Promoting Quality Patient Care Through Physician Competence: Applying Deliberate Practice to Lifelong Learning
Abstract
Poor-quality patient care can result from issues pertinent to the health system, patients, or the competence of physicians. A competent physician possesses and demonstrates the special knowledge, skills, attitudes, and behaviors required to provide quality patient care. Physician competence is a continuous, evolving concept driven at least in part by peers and patients, and, in our current era of accountability, it must be demonstrated in practice and documented objectively. Physician competence is at the center of current training program accreditation and board certification and maintenance of certification standards. Problems in physician competence can result from insufficient training; inadequate self-assessment; the negative effects of time; or failure to follow evidence-based standards of care, consider patient perspectives about care, consider the feedback from peers, or adhere to appropriate standards of professional conduct. Problems in physician competence can be addressed by a carefully designed program of lifelong learning that promotes professionalism, quality improvement, and the demonstration of acceptable medical knowledge. The principles of deliberate practice can be used to overcome significant challenges to lifelong learning, advance physician competence, and promote quality patient care.
Significant quality of care problems continue to plague the U.S. health care system (1, 2). In its 1999 landmark report, To Err Is Human: Building a Safer Health System (3), the Institute of Medicine focused special attention on “the nation's epidemic of medical errors,” concluding that somewhere between 44,000 and 98,000 deaths in U.S. hospitals each year were the result of injuries and complications of care, and outlined a strategy to address safety problems. In Crossing the Quality Chasm: A New Health System for the 21st Century (4), the Institute of Medicine went on to suggest that medical errors might be reduced and the quality of U.S. health care improved through the proper redesign of the health care system with aims to make it more safe, effective, patient-centered, timely, efficient, and equitable. It suggested system rules that reinforced care based on continuous healing relationships, customization according to patient needs and values, the patient as the source of control, shared knowledge and the free-flow of information, evidence-based decision making, safety as a system priority, the need for transparency, anticipation of needs, continuous decrease in waste, and cooperation among clinicians.
Although it is clearly essential to document that problems do exist in the quality of patient care, it is even more important to identify the major factors that might be responsible for those problems. One approach to this complicated issue is to divide quality problems into those that result primarily from three sources: the health care system, the patients, or the physicians (5). Poorly designed and implemented health care delivery systems can impede the delivery of quality care. Patients with complex, comorbid conditions or compliance difficulties can also make it more difficult to provide quality care. Finally, deficiencies in the basic competency of physicians themselves might contribute to quality-of-care problems. Although addressing each of these complex factors is crucial to the promotion of quality patient care, this article will focus on the issue of physician competence. Understanding important aspects of physician competence and the factors contributing to deficiencies may suggest a strategy to not only address those problems but also promote quality patient care.
A DEFINITION OF PHYSICIAN COMPETENCE
Assuming that quality patient care is at least partly related to the manner in which physicians deliver that care suggests a possible definition of a competent physician:
There are several important aspects of physician competence that deserve special emphasis. First, physician competence is inherently peer-driven. Requirements and standards for competence found in training program accreditation, board certification and maintenance of certification, patient care practice guidelines, credentialing, licensing, and peer review are all developed and administered by special committees of physician peers. Second, physician competence is in part patient-determined. In the era of patient advocacy and patient-centered care, the assessment of a physician's competence is incomplete without considering the opinions of patients served by that physician (6). Third, physician competence is constantly evolving. The basic knowledge, skills, attitudes, and behaviors for competence must of necessity change with new discoveries, technologies, health care system structures, and social mandates (7). Fourth, physician competence is a continuous process. Partly because of the evolving nature of competence, physicians cannot maintain those abilities without ongoing attention to their knowledge and skills (8). Fifth, physician competence is behavioral. Physicians must not only possess the knowledge, skills, and attitudes to provide quality care, but they must also demonstrate that competence when they evaluate and treat their own patients (9). Finally, physician competence requires documentation. In a society that focuses increasing attention on accountability, physician training, board certification, and reputation for competency are being replaced by increasing demands for the on-going, objective documentation of acceptable performance (10).A competent physician possesses and demonstrates the special knowledge, skills, attitudes, and behaviors required to provide quality patient care.
