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.'
盡管每10年重新考核的要求依然有效，但近些年美國醫學專業委員會(American Board of Medical Specialties)已開始要求醫生更頻繁地證明他們了解最新的醫學知識。該委員會監管24個不同的醫學委員會，涵蓋美國約80%的執業醫生。各醫學委員會的認證維護要求各有不同，但它們的計劃都是類似的。
美國內科學委員會(American Board of Internal Medicine)是其中最大的委員會之一，它從今年開始要求其認證的醫生從一系列不同的活動中進行選擇，每隔兩到五年時間來維護他們的認證。該委員會為內科醫生及其他20個專業提供認證，涵蓋美國25%的醫生。<-->紐約時報中英文網 http://www.gwbyzx.live<-->
美國內科學委員會首席執行長理查德·J.巴倫(Richard J. Baron)說：“醫生有義務要跟上其執業領域的最新發展趨勢，聽取患者的意見，查驗自己的醫療業務并加以改善。”認證維護“給他們提供了一個這么去做的有條理的方法，同時也讓患者相信他們的醫生是符合嚴格的知識標準的”。
研究表明，醫生的臨床技能會逐漸退化，而且醫生的過度自信會造成誤診。《美國醫學會雜志》(Journal of the American Medical Association)2006年的一篇綜述發現，醫生們不是非常善于評估自己的技能。該研究文章的作者、密歇根大學(University of Michigan)教授R.范哈里森(R. Van Harrison)說，認證維護“是整個醫療體系大發展的一部分”。他說，作為大規模醫療質量改進計劃的一部分內容，一些大醫院也在幫助醫生滿足認證要求。
威斯康星州馬什菲爾德醫院(Marshfield Clinic)皮膚病醫生埃里克·斯特拉特曼(Erik Stratman)稱，他為滿足美國皮膚病學委員會(American Board of Dermatology)的要求承擔了一個項目，這幫助他提高了他的業務水平。在斯特拉特曼博士的病人中有很多銀屑病患者，他們患心臟病、糖尿病及高膽固醇的風險較高。在為該項目考察數據的過程中，他發現患者未定期接受有關那些疾病的篩查，而且有40%的人沒有可跟進治療的初級保健醫生。他說他的醫療團隊此后一直在努力更密切地照管那些患者或幫他們介紹初級保健醫生。
醫生團體美國內科及外科醫生協會(Association of American Physicians and Surgeons)在新澤西的聯邦法院提請了針對美國醫學專業委員會的反壟斷訴訟，指控后者的項目是“一個充實自身腰包的斂財計劃”，它會降低完全受雇于醫院的醫生的儲備，并減少醫生得花在病患身上的時間。該團體的總顧問安德魯·施拉夫利(Andrew Schlafly)說，這些要求與“醫療質量的改善不存在任何已得到證實的關聯”。
美國醫學專業委員會的首席執行長洛伊絲·瑪格麗特·諾拉(Lois Margaret Nora)說，這起訴訟的指控毫無根據，認證維護是一個“推動醫生終身學習、自我評估和改進的自愿性計劃”。該委員會已提起動議要求駁回這樁訴訟。
杰伊·喬根甘(Jay Geoghagan)是阿肯色州小石城(Little Rock)的心臟病學家，他在去年通過了10年一次的心血管疾病重新認證考試。作為考試要求的一部分，他還評估了其團隊對高血壓的治療情況，調研患者并審核他們的病歷以查看他們是否做過醫生建議的腎功能檢查。盡管喬根甘博士說他認為他在90%的治療中都實施過該項檢查，但病歷記錄顯示只有40%的患者做過檢查。他說：“這不是因為沒有做過檢查，而是因為我們找不到文件。”這促使他的職員更密切地監護病患并保證了檢查結果會被輸入電子病歷中。