1. 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

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

3. 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

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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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”

11. 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

12. 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

13. 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

14. 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”

15. 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”

16. 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

17. 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

18. 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!

19. 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

20. Questions and Discussion
Thank you!
Questions and Discussion

21. 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

22. 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