Promoting Physician Competence Across the Lifespan Targeted Structured Lifelong Learning and Practice Improvement Sandra B. Sexson, MD Professor and Chief Child, Adolescent and Family Psychiatry Medical College of Georgia
Disclosures • No financial conflicts of Interest • Chair Organizational Components that develop products and tools for Lifelong Learning and Assessment of Performance in Practice – American Academy of Child and Adolescent Psychiatry • Committee on Lifelong Learning – American College of Psychiatrists • Physician-in-Practice -Exam (PIPE) Commission – Chair – ABPN • ABPN Ambassador
Presentation Objectives • After this presentation, the learner will be able to: – Recognize the importance of maintaining physician competence across the lifespan – List the four components of maintenance of specialty certification – Discuss the ABPN requirements for MOC depending on whether you are in the 10 year cycle or the continuous MOC program
“The Duties of a Physician” Bard, 1769 • “Do not therefore, imagine, that from this time [the receipt of the MD degree] your studies are to cease; so far from it, you are to be considered as but just entering upon them; and unless your whole lives are one continued series of application and improvement, you will fall short of your duty.” Bard, 1769 in his graduation address
Questions for Discussion or Thought • What is your experience with CME? • How do you decide what continuing education to pursue? • What types of educational programs do you prefer?
Traditional Measures of Physician Competence • Successful completion of: • Undergraduate Medical Education • Graduate Medical Education • Board Certification • Ongoing participation in unstructured continuing medical education • Unquestioned as necessary by most physicians • Required in most countries for ongoing licensure and board certification • Self-selected by the physician • Usually characterized by passive knowledge acquisition
What and How do Physicians Choose? • Topics that appeal to them – Not necessarily gaps in knowledge – No efforts typically to focus on identifying areas that need updating, and when do consider areas of need, basis is unguided self assessment • Traditional passive types of CME offerings – Lectures in large group settings ( ? in nice places) • Specialty association meetings most preferred setting – Lack of active participation
Why Unguided Passive CME is not Enough • 1999 Institute of Medicine report revealed high rates of medical errors and unnecessary deaths – In US alone there were medical errors annually that ended in 44000 patient deaths in the early 90s, a number that more than doubled in less than 10 years. Kohn, et. al., 1999; Berlinger, 2008 • Studies on pass rates for recertification after the advent of time limited board certification Rhodes, 2007 – Demonstrated significant decrease in pass rate as diplomates were further from initial certification suggesting clinical experience does not assure being up-to- date…also those in solo practiced fared less well than those in groups • Exploding information – Concerns that lifetime certification was insufficient to assure that physicians stayed current in age of burgeoning information advances • The issue of the public trust
Medical Education: Not a Destination, But a Structured Lifelong Journey
Definition of Lifelong Learning Collins, 2009 • Continuous – Never stops • Supportive – Done with others • Stimulating and empowering – Self directed, active • Incorporates knowledge, skills, and attitudes – More than knowing • Spans the lifetime – Implies the journey, not the destination or an end point • Leads to creative, confident and enjoyable application
More than Knowing • “Knowing is not enough; we must apply. Willing is not enough; we must do.” Goethe, Brainyquote – Little evidence in past that CME leads to better patient care and outcomes – Experience with the lack of translation of scientific evidence to the bedside – Discrepancies between perceived competence and actual performance • Reading the literature • Applying EBM to clinical practice
Self-Assessment Not a New Idea outside of Medicine • “He who knows best, best knows how little he knows.” -- Thomas Jefferson Silver, et. al., 2008 • “In all affairs it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted.” Bertrand Russell Brainyquote.com
Why is Guided Self-Assessment Important? • Identifies the learning gaps for the individual clinician • Unguided self assessment does not work – Comparisons of self-assessment vs. observed measures of competency • Most studies demonstrated little, no or an inverse relationship between self and external assessments (observations, comparisons to benchmarks, etc.) • The worse accuracy in self-assessment was most frequently among the least skilled, yet most confident physicians
“ The whole problem with the world is that fools…are always so certain of themselves, and wiser people so full of doubts.” -- Bertrand Russell Brainyquote.com
Factors Contributing to Problems with Physician Competence Failure to adhere to professional conduct standards Insufficient training to keep up in a time of burgeoning growth of knowledge Inability to adequately self-assess both our knowledge and what we actually are doing in practice Disregarding the effect of time on knowledge and skills Failure to use EB M in our practice Resistance to consider patient perspectives about care Resistance to feedback from peers
Why Not Maintenance of Competence ? • Targeted lifelong learning that is informed by self assessment and identification of “practice gaps” – Using knowledge-based exams to identify areas of weakness and then seeking formal or informal opportunities to address those identified learning issues • Openness to learning beyond the traditional lecture experience – Small group interactive sessions, either formal or informal – Critical journal reading with post-test, either alone or in a group – Interactive computer programmed learning with assessment – Individually arranged study – Personal commitment to ask questions and find answers for implementation at the point of care.
“The next time you’re at the doctor’s office, take a peek at those certificates hanging on the wall. Like gallons of milk, some of them are expiring .” Associated Press April 5, 2010
ABPN Maintenance of Certification (MOC) Jeffrey Hunt, MD Professor and Program Director CAP Fellowship and Triple Board Program Alpert Medical School of Brown University Chair ABPN CAP MOC Committee
Disclosures • Financial – Wiley Publishers • Organizations – American Academy of Child and Adolescent Psychiatry • Co-chair Training and Education Committee – ABPN • Chair CAP MOC Committee – ACGME • Chair CAP Milestones Work Group
Survey Results of RI Chapter of APA THE MOC PROCESS LIFETIME CERTIFICATION WILL HELP PSYCHIATRISTS GIVE I DISAGREE STRONGLY BETTER CARE TIME LIMITED CERTIFICATION Number of respondents = 96 Lifetime certification = 26 Time limited certification =70
Survey Results of RI Chapter of APA LIFETIME CERTIFICATION • THE MOC PROCESS IS CONFUSING I AGREE STRONGLY TIME LIMITED CERTIFICATION Number of respondents = 96 Lifetime certification = 26 Time limited certification =70
Maintenance of Certification (MOC) Requirements 1. Evidence of professional standing (licensure). 1. Evidence of CME and self-assessment (AACAP MOC modules). 1. Evidence of cognitive expertise (proctored recertification exam). 1. Evidence of improvement of performance in practice (AACAP PIP tools).
10 year certification
Continuous ABPN MOC Program • Implemented for those certified 2012 and later • Requirements – Unrestricted medical license – Cognitive exam every 10 years – Specific MOC activities every 3 years • 24 CME hours of SA activities • Total CME hours 90 • 1 PIP Unit • Annual registration on individual ABPN Folio • Annual MOC fee ($ 175 in 2015) – No additional fee for the MOC cognitive exam
Summary of C-MOC
Medical Knowledge Quality Improvement Cycle Self- Assessment Activities Knowledge CME Activities Deficiencies
CME requirements • 30 specialty and/or subspecialty CME credits/year averaged over three years. – CME credits must be relevant to the specialty and/or subspecialty – The CME activities do not need to come from ABPN Approved MOC Products list. • At least 8 CME per year, averaged over three years, must involve self-assessment and do need ABPN approval starting 2014
Self Assessment (SA) CME • At least 8 CME per year • Beginning in 2014, must come from ABPN-approved SA activities. • www.abpn.com/moc_products.asp • Each SA activity must: • cover new knowledge and/or current best practices • guide focused CME, lifelong learning • And include – the correct answer, recommended literature resources for each question, and comparative performance to peers.
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