Do We Need to Re-test or Re-educate the Experienced Doctor of Chiropractic?

States should require each board to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals.

• Require the regulated health professionals to periodically demonstrate competence through appropriate testing mechanisms. Competence assessment testing could be triggered" by a variety of markers or random/targeted peer reviews.


• Cooperate with relevant private sector organizations and with other states to develop and use standard continuing competency examinations to test minimum competence for continuing practice.


• Support expanded use of modern technological tools to enhance traditional competencies and their assessment."

Excerpted from recommendation #7, "Assuring Practitioner Competence: Assessing the Continuing Competence of Health Care Practitioners," from the PEW Health Professions Commission Report on Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century.

These recommendations from the PEW Commission (and others from similar organizations) are already influencing proposed legislation at both the federal and state levels that may affect your practice.
We all know a chiropractor who is practicing below the minimum effective levels. You have treated his or her patients, who came to you because they just weren't getting well. Or you have been in a professional discussion with a doctor, when the level and content of his knowledge made the hairs on the back of your neck stand up.

These are not doctors committing clear cut violations of regulatory law. They are not deliberately defrauding patients or violating their trust for personal gain. They are simply out of touch with practice norms. This can occur because of isolation, age-related decline in skills, chemical dependencies, emotional pressures, etc.

Fueled by the PEW Commission and other public forums, the movement to protect the public from incompetent health care is an increasingly powerful force. And it's a two-edged sword, with some possible benefits for chiropractic. Is it incompetent practice for a medical doctor to operate on a patient who could be helped by a non-invasive approach? Shouldn't MDs be required to demonstrate current knowledge of the effectiveness of chiropractic care?

The issue boils down to several key questions. Are you and your fellow practicing chiropractors ready to be re-examined every 10 years, or are other approaches to identify incompetent practitioners more effective? Does our current chiropractic model of mandated continuing education solve the problem?

Assessing continuing competency is clearly one of the hottest emerging topics in health care regulation. The Federation of Chiropractic Licensing Boards (FCLB) has been actively involved in an interprofessional forum to explore both the issues and appropriate solutions connected with a highly complex subject. This multidisciplinary effort proposes a broader solution than the limited periodic examination promoted by the PEW Commission report and its spin-off legislation.

Questions and Challenges for Chiropractic

1. How widespread is the problem of incompetent doctors? How do we deal with varying levels of incompetency (also called dyscompetency by the medical community)?


2. To what degree is the public endangered by incompetent chiropractors? What are the roles and responsibilities of chiropractic peers and patients in identifying incompetent practitioners?


3. What specific types of incompetent practice exist, and what remedial efforts are most effective in correcting each one?


4. How can a profession best encourage its practitioners to become lifelong learners?


5. Are our current continuing education programs adequate?


6. How can we develop outcome-based changes in continuing education? How do we evaluate the effectiveness of both current and future efforts?


7. Who is responsible for identifying and remediating incompetent practitioners? What types of partnerships need to evolve among the regulatory boards, professional associations, chiropractic colleges, specialty councils, malpractice insurers, managed care organizations, larger business employers, and the public?

Interprofessional Summit Conference Tackles the Issues

Chiropractic had surprisingly strong representation (nine people from seven organizations) at the North American Continued Competency Summit -- Assessing the Issues, Methods, and Realities for Health Care Professions, held July 24-25 in Chicago. The summit was the brainchild of a coalition of about 14 major health care professions, including the FCLB, called the "Interprofessional Workgroup on Health Professions Regulation."

The IWHPR was originally formed because of concerns about recommendations published by the PEW Health Commission Task Force's report, Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. This November 1995 document proposed sweeping changes to the way health professionals are managed, including such controversial recommendations as: licensure based on demonstrated competence only; and oversight boards holding final authority, with the majority of the board members from the public sector. The IWHPR subsequently issued an analysis of the PEW report and its own recommendations on health professions regulation.

Another point in the PEW Commission report was directed to ongoing assessment of the clinical competency levels of licensed health care providers. This issue has also risen to a prominent public position as the result of the Citizen Advocacy Center's December 1996 conference, "Continuing Professional Competence: Can We Assure It?" Both of these groups take issue with the current "licensure for life," and recommend periodic reassessment of health professionals.

