Evolution in Competence Assessment Programs: Meeting emerging trends in licensure and credentialing Elizabeth J. Korinek, MPH CEO Center for Personalized Education for Physicians (CPEP) David E.J. Bazzo, M.D. Director Fitness for Duty UC San Diego Physician Assessment and Clinical Education (PACE) Program

Overview Assessment of Physicians Competence Fitness for Duty Re-Entry Health Physical, mental, cognitive Aging Intensive remedial education Non-traditional CME

1980s… some of us remember! Physician Health Programs were founded to provide resources for physicians with health concerns such as mental health issues, addictions, etc. (AIDS used to be called GRID – sign of the times – and how far we’ve come). 3

American Medical Association “… highly complicated and sensitive matter of providing help to physicians whose practice performance is sub-par.”

Competence Assessment Programs Assess and educate individual clinicians whose clinical competence has been questioned Referred by disciplinary agency or regulatory agency Conduct comprehensive assessment of an individual clinician To identify his/her educational needs or deficiencies that negatively impact the practice of medicine Assist the participant and/or referrer in determining Whether the clinician can safely remain in/return to independent clinical practice Clinician’s strengths and weaknesses, as well as educational or other needs Whether an intervention is indicated to improve the clinician’s clinical competence and/or performance Design and implement a goal-directed plan to address the assessment findings Determine activities, monitor progress and evaluate change/improvement CPEP Guidelines for Physician Enhancement Programs Coalition for Physician Enhancement 5

When to consider an Assessment… To address performance improvement needs In anticipation of pending Board or hospital review As part of a voluntary agreement reached prior to or as the result of an investigation As a provision of a disciplinary agreement Part of substandard care stipulation/probation Prior to restoration of license or privileges Confidential – not reportable unless part of other reportable action

Assessment Process Intake Assessment Outcomes Participant intake information Referrer information Used to design assessment process - Address reason for referral - Personalized to physician’s specialty and scope of practice Assessment 2-5 day on-site Comprehensive evaluation Uses multiple testing modalities -Clinical interviews and chart reviews -Simulated patient encounters - Standardized testing -Health review/cognitive function screening Outcomes Pass (limited/no ed needs) Pass with educational recommendations (2 levels) Fail (unsafe to practice independently)

Case Study: Missed Management Internist New to small community hospital Moved after long career at academic medical center Nurses began complaining about care Patient death shortly after doctor saw the patient 8

Case Study: Missed Management Assessment Findings Acceptable documentation, communication and health/cognitive function Knowledge and judgement deficits Struggled with management of complicated cases Educational Intervention Targeted CME courses Related to inpatient care and treating patients with multiple co-morbid conditions Met with preceptor weekly for six months Reviewed patient charts, discussed care and application of knowledge Outcome Successfully completed post-education test Hospital satisfied with improvements Physician felt reconnected to medicine and rejuvenated in career 9

Reentry to Practice Reentry definition: Physicians returning to practice after an extended voluntary absence Recently also seeing trend of currently practicing physicians seeking to resume privileges due to change in scope of practice Licensure board reentry policies Most boards have reentry policies – began in early 2000s Time out of practice generally 2 years (varies) May include requirement to demonstrate competence or submission of learning plan Generally decide on “case-by-case basis” Hospital credentialing and health plan requirements Performance of a minimum number of procedures within the previous 24 months Many physicians, especially physicians who thought they were retiring for good, let their license lapse. 30 of 78 licensure boards in the US have reentry policies, but they vary quite a bit – require demonstration of competence after a leave as short an one year, while a different state does not require anything special until you have been out five years. The most common threshold is 2 years. Half of the states with policies indicated in an AMA survey that what they require of physicians who meet their threshold are “decided on a case-by-case basis”

Reentry Programs Developed to help physicians meet medical board reentry requirements Several Competence Assessment Programs offer reentry to practice services Generally use similar tools and processes Help physician prepare for practice and demonstrate competence Can address credentialing questions Help ensure patient safety while physician regains/resumes skills