PERSPECTIVES ON PHYSICIAN COMPETENCE
Recognizing the importance of ensuring that graduates of medical education programs actually achieve an acceptable level of competence as a result of their training, in 1999 the Accreditation Council for Graduate Medical Education (ACGME) joined together with the American Board of Medical Specialties (ABMS) to support a process designed to identify the General Competencies required of physicians in the current health care era (11). Once developed, the General Competencies became the foundation for the ACGME accreditation guidelines for all graduate medical education programs (12) as well as the ABMS standards for board certification and maintenance of certification (MOC) in all medical specialties (13). The General Competencies are divided somewhat arbitrarily into the following six areas:
1.
Professionalism. Demonstrating commitment to professional responsibilities, ethical principles, and sensitivity to diverse populations.
2.
Medical Knowledge. Understanding the application of biomedical and clinical sciences in patient care.
3.
Patient Care and Procedural Skills. Providing patient care that is compassionate, appropriate, and effective.
4.
Interpersonal and Communication Skills. Demonstrating effective information exchange with patients, their families, and professional associates and fostering an ethical therapeutic relationship with patients.
5.
Practice-based Learning and Improvement. Evaluating patient care practices and assimilating scientific evidence to improve practice.
6.
Systems-based Practice. Demonstrating awareness of responsibility to the larger context and systems of health care.
Although most of the General Competencies are familiar to many physicians, Practice-based Learning and Improvement and Systems-based Practice focus on areas of competence that have been underemphasized in traditional medical education programs. Berwick and Finkelstein (7) underscore the requirement for physicians to be able to respond to the current needs of society by learning to “navigate in and continually improve complex systems to improve the health of patients and communities they serve.” In addition to technical and humanistic skills, Berwick and Finkelstein call for special attention to the education of medical students and residents on the scientific foundations of system performance as well as team-based improvement. For physicians to be maximally effective in the new health care era, it will be especially important for them to practice in a manner demonstrating that they understand the needs and preferences of patients and their families, the components of the health care system and their interrelationships, the basic processes of quality improvement, the value of collaboration and teamwork, and the social context in which they practice.
DOCUMENTING CONTINUOUS PHYSICIAN COMPETENCE THROUGH MAINTENANCE OF CERTIFICATION
The ABMS has designed its Maintenance of Certification (MOC) Program to reassure the public that all board-certified physicians have taken specific steps to remain proficient in the six General Competencies throughout their professional careers (14). All 24 ABMS Member Boards must design their MOC programs to include the following four components:The MOC Program of the American Board of Psychiatry and Neurology (ABPN) fulfills all of the ABMS requirements (15). ABPN diplomates must maintain a valid, unrestricted license to practice medicine (Part 1), complete at least two self-assessment activities and earn an average of at least 30 Category 1 CME credits per year over 10 years (Part 2), pass a MOC examination at least once in 10 years (Part 3), and complete at least three performance improvement activities with patient and peer feedback over 10 years (Part 4).
1.
Part 1—Professional Standing. Board-certified physicians must maintain a valid, unrestricted license to practice medicine.
2.
Part 2—Self-assessment and Continuing Medical Education (CME). Board-certified physicians must objectively assess gaps in their medical knowledge at regular intervals and participate in CME activities to address those gaps.
3.
Part 3—Cognitive Expertise. Board-certified physicians must document that they have the fundamental knowledge to provide competent patient care by passing a secure, proctored examination at regular intervals.
4.
Part 4—Performance in Practice. Board-certified physicians must regularly compare the quality of care they provide to patients against peer-based standards and obtain feedback from patients and peers about their clinical practice. They must identify any areas of practice deficiencies, modify their practices to address those deficiencies, and subsequently reevaluate their patient care to determine whether those deficiencies have been corrected.
The ABPN has developed its MOC Program to incorporate 10 important philosophical principles:It is important to note that several of these principles may conflict with one another. For example, there is constructive tension between the principles of accountability and credibility on the one hand and convenience on the other. Likewise, the principles of independence and collaboration are potentially at odds with one another. These examples merely underscore some of the challenges faced by the ABPN and other ABMS Member Boards as they attempt to design their MOC programs to balance the desire of the public and external credentialing, funding, and licensing organizations for the documentation of physician competence with the practical realities facing busy physicians.
1.
Accountability. It must reassure the public that ABPN diplomates complete specific activities designed to maintain their competence.
2.
Independence. It must be developed by the ABPN itself within the guidelines set by the ABMS.
3.
Peer-Driven. It must be developed by ABPN diplomates for ABPN diplomates.
4.
Competence. It must be designed to assess and improve the performance of ABPN diplomates in all six General Competencies.
