Shared Medical Regulation in a Time of Increasing Calls for Accountability and Transparency: Title and subTitle BreakComparison of Recertification in the United States, Canada, and the United Kingdom

Recertification or revalidation as it is called in the United Kingdom and Canada is not a new concept. The term recertification is used generically in this article even though specific definitions vary between countries (Table 1). It has been more than 30 years since a process for the ongoing evaluation and confirmation of physician knowledge, skills, and practice was first considered in the United Kingdom¹ and in the United States voluntary recertification for most medical specialties has been in place for 2 decades.²

Throughout the last decade, recertification has increased in importance due to increased patient expectations about the quality of care³ ; challenges to the acceptability of professional self-regulation⁴ ; the increasing concern about the cost of medical care; and widely publicized cases, most notably in the United Kingdom, in which the clinical practice of some physicians was shown to be inadequate.⁵ (In the United Kingdom, the term physician is not used inclusively and therefore does not include surgeons. This article uses the term inclusively.) In each country there is increasing pressure to shift the regulation of physicians out of the hands of the profession itself to organizations with different accountability measures that may not be driven by medical professionalism. This has been most prevalent in the United Kingdom where the composition of its medical regulator, the General Medical Council, has been legislated to include an equal number of lay members and physicians.

Although the details and terminology vary, the purpose of recertification is largely consistent across the 3 countries with the common goal of improving patient care and encouraging physicians to maintain their clinical knowledge and skills, professional attitudes, and behaviors. The General Medical Council described recertification as “one element of the quality framework which aims to address two distinct but complementary purposes—ensuring patient safety and improving the quality of patient care.”⁶ It is primarily a process designed to provide regular evaluation of the standard of a physician's knowledge, skills, and practice and to encourage ongoing quality improvement in the delivery of care to patients.⁷

In the United Kingdom, a secondary outcome of the process is the identification of underperforming physicians. Recertification is an opportunity for the medical profession to set and maintain standards through sound governance and professionalism.⁸ It is the formal method the profession uses to demonstrate that physicians are practicing to a requisite standard of medical care and to exercise the profession's accountability to stakeholders including employers, payers, patients, and members of the public.⁹

It is important and, we believe, better for physicians and for patients that the medical profession continues to lead in setting standards of good practice. The profession is best able to determine appropriate standards based on its unique knowledge, and physicians are more receptive to standards created by experts in their field than by those outside of clinical practice. To ensure that physicians' self-interest does not limit their ability or willingness to make the standards rigorous or to enforce them, a growing need exists for accountability and transparency. Regulation may require a new shared approach that includes collaboration with other stakeholders and an acceptance by physicians of the need to be increasingly publicly accountable. This balance between the profession setting the standards and the public holding them accountable to meet those standards can be called “shared regulation.”¹⁰

Although certification in the United States is voluntary, most primary care physicians and specialists choose to certify once they complete their training through one of the American Board of Medical Specialty member boards. The focus of this article is on the majority of physicians who train in an allopathic program in the United States. This does not include osteopathic physicians or international trainees who are not eligible for American Board of Medical Specialty certification. Because licensing in the United States does not differentiate between specialties, certification is a way for physicians to demonstrate their knowledge in a particular specialty, subspecialty, or both.

Since 1990, physicians who choose to certify after training must regularly recertify (every 5-10 years depending on their specialty) to retain board-certified status.¹¹ Certification is conducted by specialty boards, which are independent medical bodies, led by physician member directors who define the standards for a clinical domain. For all specialties, the Maintenance of Certification process includes 4 elements: evidence of good professional standing (usually defined as an unrestricted license to practice in a jurisdiction); participation in knowledge self-assessment; a secure examination; and a practice audit and improvement exercise.¹²

Driven largely by external pressures, recertification is a relatively new process in the United Kingdom and is under development for full implementation in 2011. It will be a single process for both general practitioners and specialists leading to 2 outcomes—relicensing and recertification.¹³ Relicensing will require all physicians to demonstrate that they have taken part in annual appraisals; undergone peer and patient feedback; continued their professional development; and have no unresolved concerns about their practice.

Additionally, specialists will need to demonstrate the quality of their practice using a variety of evidence-based tools that could include clinical audits; knowledge assessment; and clinical outcomes data. The process will be regulated by the General Medical Council and implemented within local hospitals, with specialist standards set by the individual Royal Colleges. In contrast to the United States and Canada, the United Kingdom has no multispecialty standard-setting organization. This role is undertaken by the separate specialty colleges. All of the results of the recertification processes in the United Kingdom are discussed with physicians during annual appraisals and are reviewed every 5 years by a locally based responsible officer who will make recommendations about individual physicians to the General Medical Council.

