Kristine M. Conner
University of Pennsylvania Cancer Center
Last Modified: October 22, 2000
Patients have become much more educated over the past few years, thanks in large part to the unprecedented availability of medical information on the Internet. They also are demanding greater assurance that their physicians are competent. This public movement has been fueled by reports like the one issued by the Institute of Medicine last year, "To Err Is Human," which chronicled the prevalence of medical mistakes in this country. Many medical specialties are now instituting new requirements for physician recertification as well as ongoing evaluation of competence.
David Hussey, MD, president of the American Society for Therapeutic Radiology and Oncology (ASTRO), talked about this "continuing competence movement" and its likely effects on radiation oncologists-both those currently in practice and those now completing their residencies-during his Sunday afternoon address on the first day of ASTRO's annual meeting. Changes in the way that we assess physician competence are imminent, he said, using the metaphor of a "train coming down a track", there is no way to stop them and no way to avoid them. But he also added that these changes will "not be too onerous" and "are likely to improve the quality of care for us as physicians and us as patients."
The changes in radiation oncology are already affecting and will continue to affect the certification process. Dr. Hussey noted that, as of 1995, the American Board of Radiology began issuing certifications with a ten-year time limit. These certificates are valid for only ten years, which means that all radiation oncologists certified after 1994 will have to take a recertification exam every ten years. (Those certified before that year are not subject to this requirement.) The first exam was offered last year and was taken by 250 radiation oncologists.
"Recertification is becoming extremely important", Hussey noted, not only for radiation oncology, but for all medical specialties. He also reminded his audience that "assessment drives learning" and that this process is likely to provide an "incentive for learning" that might not otherwise exist.
He also spent some time discussing the current certification process for medical residents seeking first-time board certification in radiation oncology. The exam as currently administered consists of oral and written parts, with both having their advantages and disadvantages. For instance, while written tests are easier to give, oral exams are a better test of what the physician can actually do. But oral exams are also more subjective, more time-consuming, and involve what Hussey termed "personalities" -- that is, some examiners are more challenging than others. Overall, though, Hussey noted that board exams do not test for what the public most wants from the aspiring radiation oncologist: that is, can he or she actually do what really should be done when working with real cancer patients in real situations? Rather, he said, these exams ask physicians what they know (in terms of facts), what they know how to do, and whether they can show how to do something.
Replacing the current oral exam portion, which is administered by certified physicians, with a computerized exam may help to improve this situation. Hussey demonstrated a prototype of an interactive case management examination that would ask the candidate to stage a cancer and identify the appropriate field and dosage for radiation. Not only would this test remove the subjectivity that human examiners bring to the table, he said, it would grade more accurately for "degree of wrongness." Hussey forecast that this type of technology will come into use in the near future.
Once a physician is certified in radiation oncology, recertification involves just a written examination that assesses one area of competence, medical knowledge, every ten years. It was given for the first time last year in both written and computerized formats. Performance was about equal for both formats and the "overall pass rate was high," Hussey noted. However, he added that even greater changes than recertification testing are on the horizon for radiation oncologists.
"Recertification is not enough," said Hussey. "The public wants assurance that the physician is competent." This demand has come not only from the public, but also from third-party payors and governmental agencies. The result is a process called "Maintenance of Certification," which is different from recertification in that it requires the certified physician to maintain his or her knowledge base continually rather than periodically. Hussey said that the American Board of Medical Specialties has described six areas of physician competence: patient care; medical knowledge; interpersonal skills and communication; practice-based learning and improvement; professionalism; and systems-based practice.
Each medical specialty is now determining how these "general competencies" will apply to their particular area and how best to assess them. Overall, new requirements will involve four components-cognitive expertise, commitment to lifelong learning, professional standing, and practice performance-which will be evaluated through a combination of testing, peer review, continuing medical education credits, perhaps chart review, and other methods. Radiation oncology, like other medical specialties, is still determining exactly what the process will look like. However, radiation oncologists can expect to start demonstrating that they meet certain standards of competency on an ongoing basis.
While some have argued against such assessment of physicians' "continuing competence," noting that there is no real groundswell of public opinion demanding this and that physicians in general are well-qualified, Hussey stressed the potential positive impact that this new movement can have on the quality of patient care. "The public wants greater oversight of physician performance," he said, and the coming changes, like other certification requirements instituted in the past, will have a positive impact on the quality of patient care. "I don't see why this should be any different," he stressed.