Structured Training Programs, Certification & Re-Certification: Perspectives from Overseas

2. Structured Training Programs,Certification & Re-Certification:Perspectives from Overseas David Ingbar, MD Director, Pulmonary, Allergy & Critical Care Division, University of Minnesota President-Elect, ATS

3. U.S. Training Schema • College – 4 years • Medical School – 4 years • Residency – 3 years • Fellowship • Pulmonary only - 2-3 years • Critical Care only - 2 years • Pulmonary & Critical Care (combined) – 3 years • “Real Doctor”

4. Point of Confusion (?) Medical License Is not the same as Certification in a Specialty

5. U.S. Medical Licensing • State specific licensing requirements – vary significantly state to state • Most require degree (MD, DO, etc) plus one year of residency • License does not restrict the type of practice • Hospitals, Payors or Employers may restrict the types of practice • Renewal of license requires: $; CME; and “staying out of trouble”

6. Medical Certification in the US • Individuals become certified in specialty and/or subspecialty areas through Graduate Medical Education (GME) and meeting certification requirements • Training programs are accredited for the quality of their training • If a training program is not accredited, then graduates usually can’t be certified. • Different organizations involved in certification of individuals and training programs

7. The (American) Accreditation Alphabet ABIM ABP American Board of Internal Medicine American Board of Pediatrics AAMC Assoc American Medical Colleges ABMS American Board of Medical Specialties ACGME Accreditation Council for Graduate Medical Education AHA American Hospital Assoc AMA American Medical Assoc

8. ABMSAmerican Board of Medical Subspecialties • Medicine and Pediatrics each are single Boards, including many subspecialties • Surgery has separate Boards of: • General Surgery • Thoracic (& CV) Surgery • Colon & Rectal Surgery • Orthopedic surgery • Otolaryngology • Emergency Medicine recently developed • Sleep recently recognized as a specialty

9. American Board of Medical Specialties • Organization of 24 ABMS Approved medical specialty boards. • Mission of ABMS: maintain and improve the quality of medical care via the Member Boards’ professional and educational standards for the evaluation and certification of physician specialists. • Certification to assure public that a physician specialist certified by a Member Board of the ABMS successfully completed an approved educational program and evaluation process, including a specialty exam. • Coordinate the activities of its Member Boards • Inform public, government, profession and its Members concerning issues involving specialization and certification in medicine.

10. Individual Certification Graduate from approved program Meet requirements to sit for Board exam Pass Board exam(s) Ongoing Continuing Medical Education Meet on-going Board requirements Re-certify (Maintenance of Certification) Program Certification Intermittent review of training programs by ACGME Specify required: curricula; training experience; faculty composition research Procedure competencies Individual vs Program Certification

11. ACGMEAccreditation Council for Graduate Medical Education • Non-profit council established in 1981 to evaluate and accredit medical residency training programs • Member Organizations: • American Board of Medical Specialties • American Hospital Assn • American Medical Assn • Association of American Medical Colleges • Council of Medical Specialty Societies. • 27 Residency Review Committees (RRCs) set standards in individual areas

12. ACGME and the RRC for Internal Medicine (RRC-IM) • Internal Medicine RRC sets standards for Internal Medicine residency and most sub-specialties of internal medicine • Includes pulmonary & critical care • Pediatrics RRC has similar function • Sleep and Allergy/Immunology each have their own RRCs

13. What Does the RRC Do? • Issue general and subspecialty specific standards – change every 5 years • Specify training program requirements • Certify/Re-certify programs (3-5 years) • On-site investigation & review for program certification • Review individual programs – can approve fully, approve with citations, put on probation or decertify

14. Pulmonary Training ProgramSelected RRC-IM Requirements I. Program Director: • Receives at least 25-50% salary support • Protected time (average > 20 hrs/wk); • Certified with at least 5 yrs experience; Faculty: • majority involved in scholarship with productivity; • > 2 key clinical faculty (+PD) devoting > 10 hrs/wk to program Curriculum: • written goals & curriculum for each rotation; • defined supervision & responsibilities for each rotation • structured educational lectures (> 5/month) • significant research component (most with publications)

15. Pulmonary Training ProgramSelected RRC-IM Requirements II. Duty Hours • <80 hrs/wk; average 1/7 days off; • not > 24 continuous hrs; > 10 hrs off between days; • On call not more than 1/3 Assessments • regular evaluations of fellows & program • Annual written evaluations Didactic Education • Required core curriculum/ procedures • Clinical rotations > 5 hrs/wk beyond pt care • Biostats; epidemiology; administration • Ethics & responsible conduct of research

