Linda L. Blank

The value of patient and peer ratings in recertification.

Recertification of practicing physicians, also termed ‘‘maintenance of certification,’’ is now at the forefront of activities for virtually all member boards of the American Board of Medical Specialties. The goal of recertification is to maintain high standards of medical practice that protect the public by using fair, valid, and reliable methods to assess professional competence. To fulfill this goal, a comprehensive framework that integrates self-evaluation and practice improvement with a secure, proctored examination defines the recertification process for the 21st century. Concern about the inability of proctored examinations to assess the full spectrum of clinical competence, including humanistic qualities, professionalism, and communication skills, stimulated the American Board of Internal Medicine (ABIM) to introduce the ‘‘patient and peer assessment module,’’ a practice-based assessment tool, into its new recertification program called Continuous Professional Development (CPD). Whereas residents seeking initial Board certification are required by the ABIM to achieve satisfactory ratings of the core components of clinical competence from their program directors, there is no parallel method for practicing physicians who seek recertification. The ABIM’s CPD program is composed of three components: self-evaluation, a secure examination, and verification of credentials; the physician pays the fee for the program. The first component, self-evaluation, comprises a series of modular examinations taken at home. Its purpose is both to stimulate study in the disciplines of internal medicine and to encourage improvement of one’s practice. The second component, the secure examination, is a traditional proctored examination featuring single-best-answer questions designed to evaluate clinical knowledge and judgment about essential aspects of patient care that a physician should have without reference to medical resources. The third component, verification of credentials, requires both good standing in a hospital or health care delivery system and maintenance of an unchallenged, unrestricted license to practice medicine. As part of the self-evaluation component, physicians may select, as an elective, the patient and peer assessment module, which incorporates confidential, anonymous surveys of patient and peer ratings pertaining to physician–patient communication and peer assessment of clinical performance. The module also requires completing self-rating surveys and a quality improvement plan (QUIP). The ratings are administered through a touch-tone telephone, using a toll-free number and an automated voice-response system. Once the self-ratings and the required number of patient and peer ratings are achieved, ABIM provides performance feedback; there is no passing standard associated with this module. After submitting the QUIP, the diplomate receives credit for the module. The feedback and QUIP are intended to stimulate diplomates to selfreflect and improve the quality of the medical care they provide. Prior to implementation, a pilot study assessed the feasibility of the module using 100 volunteers. Participants highly approved of the survey questions, and more than two thirds agreed that the module was a valuable learning experience. The technology used to record the survey ratings performed well. The purpose of this study was to assess the value of the patient and peer assessment module. Specifically, we raised four measurement questions:

Medical Professionalism in the New Millennium: A Physician Charter 15 Months Later

