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Report of the AGA Institute Education and Training Committee Task Force on Physician Reentry
GASTROENTEROLOGY 2010;139:e17– e26
AGA Report of the AGA Institute Education and Training Committee Task Force on Physician Reentry
T
he Council on Medical Education of the American Medical Association (AMA) has requested a study of the issue of physician reentry into clinical practice, in collaboration with the respective specialty societies, the Accreditation Council on Graduate Medical Education (ACGME), the American Board of Medical Specialties (ABMS), and the Federation of State Medical Boards (FSMB). Reentry is defined as a return to clinical practice within the field in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment.1 Clinical inactivity is defined by the ABMS as the complete and total absence of direct and/or consultative care for 24 months.2 Such a benign hiatus from clinical practice may occur as a consequence of illness, the pursuit of alternative career paths (eg, industry, insurance management, administrative directorships), career dissatisfaction, premature retirement, military or humanitarian service, or a leave of absence to provide child care or fill other caregiver roles. There are relatively little published data on physician reentry. In a study of Arizona physicians (all specialties combined) who renewed their medical licenses between 2003 and 2006, 4.6% were reentering clinical practice.3 The North Carolina Medical Board has noted changing demographics among physicians seeking reentry, suggesting an increasing contribution from adverse economic circumstances forcing physicians to reconsider early retirement and alternative career path decisions.4 Intuitively, one might suspect that the issue of reentry may be more visible currently due to the sharp increase in women among the physician workforce; the Association of American Medical Colleges estimates nearly half of the medical graduates in 2007–2008 were women, up from 30% 2 decades ago.5 In fact, however, the vast majority of women physicians choose to work part-time while providing child care or filling other caregiver roles, and these women are therefore excluded from the demographics of physicians seeking reentry into the workforce, with less than 10% of female residents and practitioners in all fields combined choosing to take more than a year of maternity leave.6 Subspecialty-specific data with respect to maternity leave and child care issues are not available, although it is noted that the field of gastroenterology is underpopulated with women, who constitute only 15% of the workforce.7 For that matter, subspecialty-specific
data regarding the contribution of gastroenterologists to the burden of physician reentry are not available. Understandably, the AMA is concerned with identifying barriers to successful and appropriate physician reentry. Variability in credentialing requirements for state licensing, professional liability insurance, facility privileges, and insurance panel memberships are all significant issues further aggravated by the most significant barrier, which is the relative paucity of formal physician reentry programs. There are only four reentry programs in the United States,3 including the Center for Personalized Education for Physicians in Denver, Colorado;8 the Interinstitutional Physician Reentry Program in Portland, Oregon; the Drexel Medicine Physician Refresher/ Reentry course in Philadelphia, Pennsylvania;9 and the Physician Reentry Project in Fort Worth, Texas.3 These are comprehensive programs, but they are tailored primarily to the general and primary care specialties. They may be too few to meet the anticipated numbers of physicians seeking reentry, and they may be relatively geographically inaccessible for the majority of these physicians, particularly those who may be transitioning from their caregiver roles. Furthermore, none of these programs are specifically tailored to subspecialty training in internal medicine. Of further concern is the lack of an accreditation process for the reentry programs themselves. Accordingly, the American Gastroenterological Association (AGA) has been asked to examine how the issue of physician reentry into the workforce might be considered within the subspecialty of gastroenterology. A task force was appointed by the Education and Training Committee of the AGA Institute to research the issues and draft a report of guidelines. The report of this task force has been reviewed through the Education and Training Committee, the Women’s Committee, the Practice Management and Economics Committee, the Clinical Practice Abbreviations used in this paper: ABIM, American Board of Internal Medicine; ABMS, American Board of Medical Specialties; ACGME, Accreditation Council on Graduate Medical Education; AGA, American Gastroenterological Association; AMA, American Medical Association; FSMB, Federation of State Medical Boards; MOC, maintenance of certification; PIM, practice improvement module. © 2010 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.06.012
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and Quality Management Committee, and the Governing Board of the AGA Institute. We propose guidelines for defining what constitutes appropriate reassessment and retraining processes for previously competent gastroenterologists seeking to reenter the workforce after a nondisciplinary hiatus from clinical practice. It is our intent that these guidelines serve as a platform for the creation of subspecialty-specific reentry programs in gastroenterology. These guidelines are likely to be adjusted for variations in individual requirements between the various state medical licensing boards and are expected to evolve over time as validated tools for assessment and competency outcomes measurements become available. Ultimately, however, the authority for the implementation of such guidelines for reentry programs is the sole purview of each state medical licensing board.10 Since 2004, it has been official FSMB public policy that “state medical boards have a responsibility to the public to ensure the ongoing competence of physicians seeking relicensure” and that these boards should set the requirements for maintenance of licensure.10 Nonetheless, the Committee on Maintenance of Licensure of the FSMB expects, as a guiding principle, that state medical boards may rely on external parties to develop the tools and resources necessary to meet these requirements.10 The highlights of our recommended guidelines, discussed in further detail in the following text, include (1) a stratification of the reassessment and retraining processes based on the length of hiatus from practice and the degree of preexisting clinical practice experience; (2) a stratification of these processes formulated to acknowledge a differential rate of decay or durability among the 6 competencies of graduate medical education and clinical practice; (3) a subspecialty-specific, competencybased curriculum for each process; and (4) utilization of preexisting, standardized resources and programs that should be locally or regionally available and, in the case of training programs, fully accredited to train in the subspecialty of gastroenterology. Our remarks are confined to the consideration of gastroenterologists who have already completed training and achieved competence and for whom the hiatus from clinical activity has not been a consequence or avoidance of any disciplinary action or resulting from impairment. To qualify for reentry, physicians must have left the active clinical practice of gastroenterology in good standing, and our recommendations and guidelines are only intended to apply to those physicians who seek reentry to the workforce in the absence of any active issues for which their competence might reasonably be challenged. Special note is made of the fact that the remediation of the dyscompetent physician (dyscompetence is defined as the failure to maintain acceptable standards within one or more areas of professional physician practice), the incompetent physician (incompetence is defined as lack-
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ing the requisite ability and qualities to effectively perform within the scope of professional physician practice),11 or the impaired physician (impairment defined by the AMA as the inability to practice medicine with reasonable skill and safety . . . by reason of physical or mental illness, including alcoholism and drug dependence)12 is technically outside the focus of reentry programs and beyond the purview of this task force. We do, however, note that a recent review of the literature on the remediation of physicians from medical school through residency training and clinical practice found just a handful of small, single-institution studies that primarily focused on identifying and remediating deficient medical knowledge or clinical skills among students and trainees. Of those few studies of remediation among practicing physicians, it was acknowledged that there were difficulties in measuring high-quality patient care, and the studies did not measure the more difficult outcomes of patient satisfaction or improved measures of disease control. The efforts to implement remediation for practicing clinicians were believed to be far more daunting for a variety of reasons.13 We did not recognize any models of competency retraining among these studies that we found specifically applicable to the task of retraining gastroenterologists for physician reentry. Appreciating the absence of preexisting, specifically structured programs for retraining in gastroenterology, and the relative dearth of specific research on this topic, the basis for this report and suggested guideline is admittedly rooted in the expertise and experience of the task force members and therefore constitutes expert opinion rather than evidence-based recommendations. The three authors have all been program directors in gastroenterology fellowship training programs for a cumulative 28 years and academic faculty in clinical practice for 45 years. Additionally, we have been involved in the AGA Institute Education and Training Committee and related subcommittees for many years and have been involved in writing the national curriculum in gastroenterology as well as more recent proposals for curriculum redesign. The foundation of our recommendations lies in the self-evident expectation that the competency skills of a gastroenterologist, like any physician, will erode over time during a period of prolonged inactivity. From this simple concept, several direct corollaries are derived. Firstly, the degree of erosion in competence will increase as the hiatus from active clinical practice lengthens. However, the rate of decay will not be linear or occur in incrementally equal portions over time. Rather, we anticipate that there will be a certain period of durable maintenance of competency, without appreciable loss of skills, despite inactivity. After this period, skill sets in the various competencies will begin to decline, until after a certain amount of time has passed, the decline will be sufficient to cross a threshold and leave the clinician
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without adequate competence to practice. After that threshold, it matters little how much more time has passed. We believe that the grace period in gastroenterology can be reasonably set at 6 months, which is to say that previously competent gastroenterologists who are clinically inactive for 6 months or less should maintain sufficient skills for competent practice during this brief hiatus. We do not advocate any element of reassessment or retraining for this brief hiatus. We feel confident in this assertion as educators and trainers, noting that such a hiatus from all procedural and most clinical activity is not uncommon in many training programs for gastroenterology fellows without significantly disrupting competence or progress in clinical education. Furthermore, 6 months has been a customary term of sabbatical for attending clinicians, and historically a return to clinical practice from sabbatical has not generated concerns over clinical practice reentry at facilities and institutions. Another threshold of which we must be cognizant is at 2 years. The ABMS has developed this empiric threshold recommendation, adopted by many state medical boards,4 which states that the physician who has been completely clinically inactive for 2 years or more should participate in a physician reentry program. In our guidelines, therefore, for a hiatus from clinical practice of 2 years and longer, all gastroenterologists must be engaged in a formal retraining program. However, the AMA has requested input for specialty-specific guidelines, and for reasons to be explained in the following text, we would also suggest that for a practice hiatus between 6 months and 2 years, gastroenterologists should undergo some degree of formal reassessment and redemonstration of competence. There are further direct corollaries to the simple assertion that skills erode over time. Therefore, our second corollary is that the rate of decay in competence will vary among individuals and that the time required for an unused skill set to decay below a threshold of competence will likewise vary. We believe that this likely will reflect diverse factors, most importantly the experience or length of time in (uninterrupted) practice before the hiatus, and the achievement or expertise level of the physician before the hiatus. Unfortunately, by the time of entry into a retraining program, it is impractical to consider measuring a physician’s competence before their practice hiatus. Additionally, we know of no reproducible, reliable method of quantifying this concept. Alternatively, it is relatively easy to measure the length of time in practice, and from the perspective of educators, trainers, and practicing physicians, there is practical value to this parameter. We believe that while gastroenterology fellows are graduated with the skill sets adequate for competent and independent practice, there is nonetheless a progressive learning curve during the first few years of clinical practice, during which procedural and clinical skills and experience continue to increase considerably.
