How Can We Learn from History Repeating Itself?

When I saw the story on CNN about the Kentucky Children’s Hospital resuming heart surgeries for kids, I couldn’t help but think of history repeating itself and to be reminded of similar sad story, the Bristol inquiry, about the Bristol Heart Babies scandal. It’s hard not to see the parallels between the two tragedies and their link to the establishment of ways to ensure doctors are doing everything they possibly can to see to it their clinical knowledge and skills are up to date.

High profile cases like these which detail the public perception of the harms that physicians can perpetrate on patients form a very large part of the rationale for programs like revalidation in the United Kingdom and Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) in the United States and Canada [1,2,3].

The question is whether or not these programs work to eliminate the kinds of disasters which boards tend to point to as justification for the complex processes the validity of which are questioned by many. The concerns about whether the components of programs like the MOC are relevant to the practices of doctors is critically important to their continuation. Research tends to reveal that processes like the MOC, like the physicians whose lifelong learning it purports to improve, need continuous revision [4].

A majority of internists believe in the principle of lifelong learning, but far less believe that current programs like the MOC help them achieve that goal [5]. Back in the 1970s there was considerable apprehension about mandatory Continuing Medical Education (CME) toward recertification as a condition for membership in the American Psychiatric Association (APA) and many thought the proposal was coercive–about the same situation that exists today with respect to MOC. Some of the objections sound eerily familiar today. I found an old article published in the American Journal of Psychiatry, summarizing a survey of psychiatrists about how they felt about CME, which may help to give us some perspective on the great reluctance of most physicians to embrace programs like the MOC [6]:

“One of the most common objections was to any learning process that was coercive or mandatory.”

“The most frequently mentioned objection to CME in this survey was the commercialization of medicine. Respondents stated that a whole new industry has been created that enriches hospital and university departments of psychiatry; sells CME credits as indulgences were sold in the Middle Ages; cheapens and degrades the educational process; encourages programs to offer competing and similar CME courses; and has created a ‘paper industry’…”

“Akin to the criticism of commercialization is that of the bureaucratization of medical education. Critics pointed out that whereas in the past psychiatrists have learned from peers, professional journals, and conferences and monitored their own gaps in knowledge and progress, now a huge bureaucracy is in the making, not simply to plan, market, and conduct CME activities, but also to accredit, document, monitor, and regulate them.”

“Psychiatrists stressed that much CME is not relevant to their current activities, i.e., is not patient-centered or oriented to improving their clinical skills.”

“Critics stated that most CME activities are inefficient…they take time away from more productive learning experiences (e.g., journal reading), research, writing, and patient care… “A large number of the respondents considered the costs of CME offerings exorbitant.”

“Severe psychiatrists pointed out that there were no data demonstrating that the quality of existing care was bad due to psychiatrists’ current learning practices or any outcome studies showing a relationship between CME instruction and good patient care.”

“In addition, many respondents stressed that one cannot mandate learning, but only attendance. Thus, true learning can only be self-initiated from an individually perceived need.”

“Both directly and between the lines, there was a great deal of apprehension expressed about the increasing control over practitioners’ lives…Critics feared that eventually psychiatrists will serve the government rather than their patients ….”

“Respondents felt that coercive CME was infantilizing, especially to professionals who spend their lives learning. They also suggested that it was ‘fear-producing rather than creativity-engendering.'”

“An overwhelming number of respondents who objected to mandatory recertification felt that any such recertification should not involve a Board-type reexamination. Others expressed the fear of the establishment of another industry, like that of CME, devoted to enabling psychiatrists to obtain certification, as well as another bureaucracy to plan, administer, and monitor the process.”

“Many persons felt that physicians are unfairly singled out for recertification and suggested that they would cooperate with the idea when others (e.g., lawyers, politician, and paraprofessionals) mandate their own recertification. Other respondents suggested that some groups, such as older practitioners and teachers, be exempt from recertification requirements.”

Nowadays most doctors say that CME is sufficient for maintaining certification status. The boogie man is now the MOC.

Talbott’s conclusion from the survey is that there was not so much opposition to the concept of mandatory CME and recertification as there were reservations about the methods of implementation–exactly the sentiment expressed today about MOC. And Talbott’s questions remain:

“Who learns best, and how do they learn?”