As we mark the 15-month anniversary of the physician charter that was published simultaneously in Annals of Internal Medicine and The Lancet in 2002 (1, 2), the members of the Medical Professionalism Project are pleased by the level of interest and activity the charter has engendered. Several hundred U.S. and international newspapers cited the charter in related stories; more than 70 radio, television, and online interviews have been conducted with individual project members; over 65 000 reprints have been requested from around the world; and, collectively, the Annals, Medical Professionalism Project and European Federation of Internal Medicine (EFIM) Web sites have logged more than 70 000 related visits. In addition, this issue of Annals features a collection of provocative Letters about the charter. Building on this level of responsiveness, the ABIM (American Board of Internal Medicine) Foundation and the ACP (American College of Physicians) Foundation will sponsor phase II of the Project, planned as a 2-year initiative. Phase II will encompass reviewing the charters initial impact and, within that context, explore the opportunity to define the health rights and responsibilities of patients, physicians, and society. Background and Rationale The Medical Professionalism Project, jointly sponsored by the ABIM Foundation and the ACP Foundation, began in November 1999 as a collaborative effort designed to raise the concept of professionalism within the consciousness of internal medicine, both in the United States and Europe. The two foundations, in partnership with the European Federation of Internal Medicine, are well positioned to influence the ethical and professional standards of medicine and encourage the profession to reaffirm its civic commitment. Impetus for the Project stemmed from the following question: Why is raising awareness about the core values of medical professionalism important? As the pace of change in health care accelerated and the future of medical practice became increasingly uncertain, the ABIM and ACP Foundations and European Federation of Internal Medicine saw the need to convene this collaborative project because medical professionalism is universally endangered. Physician unionization, waning ability to self-regulate, medical errors, bioterrorism, compromised access and health care delivery, conflicts of interest precipitated by managed care and for-profit medicine, and the pharmaceutical industrys role in patient care and medical education reflect the range of issues that challenge the medical profession globally. At this crossroads, the medical profession urgently needs a united front to influence and inform the culture and context of both clinical practice and medical training. The charters three fundamental principles and set of professional responsibilities are intended to encourage such dedication and debate (Table). Table. Charter on Medical Professionalism: Fundamental Principles and Professional Responsibilities Publications To date, in addition to Annals of Internal Medicine and The Lancet, the charter has been published in the following journals: Clinical Medicine (formerly Journal of the Royal College of Physicians), European Journal of Internal Medicine, American Journal of Obstetrics and Gynecology, The American Journal of Surgery, Journal of the American College of Dentists, Annals of the Royal College of Physicians and Surgeons of Canada, Canadian Medical Association Journal, The Medical Journal of Australia, Bollettino Ordine Provinciale Medici Chirurghi e Odontoiatri-Milano, La Revue de Mdecine Interne, and La Radiologia Medica. The charter has been translated into Italian, French, Spanish, Portuguese, German, and Polish. The Health Ministry of Italy also published the charter and distributed it to every medical student and faculty member throughout the country. Translations into Dutch, Swedish, Japanese, and Turkish should lead to future publication in journals written in these languages. Presentations Since the charters publication, project members and others have collectively given more than 100 related presentations in a variety of formats: named lectures, grand rounds, medical school graduation addresses, plenary sessions at national and international meetings, workshops, and seminars. National meetings have included those of the Association of American Medical Colleges, ACP, American College of Obstetricians and Gynecologists, American Medical Association, Arnold P. Gold Foundation, Council of Medical Specialty Societies, Accreditation Council for Graduate Medical Education, American Board of Medical Specialties, American College of Surgeons, Association for Hospital Medical Education, and Federation of State Medical Boards. International meetings have included those of the Association for Medical Education in Europe and the European School of Internal Medicine; the European Federation of Internal Medicine Congresses in Edinburgh and Berlin; the International Society of Internal Medicine Congress in Kyoto; and the Association of Canadian Medical Colleges, Ottowa Conference, and Royal College of Physicians and Surgeons of Canada. Endorsements To date, the following 90 professional associations, colleges, societies, and certifying boards have endorsed the charter: Accreditation Council for Graduate Medical Education; American Academy of Allergy, Asthma & Immunology; American Academy of Dermatology; American Academy of Family Physicians; American Academy of Neurology; American Academy of Ophthalmology; American Academy of Orthopaedic Surgeons; American Academy of OtolaryngologyHead and Neck Surgery; American Academy of Pediatrics; American Academy of Physical Medicine and Rehabilitation; American Board of Medical Specialties; American Board of Allergy and Immunology; American Board of Anesthesiology; American Board of Colon and Rectal Surgery; American Board of Dermatology; American Board of Emergency Medicine; American Board of Family Practice; American Board of Internal Medicine; American Board of Medical Genetics; American Board of Neurological Surgery; American Board of Nuclear Medicine; American Board of Obstetrics and Gynecology; American Board of Ophthalmology; American Board of Orthopedic Surgery; American Board of Otolaryngology; American Board of Pathology; American Board of Pediatrics; American Board of Physical Medicine and Rehabilitation; American Board of Plastic Surgery; American Board of Preventive Medicine; American Board of Psychiatry and Neurology; American Board of Radiology; American Board of Surgery; American Board of Thoracic Surgery; American Board of Urology; ABIM Foundation; American College of Dentists; American College of Medical Genetics; American College of Obstetricians and Gynecologists; ACP; American College of Radiology; American College of Surgeons; ACP Foundation; American Psychiatric Association; American Society of Anesthesiologists; American Society of Clinical Pathologists; American Society of Plastic Surgeons; American Urological Association; Association of Academic Physiatrists; Association of Physicians of Ireland; Association of Physicians of Malta; Austrian Society of Internal Medicine; Belgian Society of Internal Medicine; College of Physicians and Surgeons of British Columbia; Council of Deans, Association of Canadian Medical Colleges; Council of Medical Specialty Societies; Czech Society of Internal Medicine; Danish Society of Internal Medicine; Estonian Society of Internal Medicine; European Federation of Internal Medicine; Federation of Royal Colleges of Physicians of United Kingdom; Federation of State Medical Boards; Finnish Society of Internal Medicine; French Society of Internal Medicine; German Society of Internal Medicine; Hellenic Society of Internal Medicine; Hungarian Society of Internal Medicine; Israeli Society of Internal Medicine; Italian Society of Internal Medicine; Latvian Society of Internal Medicine; Lithuanian Society of Internal Medicine; Luxembourg Society of Internal Medicine; Ministero della Salute; Netherlands Society of Internal Medicine; Polish Society of Internal Medicine; Portuguese Society of Internal Medicine; Royal Australasian College of Physicians and Surgeons; Royal College of Physicians of Edinburgh; Royal College of Physicians of Ireland; Royal College of Physicians of London; Royal College of Physicians and Surgeons of Canada; Slovak Society of Internal Medicine; Slovenian Society of Internal Medicine; Society of Neurological Surgeons; Society of Nuclear Medicine; Society of Thoracic Surgeons; Spanish Society of Internal Medicine; Swedish Society of Internal Medicine; Swiss Society of Internal Medicine; and Turkish Society of Internal Medicine. During the remainder of the year, additional endorsements will be sought from state medical societies, educational organizations, and other national and international medical associations. Future Activities The ABIM Foundation has launched a series of targeted activities to promote the charter: 1) an attractive charter publication for distribution at medical school and residency orientation, white coat ceremonies, and graduation; 2) a charter wall poster suitable for framing; 3) Putting the Charter into Practice [small seed grants for implementation were awarded to McGill University; New York University School of Medicine; University of California, San Francisco; University of Michigan Medical School; and University of Texas Medical Branch, Galveston]; 4) Medical Professionalism Project colloquia and conferences; 5) professionalism portfolios designed to promote self-reflection and use of self-assessment tools; 6) inclusion of the charter with each ABIM diplomates Board certificate; 7) a proposed charter series in peer-reviewed journals; and 8) a proposed award recognition program. The past, present, and future activities stimulated by the charter are being chronicled and will be essential in determining its short- and long-term imp