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This is viewed as a period of considerable skill set enhancement and reinforcement, during which the clinician matures from passable competence toward true expertise. A significant interruption in their clinical practice during these very early years is viewed by the authors as more disruptive to their maintenance of competency than a similar hiatus taken by a far more experienced clinician. Additionally, for physicians to engage a reentry program, they need to have taken leave of practice while in good standing. By virtue of this requirement, a cohort of clinicians who have practiced for many years, and yet are able to take leave in good standing, are less likely to include members with active issues of impairment, incompetence, or unprofessional conduct. Our third and equally important corollary is that the various competencies will not deteriorate at the same rate, a position echoed and emphasized by the AMA. As it applies strictly to the consideration of the practice of our subspecialty, certain competencies are intrinsically more time sensitive. This would apply especially to the competent performance of invasive endoscopic procedures as an integral part of our patient care competency, a skill set that is dependent on a certain level of continuous reinforcement and repetition of activity as muscle memory and hand-eye coordination develops. This is widely acknowledged as a high maintenance skill set and for this reason alone would serve to challenge the empiric 2-year threshold suggested broadly for all physicians by the ABMS. It should also be obvious that medical knowledge is a more time-sensitive competency and will decay in the absence of use or reinforcement. Conversely, in comparison, the competencies of professionalism and interpersonal/communication skills are judged to be more durable in the absence of continuous clinical activity. To summarize, the authors believe that the fundamental principle that the competency skills of a gastroenterologist will deteriorate over a period of clinical inactivity is more completely understood and more accurately described by recognizing that (1) there is a nonlinear erosion in competency that increases as the hiatus from clinical activity lengthens; (2) the rate of erosion in competency is variable among individuals but is believed to be greatest among physicians with relatively little clinical experience before their practice hiatus; and (3) the various competencies deteriorate at a differential rate, with endoscopic skills and medical knowledge believed to be the more time-sensitive elements. We therefore propose a stratification of recommendations for different pathways in a process of gastroenterologist physician reentry into clinical practice based on these concepts. These pathways of participation in the process of physician reentry are described fully in the following text, with a proposed curriculum, and are summarized in Table 1, which stratifies the pathways of participation across the parameters of duration of practice hiatus and physician experience before the practice hiatus.
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Table 1. Pathways for Reassessment and Retraining for Physicians Seeking Reentry in Gastroenterology Physician experience before practice hiatus (uninterrupted years of practice since completion of training)
Duration of practice hiatus
⬍6 mo
6 to ⬍12 mo
1 to ⬍2 y
2 to ⬍4 y
ⱖ4 y
⬍5 y
No reassessment No reassessment
⬎10 y
No reassessment
Redemonstration of competencea,b Redemonstration of competencea Redemonstration of competencea
Full retraining for 12 mo
5–10 y
Redemonstration of competence Redemonstration of competence Redemonstration of competence
Full retraining for 24 mo Full retraining for 18 mo Full retraining for 12 mo
aWith bWith
Competency selective retraining for 6 mo Competency selective retraining for 6 mo
medical knowledge modules. PIMs.
Pathways and Curricula for Physician Reentry Programs in Gastroenterology Redemonstration of Competence This first pathway of participation in the process of physician reentry in gastroenterology is intended for physicians on hiatus from 6 to 24 months, for whom we might reasonably anticipate some decrement in the timesensitive competencies of medical knowledge and certain aspects of patient care, particularly the skilled performance of invasive endoscopic procedures. Its positioning on our recommendations grid takes into account a certain durability of these skills acquired after the first few years in practice. This program pathway is intended to be completed locally by the reentrant physician and will consist of having a required procedural proctor at each facility in which clinical privileges are sought until a resumption of procedural competency has been independently determined by each proctor. Although it seems reasonable to allow the credentialing facility to select its own proctor, the authors recommend a formal reporting relationship subsequently between that proctor, the facility, and the state medical licensing board to establish accountability, set protocol, and review progress reports. The role of an endoscopic proctor has been defined by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.14 It is important to remember that proctors are not trainers. Proctors will assess and review performance, but patient care responsibility and liability remain with the physician reentrant candidate, not the proctor.14 A built-in feature of this pathway is that the more experienced and skilled clinicians will be proctored more quickly to competence, and so the duration of program participation in redemonstrating procedural competence is not predetermined and will be flexible according to achievement and skill. While we acknowledge that concurrent proctoring at multiple facilities may be cumbersome for the reentrant candidate, the simple existence of procedural privileges at one facility is not currently routinely accepted as the basis for credentialing privileges at another facility. It is
suggested, therefore, that if such a proctoring program is implemented by the relevant state medical licensing board, the formality of the program should be recognized at multiple facilities and circumvent the need for multiple concurrent proctors. It is therefore our recommendation that all gastroenterologists on hiatus from active clinical practice for 6 to 24 months be proctored to redemonstrate their competence in invasive endoscopic procedures; furthermore, for a practice hiatus of only 6 to 12 months, such procedural proctoring will suffice for completion of this pathway. However, for gastroenterologists on hiatus from active clinical practice for 12 to 24 months, we additionally recommend the completion of 30 points in medical knowledge self-assessment modules in gastroenterology and/or hepatology approved by the American Board of Internal Medicine (ABIM). A positive feature of this element is that the ABIM maintenance of certification (MOC) pathway is already an active requirement for all gastroenterologists with a time-limited board certification, and therefore the cost of enrollment in the program is a necessary and not an additional practice expense. Furthermore, we are making use of preexisting, validated modules designed to be specialty specific, which can be completed from home anywhere in the country. It is a relatively simple matter to have progress reports in the MOC pathway reported to any certifying or credentialing body. Finally, for gastroenterologists on hiatus from active clinical practice for more than 12 months but who were in practice for less than 5 years before their hiatus, we further additionally recommend the completion of 40 points in ABIM practice improvement modules (PIMs) before the completion of this reentry pathway. As discussed previously, we believe that this group is particularly sensitive to a prolonged interruption in clinical practice so soon after completing fellowship training, while they are still in a formative stage of enhancing and reinforcing clinical skills sets.