Canada has no national recertification system, although the question is attracting attention and causing debate.¹⁴ The Canadian Federation of Regulatory Authorities, a national organization of the provincial regulators, recently issued a report supporting recertification that suggests a set of guiding principles.¹⁵ However, the process for ensuring that physicians maintain their clinical competence depends on the independent and heterogeneous regulatory decisions of each provincial College of Physicians and Surgeons that licenses physicians. Several provinces, but not all, have mandated that physicians participate in an educational program, typically the Royal College of Physicians and Surgeons' Maintenance of Certification program or the College of Family Physicians' Maintenance of Proficiency program, to maintain licensure. These programs require physicians to report their participation in a variety of educational activities annually, with the colleges conducting random audits of the documentation. Several provinces also require a peer review process in which practice is assessed through office visits conducted by colleagues.

The recertification processes in each of these 3 countries have a number of similarities (Table 2). First, each is founded on systems of medical education driven by standards and assessments in training that are developed by the profession. Second, an element of self-regulation is retained with professional organizations' taking the responsibility of establishing, implementing, and maintaining processes that are an integral part of the overall regulatory framework. Third, there is recognition that any evaluation of practice needs to be robust, objective, based on evidence, and consistently applied. Fourth, the evaluation of physicians requires evidence that is up-to-date in both knowledge and clinical practice. Fifth, the process is primarily designed to ensure a basic standard of competence rather than distinguishing a subgroup of higher-performing physicians.

The 3 programs also have differences. First, only the United States has a physician-led standard-setting organization independent from physician membership organizations. In both Canada and the United Kingdom, the Royal Colleges are both membership and standard-setting organizations. Second, only the United States' program has high-stakes assessment that requires a summative assessment of knowledge through a pass-fail examination in the area of specialization. Third, physician leadership in the process varies. For example in the United Kingdom, self-regulation is diluted with greater responsibility assigned to the regulator and employers. Fourth, the ways in which the external environment uses the credential varies. In the United States, where recertification is voluntary, many hospitals and health plans require certification for privileges or participation in their networks. In Canada, some provinces require participation for a license to practice the specialty. In the United Kingdom revalidation is mandatory for all practicing physicians.

There are 4 main types of drivers for the development of recertification systems: economic, political, social, and professional. The primary drivers in the countries have varied, but the resulting systems all share similar attributes. Most health care in Canada and the United Kingdom is funded by the government, whereas health care in the United States is supported by a mixture of public and private funding. Not surprisingly, the influence of economic drivers for recertification has been the strongest in the United States. The increasing cost of medical care and a heightened awareness of employers, government, and private insurers of the quality gaps have been powerful forces for increased regulation.

Recertification in the United States is part of a broader movement of accountability that includes the performance assessment of physicians, the public availability of physicians' certification status, and creation of greater links between pay and performance.¹⁶ Third parties have used the US certification system to make decisions about credentials, employment, and reimbursement, and the public has begun to expect physicians to participate in an ongoing assessment program.

Political drivers for recertification are linked to close government involvement in the development of health care policy and delivery. The primary impetus for the United Kingdom has come from the government, chiefly in response to a number of damaging high-profile cases of inadequate or incompetent clinical practice, for example, the Bristol inquiry.¹⁷ Mortality rates for children undergoing cardiac surgery were discovered to be more than twice as high as in other centers due to a combination of inadequate infrastructure, limited monitoring of medical standards, and an inappropriate professional culture. A full public inquiry by the UK government resulted in highly publicized criticism of the hospital management, physicians, and team members and led to calls for increased accountability and scrutiny of the medical profession. As a consequence, there has been an expansion of regulatory systems within the National Health Service including local clinical oversight, annual appraisal, and legislative amendments to medical regulation.^{18 - 21} Moreover, as part of a wider agenda to improve the quality and management of health care, the UK government has proposed the development of a compulsory, integrated regulatory program with oversight in all levels of medical care from hospital systems to the practice of individual physicians.²² Although political drivers are also evident in the United States^{22 - 23} and Canada, the United Kingdom has a higher level of governmental involvement. In the United States and to some extent in Canada, government programs such as pay-for-performance have emerged but they are relatively modest.

Social drivers for recertification have increased patient awareness and expectations about the quality of care that they should receive. With an increasing number of individuals searching for physician-specific information on the Internet, there is an increased desire for relevant, accessible, and meaningful differentiation of physician competence with public ratings of physicians on Web sites like Yelp, Zagat, and RateMDs.com.^{24 - 26} In the United Kingdom, patients and the public have become increasingly vocal arguing that self-regulation is not adequate and calling for a more transparent and objective system of medical regulation.³ One of the primary aims of recertification in the United Kingdom is to increase public confidence in regulatory mechanisms following a number of high-profile scandals involving physicians, hospital services, or both.⁵

In the United States and increasingly in Canada, organized consumer advocates are knowledgeable and vocal in their call for more detailed information about the quality of physicians. As pressure increases in each country for more and more differentiated information related to physician performance, recertification could lead to more detailed, publicly available information about individual physician performance—providing clinically relevant information for individuals to enable more informed physician choice and increasing pressure on physicians for quality improvement. Furthermore, in the United States and Canada the Institute of Medicine reports on quality and patient safety heightened public awareness of gaps in quality of care.^{27 - 28} The release of the reports has led to increased governmental oversight in regard to medical errors and government programs that reward higher quality.

