Professional Accountability and Certification in Internal Medicine DANIEL D. FEDERMAN, MD* THE AMERICAN BOARD OF INTERNAL MEDICINE (ABIM) should be considered accountable professionally to two material and two immaterial referents. The first of the material is the public, the source of the mandate that allows a private, self-constituted b o d y to evaluate and certify the potential of the physicians to p r o v i d e excellent care in their discipline. The p u b l i c ' s trust in physicians, other than their own, is at a l o w point. We are considered overpaid, impatient, p o o r listeners, and insensitive to the n o n u r g e n t aspects of the patient's illness. Physicians are increasingly h e m m e d in b y regulation, utilization review, and third-party dictates. It w o u l d not b e surprising for public skepticism to extend to the Board and be attached to the ABIM's efforts. The ABIM c o u l d be challenged on the basis that licensure and certification are not truly different. Thus the Board's first target of accountability is to e x p a n d its attention to the public and be p r e p a r e d to explain certification in terms that are clear, fair, and convincing, x The second g r o u p to w h i c h the Board must b e accountable is the applicants for certification in internal m e d i c i n e - - y o u n g physicians w h o fulfill o u r training r e q u i r e m e n t s and p r e p a r e to take an expensive examination of great i m p o r t to their s u b s e q u e n t careers. Students entering internal m e d i c i n e n o w are different from those of prior years in important ways. They are more inclined to pursue other interests, to plan for dual careers in their families, to be in debt and, thus, to question major expenses. The Board must be seen as fair, p e r h a p s demanding, but clearly justified in its approaches, and responsive to the personal and professional goals of the y o u n g internist. In particular, candidates will e x p e c t to see a "value a d d e d " to being certified. To b o t h the p u b l i c and the applicant, then, the Board owes a process that is fair, rational, and valid. In addition, however, the Board owes accountability to two immaterial standards. One is that of " B o a r d n e s s " - - a term I shall use to represent the principle of the Board p h e n o m e n o n as distinct from any immediate example. 2 In this sense, as in any philosophic ideal, there are universal attributes of Board identity that the ABIM must honor. These include a dedication to the standards of a profession, a p r i m a r y belief in the intellectual process, a willingness to learn
"Dean for Medical Education, Professor of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115. Presented at the Symposium to Honor John Benson, Philadelphia, Pennsylvania,June 12, 1991. Address correspondence and reprint requests to Dr. Federman.
from evidence, a n d - - a t its b e s t - - a determination to study the validity of claims attached to scoring. Although the i n d e p e n d e n t establishment of validity has so far defied precise application, it is a necessary comp o n e n t o f "Boardness." The last of the standards to w h i c h the ABIM must be accountable is the discipline of internal medicine. This specialty, still not identifiable in most laymen's minds, is constantly changing as it seeks to a c c o m m o d a t e n e w scientific and technologic d e v e l o p m e n t s w h i l e keeping sight of o u r basic field. In other words, the abstract and immaterial ideal of "Boardness" must b e conn e c t e d to the abstract ideal of internal medicine. The question arises: w h a t c o m p o n e n t s of behavior b y the Board will p r o d u c e the accountability I have referred to? I shall e x a m i n e this question f r o m several perspectives. First, I w o u l d urge that one major t h e m e of the next 20 years for the Board should b e a fusion of science and clinical skills as the underpinnings of g o o d internal medicine. The true challenge of k e e p i n g biological science annealed to medicine is just beginning. A f e w major scientific advances have direct clinical app l i c a b i l i t y - usually through the d e v e l o p m e n t of n e w drugs. But, in fact, the extraordinary progress in basic biology has little direct expression in the general internist's care of patients. This gap is certain to be closed in the c o m i n g years, and the ABIM should b e alert to a r e a s of major scientific advance w h o s e relationship to the practice of internal m e d i c i n e should be constantly probed. Incidentally, the evaluation of n e w k n o w l e d g e for its relevance to internal m e d i c i n e is not a simple assignment. It was easy to recognize the i m p o r t a n c e of p a t h o p h y s i o l o g y in the interpretation of physical findings, laboratory tests, and responses to drugs. It was similarly easy to recognize and measure the interpretation of chest roentgenograms and electrocardiograms in the m a n a g e m e n t of p n e u m o n i a s and congestive heart failure. But should a general internist interpret a Southern gel or a MRI? In the fusion of science and clinical skills, the skills side of the linkage also needs strengthening. Although the Board has c e d e d direct responsibility for evaluating clinical skills to the p r o g r a m directors, constant attention to its i m p o r t a n c e is a c o m p o n e n t of accountability. Every attending recalls asking " w e r e there any signs of mitral stenosis?" and being told "... the echo will be back tonight." It w o u l d be idle nostalgia to want to substitute bad clinical skills for technologic progress; but imaginative examination for2ZS