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Competency-Specific Recommendations for the Redemonstration of Competence Pathway Patient Care
Goals and Objectives: ●
●
Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures Demonstrate competence in the performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
Learning Methods: ●
Perform endoscopic procedures at each facility under the direct observation of an appointed proctor, who will review the performance of the candidate in the cognitive and technical aspects of the procedure
Assessment Methods: ●
Direct evaluation by the appointed proctor
●
Utilization of objective, performance criteria– based endoscopic procedure evaluations by the proctor
●
Maintenance of endoscopy procedure logs by the credentialing facility
Medical Knowledge (for gastroenterologists on hiatus from practice for 12–24 months)
Goals and Objectives: ●
Demonstrate proficiency in the clinically applicable knowledge for the spectrum of conditions commonly encountered in the practice of gastroenterology and hepatology
Learning Methods: ●
Self-directed reading, web-based learning
●
Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Completion of 30 points in gastroenterology and/or hepatology medical knowledge self-assessment ABIM MOC–approved modules in the ABIM MOC pathway
Practice-Based Learning and Improvement (for gastroenterologists on hiatus from practice for 12–24 months who were in practice less than 5 years before the hiatus)
Goals and Objectives: ●
To learn how to analyze practice experience to facilitate performance improvement
●
Learning Methods:
●
Retraining fellows must complete 40 points in ABIM-approved PIMs, pertinent to gastroenterology
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and hepatology, before completing this training pathway Assessment Methods: ●
Satisfactory completion of at least 40 points in ABIM PIMs pertinent to gastroenterology and hepatology
Competency Selective Retraining This second pathway of participation in the process of physician reentry in gastroenterology is intended for more experienced physicians on hiatus from 2 to 4 years, for whom we might reasonably anticipate a more robust decrement in most but not all competencies as a consequence of the length of hiatus from active clinical practice. The positioning of this pathway on our recommendations grid is based on several points: (1) physicians with more clinical experience are less susceptible to a loss of clinical competence resulting from a significant hiatus in active practice; (2) the most durable of the general competencies include professionalism and interpersonal and communication skills, which do not necessarily require reassessment and retraining for every reentrant physician; and (3) in many states, based on ABMS recommendations, reentrant physicians out of clinically active practice for more than 2 years are recommended to be in a formal reentry program. The purpose of competency selective retraining is to formally retrain, not merely reassess, clinical practice competencies in patient care (including endoscopy), medical knowledge, practice-based learning, and systemsbased practice over a program duration of 6 months. We propose that the ideal setting for this retraining is within an already established, accredited gastroenterology fellowship training program for several reasons. These programs have been reviewed and accredited by the ACGME and deliver a specialty-specific curriculum. They are sites of training expertise and, by virtue of their accreditation, possess adequate resources in terms of patient volume, with breadth and depth of exposure to the relevant clinical conditions. Equally important, there are already more than 150 such programs throughout the country, and they are therefore geographically available to the vast majority of reentrant physicians. We envision that the physician reentrant candidate in this pathway would be enrolled as a postgraduate fellow, which may be designated a “retraining fellow,” but would be appointed by the institution as a faculty instructor without procedural privileges. However, it is not the intention that the reentrant physician trainee will take the place of an ACGME-approved gastroenterology fellowship training position. Therefore, to ensure that there is no displacement or disruption of training for an institution’s current gastroenterology fellows, the authors suggest that each program that is interested in training a reentrant physician notify their designated institutional official and/or graduate medical education committee for
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approval. Consistent with existing reentry programs, this would be a tuition-based program. One suggestion to maintain fairness and consistency would be that the tuition for the program be commensurate with the average cost expense of a senior medical house officer within that state, which could be considered to include, for example, salary, health and professional liability insurance, and benefits for 6 months. This is not inconsistent with the current tuition costs of the few available reentry programs. The training program would provide routine training in all core endoscopic procedures, with each procedure fully staffed and supervised by teaching faculty, and include careful documentation of both objective methods of assessment as well as outcomes measurements. There would not be any training or certification in advanced endoscopy. The retraining fellow would be assigned to both inpatient and outpatient consultation, with approximately 30% of the clinical material to include core hepatology, consistent with the current training formula for gastroenterology fellows. In addition, we would require that the physician reentrant candidate be enrolled in the ABIM MOC program. Before completion of this reentry program pathway, the physician would need to be current in the completion of 100 points in ABIM-approved gastroenterology and/or hepatology self-assessment modules, to include at least 20 points in medical knowledge self-assessment, at least 40 points in PIMs, and the remainder in either category, according to preference and availability. This does not suggest that the entire 100 points must be taken during the 6-month retraining program, because preexisting points may still be valid; it does suggest that rather than waiting for the usual end of a 10-year MOC cycle, the retraining physician would need to be current in the amassed total of 100 points before the successful completion of this reentry program pathway. Subsequently, regardless of when the physician originally passed the ABIM (re)certifying examination, we would require that they again demonstrate a passing performance on this secure examination.
Competency-Specific Recommendations for the Competency Selective Retraining Pathway Patient Care
Goals and Objectives: ●
Demonstrate the ability to identify and extract those critical elements of patient history pertinent to the spectrum of clinical conditions commonly encountered in the practice of gastroenterology and hepatology
●
Demonstrate the ability to identify and elicit pertinent physical examination findings for the spectrum of these conditions
●
Demonstrate the ability to formulate rational, complete, and appropriately prioritized differential diag-
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noses and recommend rational, appropriate plans of management for the spectrum of these conditions ●
Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures
●
Demonstrate competent performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
Learning Methods: ●
Engagement for 6 months in an ACGME-accredited gastroenterology fellowship training program, performing inpatient and outpatient consultation, and performing core endoscopy procedures under the direct supervision of endoscopy trainers
●
Approximately 30% of the clinical material should be related to hepatology
Assessment Methods: ●
Direct evaluation by supervising attending physicians
●
Utilization of objective, performance criteria– based endoscopic procedure evaluations
●
Maintenance of endoscopy procedure logs Medical Knowledge
Goals and Objectives: ●
Demonstrate a proficiency in the clinically applicable knowledge for the spectrum of clinical conditions commonly encountered in the clinical practice of gastroenterology and hepatology
Learning Methods: ●
Self-directed reading, web-based learning
●
Active participation in the teaching rounds of both inpatient and outpatient consultative services
●
Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Retraining fellows must be current in at least 20 points of gastroenterology and/or hepatology medical knowledge self-assessment ABIM-approved MOC modules X However, they must be current in a total of 100 points distributed between medical knowledge modules and PIMs
●
Passing grade on the secure ABIM (re)certification examination, regardless of when the original ABIM (re)certifying examination was passed
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Practice-Based Learning and Improvement
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Discussion with faculty preceptors during work rounds
●
Where available, participation in patient safety courses
Goals and Objectives: ●
Demonstrate the ability to analyze practice experience to facilitate performance improvement
●
Demonstrate the ability to appraise and assimilate evidence from scientific studies and apply it to patient care
Learning Methods: ●
Retraining fellows must be current in at least 40 points of ABIM-approved PIMs, pertinent to gastroenterology and hepatology, before completing the training program
●
Active participation in the training program journal club activities
●
Active participation in the training program quality assurance or practice improvement programs/ meetings
Assessment Methods: ●
Demonstration of current, satisfactory completion of at least 40 points in the ABIM PIMs pertinent to gastroenterology and hepatology X However, retraining fellows must be current in a total of 100 points distributed between medical knowledge modules and PIMs
●
Direct evaluation by supervising attending physicians of performance in training program journal club activities and quality assurance or practice improvement activities
●
Where available, successful completion of patient safety courses Systems-Based Practice
Goals and Objectives: ●
Demonstrate an understanding of how to access and utilize the resources and health care providers necessary to provide optimal patient care in varied settings
●
Demonstrate an awareness of applying evidencebased, cost-conscious strategies for disease prevention, diagnosis, and management
●
Demonstrate an ability to collaborate with other members of the health care team to assist the patient in dealing effectively with complex health care environments
●
Demonstrate an ability to evaluate the capacity of health care systems to deliver safe, patient-centered care
Learning Methods: ●
Engagement in the varied clinical activities of the training program, inclusive of inpatient and outpatient consultative settings
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Assessment Methods: ●
Direct observation of supervising preceptors
●
360° assessments from faculty, other trainees, nurses, and patients
●
Review of patient records
Full Retraining This third and most intense pathway of participation in the process of physician reentry in gastroenterology is intended for those physicians for whom we might reasonably anticipate a loss of clinical competence due to the extensive length of hiatus from active clinical practice. Recommendations are made regarding the duration of a full retraining program, based on the physician’s clinical experience before the practice hiatus and the duration of the practice hiatus. The purpose of full retraining is to more fully retrain in all 6 general competencies over a program duration of 12 to 24 months. As in the competency selective retraining pathway, the authors propose that the ideal setting for this program is within an already established, accredited gastroenterology fellowship training program, for the reasons previously discussed. As in the prior reentry program pathway, we envision that the physician reentrant candidate would be enrolled as a postgraduate fellow, which may be designated a “retraining fellow,” but would be appointed by the institution as a faculty instructor without procedural privileges. Again, it is not the intention that the reentrant physician trainee would take the place of an ACGME-approved gastroenterology fellowship training position. Therefore, to ensure that there is no displacement or disruption of training for an institution’s current gastroenterology fellows, the authors suggest that each program that is interested in training a reentrant physician notify their designated institutional official and/or graduate medical education committee for approval. The tuition for this program would be commensurate with the longer program duration of 12 to 24 months. The training program would provide routine training in all core endoscopic procedures, with each procedure fully staffed and supervised by teaching faculty, to include careful documentation of both objective methods of assessment as well as outcomes measurements. There would not be any training or certification in advanced endoscopy. The retraining fellow would be assigned to both inpatient and outpatient consultation, with approximately 30% of the clinical material to include core hepatology. In addition, we would require that the physician reentrant candidate be enrolled in the ABIM MOC program.
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Before completion of the retraining pathway program, the physician would need to complete 100 points in ABIM-approved gastroenterology and/or hepatology selfassessment modules, to include at least 20 points in medical knowledge self-assessment, 40 points in PIMs, and the remainder in either category, according to preference and availability. This means that the entire 100 points must be taken during the 12- to 24-month retraining program. Preexisting points would not be recognized for the purposes of this reentry pathway, even if they were technically still valid within the 10-year MOC cycle. Subsequently, regardless of when the physician originally passed the ABIM (re)certifying examination, the authors recommend that a passing performance on this secure examination again be demonstrated.
