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Viewpoint
December 26, 2019

The Responsibility of Physicians to Maintain Competency

Author Affiliations
  • 1Virginia Commonwealth University School of Medicine, Richmond
  • 2Department of Emergency Medicine, New York University School of Medicine, New York
JAMA. 2020;323(2):117-118. doi:10.1001/jama.2019.21081

Physician education during residency and fellowship has shifted from a model based on how long a physician trains to one that emphasizes assessing and encouraging measurable competence.1 There needs to be a similar shift to ensuring competency for physicians who have completed their training, with an emphasis on maintaining knowledge and clinical skills to ensure patient safety. This leads to several questions. Who must be competent in what? Who decides? Does experience count? How does aging affect competence? In medicine, an expansive range of competencies are considered important, and not every physician maintains every competency. Achieving, assuring, and maintaining competency across medicine requires time and effort and involves perseverance for individual physicians and the health care system. In this Viewpoint, we discuss 2 forces that can lead to diminishing competence over time: deterioration in ability with age and decrease in opportunities for maintenance and self-improvement.

Deliberate practice, as described by Ericsson2 and demonstrated in many fields, including music, chess, and surgery, is the sequential, mindful repetition of a training task with feedback that leads to effective improvement in performance. Early in training, there is a rapid learning trajectory in which large gains in performance occur through intentional learning activities. However, for some individuals, when formal training ceases performance can eventually degrade and can be documented by a forgetting curve,3 in which the rate of decay depends on a number of factors, including the complexity of the skill in question, opportunities for practice, and support from the health system. For example, in many specialties, residents are intensively trained in procedural skills, such as intubation and central line placement; however, these skills decay without continued practice and repeated training.4 It is important to recognize that there is a threshold for competency that must be maintained. This skill decay over time may be compounded by the aging of the physician population, which has made maintenance of competency an important issue in medicine in the United States and around the world.5 The literature on aging and its effects on professional performance is mixed with evidence of cognitive and physical decline of abilities in some individuals. However, there is evidence that competency in medicine can be successfully maintained through intentional deliberate practice and mastery learning with procedural simulation training.2,4,6

Advances in medicine and clinical procedures continue to change practice, and some physicians may not have the opportunity to keep up with new diseases, diagnostics, and therapies or may not be able to achieve sufficient mastery of technical skills required for performance of new procedures.7 While physicians may retain the expertise from years of experience, in some areas (especially in procedurally oriented disciplines), some physicians may be subject to the trajectory of skill decay. Yet, their identity as physicians is an important self-concept and supports their professional credibility. As some physicians mature in their careers, they may choose to decrease their clinical time as they move toward retirement; spending more time with their family; or increasing professional administrative, research, or teaching activities. Even though these physicians have accumulated comprehensive expertise from thousands of patient encounters and a complementary understanding of the health care system, teamwork, and patient-centered care, physicians who decrease their clinical time must maintain a certain equipoise, balancing their nonclinical time against the important need to maintain skills in procedures they may be called on to perform, even if only rarely. For example, emergency physicians might need to refresh their skills in intubation, cricothyrotomy, central line placement, thoracotomy, or focused ultrasonography if they have not performed these procedures recently.

As physicians practice into their sixth, seventh, and eighth decades of life, there is a balance between their increasing depth of expertise gained through experience and the forces such as aging, other causes of cognitive decline, and decreased opportunity for deliberate practice that can lead to skill decay. Can the balance tip in a way that results in risks for the care of the patient? What can be done to mitigate risks and protect patients? The following 5 proposed considerations may be helpful to addressing competency decline.

First is the mandate for lifelong learning and the controversial issue of mechanisms to ensure maintenance of certification.8 Even though some aspects of maintenance of certification are unpopular and perhaps ineffectively implemented, the underlying principle is sound and reflects the importance of maintaining knowledge and competency as a professional responsibility. Physicians must continuously refresh their foundational knowledge and stay up-to-date with new and evolving knowledge as well as procedural competence. This continued learning can occur through formal continuing medical education courses, informal learning activities (such as listening to educational podcasts or reading), Just In Time Medicine clinical references, and interactions with consultants and colleagues. Helping physicians identify what they do not know and make knowledge gaps transparent is essential to this process.