16. Pulmonary Training ProgramsRRC-IM Clinical Time Requirements Pulmonary Only • 24 months duration (or more) • > 12 clinical months • At least 3m critical care • At least 9m pulmonary (non-CC) Pulmonary/Critical Care Combined • 36 months • Minimum clinical times: 6m pulmonary; 6m critical care; 6m P/CC

17. ACGME’s Core Competencies of Clinical Training “Programs must define the specific knowledge, skills & attitudes required and provide educational experiences for their fellows to demonstrate:” • Compassionate, appropriate, & effective medical care • Medical knowledge • Practice-based learning & Improvement • Interpersonal & communication skills • Professionalism • System-based practice

18. Common Citations of Subspecialty Programs by RRC-IM • All major dimensions of programs aren’t structured educational experiences • Continuity clinic at least ½ day per week • Insure meaningful, supervised research experience for each trainee • Monthly have at least 1 conference each: clinical; basic science; research; core conf & jrnl club • All full time faculty must do research & present scientific presentations • Residents do annual confidential program eval. • Resident feedback q 6 months & end of rotations

19. Pulmonary RRC-IM Issues • Should there be a standard curriculum or set of competencies? • What are good outcome measures to assess the quality of training? • How to best implement competency-based assessment? • Training based on time, rather than experiences or patient disease states • Is more clinical time always better? How much is sufficient? • Balance of clinical training and research time for developing academic physician-scientists • Who is setting the standards? RRC-IM includes 1-3 pulm/CC specialists out of ~ 30 people

20. Certification of Individuals • Discipline-specific Boards set standards for individual training & certification • Duration of training • Content areas to be assessed by Board exam • Procedure requirements (program director sign-off) • Nature of Board exam – written; oral; both • Maintenance of certification standards

21. American Board of Internal Medicine Personal Disclaimer: on Pulmonary Subspecialty Board for 6 years & current SEP Co-Chair ABIM Mission: “enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.” Functions: • Sets individual training requirements • Assesses individual professional credentials • Certification exams – General IM 1936; Pulmonary 1941; CC 1987 • Determines policies re profession & specialties • Interacts with other Boards • Recommends individuals for RRC service • ABIM Foundation to develop new initiatives

22. ABIM Pulmonary Exam Blueprint • Infections 13% • Critical care medicine:   Lung 9%;   Non-lung 4% • Sleep:   Respiratory 8%  Non-respiratory 2% • Neoplasms 9% • Airway Obstruction: Asthma 7%, COPD 7%, Other 2% • Interstitial lung disease-related disorders 6% • Occupational and environmental disorders 5% • Pleural diseases 5% • Quality/Safety/Complications 5% • Epidemiology/Ethics/Statistics 4% • Physiology/Metabolism 4% Cell biology 3.5% • Vascular diseases 2.5% • Congenital/Neuromuscular/Skeletal disorders 2% • Transplantation 2%

23. ABIM’s “Secure” Pulmonary Exam • Approx overall 80% pass rate for first time takers • Each new question is tested “live” and performance is assessed before it is counted in individual’s score • Statistical analysis of performance of each question – assess whether it discriminates high and low scorers on other questions and whether it is appropriately difficult • Cost per new question used = ~ $2,000 • Questions require regular review, as practice and knowledge change • Recertification exam pass rates usually 85-90%

24. Maintenance of Certification • Certification used to be permanent • Now time-limited = 10 years • Goals: • improve quality of care • insure professional competency • foster continued learning • promote quality improvement • Complete series of self-examination modules • Pass a secure examination • Cost = ~ $1200 (not including review courses) • ? Recertify in base specialty (IM) – optional??

25. MOCSelf Examination Modules • Self-Evaluation of Medical Knowledge • Open Book, take home, not time-limited • Medical Knowledge modules • ABIM OR professional societies develop • May link to educational material • Recent Advances Knowledge modules • Clinical Skills – PE & patient communication • Self-Evaluation of Practice Performance

26. MOC: Evaluation of Practice Performance Must do at least one of these (new requirement) 3 Components • Demonstrate one uses quality measurement in practice; • Select a relevant aim for improvement that is based on measurement; and redesign one or more practice processes to improve that measurement; • Repeat relevant measurement to determine if the change resulted in an improvement, and report your findings to the ABIM.