Competency-Specific Recommendations for the Full Retraining Pathway Patient Care
Goals and Objectives: ●
Demonstrate the ability to identify and extract those critical elements of patient history pertinent to the spectrum of conditions commonly encountered in the clinical practice of gastroenterology and hepatology
●
Demonstrate the ability to identify and elicit pertinent physical examination findings for the spectrum of these conditions
●
●
●
Demonstrate the ability to formulate rational, complete, and appropriately prioritized differential diagnoses and recommend rational, appropriate plans of management for the spectrum of these conditions Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures Demonstrate competence in the performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
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●
Utilization of objective, performance criteria– based endoscopic procedure evaluations
●
Maintenance of endoscopy procedure logs Medical Knowledge
Goals and Objectives: ●
Learning Methods: ●
Self-directed reading, web-based learning
●
Active participation in the teaching rounds of both inpatient and outpatient consultative services
●
Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Retraining fellows must complete at least 20 points of gastroenterology and/or hepatology medical knowledge self-assessment ABIM-approved MOC modules X However, they must complete a total of 100 points distributed between medical knowledge modules and PIMs during the retraining program
●
Passing grade on the secure ABIM (re)certification examination, regardless of when the original ABIM (re)certifying examination was passed Practice-Based Learning and Improvement
Goals and Objectives: ●
Demonstrate the ability to analyze practice experience to facilitate performance improvement
●
Demonstrate the ability to appraise and assimilate evidence from scientific studies and apply it to patient care
Learning Methods: ●
Retraining fellows must complete at least 40 points in ABIM-approved PIMs, pertinent to gastroenterology and hepatology, during the retraining program
●
Active participation in the training program journal club activities
●
Active participation in the training program quality assurance or practice improvement programs/ meetings
Learning Methods: ●
●
Engagement for 12 to 24 months in an ACGMEaccredited gastroenterology fellowship training program, performing inpatient and outpatient consultation, and performing endoscopy procedures under the direct supervision of endoscopy trainers Approximately 30% of the clinical material should be related to hepatology
Assessment Methods: ●
Direct evaluation by supervising attending physicians
Demonstrate a proficiency in the clinically applicable knowledge for the spectrum of clinical conditions commonly encountered in the practice of gastroenterology and hepatology
Assessment Methods: ●
Satisfactory completion of at least 40 points in the ABIM PIMs pertinent to gastroenterology and hepatology
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X
●
●
However, they must complete a total of 100 points distributed between medical knowledge modules and PIMs during the retraining program
Direct evaluation by supervising attending physicians of performance in training program journal club activities and quality assurance or practice improvement activities Where available, successful completion of patient safety courses
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●
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Obtain formal instruction on topics pertinent to this competency by engaging the resources of the training program or institution X Examples may include orientation lectures on the Health Insurance Portability and Accountability Act (HIPAA) or informed consent
Assessment Methods: ●
Interpersonal and Communication Skills
360° assessments from faculty, other trainees, nurses, and patients Systems-Based Practice
Goals and Objectives:
Goals and Objectives:
●
Demonstration of effective communication with patients and families
●
●
Demonstration of effective communication with referring physicians and other members of the health care team
Demonstrate an understanding of how to access and utilize the resources and health care providers necessary to provide optimal patient care in varied settings
●
Demonstrate an awareness of applying evidencebased, cost-conscious strategies for disease prevention, diagnosis, and management
●
Demonstrate an ability to collaborate with other members of the health care team to assist the patient in dealing effectively with complex health care environments
●
Demonstrate an ability to evaluate the capacity of health care systems to deliver safe, patient-centered care
●
Ability to present patient information clearly and concisely, verbally and in writing
Learning Methods: ●
Direct observation of supervising preceptors
●
Engagement in the training program’s resources for more formal instruction pertinent to this competency X Such resources may include individual lectures, or standardized curriculums such as Education in Legal Medicine, or the Duke University–sponsored LIFE curriculum
Learning Methods: ●
Engagement in the varied clinical activities of the training program, inclusive of inpatient and outpatient consultative settings.
●
Discussion with faculty preceptors during work rounds
●
Where available, participation in patient safety courses
Assessment Methods: ●
360° assessments from faculty, other trainees, nurses, and patients
●
Review of patient records
●
Any standardized curriculum pretest and posttest evaluations, as may already be used by that training program Professionalism
Goals and Objectives: ●
Demonstrate respect, compassion, and honesty in relationships with patients, families, and colleagues
●
Demonstrate sensitivity to patients and colleagues on issues of sex, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors, and disabilities
●
Adhere to principles of patient confidentiality
●
Practice informed consent and informed refusal
Learning Methods: ●
Direct observation of supervising preceptors
Assessment Methods: ●
Direct observation of supervising preceptors
●
360° assessments from faculty, other trainees, nurses, and patients
●
Review of patient records
Summary The AMA, in coordination with the FSMB, has invited the various specialty societies to formulate recommendations for physician reentry programs in their specialty. A task force of gastroenterology fellowship training program directors and educators has been assembled by the Education and Training Committee of the American Gastroenterological Association to review the available information on the issue and to formulate a guideline of recommendations. The authors have carefully considered the matter of how the competency of a
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gastroenterologist would decline during a complete hiatus in clinical practice activity. We have given consideration to 2 important concepts in formulating a stratified guideline of recommendations for how a reentry program might best meet the needs of gastroenterologists and the public they serve. This includes the concept that the various competencies deteriorate at a differential rate, with endoscopic skills and medical knowledge being the more time-sensitive elements, and the concept that there is a nonlinear erosion in competency that, while variable among individuals, is greatest among physicians with relatively little clinical experience before their practice hiatus. We have proposed a guideline of 3 distinct reentry program pathways, stratified by process intensity, duration, and requirements for successful completion. While many state medical licensing boards recommend a formal reentry program as a general rule for all medical practitioners after 2 years of complete inactivity from clinical practice, we believe that in the interest of public safety and quality assurance, all gastroenterologists with a complete practice hiatus between 6 months and 2 years should be proctored to assure a resumption of endoscopic procedural competence. We consider it to be a distinct strength of these pathways that they utilize widely available, preexisting ABIM-validated resources, as well as standardized, specialty-specific curricula within preexisting ACGME-accredited gastroenterology training programs. We anticipate that these features within our guideline will address current concerns over reentry program accessibility and standardization of curricula, as well as the lack of reentry program accreditation. It is hoped that this guideline helps state medical licensing boards establish standardized, transparent mechanisms to recertify the competence of the gastroenterologist clinician reentering the workforce and that, ultimately, an improvement in the accountability and specialty-specific retraining of these physicians will lead to improved patient safety and a reduction in medical errors. Because the need for a formal reentry program requires a complete absence of clinical activity for two years, we do not anticipate that the volume of gastroenterology specialists seeking reentry would place an undue burden on our training programs. We also do not anticipate an undue burden on any one particular demographic of physician because a complete cessation of clinical activity for 2 years is relatively uncommon, even among young women physicians participating in child care and other caregiver roles. However, we would strongly urge a more complete analysis of the reentry data between the AMA and the various state medical licensing boards to derive subspecialty-specific demographics for gastroenterology.
ARTHUR J. DECROSS GI Fellowship Training Program Director University of Rochester Medical Center Rochester, New York
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DARRELL S. PARDI GI Fellowship Training Program Director Mayo Clinic College of Medicine Rochester, Minnesota DEBORAH D. PROCTOR GI Fellowship Training Program Director (1998 –2009) Yale University School of Medicine Division of Digestive Diseases New Haven, Connecticut References 1. Report of the Council on Medical Education of the American Medical Association, Report 6 (A-08) on Physician Reentry. Chicago, IL: American Medical Association, 2008:2. 2. News release: Clinically active terms redefined in a push for clarity in reporting. American Board of Medical Specialties (ABMS). 2007. Available at: http://www.abms.org/News_and_Events/news_ archieve/release_ClinicalActivityStatus_12_07.aspx. 3. Report of the Council on Medical Education of the American Medical Association, Report 6 (A-08) on Physician Reentry. Chicago, IL: American Medical Association, 2008:3. 4. Crosdale M. Doctors seek more help to get back in practice; refresher programs considered. AMNews. 2006. Available at: http://www.ama-assn.org/amednews/site/free/prl20724.htm. 5. US medical school applicants and students 1982-83 to 2007-08. Association of American Medical Colleges (AAMC). 2008. Available at: http://www.aamc.org/data/facts/charts1982to2007.pdf. 6. Potee RA, Gerber AJ, Ickovics JR. Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med 1999;74:911–919. 7. Burke CA, Sastri SV, Jacobsen G, et al. Gender disparity in the practice of gastroenterology: the first 5 years of a career. Am J Gastroenterol 2005;100:259 –264. 8. Center for Personalized Education for Physicians (CPEP). Clinical practice re-entry program. Available at http://www.cpepdoc.org/ re-entry-program.cfm. 9. Drexel Medicine Physician Refresher/Reentry Course. Available at: http://webcampus.drexelmed.edu/refresher/default.asp. 10. Draft Report on Maintenance of Licensure February 2008. Federation of State Medical Boards Special Committee on Maintenance of Licensure. Dallas, TX: Federation of State Medical Boards, 2008. 11. Miller S. Essentials of a Modern Medical Practice Act. Federation of State Medical Boards (10th Edition). 2003. As reviewed in http://cme.medscape.com/viewarticle/709335. 12. Winter R, Birnberg B. Working with impaired residents. Fam Med 2002;34:190 –196. 13. Hauer K, Ciccone A, Henzel T, et al. Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. Acad Med 2009;84: 1822–1832. 14. Renewal of and proctoring for endoscopic privileges. Standards of Practice Committee. Gastrointest Endosc 2008;67:10 –16.
Reprint requests Address requests for reprints to: Tamara Jones, American Gastroenterological Association, 4930 Del Ray Avenue, Bethesda, Maryland 20814. e-mail: [email protected]; phone: (301) 654-2055 ext. 659. Conflicts of interest The authors disclose no conflicts.