5.
Continuous Quality Improvement. It must require continuous assessment and improvement in the medical knowledge and clinical activities of ABPN diplomates.
6.
Professionalism. It must mandate acceptable professional behavior by ABPN diplomates.
7.
Credibility. It must fulfill the competency requirements of major external organizations.
8.
Collaboration. It must be developed in cooperation with professional organizations affiliated with the ABPN (e.g., APA, American Academy of Neurology, etc.).
9.
Convenience. It must be designed in a manner so that its requirements are not overly burdensome for busy ABPN diplomates.
10.
Lifelong Learning. It must reinforce the performance improvement activities of ABPN diplomates over their entire professional careers.
FACTORS CONTRIBUTING TO PROBLEMS IN PHYSICIAN COMPETENCE
There are a number of factors that may contribute to problems in physician competence and undermine the quality of patient care:
1.
Insufficient training for the realities of the current health care era. Current medical education programs do not adequately prepare physicians for the challenges they will face in modern clinical practice (7). Educational reforms need to place more emphasis on improvement science; patient safety; team-based care; the integration of basic science, clinical experiences, and health systems; longitudinal training; and patient-centered care.
2.
Failure to follow evidence-based standards of care. The existence of evidence-based practice guidelines for patient care does not necessarily mean that they will be used (5). Many physicians seem to be unaware of existing practice guidelines, find them too complicated to understand, or simply delay using them in the evaluation and treatment of their own patients.
3.
Inadequate self-assessment. The research on self-assessment underscores the difficulty that many physicians have in identifying their own competence problems (16). A majority of the studies demonstrate little, no, or an inverse relationship between self-assessments done by physicians themselves and external assessments of those physicians. More problematic is the observation that the worst accuracy in self-assessment is frequently among the least skilled and most confident physicians.
4.
The negative effects of time. Time often has an insidious effect on the knowledge, skills, and performance of physicians (17). Research studies reveal problems in knowledge, performance, adherence to standards of practice, and actual health outcomes with the increasing age and experience of many physicians.
5.
Failure to consider patient perspectives about care. Consideration of patients' wants, needs, values, and opinions has become an essential component of quality care (4, 6). The competence to provide such patient-centered care is an important current component of efficient, individualized evaluation and treatment.
6.
Failure to consider feedback from peers. The complexity of modern medical practice mandates effective teamwork and collaboration (4, 7, 18). There is growing sentiment that professional colleagues might be in the best position to provide physicians with constructive criticism and recommendations for improvement, especially in the humanistic, noncognitive aspects of their performance.
7.
Failure to adhere to appropriate standards of professional conduct. Disciplinary actions by state medical boards clearly document problematic professional behaviors by some physicians, including negligence, incompetence, and inappropriate contact with patients (19). Although there may be disagreement about some of the nuances concerning the assessment of physician performance, professionalism must be the bedrock of any framework for competence.
PROMOTING PHYSICIAN COMPETENCE THROUGH LIFELONG LEARNING
Many physicians seem confused by the requirements for MOC and unsure about some of its requirements as measures to document their competence to provide quality patient care (20, 21). Current attempts to encourage diplomates to pursue MOC have mainly emphasized the potential rewards for participation and the punishments for failing to do so (22). To many diplomates, the term MOC itself is perceived as unfamiliar, abstract, complex, regulatory, and negative. In addition, framing any discussion about MOC by trying to convince diplomates that it is indeed in their best interests invites a never-ending debate about what are, at present, inherently subjective reasons for participation. Recent understanding of human motivation suggests that an attempt to convince diplomates to participate in MOC is more likely to succeed if it is based less on possible diplomate extrinsic rewards and punishments and more on their intrinsic identities as competent physicians (23). One strategy to encourage diplomates to embrace this professional identity is through their ongoing participation in a program of lifelong learning (LLL). Unlike the term “MOC,” most diplomates will perceive “LLL” as being inherently more familiar, concrete, straightforward, self-directed, and positive. Whereas many diplomates might debate the need for MOC, few will deny the value of LLL.
