How Qualified Is Your Doctor?
Doctors are facing new requirements to keep up-to-date in their knowledge and care for patients in order to stay certified by medical boards.
The new requirements, called maintenance of certification, are controversial among some physicians. But they reflect growing evidence that doctors, who are now recertified every 10 years, need to be more regularly assessed for competence in a fast-changing medical world.
While the 10-year retesting requirement still stands, the American Board of Medical Specialties has begun in recent years asking doctors to demonstrate more frequently that they are current in their medical knowledge. The group oversees 24 separate medical boards covering about 80% of licensed physicians. Maintenance-of-certification requirements vary among medical boards, but the programs are similar.
One of the largest medical boards, the American Board of Internal Medicine, beginning this year is requiring the doctors it certifies to choose from a variety of activities at intervals of two and five years to maintain their certification. The board certifies internists and 20 other specialties covering 25% of U.S. physicians.
Doctors can earn points toward maintenance of certification in several ways. They can take open-book tests to show they are keeping up with new developments in their field. They can undertake projects to improve care, such as evaluating how well their practice treats patients with chronic conditions. Every five years doctors must complete a patient-safety requirement and conduct a patient survey to help assess their communication skills.
'Physicians have an obligation to keep up with the latest in their field of practice, listen to their patients, look at their practice and improve,' says Richard J. Baron, the American Board of Internal Medicine's chief executive. Maintenance of certification 'gives them a structured way to do that and at the same time assure patients and peers that their physicians have met a rigorous standard for knowledge.'
Patients can check online whether doctors are board certified, including at the American Board of Internal Medicine website, which will begin publicly reporting in April whether its doctors are meeting the new requirements. Board certification can affect a physician's inclusion in health-plan networks and hospital privileges.
Doctors were once board-certified for life, but in the 1970s some boards began to issue time-limited certificates. Dr. Baron says physicians certified by his board before 1990 will remain certified for life but will be reported as 'not meeting requirements' if they don't participate in maintenance activities.
Studies show clinical skills deteriorate over time and doctor's overconfidence can lead to diagnostic errors. A 2006 review in the Journal of the American Medical Association found that doctors aren't very good at evaluating their own skills. University of Michigan professor R. Van Harrison, an author of the study, says maintenance of certification 'is part of a larger evolution of the health-care system.' He says big hospital systems are helping doctors meet certification requirements as part of larger quality-improvement programs.
Erik Stratman, a dermatologist at Marshfield Clinic in Wisconsin, says a project he undertook to meet the American Board of Dermatology's requirements has helped improve his medical practice. Dr. Stratman treats many psoriasis patients, who are at increased risk for heart attacks, high cholesterol and diabetes. In reviewing data for the project, he found that patients weren't being regularly screened for those diseases and 40% didn't have a primary-care doctor who could follow up. He says his medical team has been working to manage those patients more closely or connect them to primary care.
'Taking a single test at a single point in time [to get certified] doesn't mean you are forever ready to practice in the current era of medicine,' Dr. Stratman says.
Some physicians are resisting the new board requirements. They say they can keep up-to-date through the continuous-medical-education courses they must take to meet state-licensing requirements, which are separate from board certification. These doctors complain that failure to participate in maintenance of certification could hurt their business should they lose their board certification.
The Association of American Physicians and Surgeons, a doctors' group, has filed an antitrust suit in a federal court in New Jersey against the American Board of Medical Specialties, claiming its program is 'a moneymaking self-enrichment scheme' for medical boards that reduces the supply of hospital-based physicians and decreases the time doctors have to spend with patients. Andrew Schlafly, general counsel for the physician's group, says the requirements don't have any 'proven connection with improving quality of care.'
Lois Margaret Nora, chief executive of the American Board of Medical Specialties, says the suit's claims are without merit and that maintenance of certification is a 'voluntary program that promotes lifelong learning, self-assessment and improvement for physicians.' The board has filed a motion to dismiss the suit.
Doctors stand to earn incentive payments from Medicare for participating in maintenance-of-certification activities. They can also earn credit for the state-required courses in continuous medical education.
Jay Geoghagan, a cardiologist at Little Rock, Ark.-based Arkansas Cardiology, passed his 10-year recertification test in cardiovascular disease last year. As part of his requirements, he also evaluated his team's care for high blood pressure, surveying patients and auditing their charts to check if they had taken a recommended kidney-function test. The records indicated only 40% had the test, though Dr. Geoghagan says he thought he had performed them in 90% of cases. 'It wasn't that they hadn't been done but we couldn't find documentation,' he says. It reinforced his staff's efforts to monitor patients more closely and ensure tests were entered into electronic records.