AGA Report of the AGA Institute Education and Training Committee Task Force on Physician Reentry
T
he Council on Medical Education of the American Medical Association (AMA) has requested a study of the issue of physician reentry into clinical practice, in collaboration with the respective specialty societies, the Accreditation Council on Graduate Medical Education (ACGME), the American Board of Medical Specialties (ABMS), and the Federation of State Medical Boards (FSMB). Reentry is defined as a return to clinical practice within the field in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment.1 Clinical inactivity is defined by the ABMS as the complete and total absence of direct and/or consultative care for 24 months.2 Such a benign hiatus from clinical practice may occur as a consequence of illness, the pursuit of alternative career paths (eg, industry, insurance management, administrative directorships), career dissatisfaction, premature retirement, military or humanitarian service, or a leave of absence to provide child care or fill other caregiver roles. There are relatively little published data on physician reentry. In a study of Arizona physicians (all specialties combined) who renewed their medical licenses between 2003 and 2006, 4.6% were reentering clinical practice.3 The North Carolina Medical Board has noted changing demographics among physicians seeking reentry, suggesting an increasing contribution from adverse economic circumstances forcing physicians to reconsider early retirement and alternative career path decisions.4 Intuitively, one might suspect that the issue of reentry may be more visible currently due to the sharp increase in women among the physician workforce; the Association of American Medical Colleges estimates nearly half of the medical graduates in 2007–2008 were women, up from 30% 2 decades ago.5 In fact, however, the vast majority of women physicians choose to work part-time while providing child care or filling other caregiver roles, and these women are therefore excluded from the demographics of physicians seeking reentry into the workforce, with less than 10% of female residents and practitioners in all fields combined choosing to take more than a year of maternity leave.6 Subspecialty-specific data with respect to maternity leave and child care issues are not available, although it is noted that the field of gastroenterology is underpopulated with women, who constitute only 15% of the workforce.7 For that matter, subspecialty-specific
data regarding the contribution of gastroenterologists to the burden of physician reentry are not available. Understandably, the AMA is concerned with identifying barriers to successful and appropriate physician reentry. Variability in credentialing requirements for state licensing, professional liability insurance, facility privileges, and insurance panel memberships are all significant issues further aggravated by the most significant barrier, which is the relative paucity of formal physician reentry programs. There are only four reentry programs in the United States,3 including the Center for Personalized Education for Physicians in Denver, Colorado;8 the Interinstitutional Physician Reentry Program in Portland, Oregon; the Drexel Medicine Physician Refresher/ Reentry course in Philadelphia, Pennsylvania;9 and the Physician Reentry Project in Fort Worth, Texas.3 These are comprehensive programs, but they are tailored primarily to the general and primary care specialties. They may be too few to meet the anticipated numbers of physicians seeking reentry, and they may be relatively geographically inaccessible for the majority of these physicians, particularly those who may be transitioning from their caregiver roles. Furthermore, none of these programs are specifically tailored to subspecialty training in internal medicine. Of further concern is the lack of an accreditation process for the reentry programs themselves. Accordingly, the American Gastroenterological Association (AGA) has been asked to examine how the issue of physician reentry into the workforce might be considered within the subspecialty of gastroenterology. A task force was appointed by the Education and Training Committee of the AGA Institute to research the issues and draft a report of guidelines. The report of this task force has been reviewed through the Education and Training Committee, the Women’s Committee, the Practice Management and Economics Committee, the Clinical Practice Abbreviations used in this paper: ABIM, American Board of Internal Medicine; ABMS, American Board of Medical Specialties; ACGME, Accreditation Council on Graduate Medical Education; AGA, American Gastroenterological Association; AMA, American Medical Association; FSMB, Federation of State Medical Boards; MOC, maintenance of certification; PIM, practice improvement module. © 2010 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.06.012
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and Quality Management Committee, and the Governing Board of the AGA Institute. We propose guidelines for defining what constitutes appropriate reassessment and retraining processes for previously competent gastroenterologists seeking to reenter the workforce after a nondisciplinary hiatus from clinical practice. It is our intent that these guidelines serve as a platform for the creation of subspecialty-specific reentry programs in gastroenterology. These guidelines are likely to be adjusted for variations in individual requirements between the various state medical licensing boards and are expected to evolve over time as validated tools for assessment and competency outcomes measurements become available. Ultimately, however, the authority for the implementation of such guidelines for reentry programs is the sole purview of each state medical licensing board.10 Since 2004, it has been official FSMB public policy that “state medical boards have a responsibility to the public to ensure the ongoing competence of physicians seeking relicensure” and that these boards should set the requirements for maintenance of licensure.10 Nonetheless, the Committee on Maintenance of Licensure of the FSMB expects, as a guiding principle, that state medical boards may rely on external parties to develop the tools and resources necessary to meet these requirements.10 The highlights of our recommended guidelines, discussed in further detail in the following text, include (1) a stratification of the reassessment and retraining processes based on the length of hiatus from practice and the degree of preexisting clinical practice experience; (2) a stratification of these processes formulated to acknowledge a differential rate of decay or durability among the 6 competencies of graduate medical education and clinical practice; (3) a subspecialty-specific, competencybased curriculum for each process; and (4) utilization of preexisting, standardized resources and programs that should be locally or regionally available and, in the case of training programs, fully accredited to train in the subspecialty of gastroenterology. Our remarks are confined to the consideration of gastroenterologists who have already completed training and achieved competence and for whom the hiatus from clinical activity has not been a consequence or avoidance of any disciplinary action or resulting from impairment. To qualify for reentry, physicians must have left the active clinical practice of gastroenterology in good standing, and our recommendations and guidelines are only intended to apply to those physicians who seek reentry to the workforce in the absence of any active issues for which their competence might reasonably be challenged. Special note is made of the fact that the remediation of the dyscompetent physician (dyscompetence is defined as the failure to maintain acceptable standards within one or more areas of professional physician practice), the incompetent physician (incompetence is defined as lack-
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ing the requisite ability and qualities to effectively perform within the scope of professional physician practice),11 or the impaired physician (impairment defined by the AMA as the inability to practice medicine with reasonable skill and safety . . . by reason of physical or mental illness, including alcoholism and drug dependence)12 is technically outside the focus of reentry programs and beyond the purview of this task force. We do, however, note that a recent review of the literature on the remediation of physicians from medical school through residency training and clinical practice found just a handful of small, single-institution studies that primarily focused on identifying and remediating deficient medical knowledge or clinical skills among students and trainees. Of those few studies of remediation among practicing physicians, it was acknowledged that there were difficulties in measuring high-quality patient care, and the studies did not measure the more difficult outcomes of patient satisfaction or improved measures of disease control. The efforts to implement remediation for practicing clinicians were believed to be far more daunting for a variety of reasons.13 We did not recognize any models of competency retraining among these studies that we found specifically applicable to the task of retraining gastroenterologists for physician reentry. Appreciating the absence of preexisting, specifically structured programs for retraining in gastroenterology, and the relative dearth of specific research on this topic, the basis for this report and suggested guideline is admittedly rooted in the expertise and experience of the task force members and therefore constitutes expert opinion rather than evidence-based recommendations. The three authors have all been program directors in gastroenterology fellowship training programs for a cumulative 28 years and academic faculty in clinical practice for 45 years. Additionally, we have been involved in the AGA Institute Education and Training Committee and related subcommittees for many years and have been involved in writing the national curriculum in gastroenterology as well as more recent proposals for curriculum redesign. The foundation of our recommendations lies in the self-evident expectation that the competency skills of a gastroenterologist, like any physician, will erode over time during a period of prolonged inactivity. From this simple concept, several direct corollaries are derived. Firstly, the degree of erosion in competence will increase as the hiatus from active clinical practice lengthens. However, the rate of decay will not be linear or occur in incrementally equal portions over time. Rather, we anticipate that there will be a certain period of durable maintenance of competency, without appreciable loss of skills, despite inactivity. After this period, skill sets in the various competencies will begin to decline, until after a certain amount of time has passed, the decline will be sufficient to cross a threshold and leave the clinician
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without adequate competence to practice. After that threshold, it matters little how much more time has passed. We believe that the grace period in gastroenterology can be reasonably set at 6 months, which is to say that previously competent gastroenterologists who are clinically inactive for 6 months or less should maintain sufficient skills for competent practice during this brief hiatus. We do not advocate any element of reassessment or retraining for this brief hiatus. We feel confident in this assertion as educators and trainers, noting that such a hiatus from all procedural and most clinical activity is not uncommon in many training programs for gastroenterology fellows without significantly disrupting competence or progress in clinical education. Furthermore, 6 months has been a customary term of sabbatical for attending clinicians, and historically a return to clinical practice from sabbatical has not generated concerns over clinical practice reentry at facilities and institutions. Another threshold of which we must be cognizant is at 2 years. The ABMS has developed this empiric threshold recommendation, adopted by many state medical boards,4 which states that the physician who has been completely clinically inactive for 2 years or more should participate in a physician reentry program. In our guidelines, therefore, for a hiatus from clinical practice of 2 years and longer, all gastroenterologists must be engaged in a formal retraining program. However, the AMA has requested input for specialty-specific guidelines, and for reasons to be explained in the following text, we would also suggest that for a practice hiatus between 6 months and 2 years, gastroenterologists should undergo some degree of formal reassessment and redemonstration of competence. There are further direct corollaries to the simple assertion that skills erode over time. Therefore, our second corollary is that the rate of decay in competence will vary among individuals and that the time required for an unused skill set to decay below a threshold of competence will likewise vary. We believe that this likely will reflect diverse factors, most importantly the experience or length of time in (uninterrupted) practice before the hiatus, and the achievement or expertise level of the physician before the hiatus. Unfortunately, by the time of entry into a retraining program, it is impractical to consider measuring a physician’s competence before their practice hiatus. Additionally, we know of no reproducible, reliable method of quantifying this concept. Alternatively, it is relatively easy to measure the length of time in practice, and from the perspective of educators, trainers, and practicing physicians, there is practical value to this parameter. We believe that while gastroenterology fellows are graduated with the skill sets adequate for competent and independent practice, there is nonetheless a progressive learning curve during the first few years of clinical practice, during which procedural and clinical skills and experience continue to increase considerably.
