Correspondence
Accreditation and Certification
N Engl J Med 1997; 337:857-859September 18, 1997
- Article
To the Editor:
Your editorial on the American Medical Accreditation Program (AMAP) (July 3 issue)1 was flawed both logically and factually. The American Medical Association (AMA) did not design AMAP as a “surrogate” for board certification. AMAP accreditation and specialty-board certification differ substantially in their requirements. Board certification attests to the physician's completion of prescribed training in a specialized area of medicine and to the successful completion of examinations that primarily test the fund of knowledge in that specialty. AMAP accreditation is based not only on education and training but also on such personal characteristics as ethical behavior, involvement in a biennial self-assessment, willingness to be reviewed by peers, and participation in programs of clinical-data collection and feedback. Furthermore, the AMAP office-site review addresses the practice's safety, facilities, administrative systems, staffing, and medical records with a standardized set of review criteria. A score of at least 70 percent on the site review is one requirement for AMAP accreditation. Field tests have shown this to be a rigorous standard for even board-certified physicians to meet. And AMA membership is not required for a physician to be accredited by AMAP.
Despite the breadth of AMAP accreditation and its different focus, the program reinforces the considerable importance of board certification as one characteristic of a high-quality physician. Together, certification and recertification by a board recognized by the American Board of Medical Specialties (ABMS) carry more weight than any other factor in qualifying a physician for AMAP accreditation.
You also criticized AMAP governance because “a large plurality of its 17 [voting] members currently have or have had direct ties to the AMA.” You neglected to mention that AMAP governance includes representation from consumers, employers, managed-care organizations, hospitals, and others to ensure the credibility and accountability of the program. Unless a recent change has occurred, the governance of the American Board of Internal Medicine (ABIM) includes only board-certified internists. Those who live in glass governance houses should probably not cast stones.
1 ReferencesRandolph D. Smoak, Jr., M.D.
American Medical Association, Chicago, IL 606101
Kassirer JP . The new surrogates for board certification -- what should the standards be? N Engl J Med 1997;337:43-44
Full Text | Web of Science | Medline
To the Editor:
AMAP has been designed to facilitate measurement against standards for all physicians. Those of us who are in private practice and are board-certified (and proud of it) recognize that we are in an age of accountability. Unfortunately, the measurement process can interfere with patient care. AMAP addresses the need for accountability in a number of constructive ways.
My obstetrics and gynecology practice of nine physicians contracts with 23 managed-care plans, each one trying to respond to the requirements of the National Committee for Quality Assurance (NCQA) for standards of quality. If each of those plans wished to evaluate the clinical care provided by each physician by examining patients' records, verifying credentials, doing site visits, and monitoring outcomes, there would be an extraordinary amount of wasted time and energy and duplication of effort. Having AMAP perform those tasks once every two years makes considerably better sense.1
Respect for patients' privacy and confidentiality is already a thing of the past.2 AMAP helps prevent the wholesale destruction of that fundamental cornerstone of the patient–doctor relationship by diminishing the number of requests for information and safeguarding that information . . . .
AMAP has developed a rigorous set of standards that sets the bar high.3 Its governing board includes representatives of industry, government, consumer-advocacy groups, and other credentialing organizations — and yes, doctors (who better?) — in an attempt to bring accountability and professionalism to all physicians. The AMA should be more than a membership organization. It should be the voice and conscience of the profession.
3 ReferencesJoseph M. Heyman, M.D.
Women's Health Care, West Newbury, MA 01985-1922To the Editor:
Your editorial refers to the Effective Medical Management Certification Program as being offered by the American Society of Internal Medicine (ASIM). This is not accurate. The House of Delegates of the ASIM authorized the board of trustees to develop a voluntary program to certify practitioners who maintain the knowledge base and have the attitudes and values that lead to effective medical care in the ambulatory setting. The elements of this program are being developed; it has not been approved by the board and is certainly not being “offered” at present.
It seems premature to conclude that any standards associated with the program “lack rigor.” Since the elements of the program will probably include the systematic measurement of patients' satisfaction and participation in a continuous quality-improvement network on an ongoing basis, it is reasonable to assume that participants will be motivated to provide care of high quality. They will receive continuing feedback. The ASIM's program is analogous neither to ABIM board certification nor to licensure. It is being designed to reflect ongoing competence in practice, as opposed to providing an assessment of the completeness of training after one's formal education. . . .
Alan R. Nelson, M.D.
American Society of Internal Medicine, Washington, DC 20006-1808To the Editor:
You assert that the Effective Medical Management Certification Program being developed by the ASIM “lacks rigor” because the test is an open-book effort without a failure rate. What you fail to acknowledge is that the program is a work in progress that has not been fully developed and presented to internists and that the self-assessment examination is only one of its components.
Competitive examinations have value in measuring the internist's knowledge base. However, this knowledge base is only part of the measure of excellence. Board examinations cannot assess motivation, adaptability, clinical judgment, manual dexterity, work habits, responses to criticism, or the ability to handle stressful situations.1 In fact, there may be little correlation between factual knowledge and the application of that knowledge to patient care. . . .
