says peer review is a better way to determine competency. "Local peer review that is protected from lawsuits is the way to check competency, not a test. Some doctors may take tests well, but do they transfer that knowledge to the patient and to each patient's situation well? How does a competency exam test that?"

Even if SPEX or another exam can't measure specific clinical skill, it can at least show that a physician has some cognitive ability, Dr. Anderson says. "The Special Purpose Examination is a general medical examination, and I would agree that it wouldn't show any degree of proficiency in my specialty for me to go study a textbook and then take that test. But it would show that I did have the wherewithal to sit down, review information, maybe dust a few cobwebs out of my brain, and show that I have the cognitive ability to make a differential diagnosis and come up with some kind of action plan."

A Moving Train  

Despite physicians' skepticism, it appears competency testing is a moving train that's gathering steam. While TSBME is the first state medical board to announce it will seek testing authority, several other state boards also are looking at the issue, says Dale L. Austin, MHSA, deputy executive vice president of the Federation of State Medical Boards. States looking at the idea most seriously are Nevada, California, and Nebraska, he says.

Mr. Austin says the federation has no position on requiring competency testing of all physicians, but it is moving forward with initiatives to facilitate testing should boards across the country decide to travel that route.

First, the federation has developed several testing modules that could be used as addenda to SPEX to address the criticism that it does not measure skills used in everyday practice.

For example, a module covering women's health could be added when testing physicians who specialize in obstetrics and gynecology, Mr. Austin says. While some modular exams have been developed, the federation does not plan to move forward with modules for all specialties until the state boards commit to using them.

A second federation initiative involves assessment and remediation. Critics of proficiency testing question whether enough programs would be available to assess the shortcomings of physicians who failed the test and to provide remedial education. The Colorado Physician Evaluation Program is the most widely known program of that type, but Mr. Austin says there are several others around the country, including one in the Dallas-Fort Worth area that was scheduled to be launched by the federation in mid-September. A hospital peer review committee, state licensing board, or other group may refer a physician to the Colorado program because of concerns about substandard care.

The Dallas program initially will focus on primary care physicians, but Mr. Austin says they hope to be able to handle all specialties by January.

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.  


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