The fourth driver for recertification comes from within the medical profession. In the United States, self-regulation and recertification has been in place for several decades reflecting the profession's desire to ensure the standard of the medical care. Physicians in all 3 countries have long undertaken a range of activities designed to encourage reflection on their practice and working for ongoing quality improvement of care. Such activities include clinical audit, the development and implementation of clinical guidelines, continuing professional education and development, and peer review systems.

Professional standard-setting bodies often require higher standards of practice than either governments or the public. Standards set by these professional bodies are more likely to be supported and acceptable to physicians than those set by external groups. Moreover, professional bodies are becoming increasingly aware that if they do not lead the physician regulatory process, this privilege will be lost.

One of the most challenging aspects of any recertification system is determining the level at which performance is deemed as acceptable. If the primary purpose of recertification systems is to ensure that physicians meet a minimum standard of competence, then the required level of performance could be set at a lower level. Setting standards for this purpose would involve the identification of a minimum level of performance that reflects competence rather than comparative or exemplary high quality. In contrast, if a recertification system is designed for ongoing quality improvement, the level of acceptable performance would periodically move upward to reflect an overall improvement in performance over time. Physicians could be recognized for achieving higher levels of performance, by quartiles overall or by excelling in specific clinical areas, although none of the 3 countries has adopted this approach. Typically physician organizations prefer a minimal standard, whereas stakeholders outside the profession—including the public and payers—would prefer a graded standard to distinguish between acceptable and excellent physicians.

A question associated with the aim of recertification is whether the process should be purely summative or retain a formative element.^{29 - 30} All 3 countries are trying to incorporate both formative and summative assessments into their process. Ultimately, any process should lead to a summative decision about performance (pass/fail) to meet the need for a minimum standard of competence, but equally important is designing a process that allows a physician to learn and improve. The aim of continuous quality improvement extends the purpose of recertification beyond a pass/fail evaluation to one that also incorporates formative components. In these models, physicians measure aspects of their practice, identify areas for improvement, undertake activities to improve, and then remeasure. Because the current processes are driven largely by physicians, the programs in all 3 countries are designed to build knowledge, not just test it, and to improve skills.

Proponents have suggested that recertification in medicine should be able to adapt a number of methods or tools that are already used in other disciplines for performance evaluation, such as simulators in aviation or 360-degree feedback in industry.³¹ Across all 3 countries, a range of projects are in place for which new methods and tools are being developed, piloted, and evaluated.^{32 - 34} Recertification needs to include assessments that cover the full range of skills, knowledge, behaviors, and attitudes required to practice medicine to a high standard. No single method or measure can demonstrate all these attributes; rather, it requires a multiple assessment approach in which evidence can be triangulated to provide a comprehensive view of a physician's knowledge and practice.

Knowledge can be evaluated through an examination; behaviors and attitudes evaluated through multisource, 360-degree feedback surveys, peer review, or patient surveys; and skills and practice evaluated through a range of clinical data including clinical audit, clinical outcomes, mortality and morbidity, complaints, incidents, procedural logbooks, or structured case reviews. The CanMeds roles and the Accreditation Council for Graduate Medical Education assessment programs attempt to evaluate all the competencies in Canada and the United States, respectively. The Accreditation Council competencies include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.^{35 - 36}

Another consideration is whether recertification should include a regular examination of knowledge. Cognitive examinations are used to evaluate knowledge, diagnostic skills, and clinical reasoning.³⁷ Surveys find that the public mistakenly believe that regular examinations are already in place, and survey respondents strongly support the introduction of regular testing when they learn that this is not already the case.³⁸ Moreover, increasing evidence suggests that performance in an examination is correlated with the quality of care provided by individual physicians.^{39 - 43} For example, Holmboe and colleagues found that higher scores on the American Board of Internal Medicine examination were associated with higher rates of performance in providing care for Medicare patients.⁴¹

Although secure examinations are an established part of recertification in the United States, their consideration is highly contentious in Canada and the United Kingdom. A number of arguments have been put forward against the introduction of a regular, formal knowledge assessment.⁴⁴ Opponents of a cognitive examination argue that the process should test competence in actual practice, something an examination cannot do. Second, some physicians contend that an examination fails to take into account the specific expertise and experience gained through years of practice. Yet evidence demonstrates that physicians' knowledge declines with increasing years since graduation.⁴⁵ Third, many argue that as physicians progress in their career, they often become highly specialized in their practice and a general examination would not be relevant. In the United States physicians are offered the opportunity to be tested in a number of areas of specialization and the US boards continue to receive requests from physician organizations for new areas of specialization to be recognized through the certification process. Moreover, it is difficult and expensive to design a range of examinations to cover the highly individualized and specialized practice of physicians throughout medicine.

