Abstract
The evaluation of professionalism is embedded in the American Board of Medical Specialties’ continuing certification programs for its 24 member boards.1 Currently, professionalism assessment is largely restricted to documenting professional standing, such as the status of medical licenses and medical staff privileges. With increased recognition of an expanded view of professionalism to include professional behaviors and competencies comes an opportunity for medical specialty boards to embrace a more formative approach to professionalism assessment. The goal of such an approach is to educate, reaffirm, and reinforce positive professional behaviors long beyond completion of formal medical education.
- Certification
- Licensure
- Medical Education
- Medical Staff Privileges
- Physicians
- Professionalism
- Quality Improvement
- Specialty Boards
In the framework of the American Board of Medical Specialties (ABMS) continuing certification program, Part I—professionalism and professional standing—is arguably the most important in fulfilling the social contract between the medical specialty boards and the public. The other 3 pillars of this framework, lifelong learning and self assessment (Part II), assessment of knowledge, judgment, and skills (Part III), and improvement in medical practice (Part IV),1 can be incorporated into the many professionalism behaviors of medical practice.2 Although professionalism is the underpinning of board certification, and more broadly, medical practice, the ABMS member boards are challenged in adequately incorporating professionalism assessment into both initial and continuing certification.
The 2 universal sources of information used by the ABMS boards to assess professionalism are evidence of a current and unrestricted medical license, and the receipt of disciplinary action reports from the Federation of State Medical Boards.3 These reports categorize state medical board disciplinary actions for physicians and report them regularly to medical certifying boards. While these reports provide a valid source of information on physician professionalism behaviors, they are described as identifying only the “tip of the iceberg” in physician professionalism problems.4 In addition, the binary response to these reports from the majority of ABMS certifying boards—certification revocation or not—fulfills a duty to the public but offers little guidance or assistance to physicians. The epidemic rise of burnout among physicians reflects the extreme conflict of personal and societal expectations of exceptional professional performance, and the heavy workloads, educational debt, time, and resource constraints faced by physicians.5
In response to concerns about the value of continuing certification, the ABMS member boards are developing more formative assessments, mostly in the domain of medical knowledge, to better engage physicians in the process.6 The boards also have a collective opportunity to envision the domain of professionalism as more than compliance activity. A positive approach to professionalism includes both incorporating formative approaches to its assessment and highlighting professionalism successes that support and reinforce professionalism behaviors in medical practice.
The assumptions framing the assessment of professionalism do not differ from those for the other components of continuing certification; professionalism incorporates a learned series of competencies that, like other knowledge and skills, must be renewed.7 While a complete definition of medical professionalism continues to be debated, a core list of teachable and measurable professional behaviors is the framework for assessment in medical school and residency. In the complex environment of today’s medical practice, skills such as situational analysis, effective apologies or managing conflicts of interest require far more than virtuous personal attributes; they require study and mentoring.4 In starting with the positive assumption that physicians are motivated to model professionalism and that continuing certification can assist physicians in attaining that aspiration, the certifying boards can do more than enforce; they can facilitate and guide.
Accreditation Council of Graduate Medical Education standards for residency training now include professionalism milestones among the core competencies for all specialties.8 The premise is that learners will achieve these competencies over their residency years. It is logical to consider these competencies could wane over time in a dynamic environment or in a culture promoting some values over others. Professionalism competencies, along with other competencies acquired in training, can be renewed through the more formative approach to continuing certification now emerging in the ABMS Boards.
The domains of lifelong learning and self assessment (Part II) and assessment of knowledge (Part III) offer ready structures for professionalism activities. Cased-based studies and discussion in innovative formats such as webinars or learner feedback programs facilitate the conversations that enhance the sense of shared challenges and peer support. These can be offered to both resident learners and board-certified physicians in practice. The ABMS member boards are developing innovative longitudinal knowledge assessments, more formative “assessments for learning,” which allow for the inclusion of a wide variety of educational materials, such as articles, case presentations, digital media, in addition to knowledge questions. Although these assessments are primarily geared to continuing certification, the American Board of Nuclear Medicine has invited residents to participate in their longitudinal assessment, thereby introducing residents to the professional role of self-directed learning.9 In addition, the longitudinal assessment platforms provide feedback to learners and links to additional resources. Physician performance on topics addressing professionalism can guide both individual learning plans and group activities and provide opportunities for meaningful collaboration with specialty societies. Given the cross-specialty nature of professionalism issues, the certifying boards community could jointly develop and share assessment for learning materials.
