Performance measures may be part of recertification
■ Older doctors still might resist periodic retesting, but younger ones recognize it as a "necessary evil."
By Andis Robeznieks — Posted March 8, 2004
A medical school diploma on the wall only goes so far these days.
It seems that everyone is demanding more evidence that doctors know what they're doing and more proof that they are keeping up with the latest medical advances. Public reporting of performance measures and required recertification are often cited as methods for achieving this objective.
In fact, some proponents of performance measures advocate weaving them into the recertification process to get physician buy-in. But such a plan is not without peril.
While recertification has its advocates among health care leaders, it is not uniformly accepted among physicians. In addition, the process is in the midst of a transformation from a requirement imposed every seven or 10 years to an ongoing "maintenance" program involving continuous education and assessment. Technology also is likely to be key to future recertification efforts, and physicians are known to grumble when forced to incur new technology costs.
"What we're resisting wholeheartedly is the intrusion into our practice," said San Fernando Valley, Calif.-based internist Sam Fink, MD. "I don't know any physician who speaks in favor of performance measures. I think we're tired of being capitated, manipulated and frustrated."
Jasper, Texas-based family physician Peter Bidwell, MD, said the problem with recertification is that it emphasizes the science of medicine while diminishing the art.
"There are a lot of parameters that make up a good doctor that can't be measured with ones and zeroes," he said. "Qualities like building patient morale, being empathetic and helping families make the right decisions -- these are things you can't test for."
Indeed, some doctors view the problems of recertification to be the same as those of performance measures.
"If you think a patient is suicidal, going through the required performance measures for hypertension is a waste of time," Dr. Fink said. "You can't measure compassion, warmth or communication. These things aren't important for someone fixing your carburetor, but they are to medicine."
Neither Dr. Fink, certified in 1987, nor Dr. Bidwell, who graduated from medical school in 1965, are required to undergo recertification.
"I graduated before there was anything called 'family practice certification.' We learned family practice by just getting out there and doing it," Dr. Bidwell said. "A lot of us who have been doing it for 30 years and have been keeping up with CME are doing just as well as these kids who have to get certified."
A "necessary evil"
But younger doctors who have to go through the process view it more as "a necessary evil," said Saria Carter, MD, a resident member of the American Academy of Family Physicians board of directors.
"We're used to taking exams over and over again to see if we learned what we think we've learned," said Dr. Carter, a family physician at Miami's Jackson Memorial Hospital. "We've grown up in a world that accepts managed care organizations and the fact that quality needs to be measured, whether we like it or not."
Dr. Carter supports the idea, now being implemented by the American Board of Medical Specialties through its Maintenance of Certification and the American Board of Internal Medicine through its Continuous Professional Development program, that recertification needs to be ongoing.
"New information comes out every day, not just every seven years," she said. The ABMS and ABIM programs feature ongoing formal examination, self-evaluation and education.
"That is, in fact, where it's going," said National Quality Forum President Ken Kizer, MD. "It's a continuous effort to make sure one stays current."
AMA Immediate Past President Yank Coble, MD, called this a positive development. "The moment they walk into medical school, students know [that] what they learn will be outdated in five years. So what's important is how they learn to continue to learn."
The AMA opposes specialty board recertification as a sole condition of employment and favors voluntary "validation of excellence."
Jeffrey Collins, MD, president of the Washington State Medical Society, said recertification forces physicians to be diligent in keeping current about medical advances and helps doctors use what they learn.
"There is a huge body of literature to keep up on, so going through the recertification process means having to be disciplined about sitting down and reading all of it," the Spokane internist said. "This adds to people's knowledge base, and that adds an element of quality that's worthwhile. Recertification helps you integrate what you learn into what you do. You get information at a meeting, and it becomes part of the ongoing fabric of your practice. I think it's a good thing."
But Dr. Bidwell said an individual's commitment to continuous learning must be personally desired, and having it mandated by the government or medical boards will not accomplish the goal of weeding out unprofessional doctors.
"If a day goes by that you don't learn something new, you're not paying attention to what's going on around you," he said. "In Texas, you have to take 25 hours of CME, and you can fudge it, or you can do it in earnest and learn a lot and really advance yourself."
Tossing in technology
Robert Brook, MD, professor of medicine and public health at the University of California Los Angeles, said if the goal of recertification is to prove competency and knowledge, then real-time electronic record-keeping of performance measures could replace it.
He proposes using a "quality score" to electronically measure how well a physician practices medicine.
"If you're over a certain cutoff point, you'd be automatically recertified," Dr. Brook said. "The score would show that you're a good doctor and deserve recertification."
Dr. Fink said the cost of implementing an electronic medical record system dampens his enthusiasm for Dr. Brook's proposal. He also said unprofessional physicians would start "gaming the system."
"It's called 'buffing the charts,' " he said. "Doctors will learn very quickly how to give them what they want."
Dr. Fink also is concerned about the cost associated with recertification and questioned if collecting fees and not proving competency was the main motivation for recertification. But Dr. Carter, as an AAFP board member, said she knows the costs involved in setting up CME programs and maintenance of certification modules and thinks participants are not being overcharged. Nevertheless, she said, physicians need to find a better way to divide these costs between themselves and should be allowed to make lower payments spread out over a longer period.
But Dr. Carter said young doctors don't believe in abandoning recertification because of its price tag, and she doesn't think it's a burden that could turn them away from the profession.
"Students come out of med school owing $100,000," she said. "If debt and malpractice insurance don't scare them away, I don't think that the maintenance of certification fee will. If anything, it gives them confidence that they're providing good care."