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Navigating Tumultuous Change in the Medical Profession: The Coalition for Physician Accountability

Chaudhry, Humayun J. DO, MS; Kirch, Darrell G. MD; Nasca, Thomas J. MD; Katsufrakis, Peter J. MD, MBA; McMahon, Graham T. MD, MMSc; Shannon, Stephen C. DO, MPH; Ciccone, Andrea L. JD

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doi: 10.1097/ACM.0000000000002801
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Abstract

Achieving the quadruple aim of enhancing the patient experience and improving population health while lowering costs and improving the work life of clinicians and staff1 is becoming more challenging in the United States. Patients are living longer with chronic disorders, and there is a nationwide opioid epidemic. Acute care is increasingly complex, and addressing the social and economic determinants of health makes delivery of meaningful care even more complicated. There is uncertainty about the future of the Affordable Care Act’s provisions and applicability, while millions of people still do not have adequate, convenient, or timely access to affordable primary or specialty care. The United States ranks last among comparable countries for mortality rates amenable to health care,2 and medical error is one of the most common causes of death.3,4 Clinicians’ administrative and clinical workloads are increasing, and burnout is a concern.5,6 In addition, news reports of physicians engaging in unprofessional or criminal conduct are raising questions about the profession’s ability to self-regulate and ensure the safety of the public.

We and other leaders of the national organizations responsible for self-regulation—accreditation, assessment, licensure, and certification—in medicine struggle with these challenges. We recognize that health care administration is complex, there are many barriers to evolving beyond the familiar status quo, and seemingly straightforward interventions may have significant unintended consequences. We also realize that through frank discussion and collaborative leadership efforts, meaningful change may be achieved while minimizing those consequences. Here, we describe how leaders of these national organizations have come together as the Coalition for Physician Accountability, with the mission to advance health care and promote professional accountability by improving the quality, efficiency, and continuity of the education, training, and assessment of physicians.

Self-Regulation in Medicine

The notion of self-regulation in medicine predates the founding of the United States, when colonial boards of medicine sought to register physicians and regulate the costs of care to protect the public.7 The rights of the states to regulate medicine were ultimately vested in the truism of the 10th Amendment to the Constitution, which expresses a basic principle of federalism that empowers state governments to act in furtherance of the health, safety, and welfare of the public. Self-regulation matured in the aftermath of the Civil War, as scientific knowledge and germ theory advanced, with states promulgating medical practice acts and establishing examining boards to license physicians. The earliest actions of state boards, which were then wholly composed of practicing physicians, focused on preventing so-called quacks and charlatans from practicing medicine.8

These regulatory developments coincided with the establishment of national organizations representing practicing physicians (American Medical Association [AMA], 1847; American Osteopathic Association [AOA], 1897; and, much later, the Council of Medical Specialty Societies, 1967); medical schools (Association of American Medical Colleges [AAMC], 1876; American Association of Colleges of Osteopathic Medicine [AACOM], 1898); and state medical boards (National Confederation of State Medical Examining and Licensing Boards, 1890, succeeded by the Federation of State Medical Boards [FSMB] in 1912). These organizations were later supplemented by national organizations focused on assessment for licensure (National Board of Medical Examiners, 1915; National Board of Osteopathic Medical Examiners, 1934); certification (American Board of Medical Specialties [ABMS], 1933; AOA Bureau of Osteopathic Specialists, 1939; Educational Commission for Foreign Medical Graduates, 1956); and accreditation (Accreditation Council for Graduate Medical Education [ACGME], 1981; Accreditation Council for Continuing Medical Education [ACCME], 1981).

Some of these organizations worked together to solve shared issues, leading to the creation in 1942 of the Liaison Committee on Medical Education, sponsored by the AAMC and the AMA, to accredit MD-granting medical schools in the United States and Canada. The AOA’s Bureau of Professional Education, now known as the Commission on Osteopathic College Accreditation, started accrediting DO-granting medical schools in 1952. The AOA began accrediting hospitals in 1945, and the Joint Commission, established in 1951, accredits both hospitals and health care organizations. The ACCME and AOA both set and enforce standards in continuing medical education (CME), which is required in nearly every state for medical licensure renewal. The AMA and ACCME have aligned expectations for accredited CME activities for AMA Physician’s Recognition Award credit, and the American Academy of Family Physicians certifies CME for its physician members and others. The ACGME and, until 2020, the AOA accredit graduate medical education (GME).

The Coalition for Physician Accountability

In 2009, leaders from many of these organizations participated in a summit meeting sponsored by the Robert Wood Johnson Foundation. In recognition of the value of the leaders’ nascent conversations, the Coalition for Physician Accountability was soon organized into its current form (Chart 1) as a consortium of related health care organizations represented by their leadership, including chief staff officers and chief elected officers, to create a discursive space for group discussion and action.

