A Model for Physician Competence in 2020: A Thought Experiment

1. A Model for Defining, Assessing and Monitoring Physician Competence in 2020:A Thought Experiment A Synthesis of Creativity Exercises at the Physician Accountability for Physician Competence Summit II December 8-9, 2005 Physician Accountability for Physician Competence Summit II

2. “Educators” Physician’s Career Pre Med Med School GME Practicing “Regulators” Thought Experiment: Physician Competence in 2020 The model presented in the following pages was developed as a thought experiment during the second Physician Accountability for Physician Competence Summit in December 2005. The group that developed this model was given an assignment by InnovationLabs (the facilitators of the Summit) to create a new system for determining, assessing and monitoring physician competence in 2020 that looks different from the qualification systems that are in place today. The purpose of this assignment was to stimulate new thinking and new conversations, not to make recommendations for change. This model has not been validated, tested or endorsed by any individual or organization associated with the Summit. Instead, our purpose in presenting this model in further detail is to foster further conversations. Assignment for the Reader: As you explore this model on the following pages, identify ways in which this system addresses challenges associated with transparency, portability, validation of competence, and physician currency. Also identify gaps – ways in which this system does not address these issues and others that may occur to you. Most importantly, as you read through the description of this hypothetical system, what other ideas, discoveries, insights or questions come to mind? We encourage you to share these insights and questions with us or with your colleagues. Physician Accountability for Physician Competence Summit II

3. Structure of the “Regulators” in 2020 We will begin our description of this hypothetical system for physician competence with an exploration of a new regulatory system. The largest change in this model from 2005 is the introduction of a National Certification Agency for Boards. This organization defines national standards and competencies for physicians, and certifies Specialty Certification Boards. It is the Specialty Boards in this model which certify physicians to practice medicine. This certification will be limited in scope, however, so that a physician will only be able to practice medicine within his or her specialty. Over time physicians will be able to expand or change their specialty through the recertification process (see below). The State Licensing Board is responsible for issuing licenses to practice medicine. These boards will meet certain national criteria for licensing which will allow a physician licensed in one state to practice medicine anywhere in the US. This license will be valid for a limited time, and the re-licensing process will require that a physician demonstrate competence. “Regulators” National Certification Agency for Boards State Licensing Board Specialty Certification Board Physician Accountability for Physician Competence Summit II

4. “Educators” ACGME Pre Med LCME ACCME Accreditation Oversight Alliance Standards &Competencies Med School Standards &Competencies GME National Certification Agency for Boards “Regulators” Structure of the “Educators” in 2020 In this thought experiment, we decided that the three major educational bodies, the LCME, the ACGME and the ACCME, should coordinate their efforts in an Accreditation Oversight Alliance. This organization would work closely with the National Certification Agency to define standards and competencies for physicians. These standards and competencies would then be rolled out into the medical education system from Pre-Med programs through Graduate Medical Education and even Continuing Medical Education. These changes will also be reflected in all examinations, including the MCAT. Physician Accountability for Physician Competence Summit II

5. Roles of the “Educators” in 2020 “Educators” ACGME Pre Med LCME ACCME Accreditation Oversight Alliance Standards &Competencies Evaluation Med School Standards &Competencies GME Evaluation National Certification Agency for Boards In addition to competencies, the Alliance will introduce a common evaluation system – of a physician’s quality and behavior indicators – throughout the education system. These will be the same evaluation protocols that will be used for practicing physicians. Thus, physicians trained in this system will not be surprised by new standards of performance and behavior when they begin practicing medicine. “Regulators” Physician Accountability for Physician Competence Summit II

6. Physician’s Career GPA MCAT IT Skills Pre Med Resume Behavior CBI Drug Screens Med School The Physician’s Career in 2020 – Getting to Med School In order for competency to be assured in practicing physicians, certain competencies should be sought out as early as the Pre-Med years. Students applying to Medical Schools should expect to have a high GPA and as strong a resume as ever. The MCAT will also be required, although some of the focus of the exam may shift to include measures of competencies. Drug screening and Criminal Background Investigations (CBI) will become standard for Med School applicants. Moreover, these applicants will be screened for favorable (and demonstrable) behaviors that will suit medical practice in 2020, and they will be required to demonstrate strong skills with Information Technology. Physician Accountability for Physician Competence Summit II

7. Physician’s Career Clinical Skills 1 Portfolio Evaluation Med School USMLE Mod 1 & 2/COMLEX GME The Physician’s Career in 2020 – Getting through Med School As we mentioned above, the evaluation criteria for Med School students in 2020 will reflect the same standards that are used to evaluate practicing physicians. Students will be monitored for both quality and behavior. Physicians in 2020 must not only be technically proficient, they must also demonstrate qualities and skills like strong ethics, teamwork, communication and leadership. While in Medical School, students will begin their Learning Portfolio. This portfolio will include everything from competencies and behaviors they have demonstrated, to evaluations from peers and patients, to insights and “near-misses” they have had. This portfolio becomes one of the key tools for measuring competence. In order to move on to residency, students must pass USMLE Modules 1 and 2 (COMLEX), and pass the Clinical Skills 1 exam. (Clinical Skills 2 is introduced later in the physician’s career.) Physician Accountability for Physician Competence Summit II

