Task force IV: Evaluation of professional competence

Task Force IV: Evaluation of Professional

WENGER

(Chairman),

NOBLE (Cochairman),

BURG, CAMPBELL,

CRAIGE,

This proposal is designed to assess the factors necessary to maintain and improve cardiovascular professional performance and to provide patients with some assurance of physician competence. The American Board of Internal Medicine (ABIM) and the Subspecialty Board of Cardiovascular Disease (ABIM-CV) have made great efforts to test clinical competence with use of written and oral examinations. However, the testing of quality of cardiovascular care has yet to be accomplished. The following discussion and recommendations are based on a prospective approach to the evaluation of professional competence in cardiovascular disease. Three groups of physicians provide care for patients with cardiovascular disease: 1. Primary care physicians: These physicians provide primary cardiovascular care to patients-that is, prevention, treatment and rehabilitation. They do not receive specific training in cardiovascular disease over and above that provided by their conventional training programs. Primary physicians include general practitioners, specialists in family practice and general internists. Other groups of physicians such as emergency room physicians and anesthesiologists also provide cardiovascular care. This Task Force will not attempt to evaluate the competence of these other physicians, except insofar as designing and evaluating training programs is concerned. 2. Internist-cardiologists: For the purpose of this analysis, the internist-cardiologist is defined as a physician who functions both as a primary care physician and as a consultant to other generalists for cardiovascular problems. He is certified by the ABIM and has demonstrated expertise in clinical cardiology. Often, he has had training in cardiovascular disease over and above that provided in many residency programs in internal medicine. 3. Cardiac specialists: Clinical cardiology consultants and teachers of cardiology are included in this classification. These physicians function principally as consultants but may provide some primary care. Their training, which is sufficient to permit certification by ABIM-CV, provides them with special expertise in cardiovascular disease. They may or may not be trained in or use special techniques in cardiology. For each competence

of these three groups should include:

the assessment

of

Competence

EICH, KOHN, SAUNDERS,

TAYLOR,

WEISSLER

1. Evaluation of training programs. 2. Evaluation of the person during his training experience. 3. Appropriate specialty or subspecialty certification. 4. Evidence of continuing education. Limitations

of the Current Evaluation

System

Several factors seriously limit the capacity to evaluate professional competence and, as such, restrict the recommendations that can logically be proposed at this time. These factors include: 1. The relative competence of physicians who have been assessed by current evaluation procedures (such as board certification) has not been contrasted with that of physicians who have not submitted to the examination process. No information is available concerning persons who have not submitted to the process. 2. Although the board examinations certify initial competence, no information is available as to whether they assure continued competence. 3. No consistent approach to evaluation of cardiovascular training programs or of trainees in programs has been developed. 4. There is no generally available means for evaluation or certification of competence in specialized cardiovascular activities. 5. Peer assessment of physician performance in the ambulatory care setting as well as in the hospital must await development of valid instruments of measurement, preferably outcome-oriented. While the retrospective review aspect of Peer Standards and Review Organizations may provide an index of competence, it is as yet of unproved value in the general assessment of physician competence. Legal problems of privacy of patient records must be clarified before universal application of record review can be considered.

General

Principles

for Evaluation Programs

of Training

A major determinant of the quality of clinical competence is the quality of the person’s teacher and his training experience. The accreditation of cardiovascular training programs on a nationwide basis is hence a direct means of ensuring clinical competence among persons