27. Practice Performance Modules • ABIM Practice Improvement Modules (PIM) • Chart abstraction and fill out web based form • http://www.abim.org/moc/sempbpi.shtm • Asthma module currently exists • ABIM Survey Modules (Peer, Patient, and Practice Inventory) • Survey 25 patients; 10 peers & self evaluation • Communication module (CHAPS) • Consultation module – in development • Self-directed quality measurement and improvement (create your own; needs approval) • Uses data collected by others – health systems

28. Issues for ABIM • In transition from organization expert in insuring training and knowledge of physicians TO • Goal of increasing quality of patient care and promoting physician QI • Balance needs for general internal medicine and subspecialties • Currently looking at redesign of IM training to make it more popular • Emergency Medicine split off as separate Board • ? Future of hospitalists in ABIM??

29. Two Relevant Case StudiesThe Good, The Bad or The Ugly? • Critical Care Medicine • Sleep Medicine

30. Critical Care in the US • Accounts for ~ 20-25% of all hospital costs • Approx 1 of 3 ICU patients is cared for by a critical care specialist • 90% of US critical care specialists are based in Internal medicine • 85% of US critical care specialists are combined Pulmonary & Critical Care trained • Joint Society & govt studies predict increasing and major shortfall in critical care physicians • Shortage of ICU nurses, respiratory therapists also

31. Critical Care as a Specialty • As of mid 1980’s: Critical Care programs and individuals are separately accredited by American Boards of: • Internal Medicine • Surgery • Anesthesiology • Should there be one homogeneous CC training pathway and a single set of competencies? • Should CC be a primary specialty, coming straight out of medical school? (like Emergency Medicine • Should hospitalists be trained in critical care “Lite”? • ? Role of Emergency Medicine physicians?

32. Sleep Medicine – Recent Status • Growing clinical & research interest in field • Very high reimbursement for interpreting sleep studies • Proliferation of sleep labs of variable quality • High prevalence of Sleep Apnea & other diseases • Field includes pediatric, neurologic, psychiatric & psychologic components • Most pulmonologists not trained comprehensively in sleep medicine • In US, great majority of clinical care provided by pulmonologists • “Rogue” (non-ABMS approved) group = ABSM offered a certification exam for many years

33. Sleep Medicine – Present Status • ATS defined recommended “basal” sleep competencies for all pulmonary trainees • ABIM Pulmonary Board now tests sleep knowledge much more aggressively • ABMS recognized sleep as a specialty • ABIM (with Neurology, Psychiatry & Pediatrics) is developing a single certifying exam in sleep to replace ABSM exam • ACGME created a sleep RRC to certify sleep fellowship programs

34. Sleep Medicine – The Problem • Sleep certification required by increasing number of insurors/payors to reimburse study interpretation &/or pt care • Certification now will require additional one year of dedicated training beyond Pulmonary; Pulm/CC; or Internal Medicine • ? Impact on attractiveness of Pulmonary profession • ? Impact on research time and academic careers of pulmonary trainees • What happens when the high monetary reimbursement goes away?

35. ABIM – Old World • Subspecialties (require 2 – 3 years each) • Cardiology; Pulmonary; Hematology; Oncology; GI; Nephrology; Rheumatology; Infectious Disease • Added Qualifications (require additional 1 year) • Critical Care • Geriatrics • Electrophysiology; Invasive Cardiology; • Sports Medicine • Transplant Hepatology • Sleep – not included

36. ABIM – New World Problems: • Increasing subspecialization & fragmentation of Internal Medicine • Increasing training times = less appealing Altered Structure: • Subspecialties: traditional ones PLUS • Sub(sub)specialties with required parent: • Interventional Cardiology; Electrophysiology • Transplant Hepatology • Subspecialties with “variant” pathways: • Sleep medicine (only 1 year) • Critical Care (3 pathways) • Geriatrics (1 year training) • Adolescent Medicine

37. Conclusions • Rapid increase in required structures & documentation related to training • Much slower growth in development of outcomes assessment tools and ways to assess specific training experience • Setting standards for Training & Accreditation tends to be province of large multispecialty groups • Control and standard setting tend to be removed from most knowledgeable individuals on the front lines • Real risk: increasing clinical training times will damage the pipeline of academic MD scientists • Training mixed with Politics = Danger • Professional societies need to aggressively seek roles in determining proper training and certification policies

38. Questions • If learning is life-long, when is it sufficient for graduation or certification purposes? • Who should decide and how? • Is long term performance of trainees determined by the individual or their training process? • Does one size fit all? • Should we have different program training requirements for individuals who anticipate different career pathways?