8. Physician’s Career Training License GME Portfolio Evaluation State Licensing Board Specialty Certification Board “Regulators” The Physician’s Career in 2020 – Graduate Medical Education When a student enters Residency in 2020, she is granted a “Training License” from the State Licensing Board. This means that the student is NOT a physician until becoming certified in a specialty and fully licensed by the State Board. Throughout GME, the student’s evaluations on quality and behavior are submitted to the Specialty Board. During this time, the students build their portfolios as well. Physician Accountability for Physician Competence Summit II

9. Physician’s Career GME Portfolio Evaluation State Licensing Board Specialty Certification Board “Regulators” The Physician’s Career in 2020 – Board Certification Once a student finishes GME in 2020, he will apply for certification in a specialty. Among the criteria for granting certification will be the student’s GME evaluations and portfolio. Once the Specialty Certification has been issued, it will be sent to the State Licensing Board. This certification allows the physician to practice only the medicine within his given specialty. A greater scope of practice will require additional certification. Physician Accountability for Physician Competence Summit II

10. Physician’s Career Hospital Credentialing State Licensing Board Specialty Certification Board Practicing “Regulators” The Physician’s Career in 2020 – Licensing and Credentialing The State Licensing Board in 2020 will consider a Specialty Certification as necessary but not sufficient for licensure. The State Board will examine several other criteria, including drug screens and a CBI. Once the physician has been licensed, both the license and certification will be sent to the physician’s hospital for credentialing. Once the physician has been credentialed, she becomes a practicing physician. Physician Accountability for Physician Competence Summit II

11. Physician’s Career Hospital Credentialing State Licensing Board Specialty Certification Board Portfolio Practice Knowledge Peers MOC Practicing Data Patients Test Outcomes “Regulators” The Physician’s Career in 2020 – Re-Certification Board Certification must be renewed regularly in 2020, perhaps every two years. This renewal is stringent. The key component of the physician’s Maintenance of Certification (MOC) is his portfolio. The portfolio include his knowledge base (demonstrated) and a wide range of data that has been collected, including practice data, peer reviews, patient evaluations, and outcomes data. Credentialing information is also included in the MOC. The physician must pass a test of his knowledge to renew his certification (unless perhaps his data is so strong that he places out). Physician Accountability for Physician Competence Summit II

12. Physician’s Career State Licensing Board Specialty Certification Board MOC Practicing CS2 “Regulators” The Physician’s Career in 2020 – Clinical Skills 2 At some points in her career, a physician may choose or be required to take the Clinical Skills 2 exam. This exam is required if the physician wishes to change or expand her Specialty Certification. Some physicians may choose to take this exam to pursue new interests, or to expand their practices. Other physicians may be required to take this exam because their practice data indicates that they are dealing with medical issues in their patients that fall outside of their Specialty Certification. Physician Accountability for Physician Competence Summit II

13. Physician’s Career State Licensing Board Specialty Certification Board Behavioral Problems Practicing Dev. Plan Academic & Clinical Problems Problems “Regulators” The Physician’s Career in 2020 – Problems Periodically, the data being collected in a physician’s portfolio will indicate some kind of problem. Academic or clinical problems will be referred to the Specialty Board. The Specialty Board will evaluate the circumstances and send the physician a Development Plan (if necessary) to bring the physician’s knowledge or skills up to standards. Behavioral problems will be referred to the State Licensing Board. The State Board will recommend a behavior change or take further punitive actions. Physician Accountability for Physician Competence Summit II

14. “Educators” Physician’s Career Pre Med Med School GME Practicing “Regulators” Thought Experiment: Physician Competence in 2020 The system that was designed during this thought experiment was highly successful by at least one definition – it looks very different from the system that is in place today! While the system as a whole has a number of challenges associated with it, the purpose of the thought experiment was to look at the problem from a new perspective in order to (hopefully) gain some new insight. No one expects the system in 2020 to look anything like this model, but if this description has prompted new thoughts or questions or insights, then the experiment has been a success! Please share your thoughts and keep the conversation going. Physician Accountability for Physician Competence Summit II

15. “Educators” Physician’s Career GPA MCAT IT Skills ACGME Pre Med Resume Behavior LCME ACCME CBI Drug Screens Accreditation Oversight Alliance Clinical Skills 1 Portfolio Evaluation Med School USMLE Mod 1 & 2/COMLEX Training License GME Portfolio Evaluation National Certification Agency for Boards Hospital Credentialing State Licensing Board Specialty Certification Board Portfolio Practice Knowledge Peers MOC Practicing Data Patients Dev. Plan Test Outcomes CS2 Problems “Regulators” Structure and Process in 2020 Physician Accountability for Physician Competence Summit II