A cognitive examination is required by the American Board of Medical Specialty in the United States but is not part of the process in any provinces in Canada. In the United Kingdom, a number of specialties are in the process of developing open-book, online knowledge assessments. This type of informal knowledge assessment seems reasonably well accepted by the medical profession. In addition to evaluating the knowledge of the physician, these open-book formats provide an opportunity to encourage physicians to undertake additional study and update their knowledge while completing the assessment.

Recertification is created for the evaluation of the performance and competence of an individual physician. In recent years, the practice of medicine has become more team based and the quality of care provided by a single physician is linked to the performance of peers, as well as the infrastructure and support available in the medical group. Studies of medical error show that systems failure, in addition to cognitive deficiencies of individual clinicians, lead to harm.^{46 - 47} The question for recertification is whether it is desirable only to use methods and evidence that can isolate the performance of the individual or alternatively to measure both individual physician and systems factors. Furthermore, the best method to assess the physician in the organizational context is an issue of ongoing research.

What information should be available to the public? In the United States, the American Board of Medical Specialty maintains a Web site that provides information about whether individual physicians are certified or have recertified (if they completed training after recertification was implemented). The detail provided about each physician is increasing over time as the public, payers, hospitals, and others look for more information. In Canada, the public can determine whether an individual physician is certified by one of the Colleges and whether they are participating in the Maintenance of Certification program. In the evolving revalidation process in the United Kingdom, there is concern from physicians about confidentiality, freedom of information, and access to data, especially if unadjusted data related to their practice is made publicly available or used to set management targets. Undoubtedly, there will be an increasing demand for publicly available information about physicians, health care teams, or both. This information will need to be clear and unambiguous, meaningful for the intended audience, and based on valid and reliable measures.

Any form of recertification is unlikely to be more than a “check the box” exercise unless it is seen as useful and clinically relevant by the profession and external stakeholders. In the United States, the majority of physicians who have time-limited certificates are voluntarily renewing their certification, even though doing so is not a legal requirement to practice. Recertification is considered an important part of professional identity and is increasingly expected by medical groups, hospitals, and other employment settings. Employers, hospitals, and increasingly patient groups know the term “board certified” and some seek out this information in order to make informed choices about physicians.

In the United Kingdom, revalidation was initially viewed by physicians with some skepticism, possibly because it was largely driven by a regulatory, governmental agenda rather than by the profession.⁴⁸ Critics argue that the introduction of recertification is an unnecessary bureaucratic burden for physicians and employers; highly resource intensive with money and time better spent on health care service provision; a bureaucratic exercise that is unable to evaluate practice in any relevant detail; and a flawed process that will still fail to identify those physicians who act in a criminal or negligent way. Professional acceptance is more likely if the process is not unduly burdensome, uses the information and data that physicians already collect, and proves relevant to the improvement of the quality of practice and patient care.

In Canada, medical regulators are calling for ongoing assessment of physicians' competence and better methods to measure performance in practice. Although some provincial regulators have tried to introduce new approaches to practice assessment, physician organizations are often resistant to any system seen as too burdensome or time consuming. The issue of revalidation has stimulated much recent controversy.^{15 ,44}

If recertification is to become more effective in encouraging the ongoing improvement of practice and delivery of care, it will need a continuing improvement process acceptable to the majority of the profession, patients, and payers in health care. It will need to be functional and useful within day-to-day practice, pragmatic, a low burden of additional work, and resource efficient in terms of both time and cost. In each of the 3 countries, the process of recertification is undergoing continuous modification and improvement as better measurement tools are created and evidence informs best practices in the field.

It is no longer a matter of “if” but “when” widespread recertification will be required for medical practice in all 3 countries. Throughout the last 2 decades, the regulation of physicians has evolved rapidly with the introduction of recertification, a greater focus on the development of standards of practice, and the inclusion of measurement of quality of care in actual day to day practice. Recertification, if consistently implemented and robustly maintained, will lead to a process that can help protect patients from underperforming physicians, enable physicians to identify areas needing improvement and demonstrate they are up to date and fit to practice, increase public confidence in the medical profession, and improve the quality of heath care.

The challenge facing the medical profession, if it wishes to retain a significant leadership role in regulation, is to set standards that are evidence based, outcome oriented, satisfactory to the general public, not excessively demanding on physicians, and reinforcing medical professionalism. Ultimately this responsibility is likely to be shared between the profession and the public who are calling for greater accountability and oversight of the medical profession.