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Rapid Responses to:
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Electronic letters published:
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif){kind=icon}
Remedial education:Lets do it right
Doctors need help
Increasing scientific knowledge? Not always
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Edward J. Volpintesta, md
Send rapid response to journal:
evolpintesta{at}snet.net Edward J. Volpintesta
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Dr. Leape and Dr. Fromson’s ideas (“Doctors need help” Rapid Response, Feb. 4, 2008) for helping physicians’ identify areas where they may need to improve their knowledge or skills merit further discussion, particularly in the area of primary care. First, it is important to point out that any “remedial” education that is needed should be determined for the most part by the individual physician’s type of practice. For instance, not all primary care doctors have similar practices. Many customize their practices according to their particular strengths and weaknesses and particular interests. This needs to be taken into account. There is no archetypical primary care doctor as some medical educators think. Second, I’m not sure that after a physician has been certified by board he or she needs to be recertified. Why? Recertification in its present form has is punitive and has as much a penalizing effect as an educational one. Not being recertified can be harmful to an otherwise good physician and lacking certification may move an HMO to drop a physician or deny employment. If used in tiered networks lack of certification can be misinterpreted as lack of competency by patients. And there is the possibility that lack of certification may be used to refuse admission by a hospital to its staff. So what’s the point? Once certified, physicians should stay current with educational assessments and remedial education tailored to their personal needs. However, recertification should eliminate its pass/fail approach. The pressure to recertify has spawned a large number of expensive CME programs that can be compared to “performance enhancers” in professional sports, and like them can give a spurious impression of a physician’s abilities. At the same time they can disadvantage a doctor who forgoes them. Some doctors feel that the whole CME process, boards included exploit them; that they are more interested in financial gain than in education. Worse, the pressure to pass recertification encourages doctors not to study what they need in their practices but what they need to pass the next exam. How crazy is that? Clearly, physicians should not be tested in skills and knowledge they no longer use or need. Third, in addition to medical knowledge there are other qualities that make for competent physicians which the recertification exams do not measure. Some of the qualities that competent doctors should have? Are they good team members? Do they connect well with their patients? Do they spend sufficient time with them? How accommodating are they to them? How honest are they in not exploiting their patients with unnecessary tests? There are other critical qualities as well: participation in hospital affairs including committees and departmental meetings; involvement in local and state medical associations,, recommendations form their department chairpersons regarding their professionalism and integrity—all of these in addition to scientific knowledge go to make up a balanced, competent, and compassionate physician”. Fourth, I disagree with the authors’ ideas about remediation centers. For primary care physicians, there is pressure to “stay put”; most of the practical knowledge they need can be obtained at their community hospitals, eliminating the loss of time required to travel to a distant CME center. The majority of community hospitals have specialists on their staffs that can help primary care doctors keep current and the local hospitals are an ideal place for “remedial education”. Topics like treatment of congestive heart failure, new therapies for hypertension and diabetes could easily and conveniently be provided at local hospitals. Funding could be sought from drug companies or small fees collected from the doctors. Federal money is another possibility, especially since a scarcity of primary care doctors exists and policy makers seem eager to increase their numbers. Clearly, particularly for primary care a new model is needed for assessing competence and remedial CME. With renewed emphasis on the need for more primary care doctors, now is the time to make new and practical changes that will benefit all primary care doctors. Conflict of Interest:None declared |
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Lucian L. Leape, MD Harvard School of Public Health, John A. Fromson, MetroWest
Send rapid response to journal:
leape{at}hsph.harvard.edu Lucian L. Leape, et al.
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Why Doctors Don’t Report Colleagues Re: Campbell et el., Professionalism in Medicine, Annals of Internal Medicine 147:795-803, December 2007 The finding of Campbell, et al.’s survey that nearly half of physicians who witnessed an impaired or incompetent colleague practicing medicine and had not reported them to a higher authority should not be surprising. Studies of reporting systems show that people do not report harmful events unless it is both safe and worthwhile. Reporting incompetent doctors who may harm patients is usually not safe. The physician with a competency issue may be reprimanded or face license suspension or revocation. In addition, he or she almost always sees it differently, and may engage in swift and devastating retaliation against the reporter. Reporting is also not worthwhile, in that serious efforts to help physicians improve their knowledge and skills are virtually non-existent. Both state licensing boards and hospital credentialing committees tend to ignore these types of problems until a serious incident occurs, and then respond with discipline. One hopes the recent decision of the American Board of Medical Specialties (ABMS) to require diplomates to continuously demonstrate competence in order to maintain board certification status will lead to earlier identification of deficiencies. However, even if a physician in need is identified, there are few programs available nationwide for assessment (10), and fewer still for rectifying any deficiencies that are found.1 A national effort is needed to develop many more of these programs. The ABMS, Federation of State Medical Boards (FSMB), and Joint Commission should launch a joint effort to establish at least a dozen new assessment and remediation centers that health care organizations and state boards can refer doctors to. Most “incompetent” doctors can be retrained and remediated to be safe and competent once more. It is clearly in everyone’s interest that we do so. Lucian L. Leape, MD Harvard School of Public Health John A. Fromson, MD Harvard Medical School 1. Leape L, Fromson, JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144:107-115. Conflict of Interest:None declared |
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Min Liu, B.S. Kaohsiung Medical University, Taiwan
Send rapid response to journal:
maloliu{at}yahoo.com.tw Min Liu
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The Physician Charter (1) has been widely accepted since its publication (2). As a participant in translating the charter into Chinese (3), I read Dr. Campell et al. (4) article with great interest. However, I was quite confused by the question the authors selected to measure physicians attitudes toward increasing scientific knowledge. Physicians should encourage the participation of their patients in clinical trials(table 1) , and the question to survey professional behaviors. In the last 3 years, have you encourage 1 or more patients to enroll in a clinical trial?(table 2). For a physician may have several other reasons to encourage his patient to participate in clinical trial, for example, maybe it is the only chance to fight the disease, or maybe the physician will receive gifts from the research sponsors. Therefore it would be impossible to say that all the respondents who gave positive answers to these questions are based on commitment to scientific knowledge. Besides, physicians should put patients personal welfare not only prior to physicians self-interest, but also to the advancement of science. A physician who encourages a lot of patients to participate in clinical trial, may be or may not be a physician who acts professionally. 1. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. 2. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med. 2003;138:839-41. 3. Liu KM, Huang YS. Preparing health professionals for the future: 11th International Ottawa Conference on Medical Education [visitors report]. J Med Educ (Taiwan). 2004;8:216-23. 4. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795- 802. Conflict of Interest:None declared |
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