Case Study: Family Obligations Pediatrician – OOP 4 years Left practice immediately after residency to raise young children Recently passed boards Returning to inpatient/outpatient practice Asked by hospital to enroll in reentry program

Case Study: Family Obligations Assessment Findings Scattered knowledge gaps Performed poorly in clinical interviews and simulated patient encounters Judgement marred by lack of confidence Lacked experience to allow her to apply knowledge in practical setting Educational Intervention Participated in 3 month reentry plan, including initial supervision Outcome By end of plan, demonstrated significantly improved clinical reasoning and application of knowledge Gained confidence

Specialized assessment Fitness for Duty Address concerns about return to practice after significant illness or injury Illness broadly defined: physical, psychiatric, cognitive, recovering substance use Aging physician screening Address the aging physician workforce Epidemiology of aging and attendant issues that may impact practice SCREENING not “for cause”

Case Study 55 year old intensivist noted to have tremor when inserting a central line. Reported to administration Acknowledged new diagnosis of early Parkinson’s disease Put on suspension, maybe resignation “My wife is an HR attorney”

Case study Set for Fitness for Duty evaluation Health evaluation: general health, movement disorder specialist Simulation assessment Found fit with accommodation No night shifts 3 (12 hour) shifts per week Yearly reevaluation 4th yearly evaluation, skills deteriorated – medical retirement

Specialized remedial interventions Provide intensive education related to core competencies Developed to assist physicians who have skills deficiencies that need more attention than can be addressed through regular CME (white space concept) Medical Recordkeeping Communication Physician-patient Inter-professional Anger Management Professional Boundaries Ethics/Professionalism Prescribing/Pain Management Burn out Custom – Wrong site surgery, PA supervision, Informed consent, etc. General features: Several days long, limited enrollment?, specialized faculty, use personalized tools to support behavior change All of the above can focus on how the programs can be beneficial to hospitals/used as part of Remedial Agreements or Peer Review Processes

Case Study: Inter-professional Communication Surgeon yells at nurses, doctors, and staff when notified of case coming from ER Several talks with CMO “It won’t happen again…” Referred to intensive seminar Learned about personality profiles, emotional intelligence, team dynamics, stress management Developed personal improvement plan Received a written report from faculty Doctor shared with CMO that his perspective had changed… Partners called to say he was easier to work with… Wife called to thank them!

Resources and Programs FSMB Directory of Physician Assessment and Remedial Education Programs fsmb.org/Media/Default/PDF/USMLE/RemEdProg.pdf.pdf Coalition for Physician Enhancement cpe.memberlodge.org Physician Reentry into the Workforce Project physician-reentry.org/program-profiles/reentry-program-links/   US Assessment Programs Albany Medical College Center for Personalized Education for Physicians (CPEP) Pennsylvania Medical Society Foundation (Lifeguard) Texan A&M Health Sciences Center (K-Star) UCSD Physician Assessment and Clinical Education (PACE) University of Florida – Florida Cares

Questions and Discussion Thank you! Questions and Discussion

Coalition for Physician Enhancement Founded in 1995 Individuals and organizations in the United States and Canada interested in/working in the area of competence assessment and educational enhancement US Assessment Programs Albany Medical College Center for Personalized Education for Physicians (CPEP) Pennsylvania Medical Society Foundation (Lifeguard) Texan A&M Health Sciences Center (K-Star) UCSD Physician Assessment and Clinical Education (PACE) University of Florida – Florida Cares http://cpe.memberlodge.org

Measures ACGME/ABMS Core Competencies Assessment/ Education Measures ACGME/ABMS Core Competencies Medical Knowledge Patient Care Practice-based Learning Communication Skills Professionalism Systems-based Practice Clinical Interviews  Patient Chart Reviews Simulated Patient Exams Written/Standardized testing Technical Skills Simulation Pre-Assessment Measures (intake, CME, practice profile) Physician Health Information Cognitive Function Screen Education/Intervention 22