Chart 1

Member Organizations of the Coalition for Physician Accountabilitya

The first meeting of the coalition was held in 2011 at the AAMC offices in Washington, D.C., with a small invited group to encourage trust and candor. The coalition has since expanded, and the centrality of service to the public is a unifying theme in member organizations’ mission statements. While many of the coalition’s organizational representatives are physicians who are full-time administrators and executives, some are practicing physicians and medical educators. Health care experts across a variety of educational, governmental, and practice settings have been invited to help address specific issues. The coalition also includes three members of the public who are not health care professionals. The value of public members, who have served in greater numbers on state medical boards since 1961, is increasingly recognized in health care governance.9

The earliest coalition meetings were foundational in nature and featured courteous conversation, but as comfort levels have risen, discussions have become increasingly frank. Meetings are held twice per year, with locations voluntarily rotated among member organizations. A representative of the host organization makes opening remarks, facilitates discussion, and serves as timekeeper. To foster candid discussions, meetings are informal in nature. By design, no organization or individual serves as the coalition’s leader or spokesperson, and no individual leads the group’s management committee, which helps select speakers and topics of interest. Other coalition committees (e.g., communications) are established as needed. Each member organization pays nominal annual dues to support logistic and operational needs and to cover costs of staff support.

Advocacy and regulation

The coalition serves as a sounding board for members to discuss emerging challenges and opportunities to streamline regulation and improve care, which are then addressed in subgroups. One theme that has frequently emerged is the need for better alignment among organizations to reduce administrative burdens on physicians and to facilitate transformation in education and assessment to improve the quality and delivery of health care. This theme is likely to continue as member organizations explore collaborative opportunities during and between coalition meetings. Partly because of such group reflection and mutual encouragement, three coalition members (ACGME, AOA, and AACOM) are formally working together to support a single GME accreditation system; the five-year process is expected to be complete by 2020.10 A unified accreditation system for GME is anticipated to benefit all residency and fellowship programs, which will be inspected and reviewed against similar sets of quality standards; all trainees, who will be evaluated along similar pathways; and members of the public, who will be assured of a common standard for physician education and training. Several coalition members are exploring the value and use of blockchain technology to streamline medical licensure and credential verification. Others have held symposia to improve understanding of the impact of artificial intelligence and machine learning on clinical practice, regulation, and academic settings.

The coalition has addressed issues of relevance to its members with the federal government. For example, the coalition sent a letter to Congress in 2011 in support of GME funding that was threatened by deficit-reduction legislation. In 2017, the coalition issued a statement in response to the president’s executive order on immigration, citing concerns about unintended consequences on international medical graduates seeking GME positions and on the public’s access to health care. Most coalition members supported these efforts, although membership does not obligate them to do so. The extent to which coalition letters and statements ultimately have an impact with their intended audiences is difficult to measure: Although GME funding was preserved in 2011, the president’s executive order has remained largely in force. For health policy issues to advance beyond symbolic consensus statements, however, the coalition recognizes that personalized and ongoing advocacy by each organization and its members is needed.

In 2016, the coalition endorsed a framework for professional competence and lifelong learning and practice that aligned with the six domains adopted in 1999 by the ABMS and ACGME: patient care and procedural skills; medical knowledge; interpersonal and communication skills; professionalism; practice-based learning and improvement; and systems-based practice.11 In doing so, the coalition embraced an approach originally focused on residents that can also be applied to medical students and practicing physicians.

The endorsement by coalition members of a physician competence framework that specifically includes professionalism is timely, given the alarming news reports of physicians abusing their privilege to practice medicine by engaging in unprofessional or criminal conduct. Instances of sexual harassment and boundary violations are not new in medicine, but in an era that is rightly focused on greater transparency and accountability, these incidents have raised questions about the profession’s ability to maintain high standards of individual professional conduct. A physician’s ethical duty to report suspected harm is codified in many state statutes, and several states have recently tightened their regulations by imposing penalties and consequences (including licensure suspension) when physicians do not report questionable behavior or activity by another physician. Several members of the coalition are reviewing measures to improve the sharing of state board disciplinary information with medical schools and health systems, which employ physicians as full-time, part-time, and adjunct faculty and educators. Coalition members are also seeking ways within their organizations, and at their meetings, to raise awareness of acceptable and unacceptable professional behavior.

The learning and practice environment

Coalition members are unanimously concerned about medical student, resident, and physician burnout, which is also a patient safety issue. The ACGME and AAMC are the primary sponsors of a National Academy of Medicine (NAM) action collaborative, launched in 2017, to promote physician well-being.12 The FSMB has released its own recommendations13 for state medical boards to modify licensure and renewal applications to lessen the stigma sometimes associated with physicians seeking to address their own medical and behavioral health care needs, an approach championed by the Harvard T.H. Chan School of Public Health and several stakeholders.14 Five members of the coalition recently convened a diverse stakeholder group to consider the role of medical licensing exam scores in the transition from undergraduate to graduate medical education, with the goal to improve the transition process and reduce the stress that students experience.15

Together, coalition members are also addressing the needs of the nation’s aging, increasingly diverse, and frequently more complex patient population through the evolution of education and assessment approaches across several dimensions that recognize that dynamic. The coalition recognizes, for example, the critical role of medical schools and residency programs in preparing the next generation of clinicians. To help address anticipated physician workforce shortages, the coalition’s members have supported the accreditation of new medical schools.16 Medical schools and residency programs have increasingly adopted a longitudinal assessment framework that includes milestones, entrustable professional activities, and competency-based medical education expectations to better equip physicians of tomorrow with the skills they need to practice in the changing health care environment.17,18 The coalition also recognizes that movement toward interprofessional team-based care requires interprofessional learning activities with nurses, pharmacists, and other health care personnel.

