As the dust continues to settle from the 2003 legislative session, it’s clear that Texas physicians were able to claim victory in several key areas including medical liability reform and prompt pay. The passage of Proposition 12 was perhaps the most important victory. While the victories were in part the result of hard work by the medical community, it is important to realize that they also reflect the support of our initiatives from the electorate.

With these victories in hand, it is time for us to assess the obligation we have to our patients. Among other things, these legislative changes seem to say that physicians can indeed maintain discipline and assure competency of physicians outside of a tortuous environment.

Our licensing authorities are charged with assuring that licensed physicians are competent to practice medicine safely. A 1997 Harris survey shows that the public ranks assuring physician competence as the No. 2 priority for licensing boards. Toward this end, the Texas State Board of Medical Examiners along with most states are in the process of developing tools to confirm that ongoing licensure assures the public of continued physician competency.

As a member of the Federation of State Medical Boards, TAFP and a former TSBME member, I want to briefly review the issue of maintenance of competence and what I believe are our responsibilities as a specialty organization are to both our members and our patients regarding this issue.

Definition of Competency

The American Medical Association defines competency as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefits of the individual and the community being served. Competence depends on habits of mind including attentiveness, critical curiosity, self-awareness, and presence.”

Current state of affairs

Physicians licensed in Texas are required to show proof of 12 hours category 1 AMA or AOA continuing medical education annually. This includes one hour of approved ethics CME. Beyond those requirements, there are no other provisions as to type of CME. It need not be practice- or specialty-specific and does not require specific testing. Studies show that many if not most CME activities do not effect either change in professional practice or health care outcomes (Davis, et al JAMA 1999; 282:867-874).

Several states have discontinued requiring CME as a requirement for licensure for this reason. In response to this, The Accreditation Council for Continuing Medical Education has been actively engaged in developing CME requirements that are evidence-based and validated.

All of the ABMS boards are currently developing techniques for assessing ongoing competency that would include record review, CME and other modalities that would be assessed throughout the term of a physician’s active certification period. All of the member boards are expected to begin assessing maintenance of competency by 2007.

In Canada, all physicians are assessed every 10 years with an in-office chart review and, if concerns regarding competence are noted, individualized testing as well.

As regards other states, none currently require assessment of ongoing competency. Through 2003 several states have submitted plans for assessing competency of physicians, nurses and other health care professionals however none are currently in effect.

Within the private sector, the Joint Commission of Accreditation of Healthcare Organizations requires hospitals to assess the competency of employees when hired and throughout their employment.

Future Plans

As our specialty proceeds toward developing standards for maintenance of competency, the demands of the public for assurance that physicians are in fact achieving a minimum level of competency call for licensing agencies to enact some sort of requirement that provides a level of comfort to the public that they are being protected. This requirement must also address the issue of validity and include a plan for remediation for those physicians who fall short of the measure. The assessment must reflect both the public’s assessment of what doctors ought to know and be perceived by the physician as valid and fair. This is more likely to be true if the assessment is related to every day tasks.

In cases of ongoing board certification, those physicians may be perceived to have met the requirement. For those who have chosen not to maintain certification, who are practicing outside of their chosen specialty, or did not complete a residency, there will be a need to develop some method of assessment. This may be a valid “specialty friendly” examination such as the Special Purpose Examination (SPEX) or some other assessment approved by the licensing board.

In any case a method of remediation and reassessment needs to be available for physicians who fall short. Toward that end several states have become involved in the Practitioner Remediation and Enhancement Partnership program. This is a program conceived and administered by the Citizen Advocacy Center in cooperation with the Administrators in Medicine and the National Council of State Boards of Nursing. This is a framework that would allow state medical and nursing boards to work with hospitals and other health care organizations to identify, remediate and monitor health care practitioners who are found to be lacking in certain areas of knowledge or clinicical skills that may be of concern but do not rise to the level of disciplinary action. (Executive Summary, Citizen Advocacy Center, April, 2002)

In 2003, the Federation of State Medical Boards convened a special committee to assess maintenance of competency as a requirement for re-licensure and develop a national recommendation. The committee has met twice and has engaged in dialog with concerned groups including the ACCME and the ABMS. While no firm recommendation is anticipated before 2004, it appears that the recommendation will include elements that are being developed by the ABFP for their maintenance of competency program. Self-assessment and continuing education based on individual practices and recognized weaknesses will probably be a part of this. As a result, those physicians who become board certified and remain so will probably not have to make significant adjustments to maintain licensure. The challenge will be for those physicians who choose not to remain certified or who leave practice and then choose to return. The challenge for our specialty will be to assist in the development of re-education and remediation programs for these physicians. Since its inception, the AAFP and the ABFP have been leaders in educating and supporting member physicians and they should be well placed to deal with this evolving issue as well.