Second is the responsibility to keep training. While some procedures are routine, there are uncommon and complicated procedures or new techniques for procedures that require additional training, especially in procedural specialties, such as surgical fields, emergency medicine, and critical care, all of which include common and rare procedures, such as cricothyrotomy, thoracotomy, and new laparoscopic techniques. These less commonly performed procedures require disproportionate time for maintenance of skill that must be acknowledged in physician work schedules. Simulation is widely available but unevenly used by practicing physicians and usually not considered part of the department’s or simulation center’s budget for simulation or the time physicians spend retraining, relying on the volunteerism of the physician. Retraining opportunities allow physicians to refresh their procedural skills and develop familiarity with new equipment and methods. There are some national-level pressures for maintenance of skills; for example, the Joint Commission requires appropriate credentials for procedural sedation. In addition, some departments have faculty-specific procedural training that is voluntary, or may be mandated, including annual procedural sedation certification. Also, some specialties, such as electrophysiology, have delineated the knowledge and procedural competencies expected.9

However, less clear is where the locus of responsibility should lie for ensuring competency through apportioning of work hours between the time demands of nonclinical work and time for retraining to maintain and enhance clinical skills. How can continued training opportunities be designed that are proactive, judicious, individualized and transparent? To what extent should retraining depend on the physician?

Third, physicians can choose practices that involve less exposure to procedures or content for which they believe are no longer expert, such as in lower acuity areas with parallel coverage of a procedural team, more reliance on colleagues to assist when needed, or both. Maximizing collective competence is in alignment with systems-based approaches, but requires policies that do not feel punitive. The optimal solution is likely to differ between settings. Meanwhile, there is the possibility that even with diminished competency, some physicians with perhaps limited skills for some procedures may still be needed in some areas.

Fourth is the importance of self-assessment and reflection. Honest and objective self-assessment at the individual level can be challenging to achieve, especially given that professional identity is wrapped in the physician persona, and for a physician to be able to admit that he or she is not competent in something is a loss of self. It is critical that physicians intentionally seek assessment data via external metrics, such as number of patient complications, patient morbidity, or peer feedback regarding their practice.

Fifth, beyond the individual physician, the health care system has a critical responsibility for ensuring competency of physicians and surgeons for performing procedures. As medical education becomes more capable of determining competency through work-based assessments, it may be possible to determine which physicians no longer meet a competency threshold. Heath care systems need to have triggers that initiate exploration of physician competence, which might include frequency of safety events and complications, low volume of complicated procedures, patient reported outcome measures, patient and staff complaints, and low referral patterns from colleagues.10 These triggers should launch a more extensive examination of practice, including peer assessments, direct observation, health record analytics, cognitive testing, procedural testing, and other methods of competency assessment.6 It is important to recognize that the competencies that allow a physician the ability to practice are complex and multifactorial and, therefore, difficult to measure. Once an issue becomes apparent, the physician and health care system have a joint responsibility to ensure that the physician can demonstrate the necessary competency for practice skills or procedural expertise, retrain for the necessary skills, or retire that procedure from his or her practice.

Given the reality of forgetting curves, the medical profession has an important responsibility to ensure quality of care and to protect patients from potential harms. This requires physicians to understand how they acquire and maintain expertise, including the time, practice, and self-challenge necessary to achieve and maintain peak performance. Physicians also must understand that when they cease to perform certain clinical activities, such as uncommon procedures, previous experience can only go so far and performance may decline unless deliberate retraining steps are taken. However, it is first essential for physicians to be willing to recognize that safety for patients requires complete transparency about competency in clinical skills and performance.

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Article Information

Corresponding Author: Sally A. Santen, MD, PhD, Virginia Commonwealth University School of Medicine, 1201 E Marshall St, MMEC 4-214, PO Box 980565, Richmond, VA 23298 (sally.santen@vcuhealth.org).

Published Online: December 26, 2019. doi:10.1001/jama.2019.21081

Additional Contributions: We thank Chris Merritt, MD, MHPE; Meg Wolff, MD, MHPE; and Steve Cico, MD, MED (Emergency Medicine & Pediatrics, Alpert Medical School of Brown University), for critical review of manuscript and Heather Brickely, MA (Virginia Commonwealth University School of Medicine), for manuscript preparation.