A program of LLL might be conceptualized as consisting of at least four specific components that have always been the hallmark characteristics of competent physicians:Adopting a program of LLL has at least two major advantages. First, LLL reinforces the beneficence, specialized knowledge, and self-regulation aspects of professionalism (24). Physicians pursue LLL to “learn to protect” their patients through their professional behavior and their competent, state-of-the-art clinical care. Of course, in the process, they also “learn to protect” themselves professionally, legally, and financially. Second, LLL fulfills all of the requirements of MOC (14). Physicians pursue LLL to “learn to improve” in all aspects of their professional lives, including their profession (MOC Part 1), their patients (MOC Part 4), their teachers (MOC Part 2), their peers (MOC Part 4), their health systems (MOC Part 4), and themselves (MOC Parts 2, 3, and 4).
1.
Professionalism. Maintaining appropriate and ethical behavior and providing competent, state-of-the-art clinical care.
2.
Medical knowledge quality improvement. Objectively identifying and addressing medical knowledge deficiencies.
3.
Demonstration of acceptable medical knowledge. Performing adequately on formal assessments of medical knowledge.
4.
Patient care quality improvement. Conforming patient care to practice guidelines or standards of care and responding to patient concerns and peer suggestions about how to improve patient care.
OVERCOMING CHALLENGES TO LLL THROUGH DELIBERATE PRACTICE
Although a comprehensive program of LLL can be structured to promote physician competence and professionalism and to fulfill all the requirements of MOC, there are several challenges that must be overcome in its implementation. The principles of deliberate practice provide a useful six-part framework to improve performance in any area of activity (25), and they can also be used to address these challenges to LLL.
1.
Objective identification of competence deficiencies. Given the limitations of subjective self-assessment (16), more objective, external measures are needed to identify deficits in physician competence. Self-assessment and MOC examinations, comparison of clinical performance to standards of care, and feedback from patients and peers are examples of such measures.
2.
Specific programs designed to correct deficiencies. Remediation efforts of physicians should not be general in nature or directed only toward areas of personal interest, but rather should be designed specifically to address identified deficiencies in competence. Focused CME, clinical practicums, and peer consultation can be helpful in this regard.
3.
Constructive feedback to document improvements. One-time assessments of physician competence are inadequate to stimulate improvement. Regular follow-up evaluations are needed to ensure that remediation efforts have been successful. Repeat self-assessment examinations, clinical performance comparisons to standards of care, and patient and peer feedback can help keep physicians on track toward improved competence.
4.
Extensive effort over an extended period of time. Competence improvement is not a simple, time-limited activity but rather a continuous effort over the professional lifetime of a physician from medical school to retirement. Implementing on-going strategies to assess and improve competence should become part of the lifeblood of quality physicians.
5.
Commitment to complete a demanding, difficult process of improvement. Competence improvement is hard, rigorous work that will be a mental challenge for any physician. The willingness to repeatedly expose one's deficiencies and to implement difficult measures to correct them takes special discipline and fortitude, but it is the only way to promote improvement and ensure competence.
6.
Support for improvement efforts. Few physicians will be able to make significant improvements in their competence without support. Professional and regulatory organizations can help physicians in their improvement efforts, including communicating the specific LLL activities physicians must complete to fulfill the requirements of external organizations, developing practical and convenient LLL products that physicians might use to meet those requirements, and facilitating the documentation and reporting of completion of LLL activities by physicians. Perhaps most important, specific requirements for the demonstration of physician competence should be designed to stimulate the physician's intrinsic motivation to pursue LLL by promoting their autonomy, mastery, and purpose (23). The most effective requirements will reinforce the self-directed improvement efforts of physicians, include improvement activities of specific value to promoting physician competence, and establish a clear relationship between improvement in clinical performance and one's professional identity as an exceptional physician providing quality patient care.
CONCLUSION
Whereas health system and patient issues can have a major impact on the quality of patient care, problems in physician competence will undoubtedly also exert a deleterious effect. National regulatory organizations such as the ACGME and the ABMS recognize the key role of physician competence by making it the cornerstone of their accreditation, certification, and MOC programs. Although problems in physician competence may be identified and corrected through a well-designed program of LLL, there are significant challenges to implementing such a program. Application of the principles of deliberate practice can help physicians overcome those challenges and improve their competence. To succeed, that process needs the support of professional medical organizations, which effectively communicate the principles and requirements and develop and document programs. The competency requirements themselves must be designed to facilitate the intrinsic motivation of physicians and their professional identities as competent providers of quality patient care.
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Information & Authors
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Published online: 1 April 2011
Published in print: Spring 2011
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Larry R. Faulkner, M.D., President and CEO, American Board of Psychiatry and Neurology, and Clinical Professor of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine.
Reports no competing interests.
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