Promoting Quality Patient Care Through Physician Competence: Applying Deliberate Practice to Lifelong Learning

Professionalism. Demonstrating commitment to professional responsibilities, ethical principles, and sensitivity to diverse populations.

Medical Knowledge. Understanding the application of biomedical and clinical sciences in patient care.

Patient Care and Procedural Skills. Providing patient care that is compassionate, appropriate, and effective.

Interpersonal and Communication Skills. Demonstrating effective information exchange with patients, their families, and professional associates and fostering an ethical therapeutic relationship with patients.

Practice-based Learning and Improvement. Evaluating patient care practices and assimilating scientific evidence to improve practice.

Systems-based Practice. Demonstrating awareness of responsibility to the larger context and systems of health care.

Part 1—Professional Standing. Board-certified physicians must maintain a valid, unrestricted license to practice medicine.

Part 2—Self-assessment and Continuing Medical Education (CME). Board-certified physicians must objectively assess gaps in their medical knowledge at regular intervals and participate in CME activities to address those gaps.

Part 3—Cognitive Expertise. Board-certified physicians must document that they have the fundamental knowledge to provide competent patient care by passing a secure, proctored examination at regular intervals.

Part 4—Performance in Practice. Board-certified physicians must regularly compare the quality of care they provide to patients against peer-based standards and obtain feedback from patients and peers about their clinical practice. They must identify any areas of practice deficiencies, modify their practices to address those deficiencies, and subsequently reevaluate their patient care to determine whether those deficiencies have been corrected.

Accountability. It must reassure the public that ABPN diplomates complete specific activities designed to maintain their competence.

Independence. It must be developed by the ABPN itself within the guidelines set by the ABMS.

Peer-Driven. It must be developed by ABPN diplomates for ABPN diplomates.

Competence. It must be designed to assess and improve the performance of ABPN diplomates in all six General Competencies.

Continuous Quality Improvement. It must require continuous assessment and improvement in the medical knowledge and clinical activities of ABPN diplomates.

Professionalism. It must mandate acceptable professional behavior by ABPN diplomates.

Credibility. It must fulfill the competency requirements of major external organizations.

Collaboration. It must be developed in cooperation with professional organizations affiliated with the ABPN (e.g., APA, American Academy of Neurology, etc.).

Convenience. It must be designed in a manner so that its requirements are not overly burdensome for busy ABPN diplomates.

Lifelong Learning. It must reinforce the performance improvement activities of ABPN diplomates over their entire professional careers.

Insufficient training for the realities of the current health care era. Current medical education programs do not adequately prepare physicians for the challenges they will face in modern clinical practice (7). Educational reforms need to place more emphasis on improvement science; patient safety; team-based care; the integration of basic science, clinical experiences, and health systems; longitudinal training; and patient-centered care.

Failure to follow evidence-based standards of care. The existence of evidence-based practice guidelines for patient care does not necessarily mean that they will be used (5). Many physicians seem to be unaware of existing practice guidelines, find them too complicated to understand, or simply delay using them in the evaluation and treatment of their own patients.

Inadequate self-assessment. The research on self-assessment underscores the difficulty that many physicians have in identifying their own competence problems (16). A majority of the studies demonstrate little, no, or an inverse relationship between self-assessments done by physicians themselves and external assessments of those physicians. More problematic is the observation that the worst accuracy in self-assessment is frequently among the least skilled and most confident physicians.

The negative effects of time. Time often has an insidious effect on the knowledge, skills, and performance of physicians (17). Research studies reveal problems in knowledge, performance, adherence to standards of practice, and actual health outcomes with the increasing age and experience of many physicians.

Failure to consider patient perspectives about care. Consideration of patients' wants, needs, values, and opinions has become an essential component of quality care (4, 6). The competence to provide such patient-centered care is an important current component of efficient, individualized evaluation and treatment.

Failure to consider feedback from peers. The complexity of modern medical practice mandates effective teamwork and collaboration (4, 7, 18). There is growing sentiment that professional colleagues might be in the best position to provide physicians with constructive criticism and recommendations for improvement, especially in the humanistic, noncognitive aspects of their performance.

Failure to adhere to appropriate standards of professional conduct. Disciplinary actions by state medical boards clearly document problematic professional behaviors by some physicians, including negligence, incompetence, and inappropriate contact with patients (19). Although there may be disagreement about some of the nuances concerning the assessment of physician performance, professionalism must be the bedrock of any framework for competence.

Professionalism. Maintaining appropriate and ethical behavior and providing competent, state-of-the-art clinical care.

Medical knowledge quality improvement. Objectively identifying and addressing medical knowledge deficiencies.

Demonstration of acceptable medical knowledge. Performing adequately on formal assessments of medical knowledge.

Patient care quality improvement. Conforming patient care to practice guidelines or standards of care and responding to patient concerns and peer suggestions about how to improve patient care.

Objective identification of competence deficiencies. Given the limitations of subjective self-assessment (16), more objective, external measures are needed to identify deficits in physician competence. Self-assessment and MOC examinations, comparison of clinical performance to standards of care, and feedback from patients and peers are examples of such measures.

Specific programs designed to correct deficiencies. Remediation efforts of physicians should not be general in nature or directed only toward areas of personal interest, but rather should be designed specifically to address identified deficiencies in competence. Focused CME, clinical practicums, and peer consultation can be helpful in this regard.

Constructive feedback to document improvements. One-time assessments of physician competence are inadequate to stimulate improvement. Regular follow-up evaluations are needed to ensure that remediation efforts have been successful. Repeat self-assessment examinations, clinical performance comparisons to standards of care, and patient and peer feedback can help keep physicians on track toward improved competence.

Extensive effort over an extended period of time. Competence improvement is not a simple, time-limited activity but rather a continuous effort over the professional lifetime of a physician from medical school to retirement. Implementing on-going strategies to assess and improve competence should become part of the lifeblood of quality physicians.

Commitment to complete a demanding, difficult process of improvement. Competence improvement is hard, rigorous work that will be a mental challenge for any physician. The willingness to repeatedly expose one's deficiencies and to implement difficult measures to correct them takes special discipline and fortitude, but it is the only way to promote improvement and ensure competence.

Support for improvement efforts. Few physicians will be able to make significant improvements in their competence without support. Professional and regulatory organizations can help physicians in their improvement efforts, including communicating the specific LLL activities physicians must complete to fulfill the requirements of external organizations, developing practical and convenient LLL products that physicians might use to meet those requirements, and facilitating the documentation and reporting of completion of LLL activities by physicians. Perhaps most important, specific requirements for the demonstration of physician competence should be designed to stimulate the physician's intrinsic motivation to pursue LLL by promoting their autonomy, mastery, and purpose (23). The most effective requirements will reinforce the self-directed improvement efforts of physicians, include improvement activities of specific value to promoting physician competence, and establish a clear relationship between improvement in clinical performance and one's professional identity as an exceptional physician providing quality patient care.