“Can the quality of patient care be correlated with professional skill levels and education or knowledge?”

“How do we increase self-initiated learning?”

“Can we do genuine educational outcome studies along the model of patient outcome studies?”

Finally, Talbott’s view of the conflict psychiatrists had with CME indicates he thought only more education was needed–“We should redouble our efforts to inform our colleagues …lest we face an angry and still uninformed group…” This view is not very different from Gallagher et al today–“A gap exists between physicians’ interest in feedback on their competence and existing programs’ ability to provide such feedback. Educating physicians about the importance of regularly assessing their knowledge and quality of care, coupled with enhanced systems to provide such feedback, is needed to close this gap.”

History is always repeating itself, inviting us to learn from our mistakes. So why can’t we do it? Maybe it’s just the fear of change.

References:

1. Shaw K, C. C. K. B. C. L. W. (2009). “Shared medical regulation in a time of increasing calls for accountability and transparency: Comparison of recertification in the united states, canada, and the united kingdom.” JAMA 302(18): 2008-2014.

In the United States, Canada, and the United Kingdom, the medical profession is accountable to the public for the delivery and quality of care provided to patients. Traditionally, this accountability has been achieved through the development and maintenance of professional standards established by the profession itself—self-regulation. Medical self-regulation is being re-examined by regulators, government, and the profession in response to a range of drivers including payers seeking ways to hold physicians accountable for cost-effective care; patients seeking more information about their physician’s qualifications; and the emergence of a number of high-profile cases of unacceptable medical practice. This article outlines the current state of medical regulation in the United States, Canada, and the United Kingdom and highlights the increasing external pressure on the self-regulatory framework that is leading to a shift toward shared regulation between the profession and other stakeholders.

2. Archer, J. and S. R. de Bere (2013). “The United Kingdom’s Experience With and Future Plans for Revalidation.” Journal of Continuing Education in the Health Professions 33(S1): S48-S53.

Assuring fitness to practice for doctors internationally is increasingly complex. In the United Kingdom, the General Medical Council (GMC) has recently launched revalidation, which has been designed to bring all doctors into a governed environment. Since December 2012, all doctors who wish to practice are required to submit and reflect on supporting documentation against a framework of best practice, Good Medical Practice. These documents are brought together in an annual appraisal. Evidence of practice includes clinical governance activities such as significant events, complaints and audits, continuing professional development and feedback from colleagues and patients. Revalidation has been designed to support professionalism and identify early doctors in difficulty to support their remediation and so assure patient safety. The appraiser decides annually if the doctor has met the standard which is shared with the most senior doctor in the area, the responsible officer (RO). The RO’s role is to make a recommendation for revalidation every 5 years for each doctor to the GMC. Revalidation is unique in that it is national, compulsory, involves all doctors regardless of position or training, and is linked to the potentially performance moderating process of appraisal. However, it has a long and troubled history that is shaped by high-profile medical scandals and delays from the profession, the GMC, and the government. Revalidation has been complicated further by rhetoric around patient care and driving up standards but at the same time identifying poor performance. The GMC have responded by commissioning a national evaluation which is currently under development.

3. Campbell, C. M. and J. Parboosingh (2013). “The Royal College Experience and Plans for the Maintenance of Certification Program.” Journal of Continuing Education in the Health Professions 33(S1): S36-S47.

The Royal College of Physicians and Surgeons of Canada, in 2001, implemented a mandatory maintenance of certification (MOC) program that is required for fellows to maintain membership and fellowship. Participation in the MOC program is one of the recognized pathways approved by provincial medical regulatory authorities in Canada by which specialists can demonstrate their commitment to continued competent performance in practice. This article traces the historical beginnings of the MOC program, highlighting the educational foundation and scientific evidence that influenced its philosophy, goals, and strategic priorities. The MOC program has evolved into a complex system of continuing professional development to facilitate and enable a “cultural shift” in how we conceptualize and support the continuing professional development (CPD) of specialists. The MOC program is an educational strategy that supports a learning culture where specialists are able to design, implement and document their accomplishments from multiple learning activities to build evidence-informed practices. In the future, the MOC Program must evolve from assisting fellows to use effective educational resources “for credit” to enable fellows, leveraging a competency-based CPD model, to demonstrate their capacity to continuously improve practice. This will require innovative methods to capture learning and practice improvements in real time, integrate learning during the delivery of health care, expand automation of reporting strategies, and facilitate new sociocultural methods of emergent learning and practice change. Collectively, these directions will require a research agenda that will generate evidence for how transformative cultural change in continuing professional education of the profession can be realized.