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This is viewed as a period of considerable skill set enhancement and reinforcement, during which the clinician matures from passable competence toward true expertise. A significant interruption in their clinical practice during these very early years is viewed by the authors as more disruptive to their maintenance of competency than a similar hiatus taken by a far more experienced clinician. Additionally, for physicians to engage a reentry program, they need to have taken leave of practice while in good standing. By virtue of this requirement, a cohort of clinicians who have practiced for many years, and yet are able to take leave in good standing, are less likely to include members with active issues of impairment, incompetence, or unprofessional conduct. Our third and equally important corollary is that the various competencies will not deteriorate at the same rate, a position echoed and emphasized by the AMA. As it applies strictly to the consideration of the practice of our subspecialty, certain competencies are intrinsically more time sensitive. This would apply especially to the competent performance of invasive endoscopic procedures as an integral part of our patient care competency, a skill set that is dependent on a certain level of continuous reinforcement and repetition of activity as muscle memory and hand-eye coordination develops. This is widely acknowledged as a high maintenance skill set and for this reason alone would serve to challenge the empiric 2-year threshold suggested broadly for all physicians by the ABMS. It should also be obvious that medical knowledge is a more time-sensitive competency and will decay in the absence of use or reinforcement. Conversely, in comparison, the competencies of professionalism and interpersonal/communication skills are judged to be more durable in the absence of continuous clinical activity. To summarize, the authors believe that the fundamental principle that the competency skills of a gastroenterologist will deteriorate over a period of clinical inactivity is more completely understood and more accurately described by recognizing that (1) there is a nonlinear erosion in competency that increases as the hiatus from clinical activity lengthens; (2) the rate of erosion in competency is variable among individuals but is believed to be greatest among physicians with relatively little clinical experience before their practice hiatus; and (3) the various competencies deteriorate at a differential rate, with endoscopic skills and medical knowledge believed to be the more time-sensitive elements. We therefore propose a stratification of recommendations for different pathways in a process of gastroenterologist physician reentry into clinical practice based on these concepts. These pathways of participation in the process of physician reentry are described fully in the following text, with a proposed curriculum, and are summarized in Table 1, which stratifies the pathways of participation across the parameters of duration of practice hiatus and physician experience before the practice hiatus.
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Table 1. Pathways for Reassessment and Retraining for Physicians Seeking Reentry in Gastroenterology Physician experience before practice hiatus (uninterrupted years of practice since completion of training)
Duration of practice hiatus
⬍6 mo
6 to ⬍12 mo
1 to ⬍2 y
2 to ⬍4 y
ⱖ4 y
⬍5 y
No reassessment No reassessment
⬎10 y
No reassessment
Redemonstration of competencea,b Redemonstration of competencea Redemonstration of competencea
Full retraining for 12 mo
5–10 y
Redemonstration of competence Redemonstration of competence Redemonstration of competence
Full retraining for 24 mo Full retraining for 18 mo Full retraining for 12 mo
aWith bWith
Competency selective retraining for 6 mo Competency selective retraining for 6 mo
medical knowledge modules. PIMs.
Pathways and Curricula for Physician Reentry Programs in Gastroenterology Redemonstration of Competence This first pathway of participation in the process of physician reentry in gastroenterology is intended for physicians on hiatus from 6 to 24 months, for whom we might reasonably anticipate some decrement in the timesensitive competencies of medical knowledge and certain aspects of patient care, particularly the skilled performance of invasive endoscopic procedures. Its positioning on our recommendations grid takes into account a certain durability of these skills acquired after the first few years in practice. This program pathway is intended to be completed locally by the reentrant physician and will consist of having a required procedural proctor at each facility in which clinical privileges are sought until a resumption of procedural competency has been independently determined by each proctor. Although it seems reasonable to allow the credentialing facility to select its own proctor, the authors recommend a formal reporting relationship subsequently between that proctor, the facility, and the state medical licensing board to establish accountability, set protocol, and review progress reports. The role of an endoscopic proctor has been defined by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.14 It is important to remember that proctors are not trainers. Proctors will assess and review performance, but patient care responsibility and liability remain with the physician reentrant candidate, not the proctor.14 A built-in feature of this pathway is that the more experienced and skilled clinicians will be proctored more quickly to competence, and so the duration of program participation in redemonstrating procedural competence is not predetermined and will be flexible according to achievement and skill. While we acknowledge that concurrent proctoring at multiple facilities may be cumbersome for the reentrant candidate, the simple existence of procedural privileges at one facility is not currently routinely accepted as the basis for credentialing privileges at another facility. It is
suggested, therefore, that if such a proctoring program is implemented by the relevant state medical licensing board, the formality of the program should be recognized at multiple facilities and circumvent the need for multiple concurrent proctors. It is therefore our recommendation that all gastroenterologists on hiatus from active clinical practice for 6 to 24 months be proctored to redemonstrate their competence in invasive endoscopic procedures; furthermore, for a practice hiatus of only 6 to 12 months, such procedural proctoring will suffice for completion of this pathway. However, for gastroenterologists on hiatus from active clinical practice for 12 to 24 months, we additionally recommend the completion of 30 points in medical knowledge self-assessment modules in gastroenterology and/or hepatology approved by the American Board of Internal Medicine (ABIM). A positive feature of this element is that the ABIM maintenance of certification (MOC) pathway is already an active requirement for all gastroenterologists with a time-limited board certification, and therefore the cost of enrollment in the program is a necessary and not an additional practice expense. Furthermore, we are making use of preexisting, validated modules designed to be specialty specific, which can be completed from home anywhere in the country. It is a relatively simple matter to have progress reports in the MOC pathway reported to any certifying or credentialing body. Finally, for gastroenterologists on hiatus from active clinical practice for more than 12 months but who were in practice for less than 5 years before their hiatus, we further additionally recommend the completion of 40 points in ABIM practice improvement modules (PIMs) before the completion of this reentry pathway. As discussed previously, we believe that this group is particularly sensitive to a prolonged interruption in clinical practice so soon after completing fellowship training, while they are still in a formative stage of enhancing and reinforcing clinical skills sets.
