Eric G. Campbell, PhD; Susan Regan, PhD; Russell L. Gruen, MD, PhD; Timothy G. Ferris, MD, MPH; Sowmya R. Rao, PhD; Paul D. Cleary, PhD; David Blumenthal, MD, MPP
Acknowledgment: The authors acknowledge the contributions of Drs. Janice Ballou and Frank Potter for Mathematica Policy Research.
Grant Support: By a grant from the Institute on Medicine as a Profession.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Eric G. Campbell, PhD, Institute for Health Policy, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Campbell, Regan, Ferris, Rao, and Blumenthal: Massachusetts General Hospital, Institute for Health Policy, 50 Stanford Street, 9th Floor, Boston, MA 02114.
Dr. Gruen: University of Melbourne, 6th Floor, Center for Medical Research, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia.
Dr. Cleary: Yale University, School of Public Health, 60 College Street, New Haven, CT 06513.
Campbell E., Regan S., Gruen R., Ferris T., Rao S., Cleary P., Blumenthal D.; Professionalism in Medicine: Results of a National Survey of Physicians. Ann Intern Med. 2007;147:795-802. doi: 10.7326/0003-4819-147-11-200712040-00012
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Published: Ann Intern Med. 2007;147(11):795-802.
The prospect of improving care through increasing professionalism has been gaining momentum among physician organizations. Although there have been efforts to define and promote professionalism, few data are available on physician attitudes toward and conformance with professional norms.
To ascertain the extent to which practicing physicians agree with and act consistently with norms of professionalism.
National survey using a stratified random sample.
Medical care in the United States.
3504 practicing physicians in internal medicine, family practice, pediatrics, surgery, anesthesiology, and cardiology.
Attitudes and behaviors were assessed by using indicators for each domain of professionalism developed by the American College of Physicians and the American Board of Internal Medicine. Of the eligible sampled physicians, 1662 responded, yielding a 58% weighted response rate (adjusting for noneligible physicians).
Ninety percent or more of the respondents agreed with specific statements about principles of fair distribution of finite resources, improving access to and quality of care, managing conflicts of interest, and professional self-regulation. Twenty-four percent disagreed that periodic recertification was desirable. Physician behavior did not always reflect the standards they endorsed. For example, although 96% of respondents agreed that physicians should report impaired or incompetent colleagues to relevant authorities, 45% of respondents who encountered such colleagues had not reported them.
Our measures of behavior did not capture all activities that may reflect on the norms in question. Furthermore, behaviors were self-reported, and the results may not be generalizable to physicians in specialties not included in the study.
Physicians agreed with standards of professional behavior promulgated by professional societies. Reported behavior, however, did not always conform to those norms.
Kaohsiung Medical University, Taiwan
December 11, 2007
Increasing scientific knowledge? Not always
The Physician Charter (1) has been widely accepted since its publication (2). As a participant in translating the charter into Chinese (3), I read Dr. Campell et al. (4) article with great interest. However, I was quite confused by the question the authors selected to measure physicians attitudes toward increasing scientific knowledge. Physicians should encourage the participation of their patients in clinical trials(table 1) , and the question to survey professional behaviors. In the last 3 years, have you encourage 1 or more patients to enroll in a clinical trial?(table 2). For a physician may have several other reasons to encourage his patient to participate in clinical trial, for example, maybe it is the only chance to fight the disease, or maybe the physician will receive gifts from the research sponsors. Therefore it would be impossible to say that all the respondents who gave positive answers to these questions are based on commitment to scientific knowledge. Besides, physicians should put patients personal welfare not only prior to physicians self-interest, but also to the advancement of science. A physician who encourages a lot of patients to participate in clinical trial, may be or may not be a physician who acts professionally.
1. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6.
2. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med. 2003;138:839-41.
3. Liu KM, Huang YS. Preparing health professionals for the future: 11th International Ottawa Conference on Medical Education [visitors report]. J Med Educ (Taiwan). 2004;8:216-23.
4. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795- 802.