To develop the summit conference, the IWHPR secured sponsor funding from a number of health professions, including the Federation of Chiropractic Licensing Boards, and major support grant from the PEW Commission itself.

There were nine chiropractic representatives among the group of 207 individuals from 16 health care professions: Dr. Gerard Clum, president of Life Chiropractic College West; Dr. Laura Szucs, continuing education director at LCCW; Dr. Paul Morin, member of the Maine Board of Chiropractic Examiners; Dr. Jerry Grod, deputy registrar of the Ontario College of Chiropractors; Dr. Douglas Lawson, registrar of the College of Chiropractors of Alberta; Vernon Alleyne, vice president and consumer member of the New York State Board for Chiropractic; Dr. Floyd Larcher, American Board of Chiropractic Orthopedists; and the authors.

Two Models Presented

As the conference opened, two basic models were presented:

1. The markers' model, supported by the Federation of State Medical Boards, in which targeted characteristics may be used to predict doctors with higher probability of problem performance. The markers may include: age; gaps of three months or more in practice; exclusion from Medicare/Medicaid reimbursement; and disciplinary action by a regulatory agency.


2. The continuous quality assurance model was presented by the National Council of State Boards of Nursing. This option proposes that professions design their own programs for assessing competence and remediating incompetence. Several options under this model include portfolios, in which professionals individualize their programs, and regular recertification testing for all licensees.

It was agreed that regardless of the model adopted by a profession, all continued competency efforts depend on the availability of both multiple options in learning strategies, and affordable and acceptable options in assessment options.

Learning strategies may include: self-directed study; outcome-based continuing education programs; computer interactive testing; virtual reality experiences; and traditional lecture approaches. Assessment options included self-assessment tools, and cutting edge computer technology with instant and adaptive feedback.

Evaluating the Effectiveness of Learning Programs

Technical research about the effectiveness of learning programs was presented by a leading authority on continued medical education, Dr. Paul Mazmanian from the Medical College of Virginia. Not surprisingly, programs with higher relevance to practice, and those meeting pre-assessed needs of the participants resulted in the greatest demonstrated change in practice behavior. Scientific research supports the critical concepts of multiple interventions, reminders, and developing mechanisms for incorporating feedback from participants.

All options were evaluated in light of legal, political, and economic implications. Questions about programs included whether they are:

• fair;
• related rationally to job performance;
• present no undue burden;
• individually and professionally acceptable;
• legislatively feasible, and;
• economically affordable.

Participants agreed that issues of assessing clinical competency and program designs need to be well researched and supported by objective, empirical studies. Limited board and professional resources may be multiplied by new, interprofessional collaborative efforts.

Conclusion

The prospect of being re-examined for basic licensure every 7-10 years drives both practitioners and boards into an intellectual and economic frenzy. Although this design has been adopted enthusiastically by voluntary medical specialties, such as family practice certification, its appropriateness for core licensure and all specialties and professions is questionable. A more likely outcome is toward more targeted and personalized CE, with self-assessment of strengths and weaknesses a prelude to needs-based education.

Chiropractic boards require continuing education in all but about three U.S. states, while other health care professions do not exceed 25 states. By numbers of participating states alone, chiropractic may well have a legislatively built-in advantage over other health care professions.

While one benefit of CE is that it brings otherwise isolated practitioners into regular contact with each other and the evolving ethics of professional practice, we still need to determine definitively whether CE is also effective in preventing or remediating incompetency.

The real answers probably lie in our ability and willingness to address truthfully the slippery issue of varying and declining levels of practice competency within our profession. In the interest of the public's health, safety and welfare, we must become our brother's keepers, and have a creative array of remedial and healing options available to treat our practitioners and our patients.

Note: For copies of the full PEW Commission report, or a shorter brochure outlining its recommendations, contact:

PEW Health Professions Commission
Task Force on Health Care Workforce Regulation
UCSF Center for the Health Professions
1388 Sutter Street, Suite 805
San Francisco, CA 94109
Phone: (415) 476-8181
Fax: (415) 476-4113

David E. Brown, DC, FCLB Vice President
Donna M. Liewer, FCLB Executive Director
Federation of Chiropractic Licensing Boards
Greeley, Colorado