Improvement in medical practice, Part IV in the continuing certification framework, offers an additional pathway to teach and reinforce professionalism behaviors. Guided improvement projects are offered by several ABMS boards and specialty societies; topics addressing professionalism challenges, such as physician wellbeing or a peer review of communication skills, could be incorporated into the offerings and could be an additional path for specialty boards to work together on development of formative materials that are relevant to practicing physicians. Such tools provide opportunities for self reflection (and possibly, for seeking help) and underscore the value of professionalism in the continuing certification programs.
Aside from quality projects aimed specifically at professionalism education and advancement, practice improvement offers an ideal opportunity to renew professional pride through highlighting exemplar projects. For example, the American Board of Physical Medicine and Rehabilitation (ABPMR) selects “5-star” quality projects each month and highlights them on the ABPMR website, on social media, and in the ABPMR newsletter. The ABPMR facilitates presenting these projects as posters at specialty society meetings annually. This recognition celebrates professional achievement and reinforces a culture of pride in medical practice.
Likewise, peer review, a process used by several of the ABMS specialty boards to assess both quality and professionalism, can function to add important recognition of professionalism excellence. The American Board of Orthopedic Surgery (ABOS) employs rigorous peer review in its Maintenance of Certification program, with half of the survey questions devoted to professionalism behaviors.10 Local peers are identified by the diplomate, and separately by ABOS based on location information, and feedback is gleaned from 7 or more individuals. Concerning trends may lead to discussions between ABOS leaders and individual physicians. The process emphasizes the board’s commitment to the professionalism pillar of continuing certification. Peer review could be further developed to include formative opportunities, such as coaching arrangements, through the boards, local health systems, or other organizations. Few affirmations are as meaningful as the endorsement of peers. Expanding peer review beyond “enforcement” to incorporate positive feedback can strengthen a local medical culture—and a specialty culture—of exemplary professional behaviors and medical excellence.
A discussion of supporting professionalism in certification processes would be incomplete without addressing the response of certifying boards to professionalism lapses. While every ABMS specialty board has implemented a thoughtful process to adjudicate lapses in professional behaviors, these decisions are driven by the duty of the certifying boards to protect the public. This accountability is a critical function of the boards; however, it does not incorporate the additional step of providing guidance to affected physicians. In some cases, professionalism concerns may surface long before problems reach the level of a state medical board response, such as through peer review or interactions with board staff. Some boards have identified risk factors for future professionalism breaches associated with lack of participation in continuing certification or with actual performance on knowledge assessment examinations.11,12 Identifying and addressing these behaviors through individual feedback, and interventions such as coaching or guided learning, may provide the support needed to avoid ongoing or more severe breaches, and actually would align with the boards’ mission to protect the public.
The ABMS member boards have not considered remediation of professionalism lapses as within their purview, unlike their various approaches to remediation for the other components of continuing certification. The boards community can acknowledge a lack of expertise in addressing the scope and complexity of professionalism lapses for remediation, however external resources are available for both collaboration and referral. It may be one of the most significant supports of physician professionalism for certifying boards, perhaps collectively through ABMS, to become familiar with these resources and facilitate a path back to good standing for physicians who have a professionalism lapse. That said, there is a paucity of information in the literature addressing the effectiveness of remediation in professionalism lapses, and this remains an area requiring further study.13
How will we know whether any of these or other positive approaches from the specialty certifying boards will improve the culture of professionalism in medicine? The certifying boards will continue to receive the Federation of State Medical Boards (FSMB) disciplinary reports; they will analyze responses to questions posed on assessments and scrutinize quality improvement projects addressing professionalism issues. These data will be useful for following trends. A more significant measure might be a reduction in the alarming degree of burnout reported by our colleagues; this would reflect an evolution in the relationship between the certifying boards and physicians from one of enforcement to one of partnership in professionalism.
Notes
This article was externally peer reviewed.
Conflict of interest: CLK is employed by the American Board of Physical Medicine and Rehabilitation.
Funding: None.
- Received for publication October 14, 2019.
- Revision received February 2, 2020.
- Accepted for publication February 4, 2020.