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mats should r e o p e n the possibility o f valid testing. With videodiscs, audiotapes, and other stimulations it should be possible to examine clinical skills. Similarly, the n e w standardized patient testing centers should be w a t c h e d for their potential. I do not suggest that these modalities b e c o m e a major part of the examination; b u t I think it important that clinical skills b e emphasized. There is still a great deal to be learned and settled b y physical examination, and emphasis on it has a major s p i n o f f - - i t makes the doctor t o u c h and talk to the patient. A second w a y the ABIM can demonstrate its accountability is b y serving as a national standard. Local and regional differences in o u r country are c o m m o n . Even individual malpractice expectations, w h i c h w e r e o n c e linked to the standards of care in the d o c t o r ' s c o m m u n i t y , are n o w judged against a national standard. Looking at the United States as a cultural entity, diversity is the dominant theme. In 20 years, m a n y of o u r cities will be m o r e than 50% A s i a n - A m e r i c a n and H i s p a n i c - A m e r i c a n . Even at this time, the children in the Los Angeles school system speak 84 different languages in their homes. The relevance to internal medicine is the mandate to revise training programs so that they take a c c o u n t of the variability in p e o p l e and diseases that w e n o w confront. The challenge to the ABIM is to be sure that the adult health needs of this b r o a d e r c o m m u n i t y are drawn u p o n for questions a p p r o p r i a t e to certification. In other words, remaining relevant to a culturally diverse p o p u l a t i o n is an e l e m e n t o f p r o v i n g accountability. Third, the current trend for changes in medical school education provides a n e w o p p o r t u n i t y for the Board in its a p p r o a c h to certification and recertification. The residents w h o will c o m e before the Board as it m o v e s into the next c e n t u r y will have had at least s o m e of their undergraduate medical school e x p e r i e n c e in a problem-solving format rather than in the standard rote-memorization format associated w i t h medical basic science. I suggest that theABIM d e v e l o p an examination format that has a direct link to the problem-solving emphasis so widely in use in medical education. Although this m a y be difficult to do in a paper-and-pencil examination, a c o m p u t e r - b a s e d examination, taken on the doctor's o w n time, might be d e v e l o p e d w i t h this a p p r o a c h in mind. As a fourth measure of accountability, the ABIM should be engaged in research on the certifying process. Medical education and medical practice are b o t h in ferment around the issue of quality. The independence granted to Boards will need to be earned b y demonstration that certification relates to a better quality of care. At an informal c o n f e r e n c e o f the Board last year b o t h Dr. Robert Brook and Dr. Geoffrey N o r m a n averred that present research methodologies are capable of showing a relationship b e t w e e n k n o w l e d g e and clinical performance. The studies by Dr. Paul Ramsey 3
suggest but do not p r o v e that certified internists provide better care. The ABIM should use s o m e of its resources to s u p p o r t m o r e research on the validity of certification. The research agenda c o u l d have several dimensions. One w o u l d certainly b e the correlation b e t w e e n the certifying process and quality o f care. Ultimately it is the latter for w h i c h w e aim, and o u r historic failure to measure it is no reason to stop trying. I also feel that the ABIM should be studying n e w examination formats. One thing that no one in practice does is answer a m u l t i p l e - c h o i c e question. The Board is unquestionably right in emphasizing p e e r assessment and local evaluation of actual p e r f o r m a n c e as major elements in the recertification process. But w h a t of some of the c o n c e p t u a l issues of internal m e d i c i n e that n e e d discussion and exploration? First, can anything be done through the recertification process about the moral behavior of physicians? The medical literature is rife w i t h reports of inappropriate use o f medical procedures. One-fourth to one-third of pacemakers are said to be unnecessary. Similar proportions of coronary artery bypass surgeries, endoscopies, and carotid surgeries have b e e n criticized as inappropriate. Are these indictments matters o f taste, w h e r e well-intentioned p e o p l e can legitimately disagree, or are there objective grounds for consensus that certain interventions are i m p r o p e r ? A n d if the latter is the case, should an internist w h o regularly flouts a c c e p t e d standards be recertified? In o t h e r words, is there a role for ABIM to assert canons of e x c e l l e n c e in practice that must be h o n o r e d in order to justify renewal of certification? I see this as an area o f active inquiry, bringing subspecialists and generalists together in the Clinical Efficacy Assessment Program of American College of Physicians tradition, w h i c h reflects professional accountability. Another area of potential moral scrutiny is, paradoxically, in the underuse of indicated but expensive procedures. Health m a i n t e n a n c e organizations, practice guidelines, for-profit settings, and cost containm e n t all create the risk that the internist, consciously or unconsciously influenced b y e c o n o m i c considerations, will fail to order a test or p r o c e d u r e that is medically appropriate. Many a p p r o a c h e s to rationing care raise the specter of valuing e c o n o m i c s m o r e highly than a p p r o p r i a t e care for the individual patient. If this interaction can be analyzed and assessed quantitatively, ABIM w o u l d be making an important contribution to the public interest b y including it in the process of recertification. Let me be clear a b o u t m y intent for this difficult area. In alI characterizations o f a profession, there is a facet of responsibility for the p u b l i c interest. The ABIM should try, by research, to penetrate the difficult area w h e r e scientific uncertainty, clinical judgment, and moral m i s c h i e f overlap. I f objective standards can be
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drawn from such study, they should be applied as an element of the process of certification and recertification. As you can see, it is not easy to explicate features of professional accountability for a certifying body. This is principally because there have not been many studies tightly linking examination performance to patient outcomes. But perhaps continued striving for the imp r o v e m e n t of care through improved methods of certification and recertification w o u l d combine the targets of accountability I listed at the b e g i n n i n g - - the public,
the applicants, the principle o f Boardness, and internal medicine.
REFERENCES 1. McGaghie WC. Professional competence evaluation. Educ Researcher. 1991;20:3-9. 2. Benson JA. Certification and recertification: one approach to professional accountability. Ann Intern Med. 1991;114:238-42. 3. Ramsy PG, Carline JD, Inui TS, et al. Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med. 1989;110:719-26.