The IOM targets doctors

A new Institute of Medicine report calls for more-stringent licensing and recredentialing criteria.

By Gail Garfinkel Weiss
Senior Editor

Medical school and residency programs don't prepare health professionals to give patients the best and safest care possible, and CME, recredentialing, and other oversight processes don't do a very good job of monitoring proficiency. Therefore, rank-and-file physicians should face new and more rigorous recertification requirements.

That's one of the core findings of "Health Professions Education: A Bridge to Quality," an Institute of Medicine report released in April. The report has already run into resistance from physicians who worry that the new requirements could add to their workload and stress and from some in organized medicine, who say many of its recommendations have already been implemented.

Specifically, the report recommends that physicians and other providers should possess five "core competencies." They should (1) provide patient-centered care; (2) work in interdisciplinary teams to ensure that care is continuous and reliable; (3) employ evidence-based practice; (4) identify errors and hazards in care and implement basic safety design principles; and (5) utilize information technology to communicate, manage knowledge, mitigate error, and support decision-making.

To integrate these core competencies into health curricula and monitoring systems, the IOM recommends that:

• State medical boards require licensed health professionals to periodically demonstrate their ability to deliver patient care through direct measures of technical competence, patient assessment, and evaluation of patient outcomes.

• Certification bodies require physicians to periodically demonstrate their ability to deliver patient care that reflects the five competencies.

• The Agency for Healthcare Research and Quality (AHRQ) work with health care leaders to implement the core competencies, set national goals, and issue a report evaluating progress.

• Beginning in 2004, a biennial summit be held to review progress and set new goals.

The IOM committee, headed by psychiatrist Edward M. Hundert, president of Case Western Reserve University in Cleveland, would also like to see an end to what the committee refers to as the Balkanization of medicine. "What has not yet occurred is coordination across accrediting bodies of the various professions in defining a core set of competencies and designing related standards and measures," the report states. "Such coordination could obviate the need for each accrediting body to reinvent the wheel, and synergies would likely result."

License renewal: Too tough, or not tough enough?

The recommendation calling for new and more rigorous recertification requirements has elicited the most negative feedback from physicians. "Most doctors are dedicated, highly trained, motivated, and caring," says internist Gregory Hood of Lexington, KY, a member of the Medical Economics editorial board. "This report, if adopted, will further burden already beleaguered physicians."

And that could encourage them to change careers or retire. "Has the IOM studied how many patients' health care has suffered because physicians have been driven out of medicine?" Hood asks.

FP Birgit Houston of Nashua, NH, points out that family medicine requires its physicians to undergo testing every six years to maintain certification. "This entails review of patient charts and a rigorous exam similar to the medical boards. I would hate to have to take additional tests with several different organizations to maintain my credentials."

Houston has doubts about the report's other suggestions, too. "As far as patient-centered care and working in interdisciplinary teams is concerned," she says, "how would anyone monitor this? Many of the options offered are more likely to illustrate the Heisenberg uncertainty principle—that the act of observing behavior changes it—than measure clinical skills. Besides, there isn't as much good evidence-based medicine out there as people would like to believe."

Perry Pugno, the director of education for the American Academy of Family Physicians, notes that many of the IOM recommendations are already in place. "The report is a validation of the kinds of things we've been doing and suggesting for years," he says. "Family medicine was the first discipline to require periodic recertification, in addition to a certain amount of annual CME. And the CME requirements are more stringent: You must demonstrate that you learned something, not just that you were present in the room and remained conscious."

Hundert acknowledges that family medicine is ahead of the curve on competency-based evaluations. "Recertification is only one aspect of the report, though," he says. "We're also asking physicians to think across professional boundaries, make greater use of informatics, and institute new quality improvement measures."

Indeed, the report could have dramatic implications for family practice and the other primary care disciplines, says Edward O'Neil, director of the Center for the Health Professions in San Francisco. "The primary care visit still looks very much like it did 15 years ago. But many patients come to the office for management of chronic diseases and may not need to see the physician. Perhaps they'd be served just as well by a nurse practitioner, or a health educator, or by having e-mail access to the physician. I think that within the five core competencies described by the committee, a radically different primary care world can be imagined."

Putting the recommendations into effect

For physicians, the most urgent question raised by the IOM is: How will ongoing clinical competence be gauged? That will be addressed in subsequent studies, says Hundert. A promising assessment technique, he says, makes use of "simulated" patients—people who are trained to portray the emotional, symptomatic, and physical characteristics of actual patients. The technique is gaining popularity in medical schools, since it enables students to perform exams, respond to situations, and practice communication techniques without putting actual patients at risk or having to wait for a suitable patient to be available.

Simulation also allows for a more standardized exam than using real patients does, Hundert points out. "In a re-licensure exam, a physician might see a series of standardized patients—for example, a girl asking for birth control pills, an elderly person with arthritis, and someone complaining of acute abdominal pain. The physician's competence would be evaluated based on how well he interviews, examines, and responds to these 'patients.' "

FP Birgit Houston remains skeptical. "Medicine already costs a lot," she says. "I can't imagine what we will add to the total if we start paying simulated patients to visit every doctor or require expensive video set-ups. The end result will be a lot of wasted money and a lot of physician time taken up in testing."

Rather than "pressuring capable and proficient physicians with another lengthy set of hurdles," internist Greg Hood suggests that "true outliers be carefully reviewed and constructively approached to improve their skills."

In Hundert's view, however, "identifying outliers is very difficult. We need tools to demonstrate that all doctors are keeping up."

What is the likelihood that the IOM recommendations will be adopted? "The changes will be evolutionary, not revolutionary," says internist David B. Nash, associate dean for health policy at Jefferson Medical College in Philadelphia and a member of the Medical Economics editorial board. "I think the IOM's suggestions are very important, but all change creates resistance. Still, the first steps are already being taken by medical schools, the Agency for Healthcare Research and Quality, and other organizations."

Ed O'Neil of the Center for the Health Professions notes that a dramatic departure from longtime customs won't happen without strong leadership. "Those accrediting and licensing bodies that have progressive leadership will look at the report and say, 'Let's get cracking on incorporating this.' In those bodies that don't have progressive leadership, things probably won't move quickly."

Hundert is optimistic, but he concedes that integrating the core competencies into oversight processes may take as long as 10 years, and mechanisms for funding the initiatives need to be established. "The report isn't suggesting that we keep all the burdensome CME and recredentialing requirements we have now and add more," he says. "Rather, because medicine changes so rapidly, we need to begin a comprehensive reassessment of the whole process across the health professions.

"Most of the people I've talked to view a lot of the recommendations we've made as the operationalizing of common sense. They say, 'Of course we should be doing this. Let's get going.' "

 

Gail Weiss. The IOM targets doctors. Medical Economics Sep. 5, 2003;80:43.