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你的醫生是否合格?

How Qualified Is Your Doctor?
你的醫生是否合格?

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.'

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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.'

若要繼續獲得醫學委員會的資格認證,美國的醫生們現在面臨著一些新要求,這些新要求需要他們了解最新的專業知識及治療患者的最新技術。

這些新要求被稱為認證維護,它們在部分醫生中引發了爭議。但是,它們也反映出越來越多的證據表明有必要更經常地評估醫生們在迅速變化的醫學界中的能力,現在他們是每10年重新認證一次。

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<-->

醫生可通過數種方式贏取積分來維護認證。他們可通過參加開卷考試來證明他們跟上了其專業領域的新發展,也可承擔某些項目來改進醫療水平,比如評估他們的醫療業務對治療患有慢性病癥的患者的效果。醫生們每五年必須完成一項有關患者安全的要求并開展一項患者調查以便于評估他們的溝通技能。

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”。

患者可在網上查看醫生是否通過了委員會的認證,美國內科學委員會的網站就是其中一家,它將于4月份開始公開披露其醫生是否滿足新要求。委員會的認證會影響醫生是否能加入健康計劃網和享有醫院行醫權限。

醫生從委員會獲得的認證證書曾是終身有效的,但某些委員會從上世紀70年代開始頒發有時效限制的證書。巴倫博士稱,他們的委員會在1990年之前認證的醫生仍將終身獲得認證,但是如果他們未參加認證維護活動,他們會被評價為“不符合要求”。

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。

斯特拉特曼博士說:“在某一個時間點參加了某一項考試(獲得認證)并不表示你就永遠做好了在當前的醫學時代行醫的準備。”

部分醫生對委員會的這些新要求發起了反抗。他們表示自己能通過醫學繼續教育課程來了解最新知識,這些課程是滿足州許可要求必須要參加的,該要求與各醫學委員會的認證是互不相干的。這些醫生抱怨,未能參與許可認證的話,萬一他們丟掉了委員會的認證,他們的業務可能會受到損害。

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。

醫生參與認證維護活動可贏得醫療保險計劃的獎勵,參加州要求的醫學繼續教育課程可獲得積分。

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。

美國內科學委員會的認證維護費用包括業務評估工具及開卷考試的費用,內科醫生的認證維護費起價為194美元,如果醫生要維護一項以上的證書,費用還會更高。喬根甘博士說,計入準備考試的材料費、其他花費以及無法補償的時間,考試的成本還要高得多。

他說:“我們當中的許多人只是小經營者,在努力繼續經營的同時盡力在我們的生活中維持平衡和理智。”不過,他也說“患者應當得到醫療質量有掌控、自己的醫生了解最新知識的一定保證,因為有許多醫生沒有做到,或者說過去沒有做到”。

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