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Competency-Specific Recommendations for the Redemonstration of Competence Pathway Patient Care
Goals and Objectives: ●
●
Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures Demonstrate competence in the performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
Learning Methods: ●
Perform endoscopic procedures at each facility under the direct observation of an appointed proctor, who will review the performance of the candidate in the cognitive and technical aspects of the procedure
Assessment Methods: ●
Direct evaluation by the appointed proctor
●
Utilization of objective, performance criteria– based endoscopic procedure evaluations by the proctor
●
Maintenance of endoscopy procedure logs by the credentialing facility
Medical Knowledge (for gastroenterologists on hiatus from practice for 12–24 months)
Goals and Objectives: ●
Demonstrate proficiency in the clinically applicable knowledge for the spectrum of conditions commonly encountered in the practice of gastroenterology and hepatology
Learning Methods: ●
Self-directed reading, web-based learning
●
Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Completion of 30 points in gastroenterology and/or hepatology medical knowledge self-assessment ABIM MOC–approved modules in the ABIM MOC pathway
Practice-Based Learning and Improvement (for gastroenterologists on hiatus from practice for 12–24 months who were in practice less than 5 years before the hiatus)
Goals and Objectives: ●
To learn how to analyze practice experience to facilitate performance improvement
●
Learning Methods:
●
Retraining fellows must complete 40 points in ABIM-approved PIMs, pertinent to gastroenterology
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and hepatology, before completing this training pathway Assessment Methods: ●
Satisfactory completion of at least 40 points in ABIM PIMs pertinent to gastroenterology and hepatology
Competency Selective Retraining This second pathway of participation in the process of physician reentry in gastroenterology is intended for more experienced physicians on hiatus from 2 to 4 years, for whom we might reasonably anticipate a more robust decrement in most but not all competencies as a consequence of the length of hiatus from active clinical practice. The positioning of this pathway on our recommendations grid is based on several points: (1) physicians with more clinical experience are less susceptible to a loss of clinical competence resulting from a significant hiatus in active practice; (2) the most durable of the general competencies include professionalism and interpersonal and communication skills, which do not necessarily require reassessment and retraining for every reentrant physician; and (3) in many states, based on ABMS recommendations, reentrant physicians out of clinically active practice for more than 2 years are recommended to be in a formal reentry program. The purpose of competency selective retraining is to formally retrain, not merely reassess, clinical practice competencies in patient care (including endoscopy), medical knowledge, practice-based learning, and systemsbased practice over a program duration of 6 months. We propose that the ideal setting for this retraining is within an already established, accredited gastroenterology fellowship training program for several reasons. These programs have been reviewed and accredited by the ACGME and deliver a specialty-specific curriculum. They are sites of training expertise and, by virtue of their accreditation, possess adequate resources in terms of patient volume, with breadth and depth of exposure to the relevant clinical conditions. Equally important, there are already more than 150 such programs throughout the country, and they are therefore geographically available to the vast majority of reentrant physicians. We envision that the physician reentrant candidate in this pathway would be enrolled as a postgraduate fellow, which may be designated a “retraining fellow,” but would be appointed by the institution as a faculty instructor without procedural privileges. However, it is not the intention that the reentrant physician trainee will take the place of an ACGME-approved gastroenterology fellowship training position. Therefore, to ensure that there is no displacement or disruption of training for an institution’s current gastroenterology fellows, the authors suggest that each program that is interested in training a reentrant physician notify their designated institutional official and/or graduate medical education committee for
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approval. Consistent with existing reentry programs, this would be a tuition-based program. One suggestion to maintain fairness and consistency would be that the tuition for the program be commensurate with the average cost expense of a senior medical house officer within that state, which could be considered to include, for example, salary, health and professional liability insurance, and benefits for 6 months. This is not inconsistent with the current tuition costs of the few available reentry programs. The training program would provide routine training in all core endoscopic procedures, with each procedure fully staffed and supervised by teaching faculty, and include careful documentation of both objective methods of assessment as well as outcomes measurements. There would not be any training or certification in advanced endoscopy. The retraining fellow would be assigned to both inpatient and outpatient consultation, with approximately 30% of the clinical material to include core hepatology, consistent with the current training formula for gastroenterology fellows. In addition, we would require that the physician reentrant candidate be enrolled in the ABIM MOC program. Before completion of this reentry program pathway, the physician would need to be current in the completion of 100 points in ABIM-approved gastroenterology and/or hepatology self-assessment modules, to include at least 20 points in medical knowledge self-assessment, at least 40 points in PIMs, and the remainder in either category, according to preference and availability. This does not suggest that the entire 100 points must be taken during the 6-month retraining program, because preexisting points may still be valid; it does suggest that rather than waiting for the usual end of a 10-year MOC cycle, the retraining physician would need to be current in the amassed total of 100 points before the successful completion of this reentry program pathway. Subsequently, regardless of when the physician originally passed the ABIM (re)certifying examination, we would require that they again demonstrate a passing performance on this secure examination.
Competency-Specific Recommendations for the Competency Selective Retraining Pathway Patient Care
Goals and Objectives: ●
Demonstrate the ability to identify and extract those critical elements of patient history pertinent to the spectrum of clinical conditions commonly encountered in the practice of gastroenterology and hepatology
●
Demonstrate the ability to identify and elicit pertinent physical examination findings for the spectrum of these conditions
●
Demonstrate the ability to formulate rational, complete, and appropriately prioritized differential diag-
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noses and recommend rational, appropriate plans of management for the spectrum of these conditions ●
Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures
●
Demonstrate competent performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
Learning Methods: ●
Engagement for 6 months in an ACGME-accredited gastroenterology fellowship training program, performing inpatient and outpatient consultation, and performing core endoscopy procedures under the direct supervision of endoscopy trainers
●
Approximately 30% of the clinical material should be related to hepatology
Assessment Methods: ●
Direct evaluation by supervising attending physicians
●
Utilization of objective, performance criteria– based endoscopic procedure evaluations
●
Maintenance of endoscopy procedure logs Medical Knowledge
Goals and Objectives: ●
Demonstrate a proficiency in the clinically applicable knowledge for the spectrum of clinical conditions commonly encountered in the clinical practice of gastroenterology and hepatology
Learning Methods: ●
Self-directed reading, web-based learning
●
Active participation in the teaching rounds of both inpatient and outpatient consultative services
●
Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Retraining fellows must be current in at least 20 points of gastroenterology and/or hepatology medical knowledge self-assessment ABIM-approved MOC modules X However, they must be current in a total of 100 points distributed between medical knowledge modules and PIMs
●
Passing grade on the secure ABIM (re)certification examination, regardless of when the original ABIM (re)certifying examination was passed
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Practice-Based Learning and Improvement
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●
Discussion with faculty preceptors during work rounds
●
Where available, participation in patient safety courses
Goals and Objectives: ●
Demonstrate the ability to analyze practice experience to facilitate performance improvement
●
Demonstrate the ability to appraise and assimilate evidence from scientific studies and apply it to patient care
Learning Methods: ●
Retraining fellows must be current in at least 40 points of ABIM-approved PIMs, pertinent to gastroenterology and hepatology, before completing the training program
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Active participation in the training program journal club activities
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Active participation in the training program quality assurance or practice improvement programs/ meetings
Assessment Methods: ●
Demonstration of current, satisfactory completion of at least 40 points in the ABIM PIMs pertinent to gastroenterology and hepatology X However, retraining fellows must be current in a total of 100 points distributed between medical knowledge modules and PIMs
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Direct evaluation by supervising attending physicians of performance in training program journal club activities and quality assurance or practice improvement activities
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Where available, successful completion of patient safety courses Systems-Based Practice
Goals and Objectives: ●
Demonstrate an understanding of how to access and utilize the resources and health care providers necessary to provide optimal patient care in varied settings
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Demonstrate an awareness of applying evidencebased, cost-conscious strategies for disease prevention, diagnosis, and management
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Demonstrate an ability to collaborate with other members of the health care team to assist the patient in dealing effectively with complex health care environments
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Demonstrate an ability to evaluate the capacity of health care systems to deliver safe, patient-centered care
Learning Methods: ●
Engagement in the varied clinical activities of the training program, inclusive of inpatient and outpatient consultative settings
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Assessment Methods: ●
Direct observation of supervising preceptors
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360° assessments from faculty, other trainees, nurses, and patients
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Review of patient records
Full Retraining This third and most intense pathway of participation in the process of physician reentry in gastroenterology is intended for those physicians for whom we might reasonably anticipate a loss of clinical competence due to the extensive length of hiatus from active clinical practice. Recommendations are made regarding the duration of a full retraining program, based on the physician’s clinical experience before the practice hiatus and the duration of the practice hiatus. The purpose of full retraining is to more fully retrain in all 6 general competencies over a program duration of 12 to 24 months. As in the competency selective retraining pathway, the authors propose that the ideal setting for this program is within an already established, accredited gastroenterology fellowship training program, for the reasons previously discussed. As in the prior reentry program pathway, we envision that the physician reentrant candidate would be enrolled as a postgraduate fellow, which may be designated a “retraining fellow,” but would be appointed by the institution as a faculty instructor without procedural privileges. Again, it is not the intention that the reentrant physician trainee would take the place of an ACGME-approved gastroenterology fellowship training position. Therefore, to ensure that there is no displacement or disruption of training for an institution’s current gastroenterology fellows, the authors suggest that each program that is interested in training a reentrant physician notify their designated institutional official and/or graduate medical education committee for approval. The tuition for this program would be commensurate with the longer program duration of 12 to 24 months. The training program would provide routine training in all core endoscopic procedures, with each procedure fully staffed and supervised by teaching faculty, to include careful documentation of both objective methods of assessment as well as outcomes measurements. There would not be any training or certification in advanced endoscopy. The retraining fellow would be assigned to both inpatient and outpatient consultation, with approximately 30% of the clinical material to include core hepatology. In addition, we would require that the physician reentrant candidate be enrolled in the ABIM MOC program.
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Before completion of the retraining pathway program, the physician would need to complete 100 points in ABIM-approved gastroenterology and/or hepatology selfassessment modules, to include at least 20 points in medical knowledge self-assessment, 40 points in PIMs, and the remainder in either category, according to preference and availability. This means that the entire 100 points must be taken during the 12- to 24-month retraining program. Preexisting points would not be recognized for the purposes of this reentry pathway, even if they were technically still valid within the 10-year MOC cycle. Subsequently, regardless of when the physician originally passed the ABIM (re)certifying examination, the authors recommend that a passing performance on this secure examination again be demonstrated.