As currently envisioned, the program measures an internist's excellence on a continuing basis rather than at a single point in time. The process is not likely to be a competitive process with a failure rate. Instead, one test of excellence will be the internist's determination to participate in the processes of the program on an ongoing basis. Measures of the delivery of clinical care are a valuable addition to the assessment of excellence, although they do not diminish the importance of competitive written examinations.
1 ReferencesRobert D. McCartney, M.D.
American Society of Internal Medicine, Washington, DC 20006-18081
McCartney RD . Assessing a physician's true worth. The Internist 1995;36:8-10
Medline
To the Editor:
We recently surveyed 221 patients at a suburban family-practice clinic in the Midwest concerning the type of information they found valuable in choosing a family physician. Of the 12 types of information proposed, the physician's board-certification status was clearly most valued by the respondents. This information was considered very valuable by 56 percent, valuable by 34 percent, and not valuable by 10 percent. Examples of information that was much less valued include data on the medical school attended, the site of residency, and a variety of demographic factors.
Previous surveys confirm this consumer interest in physicians' certification status.1,2 However, a 1992 survey found that although 95 percent of respondents thought it was somewhat important or very important that their physicians be board-certified, only 65 percent of them knew the certification status of their own physician.2 Moreover, our survey and another one have found that patients value their physicians' interpersonal skills much more than their board-certification status.1 All eight attributes or characteristics of physicians included in our survey were highly rated by respondents. For example, 99 percent of respondents reported that characteristics such as “takes your concerns seriously,” “explains results and options clearly,” and “spends time with you; is not hurried” were of value to them when choosing a family physician.
The value patients place on a physician's approachability and manner is confirmed by the finding that most patients rely on recommendations from family and friends in choosing a new doctor, rather than on more objective sources of information.2 Therefore, competitive managed-care organizations should be making communication skills, not board certification, a major criterion in hiring physicians.
2 ReferencesDiane J. Madlon-Kay, M.D.
St. Paul–Ramsey Medical Center, St. Paul, MN 55101Suzanne Engstrom, B.S.
University of Minnesota School of Medicine, Minneapolis, MN 554551
Americans as health care consumers: the role of quality information. Menlo Park, Calif.: Kaiser Family Foundation, October 1996.
2
Mainous AG III ,Hagen MD ,Rich EC . Patient awareness of and attitudes toward physician board certification. J Am Board Fam Pract 1993;6:403-406
Medline
To the Editor:
It is not necessary to change our certification process, which has stood us in good stead for many years. But it is necessary for us to make managed care understand that the boards were never meant to infringe on physicians' ability to practice. For years, hospitals have effectively used a policy called delineation of privileges to ascertain physicians' competence. It takes into account the physician's character as well as his or her educational background.
Let us not forget that written examinations test mainly for academic knowledge. And though a certain amount of knowledge is needed for physicians to practice competently, it is no guarantee of competence. Written tests cannot assess physicians' character, their compassion, or their dedication to the ideals of medicine. Neither can they test for honesty, perseverance, or the ability to work with others — all very important qualities for physicians to have.
If managed-care organizations are truly concerned about physicians' credentials, then let them look at all the qualities that good physicians should have. If not, we will be guilty of allowing them and not us to define what we believe are the essential ones.
Edward J. Volpintesta, M.D.
Bethel Medical Group, Bethel, CT 06801Author/Editor Response
Dr. Kassirer replies:
My principal criticisms of AMAP and the Effective Medical Management Certification Program are that their proposed standards are lax and that they will be administered by organizations that have a vested interest in the success of their members. Drs. Smoak, Heyman, Nelson, and McCartney give me no reason to believe otherwise. Unlike them, I do not believe that personal characteristics, self-assessment examinations, willingness to submit to peer review, or participation in clinical data collection or programs of continuous quality improvement constitute high standards. Dr. Smoak provides no evidence of logical or factual flaws in my critique of AMAP. Rather, he and Dr. Heyman both disagree with me fundamentally about the fortitude of AMAP's standards.
Dr. Smoak's comment about governance misses the point, and his glass-house analogy is inept. The ABIM and the other ABMS member boards are composed of no more than a few dozen people; they are independent testing organizations with no vested interest in the success of their members (they have no members). Dr. Smoak seems to have forgotten that the founders of the ABIM — namely, the AMA and the American College of Physicians —appreciated more than six decades ago that to maintain high standards, boards had to be independent organizations free of membership constraints.
I agree with Dr. McCartney that measuring the delivery of care would add value to the assessment of physicians' excellence, but when such measures are perfected they should be capable of identifying and rejecting unacceptable practitioners, not passing them all.
Dr. Heyman argues that a uniform credentialing system may have great value in saving physicians' time and would help to preserve patients' privacy. I hope so, but only time will tell whether such an elaborate and expensive system can be implemented and whether it will be extensive enough to encompass the data requirements of a wide range of health care organizations.
The problem I raised concerning AMAP and the Effective Medical Management Certification Program could be easily remedied by appointing governing boards that are independent of, and not dominated by, the AMA and the ASIM, respectively, and by giving those boards the authority to set more stringent standards.
Jerome P. Kassirer, M.D.