4. Lipner, R. S., B. J. Hess, et al. (2013). “Specialty Board Certification in the United States: Issues and Evidence.” Journal of Continuing Education in the Health Professions 33(S1): S20-S35.

Background The American Board of Medical Specialties (ABMS) certification and maintenance of certification (MOC) programs strive to provide the public with guidance about a physician’s competence. This study summarizes the literature on the effectiveness of these programs. Method A literature search was conducted for studies published between 1986 and April 2013 and limited to ABMS certification. A modified version of Kirkpatrick’s 4 levels of program evaluation included the reaction of stakeholders to certification, the extent to which physicians are encouraged to improve, the relationship between performance in the programs and nonclinical external measures of physician competence, and the relationship of performance in the programs with clinical quality measures. Results Patients’ and hospitals’ value of board certification and physician participation in MOC are high. Physicians are conflicted as to whether the effort involved is worth its value. Self-reported evidence shows improvement in knowledge, practice infrastructure, communication with patients and peers, and clinical care. Certification performance is generally related to nonclinical external measures such as types of training, practice characteristics, demographics, and disciplinary actions. In general, physicians who are board certified provide better patient care, albeit the results have modest effect sizes and are not unequivocal. Conclusions Certification boards should continuously try to improve their programs in response to feedback from stakeholders, changes in the way physicians practice, as well as the growth in the fields of measurement and technology. Keeping pace with these changes in a responsible and evidence-based way is important.

5. Gallagher, T. H., C. D. Prouty, et al. (2013). “Internists’ Attitudes About Assessing and Maintaining Clinical Competence.” J Gen Intern Med.

BACKGROUND: Important changes are occurring in how the medical profession approaches assessing and maintaining competence. Physician support for such changes will be essential for their success. OBJECTIVE: To describe physician attitudes towards assessing and maintaining competence. DESIGN: Cross-sectional internet survey. PARTICIPANTS: Random sample of 1,000 American College of Physicians members who were eligible to participate in the American Board of Internal Medicine Maintenance of Certification program. MAIN MEASURES: Questions assessed physicians’ attitudes and experiences regarding: 1) self-regulation, 2) feedback on knowledge and clinical care, 3) demonstrating knowledge and clinical competence, 4) frequency of use and effectiveness of methods to assess or improve clinical care, and 5) transparency. KEY RESULTS: Surveys were completed by 446 of 943 eligible respondents (47 %). Eighty percent reported it was important (somewhat/very) to receive feedback on their knowledge, and 94 % considered it important (somewhat/very) to get feedback on their quality of care. However, only 24 % reported that they receive useful feedback on their knowledge most/all of the time, and 27 % reported receiving useful feedback on their clinical care most/all of the time. Seventy-five percent agreed that participating in programs to assess their knowledge is important to staying up-to-date, yet only 52 % reported participating in such programs within the last 3 years. The majority (58 %) believed physicians should be required to demonstrate their knowledge via a secure examination every 9-10 years. Support was low for Specialty Certification Boards making information about physician competence publically available, with respondents expressing concern about patients misinterpreting information about their Board Certification activities. CONCLUSIONS: A gap exists between physicians’ interest in feedback on their competence and existing programs’ ability to provide such feedback. Educating physicians about the importance of regularly assessing their knowledge and quality of care, coupled with enhanced systems to provide such feedback, is needed to close this gap.

6. Talbott, J. A. (1979). “Opposition to “coercive continuing medical education and mandatory recertification”.” Am J Psychiatry 136(7): 923-926.

A district branch survey on attitudes toward obligatory continuing medical education (CME) and mandatory recertification indicated that most respondents approved the concept of lifelong learning. However, proposed methods of implementation of CME were criticized on grounds of commercialization, bureaucratization, poor quality, wasting time and money, excessive external control over learning, and flawed requirements. Objections to mandatory recertification centered mainly on an abhorrence of Board-type examinations. The author offers suggestions to program directors and sponsors, educational researchers, and CME administrators as to ways to answer these criticisms of CME and recertification.

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