Competency-Specific Recommendations for the Full Retraining Pathway Patient Care
Goals and Objectives: ●
Demonstrate the ability to identify and extract those critical elements of patient history pertinent to the spectrum of conditions commonly encountered in the clinical practice of gastroenterology and hepatology
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Demonstrate the ability to identify and elicit pertinent physical examination findings for the spectrum of these conditions
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Demonstrate the ability to formulate rational, complete, and appropriately prioritized differential diagnoses and recommend rational, appropriate plans of management for the spectrum of these conditions Demonstrate an understanding of the indications, contraindications, special needs, alternatives, risk/ benefits, and purpose of any recommended diagnostic or therapeutic gastroenterology procedures Demonstrate competence in the performance of core gastroenterology procedures, to include diagnostic and therapeutic upper and lower endoscopy as well as percutaneous gastrostomy tube placement
GASTROENTEROLOGY Vol. 139, No. 3
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Utilization of objective, performance criteria– based endoscopic procedure evaluations
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Maintenance of endoscopy procedure logs Medical Knowledge
Goals and Objectives: ●
Learning Methods: ●
Self-directed reading, web-based learning
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Active participation in the teaching rounds of both inpatient and outpatient consultative services
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Attendance at conferences specific to gastroenterology
Assessment Methods: ●
Retraining fellows must complete at least 20 points of gastroenterology and/or hepatology medical knowledge self-assessment ABIM-approved MOC modules X However, they must complete a total of 100 points distributed between medical knowledge modules and PIMs during the retraining program
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Passing grade on the secure ABIM (re)certification examination, regardless of when the original ABIM (re)certifying examination was passed Practice-Based Learning and Improvement
Goals and Objectives: ●
Demonstrate the ability to analyze practice experience to facilitate performance improvement
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Demonstrate the ability to appraise and assimilate evidence from scientific studies and apply it to patient care
Learning Methods: ●
Retraining fellows must complete at least 40 points in ABIM-approved PIMs, pertinent to gastroenterology and hepatology, during the retraining program
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Active participation in the training program journal club activities
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Active participation in the training program quality assurance or practice improvement programs/ meetings
Learning Methods: ●
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Engagement for 12 to 24 months in an ACGMEaccredited gastroenterology fellowship training program, performing inpatient and outpatient consultation, and performing endoscopy procedures under the direct supervision of endoscopy trainers Approximately 30% of the clinical material should be related to hepatology
Assessment Methods: ●
Direct evaluation by supervising attending physicians
Demonstrate a proficiency in the clinically applicable knowledge for the spectrum of clinical conditions commonly encountered in the practice of gastroenterology and hepatology
Assessment Methods: ●
Satisfactory completion of at least 40 points in the ABIM PIMs pertinent to gastroenterology and hepatology
September 2010
X
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However, they must complete a total of 100 points distributed between medical knowledge modules and PIMs during the retraining program
Direct evaluation by supervising attending physicians of performance in training program journal club activities and quality assurance or practice improvement activities Where available, successful completion of patient safety courses
AGA INSTITUTE
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Obtain formal instruction on topics pertinent to this competency by engaging the resources of the training program or institution X Examples may include orientation lectures on the Health Insurance Portability and Accountability Act (HIPAA) or informed consent
Assessment Methods: ●
Interpersonal and Communication Skills
360° assessments from faculty, other trainees, nurses, and patients Systems-Based Practice
Goals and Objectives:
Goals and Objectives:
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Demonstration of effective communication with patients and families
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Demonstration of effective communication with referring physicians and other members of the health care team
Demonstrate an understanding of how to access and utilize the resources and health care providers necessary to provide optimal patient care in varied settings
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Demonstrate an awareness of applying evidencebased, cost-conscious strategies for disease prevention, diagnosis, and management
●
Demonstrate an ability to collaborate with other members of the health care team to assist the patient in dealing effectively with complex health care environments
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Demonstrate an ability to evaluate the capacity of health care systems to deliver safe, patient-centered care
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Ability to present patient information clearly and concisely, verbally and in writing
Learning Methods: ●
Direct observation of supervising preceptors
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Engagement in the training program’s resources for more formal instruction pertinent to this competency X Such resources may include individual lectures, or standardized curriculums such as Education in Legal Medicine, or the Duke University–sponsored LIFE curriculum
Learning Methods: ●
Engagement in the varied clinical activities of the training program, inclusive of inpatient and outpatient consultative settings.
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Discussion with faculty preceptors during work rounds
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Where available, participation in patient safety courses
Assessment Methods: ●
360° assessments from faculty, other trainees, nurses, and patients
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Review of patient records
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Any standardized curriculum pretest and posttest evaluations, as may already be used by that training program Professionalism
Goals and Objectives: ●
Demonstrate respect, compassion, and honesty in relationships with patients, families, and colleagues
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Demonstrate sensitivity to patients and colleagues on issues of sex, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors, and disabilities
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Adhere to principles of patient confidentiality
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Practice informed consent and informed refusal
Learning Methods: ●
Direct observation of supervising preceptors
Assessment Methods: ●
Direct observation of supervising preceptors
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360° assessments from faculty, other trainees, nurses, and patients
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Review of patient records
Summary The AMA, in coordination with the FSMB, has invited the various specialty societies to formulate recommendations for physician reentry programs in their specialty. A task force of gastroenterology fellowship training program directors and educators has been assembled by the Education and Training Committee of the American Gastroenterological Association to review the available information on the issue and to formulate a guideline of recommendations. The authors have carefully considered the matter of how the competency of a
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gastroenterologist would decline during a complete hiatus in clinical practice activity. We have given consideration to 2 important concepts in formulating a stratified guideline of recommendations for how a reentry program might best meet the needs of gastroenterologists and the public they serve. This includes the concept that the various competencies deteriorate at a differential rate, with endoscopic skills and medical knowledge being the more time-sensitive elements, and the concept that there is a nonlinear erosion in competency that, while variable among individuals, is greatest among physicians with relatively little clinical experience before their practice hiatus. We have proposed a guideline of 3 distinct reentry program pathways, stratified by process intensity, duration, and requirements for successful completion. While many state medical licensing boards recommend a formal reentry program as a general rule for all medical practitioners after 2 years of complete inactivity from clinical practice, we believe that in the interest of public safety and quality assurance, all gastroenterologists with a complete practice hiatus between 6 months and 2 years should be proctored to assure a resumption of endoscopic procedural competence. We consider it to be a distinct strength of these pathways that they utilize widely available, preexisting ABIM-validated resources, as well as standardized, specialty-specific curricula within preexisting ACGME-accredited gastroenterology training programs. We anticipate that these features within our guideline will address current concerns over reentry program accessibility and standardization of curricula, as well as the lack of reentry program accreditation. It is hoped that this guideline helps state medical licensing boards establish standardized, transparent mechanisms to recertify the competence of the gastroenterologist clinician reentering the workforce and that, ultimately, an improvement in the accountability and specialty-specific retraining of these physicians will lead to improved patient safety and a reduction in medical errors. Because the need for a formal reentry program requires a complete absence of clinical activity for two years, we do not anticipate that the volume of gastroenterology specialists seeking reentry would place an undue burden on our training programs. We also do not anticipate an undue burden on any one particular demographic of physician because a complete cessation of clinical activity for 2 years is relatively uncommon, even among young women physicians participating in child care and other caregiver roles. However, we would strongly urge a more complete analysis of the reentry data between the AMA and the various state medical licensing boards to derive subspecialty-specific demographics for gastroenterology.
ARTHUR J. DECROSS GI Fellowship Training Program Director University of Rochester Medical Center Rochester, New York
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DARRELL S. PARDI GI Fellowship Training Program Director Mayo Clinic College of Medicine Rochester, Minnesota DEBORAH D. PROCTOR GI Fellowship Training Program Director (1998 –2009) Yale University School of Medicine Division of Digestive Diseases New Haven, Connecticut References 1. Report of the Council on Medical Education of the American Medical Association, Report 6 (A-08) on Physician Reentry. Chicago, IL: American Medical Association, 2008:2. 2. News release: Clinically active terms redefined in a push for clarity in reporting. American Board of Medical Specialties (ABMS). 2007. Available at: http://www.abms.org/News_and_Events/news_ archieve/release_ClinicalActivityStatus_12_07.aspx. 3. Report of the Council on Medical Education of the American Medical Association, Report 6 (A-08) on Physician Reentry. Chicago, IL: American Medical Association, 2008:3. 4. Crosdale M. Doctors seek more help to get back in practice; refresher programs considered. AMNews. 2006. Available at: http://www.ama-assn.org/amednews/site/free/prl20724.htm. 5. US medical school applicants and students 1982-83 to 2007-08. Association of American Medical Colleges (AAMC). 2008. Available at: http://www.aamc.org/data/facts/charts1982to2007.pdf. 6. Potee RA, Gerber AJ, Ickovics JR. Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med 1999;74:911–919. 7. Burke CA, Sastri SV, Jacobsen G, et al. Gender disparity in the practice of gastroenterology: the first 5 years of a career. Am J Gastroenterol 2005;100:259 –264. 8. Center for Personalized Education for Physicians (CPEP). Clinical practice re-entry program. Available at http://www.cpepdoc.org/ re-entry-program.cfm. 9. Drexel Medicine Physician Refresher/Reentry Course. Available at: http://webcampus.drexelmed.edu/refresher/default.asp. 10. Draft Report on Maintenance of Licensure February 2008. Federation of State Medical Boards Special Committee on Maintenance of Licensure. Dallas, TX: Federation of State Medical Boards, 2008. 11. Miller S. Essentials of a Modern Medical Practice Act. Federation of State Medical Boards (10th Edition). 2003. As reviewed in http://cme.medscape.com/viewarticle/709335. 12. Winter R, Birnberg B. Working with impaired residents. Fam Med 2002;34:190 –196. 13. Hauer K, Ciccone A, Henzel T, et al. Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. Acad Med 2009;84: 1822–1832. 14. Renewal of and proctoring for endoscopic privileges. Standards of Practice Committee. Gastrointest Endosc 2008;67:10 –16.
Reprint requests Address requests for reprints to: Tamara Jones, American Gastroenterological Association, 4930 Del Ray Avenue, Bethesda, Maryland 20814. e-mail: [email protected]; phone: (301) 654-2055 ext. 659. Conflicts of interest The authors disclose no conflicts.