To mitigate the opioid epidemic now afflicting millions of Americans and killing more than 130 every day,19 coalition members have issued guidelines and support expanded education of current and future physicians about pain management, addiction medicine, and responsible opioid prescribing.20 Several coalition members are cosponsoring or participating in an NAM action collaborative focused on multistakeholder engagement to stem the opioid epidemic while responsibly addressing the needs of patients requiring pain management.21

Other major issues that have informed the coalition’s deliberations include the role of electronic health records and health information technology (HIT), the quality of the clinical learning environment, and funding for medical research as a public good. The coalition has met with leaders from the Office of the National Coordinator for HIT to better understand the nation’s investment in HIT and from the Centers for Medicare and Medicaid Services regarding federal plans for streamlining the regulatory burdens associated with physician documentation and billing.

Assessment, CME, and Licensure

High-stakes summative assessments continue to be viewed as useful tools by medical schools for decisions about entry into the medical profession and by state medical boards to assess physicians’ readiness for supervised and unsupervised practice. Testing approaches have evolved over time to adopt best practices (e.g., computer-based testing) and to deliver, in the case of medical licensing examinations, more specific feedback about expected cognitive and clinical skills in score reports. Questions raised by medical students about the value of clinical skills testing (which involves the use of standardized patients in proctored and videotaped sessions) as part of licensing examinations have prompted efforts by state medical boards and assessment organizations that are coalition members to explore improvements in the quality and meaning of score reports provided to candidates and to seek more medical student and stakeholder input in the design of these assessments.

Coalition organizations that oversee specialty certification are reviewing their roles and responsibilities in self-regulation through a deliberative process that is seeking a better system of continuous certification that is practical and meaningful to physicians and patients. CME, meanwhile, has evolved to reflect the changing needs of learners by promoting best practices in pedagogy, engagement, and evaluation; focusing on generating meaningful outcomes; encouraging interprofessional collaborative practice; creating alignment among regulators about expectations; and facilitating data sharing.22 Several coalition members are involved with the International Association of Medical Regulatory Authorities and with global efforts to advance continued professional development accreditation.

Medical licensing is also evolving. The Interstate Medical Licensure Compact, supported by many coalition members, has been adopted thus far by 29 states and 2 U.S. territories to enable physicians who meet nine eligibility criteria to rapidly receive multiple licenses to practice in multiple jurisdictions.23 More than 5,400 state medical licenses have been issued to more than 3,000 doctors through this pathway since 2017.24 Although 78% of the nation’s 953,695 licensed physicians currently have a license to practice medicine in only one state or territory, this interstate compact is expected to help improve access to care in underserved areas and facilitate telemedicine across state borders while retaining state-based medical regulation.25

In Sum

Coalition members recognize that self-regulation is an earned privilege, bestowed upon the medical profession in return for service to the public, and that it involves major shared responsibilities. Although the successes of such endeavors as the single GME accreditation system and the Interstate Medical Licensure Compact cannot directly be tied to the coalition’s efforts, we believe that the coalition’s support has played a helpful role in enabling such ventures to take root, grow, and bear fruit. Such an impact is consistent with the coalition’s mission. Issues that receive coalition attention tend to be of broad concern to the health of the public, to the profession’s self-regulatory functions, and to more than one or two member organizations. Ideas for discussion and collaboration that emanate from all dimensions of physician professional activity are welcome. Coalition members are encouraged to work within their respective organizations to advance ideas for the coalition to consider.

In sum, the coalition provides a useful avenue by which constructive, thoughtful solutions can be identified by individuals committed to their organizations’ missions to benefit the public. Building on a foundation of mutual respect and trust, coalition members are committed to seeking consensus where they can about common challenges, to supplementing their own advocacy activities on a range of issues, and to creating leadership initiatives that contribute to solving current and emerging health care challenges. At a time when civility and compromise are sometimes in short supply in the public sphere, the opportunity and willingness of coalition members to meet professionally to seek common ground and develop solutions while being respectful of each other’s opinions are noteworthy and may be reassuring to physicians and the public.

Acknowledgments:

The authors wish to thank Tom Granatir, John Gimpel, DO, David Johnson, MA, Frances Cain, MPA, Eric Fish, JD, and members of the Coalition for Physician Accountability for their helpful comments and suggestions.

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