Residents’ perception of evaluation procedures used by their training program

Objective:To determine the methods of evaluation used routinely by training programs and to obtain information concerning the frequencies with which various evaluation methods were used.Design:Survey of residents who had recently completed internal medicine training.Participants:5,693 respondents who completed residencies in 1987 and 1988 and were registered as first-time takers for the 1988 Certifying Examination in Internal Medicine. This constituted a 76% response rate.Main results:Virtually all residents were aware that routine evaluations were submitted on inpatient rotations, but were more uncertain about the evaluation process in the outpatient setting and the methods used to assess their bumanistic qualities. Most residents had undergone a Clinical Evaluation Exercise (CEX); residents’ clinical skills were less likely to be evaluated by direct observation of history or physical examination skills. Resident responses were aggregated within training programs to determine the pattern of evaluation across programs. The majority of programs used Advanced Cardiac Life Support (ACLS) certification, medical record audit, and the national In-Training Examination to assess most of their residents. Performance-based tests were used selectively by a third or more of the programs. Breast and pelvic examination skills and ability to perform sigmoidoscopy were thought not to be adequately assessed by the majority of residents in almost half of the programs.Conclusions:While most residents are receiving routine evaluation, including a CEX, increased efforts to educate residents about their evaluation system, to strengthen evaluation in the outpatient setting, and to evaluate certain procedural skills are recommended.