Lucian L. Leape
Harvard School of Public Health
February 4, 2008
Doctors need help
Why Doctors Don't Report Colleagues
Re: Campbell et el., Professionalism in Medicine, Annals of Internal Medicine 147:795-803, December 2007
The finding of Campbell, et al.'s survey that nearly half of physicians who witnessed an impaired or incompetent colleague practicing medicine and had not reported them to a higher authority should not be surprising.
Studies of reporting systems show that people do not report harmful events unless it is both safe and worthwhile. Reporting incompetent doctors who may harm patients is usually not safe. The physician with a competency issue may be reprimanded or face license suspension or revocation. In addition, he or she almost always sees it differently, and may engage in swift and devastating retaliation against the reporter.
Reporting is also not worthwhile, in that serious efforts to help physicians improve their knowledge and skills are virtually non-existent. Both state licensing boards and hospital credentialing committees tend to ignore these types of problems until a serious incident occurs, and then respond with discipline. One hopes the recent decision of the American Board of Medical Specialties (ABMS) to require diplomates to continuously demonstrate competence in order to maintain board certification status will lead to earlier identification of deficiencies.
However, even if a physician in need is identified, there are few programs available nationwide for assessment (10), and fewer still for rectifying any deficiencies that are found.1 A national effort is needed to develop many more of these programs. The ABMS, Federation of State Medical Boards (FSMB), and Joint Commission should launch a joint effort to establish at least a dozen new assessment and remediation centers that health care organizations and state boards can refer doctors to.
Most "incompetent" doctors can be retrained and remediated to be safe and competent once more. It is clearly in everyone's interest that we do so.
Lucian L. Leape, MD Harvard School of Public Health
John A. Fromson, MD Harvard Medical School
1. Leape L, Fromson, JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144:107-115.
Edward J. Volpintesta
February 22, 2008
Remedial education:Lets do it right
Dr. Leape and Dr. Fromson's ideas ("Doctors need help" Rapid Response, Feb. 4, 2008) for helping physicians' identify areas where they may need to improve their knowledge or skills merit further discussion, particularly in the area of primary care.
First, it is important to point out that any "remedial" education that is needed should be determined for the most part by the individual physician's type of practice. For instance, not all primary care doctors have similar practices. Many customize their practices according to their particular strengths and weaknesses and particular interests. This needs to be taken into account. There is no archetypical primary care doctor as some medical educators think.
Second, I'm not sure that after a physician has been certified by board he or she needs to be recertified. Why? Recertification in its present form has is punitive and has as much a penalizing effect as an educational one. Not being recertified can be harmful to an otherwise good physician and lacking certification may move an HMO to drop a physician or deny employment. If used in tiered networks lack of certification can be misinterpreted as lack of competency by patients. And there is the possibility that lack of certification may be used to refuse admission by a hospital to its staff.
So what's the point? Once certified, physicians should stay current with educational assessments and remedial education tailored to their personal needs. However, recertification should eliminate its pass/fail approach. The pressure to recertify has spawned a large number of expensive CME programs that can be compared to "performance enhancers" in professional sports, and like them can give a spurious impression of a physician's abilities. At the same time they can disadvantage a doctor who forgoes them.
Some doctors feel that the whole CME process, boards included exploit them; that they are more interested in financial gain than in education. Worse, the pressure to pass recertification encourages doctors not to study what they need in their practices but what they need to pass the next exam. How crazy is that? Clearly, physicians should not be tested in skills and knowledge they no longer use or need.
Third, in addition to medical knowledge there are other qualities that make for competent physicians which the recertification exams do not measure. Some of the qualities that competent doctors should have? Are they good team members? Do they connect well with their patients? Do they spend sufficient time with them? How accommodating are they to them? How honest are they in not exploiting their patients with unnecessary tests?
There are other critical qualities as well: participation in hospital affairs including committees and departmental meetings; involvement in local and state medical associations,, recommendations form their department chairpersons regarding their professionalism and integrity"”all of these in addition to scientific knowledge go to make up a balanced, competent, and compassionate physician".
