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Do Physicians Need More Oversight?

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Jarrod Shapiro
doctors conversing

New perspectives come at the most unexpected times. Recently, I was getting a haircut and I struck up a conversation regarding the education my hair stylist is required to maintain for her career. The initial education was not as impressive (1600 hours) as the amount of continuing education and recertification required to remain in practice.

She is required to attend continuing education at least every three months in which teachers and experts are brought in to teach new skills, methods, and styles. The attendees are required to bring in either a live person to cut their hair or a mannequin with hair on which to practice those skills. Additionally, she is required to “recertify” yearly. This recertification consists of actually demonstrating your skills to an examiner.

During the conversation, I found interesting parallels and differences between the initial and continuing education processes of this hair stylist and that of physicians. Is it possible that her continuing education and certification process is superior to that of physicians?

What Does Our Education Consist of?

What initial education and continuing education do physicians undergo? The initial education is well known to be four years of medical school and three or more years of residency and variable fellowships. Obviously, that is far beyond the training required to cut and style hair, and it should be. The human machine is highly complicated and it’s effective treatment, to be well maintained, requires a high level of skill. And yet, with all this complexity and need for expertise, the continuing education of physicians is starkly weak in requirements.

As an example, California requires the following CME credits for its doctors:

MD: 50 credits in a 2-year period1
DO: 150 credits in a 3-year period1
DPM: 50 credits in a 2-year period2

Interesting that the DO requirement is so much greater than the MD or DPM. One should also realize that obtaining these credits is relatively easy and occurs at conferences where we passively listen to lectures. How does this demonstrate maintenance of skills or knowledge?

What about certification requirements? Take a look at the chart showing a few medical professions and their certification requirements. It’s important to note that what is written here is a broad brushstroke overview of the certification system. There are a lot of small details not included here.

Medical Specialty Certification Requirements Recertification Period
Podiatry ABPM – Written exam
ABFAS – Computer-based simulated patient exam, case review.
Every 10 years
American Board of Orthopedic Surgery3 Part 1: Written exam
Part 2: Case review, Oral exam
10 years
American Board of Internal Medicine4 Written exam
10 years
American Board of Surgery5 Written exam
Oral exam
No requirement (based on specialization)
American Board of Optometry6 Computer-based patient exam Every 10 years

Most specialties also now require Maintenance of Certification (MOC), which is generally a combination of continuing education credits, some form of practice improvement, case reviews, and a recertification examination.

If you take a look at this small list, I’m sure you’ll note the themes. First, a written or computer examination is always part of the certification process, while actually submitting cases for review is a variable. Second, most of the recertification time frames are a decade in length.

Third, and perhaps most pertinent is the generally passive nature of the evaluation process of physicians. At no point do any of these professions require a surgeon to physically demonstrate his skills in person to an examiner. Case submissions are a substitute for the actual procedure itself. This process is very simple to cheat. For example, I recall a surgeon who had another more experienced surgeon assist and then submit that case for certification. Obviously, this is dishonest, but it illustrates the point that the case submission process is only a surrogate for the actual surgeon’s skills. This is reminiscent of the difference between achieving minimum activity volume and actually demonstrating competency in resident education.

Now, on the surface, it appears my hairdresser has to do more to maintain competency than physicians. (A scary thought on the surface for the obvious reason that the stakes are much higher in medicine.) However, there is one giant barrier to increasing the intensity of physician assessment (besides the simple desire of doctors not to do it) – convenience and cost.

Convenience - Imagine how difficult it would be for a surgeon going through the certification process to have a designated surgeon come to their hospital and observe cases. That surgeon observer would have to be trained in appropriate methods of assessment. That observer would have to witness a relatively large number of actual surgical cases to truly test competency. Perhaps aspects of skill could be assessed based on one case (for example dissection technique or suturing), but the overall physician’s assessment would require observing at least several cases. Multiply this by the many surgeons scheduled for recertification.

Cost - Imagine what the above scenario would cost? I’m afraid to even think about it. Travel costs, paying the observer, time out of the office, and the need to find surgical patients are just a few of the costs that would make this prohibitive.

As of now I don’t see a way that true competency can be reasonably assessed for practicing physicians and surgeons (beside what is currently in existence) other than two possible changes:

  1. Altering the method of CME courses to include one-on-one workshops with experts in certain procedures or skills with an examination component that leaves the attendee with a certificate of added credentials. The American Board of Podiatric Medicine has a computer test in wound care to demonstrate added expertise, but it is still an indirect measure of clinical competence. I’ve written about this idea before and would be first in line to participate at the next conference.  
  2. Changing our current resident education model from minimum activity volumes to a competency-based model. 

Clearly, more work needs to be done on this front. Although it is true that a full competency-based evaluation of practicing physicians is likely impossible, there are avenues available that could help doctors actively maintain their skills to benefit the public we treat.

Best wishes.
Jarrod Shapiro Signature
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
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References
  1. State CME Requirements. Medscape.
    Follow this link
  2. Information on Continuing Competence. State of California Board of Podiatric Medicine.
    Follow this link
  3. Certification Examinations. American Board of Orthopedic Surgery.
    Follow this link
  4. Internal Medicine Policies.
    Follow this link
  5. About ABS Certification.
    Follow this link
  6. How Do I Earn Board Certification? American Board of Optometry.
    Follow this link
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