May 1976

The American

Journal

of CARDIOLOGY

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TASK FORCE IV

aspiring to professional expertise in cardiovascular medicine. The evaluation of clinical competence throughout the training experience provides a critical means of testing the progress of such expertise. General Principles for Evaluating Competence

nist-cardiologist by ABIM (and he will have received additional training in cardiovascular disease) and the family practitioner by the American Board of Family Practice. 4. Standards are needed for certification of competence in specialized diagnostic activities such as: (a) electrocardiography; (b) noninvasive techniques, including stress testing, echocardiography and graphics; (c) invasive procedures, including cardiac catheterization, angiocardiography and insertion of pacemakers; and (d) supervision of coronary care. These standards may be used by hospitals and chiefs of service to delineate and determine staff privileges. Standards and testing of competence in cardiovascular procedures are currently under development by professional societies. For instance, such standards are being developed by the American College of Cardiology, and exercise testing standards by the American Heart Association. These should be used as they are developed. Whereas national standards apply to some procedures (cardiac catheterization and cardiovascular surgery), local standards must determine competence for other activities such as supervision of coronary care. The standards, once developed, would apply equally to cardiac specialists, internist-cardiologists and primary physicians. Evidence of continuing competence in these specialized activities is expected. 5. A formal recertification examination is not now recommended. It is hoped that formal reassessment of professional competence will become unnecessary with implementation of the previous recommendations. Evidence of continuing education through personal reassessment, self-assessment examinations and participation in continuing education programs will allow the certified graduates of accredited training programs to maintain the high standards of medical care for which they have been equipped. The Task Force is unaware of evidence of widespread suboptimal cardiovascular care delivered by cardiac specialists. In addition, there is no solid evidence that a recertification examination maintains clinical competence. Rather, it is recommended that a study be designed to determine the continued clinical competence of board-certified cardiac specialists over time. The results of this study would either support or refute the logic of the proposed recommendations.

Clinical

The methods used to assess physician competence should be prepared by peer experts and should be relevant to the clinical practice of medicine. In addition, they should be reliable (that is, provide reproducible information) and should be valid (that is, accurately assess competence). Finally, they should provide feedback to participants, teachers and directors of training programs of cardiovascular disease, and accrediting bodies. Recommendations

1. A system should be developed to evaluate and accredit programs in cardiovascular medicine designed to train the cardiac specialist. This system would depend upon the establishment of national standards for cardiovascular training. The system should be developed through the cooperation of ABIM, the American College of Cardiology, and the American Heart Association. Residency review committees in internal medicine would assume responsibility for assuring the education of competent internist-cardiologists. Residency review committees in family practice or in other primary care specialities should assume responsibility for assuring the education of primary care physicians in the prevention, management and rehabilitation of patients with cardiovascular problems. It is further suggested that optimal training in cardiovascular medicine for the noncardiac specialist would best be provided by cooperative arrangement with approved cardiovascular training programs. 2. Objective methods of evaluation should be developed for use by approved programs to assess the day to day performance of residents and fellows involved in the care of patients who now have or might later have cardiovascular problems. 3. Prospectively all physicians who provide cardiovascular care should be certified by the appropriate specialty or subspecialty boards. Thus, the cardiac specialist should be certified by ABIM-CV, the inter-

References 1. Adams FH, Blumenthal S, DuShane JW, et al: The review and revision of certification procedures in pediatric cardiology. J Med Educ 47:796-805, 1972 JAMA 233:1063-1065, 1975 2. Aring CC: Recertification. JA, Webster GD: The American Board of internal 3. Meskauskas Medicine recertification examination: process and results. Ann Intern Med 82:577-581, 1975 4. Noble RJ, Berry MG, Gillespie L, et al: Norms for use in the peer review of selected in-hospital cardiovascular diagnoses. Am J Cardiol 36:125-128, 1975 a good beginning. Ann Intern Med 5. Petersdorf RG: Recertification:

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85:583-584, 1975 6. Petersdorf RG: Health manpower: numbers, distribution, quality. Ann Intern Med 82:694-701, 1975 7. Petersdorf RG, Beck JC: The new procedure for evaluating the clinical competence of candidates to be certified by the American Board of Internal Medicine. Ann Intern Med 76:491-496, 1972 8. Shumacher CF: Validation of the American Board of Internal Medicine written examination. A study of the examination as a measure of achievement in graduate medical education. Ann Intern Med 78:131-135, 1973

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