Is the American Board of Emergency Medicine's Maintenance of Certification — particularly Part 4, which requires EPs to assess their own patient care — a necessary component of ensuring quality in emergency medicine? Or is it expensive busywork of minimal benefit to physicians and patients?
Those questions arose last December when ABEM sent letters to emergency physicians describing in detail the Assessment of Practice Performance, commonly called Part 4. (http://bit.ly/ABEMmoc.) It requires a Communications Professional Activity in which emergency physicians must devise their own surveys or use information from a survey such as Press Ganey to determine how well they communicate with their patients. The survey must be done every 10 years, which begins when a physician is certified or re-certified. If a physician devises his own survey, it must include questions and measure specific points that include communication, ability to listen to the patient, provide information to patients, and show concern for the patient.
Part 4 also calls for a Patient Care Practice Improvement Activity that must be completed twice every 10 years. The physician assesses how he is treating patients now and compares that to guidelines for treatment. The physician then determines whether he is practicing according to evidence-based guidelines. A physician who needs improvement must devise a plan to do that, and then resurvey 10 patients to determine if the treatment is meeting the guidelines.
Debra Perina, MD, the president of ABEM, said she understands some of the confusion about Part 4, but she also believes it is important. “I think whenever there is something new added to the process, it causes everyone to pause and be concerned about what additional requirements are being asked of them. All physicians are busy today, and are asked to do more in practice than they were 15 years ago. The whole program is designed to enhance and ensure physician commitment to lifelong competence in their specialty,” she said.
Part 4 is designed specifically to help the physicians in their clinical practice to ensure quality improvement and ongoing continuous practice improvement to benefit their patients, their practices, and the broader health care community.
Maintenance of Certification began with the American Board of Medical Specialties, and this fourth part is similar to that required for members of the other 24 specialty boards, Dr. Perina said. In part, it is a reflection of governmental and public concern over quality of care and patient safety issues that have cropped up over the past decade.
Dr. Perina said she understands that physicians want to do their best for their patients. “We are all committed, and want to do the best we can. This is a mechanism to help us do that, and for physicians to assess their practice and assure the public that they are maintaining their skills to a level of competency within their practice.”
A prominent critic of the process is Allen Roberts, MD, who blogs as Grunt Doc. (http://gruntdoc.com.) “I'm a proud member of ABEM,” he said. “I know they have this continuous certification thing going that has been forced on them by ABMS. And I understand the idea behind the yearly test [the Lifelong Learning and Self-Assessment]. Everyone knows the story about the doctor who graduated from residency, and then prescribed penicillin for everything forever.”
However, he said, the time between the articles chosen for the testing often lags current findings. And he objects to yearly tests for which he is charged but gets nothing but “a certificate and a tax write-off.” Dr. Roberts said he'd like to see physicians receive some continuing medical education credit for this part of continuing certification.
Dr. Perina countered that this is a work in progress, and the board is investigating ways to provide high-quality continuing medical education as part of the LLSA. Beginning in 2011, diplomates who successfully complete a Maintenance of Certification practice-based assessment comparing quality of care to peer and national standards will be able to use it to satisfy the Centers for Medicare and Medicaid Services Physician Quality Reporting Initiative (PQRI) requirements and to qualify for PQRI payment incentives that apply to care provided to Medicare patients. “Some synergy is starting to develop,” she said.
Dr. Perina added that ABMS is discussing with the Federation of State Medical Boards the possibility of using Maintenance of Certification as equivalency for maintenance of licensure. “Once the system starts working, and physicians understand it, they will find it helpful to make improvements that they identify in their own practices. And it will help them meet PQRI requirements without doing anything extra,” she said.
Dr. Roberts said the requirements for Part 4 seem reasonable, “but in reality it means nothing. What practicing doctor can't find 10 patients who say that their care is good? Who can't find 10 charts in which the patients got the standard of care? This is a bar that is set so low it's laughable, but it will still take time to do. You send it off, and they put it in a file.
“In medicine, we try to do things that are provably correct. We don't use leeches on people unless it's a particular plastic surgery procedure. We don't bleed people anymore. Now we are going to charge down this road, give people yearly tests, and have people submit charts, and there's no evidence that any of this is going to increase patient safety or change physician practice. And that is what this is supposed to be about.”
But Dr. Perina said a link has been shown between maintenance of certification and quality. Since boards introduced practice assessment into their maintenance of certification programs, more than 11 peer-reviewed studies have demonstrated that physicians completing the programs make changes to practice and improve patient care measured against outcomes or process measurements.
Although Dr. Roberts agreed with Dr. Perina that maintaining quality of care is important, he said he is not sure the current system works. “None of us wants practice to get worse. We want it to get better. But how do you go about doing it?” he asked. He said continuous certification might become a deterrent to maintaining certification, especially because ABEM membership is voluntary.
Dr. Perina agreed that seeking and maintaining certification is a voluntary process that demonstrates a measure of quality, and she acknowledged that emergency physicians are pushing back against Part 4. “All the other member boards that [are] ahead of us have experienced some of the same feedback,” she said. “It's just going to take time for everyone to understand what is trying to be accomplished.”
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