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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.

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    4 Comments for this article
    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.
    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.
    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.
    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.