Fourth, I disagree with the authors' ideas about remediation centers. For primary care physicians, there is pressure to "stay put"; most of the practical knowledge they need can be obtained at their community hospitals, eliminating the loss of time required to travel to a distant CME center. The majority of community hospitals have specialists on their staffs that can help primary care doctors keep current and the local hospitals are an ideal place for "remedial education". Topics like treatment of congestive heart failure, new therapies for hypertension and diabetes could easily and conveniently be provided at local hospitals. Funding could be sought from drug companies or small fees collected from the doctors. Federal money is another possibility, especially since a scarcity of primary care doctors exists and policy makers seem eager to increase their numbers.
Clearly, particularly for primary care a new model is needed for assessing competence and remedial CME. With renewed emphasis on the need for more primary care doctors, now is the time to make new and practical changes that will benefit all primary care doctors.
December 31, 2008
Re-certification's shortcomings ignored by ABMS
It's not surprising that 24% of physicians reported that board recertification is not desirable.
Initial certification acts as a comprehensive exam for residents finishing residency; it also reflects the effectiveness of the residency program itself.
But re-certification, especially in family practice and general internal medicine has defects that limit its usefulness.
For instance, when doctors sit for recertification some will have been in practice for twenty or thirty years; during which some may have tailored their practices to reflect the demographics of their communities, the number and variety of specialists available, and the socioeconomic climate, to name just a few factors.
It is not unusual for a portion of them to voluntarily have let some of the skills and knowledge they learned during residency lapse because there was no call for them, or because they were not comfortable treating certain diseases. Also after many years in practice they likely developed an effective relationship with a network of consultants. They have leaned to know when to refer their patients and when to seek advice. Also some have very stable patient populations and have stopped seeing new patients, devoting more time to the patients they have.
Recertification with its academic bias tests doctors in knowledge that often is not germane to their practices. Older doctors, many of whom are not up to taking exams based on knowledge they don't use are clearly disadvantaged. Although there are many board review courses offered (at considerable cost and time away from office) not all doctors can afford to leave their practices, especially those in solo or small practice. And it makes no sense for senior doctors to engorge themselves on information that is not applicable to their practices only to regurgitate it on an exam.
Re-certification exams should not be based on a pass or fail basis. Instead, they should focus on showing doctors where their knowledge may be deficient and offering remedial study. Failing doctors accomplishes nothing, unless stigmatizing them is considered a goal. Passing them has questionable value as well because some of them may have taken review courses or had more time to prepare-- both of which disadvantage those who didn't have such conveniences.
It is strange that the leadership of the ABMS, as well-intentioned as it may be has not been more thoughtful about its methods and consequences. Ironically, the newer methods of testing lack some of the advantages of earlier ones. In family medicine for example, previous tests included a review of several office charts. This chart review was critical because it attached value to the work doctors did in their offices. Sadly, in family medicine, this requirement has been eliminated and the entire test is question-and-computer-based. Recertification assesses nothing of physicians' character, their ability to work as team members, or their ability to ability to connect with patients and form effective therapeutic relationships. These so-called communication and interpersonal skills are cardinal attributes of what psychologists refer to as components of "emotional intelligence". They are part of all well-rounded physicians' professionalism, but of particular importance to primary care doctors.
In real- life practice physicians refer to textbooks or consultants for solutions to questions they may not have been able to answer correctly on a recertification test. Thus failing a doctor is on a test does not mean that he is incompetent or necessarily lacking in knowledge.
Because of the boards' shortcomings and their failure to correct them, an increasing number of doctors view them as a self-serving cottage industry, more interested in promoting their financial success than in helping doctors. A good number of doctors freely admit that they take the tests only out of fear of being dropped from an HMO panel or a hospital staff for lack of cerftification or re-certification.
If the ABMS explained in detail to the public what the boards actually test for and what they actually fail to test for, they would find their credibility seriously challenged. Recertification must eliminate the pass/fail method. Instead, the exam should uncover areas of weakness and suggest remedial study. The current method is an insult to physicians' professionalism.
In an era that seems hell-bent on persecuting doctors, it is maddening to see that physicians have allowed so much influence and authority to accumulate in a single organization. The recertification process is a prime example of how physicians can be taken advantage of not only by forces outside of the house of medicine but those within as well.
It persists only because physicians lack the courage to change it for the better.
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