References
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Ericsson  KA.  Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice.  Acad Med. 2015;90(11):1471-1486. doi:10.1097/ACM.0000000000000939PubMedGoogle ScholarCrossref
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Pusic  MV, Boutis  K, Hatala  R, Cook  DA.  Learning curves in health professions education.  Acad Med. 2015;90(8):1034-1042. doi:10.1097/ACM.0000000000000681PubMedGoogle ScholarCrossref
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Laack  TA, Dong  Y, Goyal  DG, Sadosty  AT, Suri  HS, Dunn  WF.  Short-term and long-term impact of the central line workshop on resident clinical performance during simulated central line placement.  Simul Healthc. 2014;9(4):228-233. doi:10.1097/SIH.0000000000000015PubMedGoogle ScholarCrossref
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Moazed  F, Cohen  ER, Furiasse  N,  et al.  Retention of critical care skills after simulation-based mastery learning.  J Grad Med Educ. 2013;5(3):458-463. doi:10.4300/JGME-D-13-00033.1PubMedGoogle ScholarCrossref
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Dellinger  EP, Pellegrini  CA, Gallagher  TH.  The aging physician and the medical profession: a review.  JAMA Surg. 2017;152(10):967-971. doi:10.1001/jamasurg.2017.2342PubMedGoogle ScholarCrossref
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Teirstein  PS.  Boarded to death—why maintenance of certification is bad for doctors and patients.  N Engl J Med. 2015;372(2):106-108. doi:10.1056/NEJMp1407422PubMedGoogle ScholarCrossref
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    4 Comments for this article
    EXPAND ALL
    Hospital Incentives to Regulate Physician Credentials
    Florence Watts, M.D. | Georgia State University
    Having practiced anesthesia for 37 years, I concur with the authors' conclusions. My concern is that the authors do not address the root cause of why a majority of U.S. hospitals do not and frequently cannot follow their fifth recommendation: "Fifth, beyond the individual physician, the health care system has a critical responsibility for ensuring competency of physicians and surgeons for performing procedures." We all know many physicians who are not competent to perform certain procedures. However, since they can bring in millions of dollars in much needed revenue, it is a rare hospital that reduces or denies them privileges. I believe that addressing the root cause for the problem, fee-for-service reimbursement as opposed to value-based care, will need to occur before we see widespread adoption of their fifth recommendation. Economic incentives matter, especially for safety net hospitals that are at risk of failing.
    CONFLICT OF INTEREST: None Reported
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    MOC Must Prove Its Competency
    Martha Oreilly, M.D. | Clifton Medical
    Please direct me to a fully independent study, written by authors who stand to gain no financial benefit from the propogation of MOC that shows improvement in patient outcomes when a doctor submits to MOC. Because i have read a retrospective study involving thousands of VA patients that shows no difference when MOCtors outcomes are compared to grandfathered doctor outcomes. MOC costs thousands of dollars and hundreds of hours of free time and fails to deliver improvement in patient outcomes. MOC needs to stop until it reformulates into a product that enriches something besides the ABIM ABP ABFP Chair holder stock portfolios.
    CONFLICT OF INTEREST: None Reported
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    MIni-Residencies
    Burden Lundgren, MPH, PhD, RN | NA
    There is little evidence for maintaining competence through exams. I don't have evidence for this suggestion either but it may be worth considering: have physicians complete mini-residencies (3-6 months?) every 10 years. Yes - very disruptive to practices and income, but 10 years to plan ahead. Benefits: practicing physicians can get updated, and, just as important, physicians in academic medical centers can have some exposure to what practice is like in the "real" world.
    CONFLICT OF INTEREST: None Reported
    Interesting Though Vague
    Ritwick Agrawal, Assistant Professor | Baylor College of Medicine
    I have thought about this topic on several occasions. While the five possible suggestions in the article are what a common sense approach would say, in practice they all fall short:

    1. MOC by no means helps with competency. The bolus of knowledge goes away shortly after the long-form exam. What works is reading on a topic encountered while seeing a patient , e.g. looking at Uptodate. It sticks for much longer.

    2. Procedure theory is always a sticky issue. Simulations are good but are not adequate for already-trained personnel. They may be good for a
    novice learner. The reality is that the majority of people who don’t do specific procedures routinely do not do it on their own. For example doctors who don’t do bronchoscopy may ask their colleagues to perform it.

    3. The recommendation for honest self-evaluation is easier said than done. Most of the time the self information mentioned, like complication rates, goes in wrong hands and the physician gets penalized.

    5. This is the root cause of the MOC controversy, Healthcare systems do not have tools to assess competency so they come up with tools like MOC which may not have enough clinical data.

    Overall I think it is a reasonable attempt to address an important topic though the papers recommendations appear to fall short.
    CONFLICT OF INTEREST: None Reported
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