The American Board of Internal Medicine maintenance-of-certification fees, which include practice-assessment tools and open-book tests, start at $194 a year for internal-medicine doctors and can rise if doctors maintain more than one certificate. Dr. Geoghagan says the cost can be much higher after factoring in materials to help prepare, other expenses and unreimbursed time.
'A lot of us are small-business men trying to continue our practice while trying to maintain balance and sanity in our life,' Dr. Geoghagan says. Still, he says, 'patients should have some assurance there is quality control and that their doctor is keeping up-to-date, because a lot of them don't, or haven't in the past.'
尽管每10年重新考核的要求依然有效，但近些年美国医学专业委员会(American Board of Medical Specialties)已开始要求医生更频繁地证明他们了解最新的医学知识。该委员会监管24个不同的医学委员会，涵盖美国约80%的执业医生。各医学委员会的认证维护要求各有不同，但它们的计划都是类似的。
美国内科学委员会(American Board of Internal Medicine)是其中最大的委员会之一，它从今年开始要求其认证的医生从一系列不同的活动中进行选择，每隔两到五年时间来维护他们的认证。该委员会为内科医生及其他20个专业提供认证，涵盖美国25%的医生。
美国内科学委员会首席执行长理查德·J.巴伦(Richard J. Baron)说：“医生有义务要跟上其执业领域的最新发展趋势，听取患者的意见，查验自己的医疗业务并加以改善。”认证维护“给他们提供了一个这么去做的有条理的方法，同时也让患者相信他们的医生是符合严格的知识标准的”。
研究表明，医生的临床技能会逐渐退化，而且医生的过度自信会造成误诊。《美国医学会杂志》(Journal of the American Medical Association)2006年的一篇综述发现，医生们不是非常善于评估自己的技能。该研究文章的作者、密歇根大学(University of Michigan)教授R.范哈里森(R. Van Harrison)说，认证维护“是整个医疗体系大发展的一部分”。他说，作为大规模医疗质量改进计划的一部分内容，一些大医院也在帮助医生满足认证要求。
威斯康星州马什菲尔德医院(Marshfield Clinic)皮肤病医生埃里克·斯特拉特曼(Erik Stratman)称，他为满足美国皮肤病学委员会(American Board of Dermatology)的要求承担了一个项目，这帮助他提高了他的业务水平。在斯特拉特曼博士的病人中有很多银屑病患者，他们患心脏病、糖尿病及高胆固醇的风险较高。在为该项目考察数据的过程中，他发现患者未定期接受有关那些疾病的筛查，而且有40%的人没有可跟进治疗的初级保健医生。他说他的医疗团队此后一直在努力更密切地照管那些患者或帮他们介绍初级保健医生。
医生团体美国内科及外科医生协会(Association of American Physicians and Surgeons)在新泽西的联邦法院提请了针对美国医学专业委员会的反垄断诉讼，指控后者的项目是“一个充实自身腰包的敛财计划”，它会降低完全受雇于医院的医生的储备，并减少医生得花在病患身上的时间。该团体的总顾问安德鲁·施拉夫利(Andrew Schlafly)说，这些要求与“医疗质量的改善不存在任何已得到证实的关联”。
美国医学专业委员会的首席执行长洛伊丝·玛格丽特·诺拉(Lois Margaret Nora)说，这起诉讼的指控毫无根据，认证维护是一个“推动医生终身学习、自我评估和改进的自愿性计划”。该委员会已提起动议要求驳回这桩诉讼。
杰伊·乔根甘(Jay Geoghagan)是阿肯色州小石城(Little Rock)的心脏病学家，他在去年通过了10年一次的心血管疾病重新认证考试。作为考试要求的一部分，他还评估了其团队对高血压的治疗情况，调研患者并审核他们的病历以查看他们是否做过医生建议的肾功能检查。尽管乔根甘博士说他认为他在90%的治疗中都实施过该项检查，但病历记录显示只有40%的患者做过检查。他说：“这不是因为没有做过检查，而是因为我们找不到文件。”这促使他的职员更密切地监护病患并保证了检查结果会被输入电子病历中。