December 4, 1998

If Congress and licensing boards heed the recommendations of the Pew Health Professions Commission, psychiatrists and other physicians may be required to take regular competency exams. The commission has urged Congress and states to adopt tougher standards to regulate the nation's health care workforce, including implementing specific competency requirements and giving the public greater representation on professional boards.

In a report released October 23, titled "Strengthening Consumer Protection: Priorities for Health Care Workforce Regulation," the commission noted that the current professional regulation system-because of its conflicting policies of protecting consumers and taking into account the economic interests of health care professionals-has "serious shortcomings."

According to the report, these shortcomings have resulted in limited public accountability on the part of professional boards, support for "practice monopolies" that hinder patient access to care, and lack of national uniformity.

The Pew Health Professions Commission was created and is funded by the Pew Charitable Trusts. It has developed recommendations for changes in health professions education and advocated for the development of policies that respond to the needs of the nation's health care workforce. Last year Congress took the commission's advice and restricted the number of young doctors allowed to pursue advanced "residency" training, and many of the nation's medical and nursing schools have incorporated commission recommendations of basic skills they should teach. Another proposal to close one out of five U.S. medical schools to lessen the glut of doctors has been rejected.

Former senator George Mitchell, chair of the commission, said, "Health care workforce regulation plays a critical role in consumer protection, yet for most of this century our country has enforced only minimal standards for governing the health care workforce. Quite frankly, these minimal standards have served only to make certain that the most egregiously incompetent health professionals are prohibited from practicing. This is not enough. In these uncertain times for health care, we must do more to make sure that every patient receives quality care."

The report builds on a set of recommendations issued by the commission in 1995 and focuses on three areas for improving how health care professionals are regulated. These include certifying boards and governance structures, scope of practice authority, and continuing competence. The report says it is important that professional boards within each state collect, manage, and publish information that would be useful to those choosing providers. In addition, it said, a persistent lack of coordination among individual boards and among the states has led to underuse of professionals, turf battles regarding scope of practice, limited professional mobility, and restricted access to care for patients.

To alleviate these problems, the report recommends that the states enact and enforce scopes of practice that are nationally uniform for each profession and based on the standards and models developed by a national policy advisory body that would be established by Congress.

Other recommendations of the commission include having states require boards to provide relevant information about health care practice licenses to the public in a comprehensible manner, having Congress enact legislation that facilitates professional mobility and practice across state boundaries, and having states provide the resources necessary to adequately staff and equip all health professions boards to meet their responsibilities.

James Scully, M.D., chair of APA's Council on Medical Education and Career Development, commented in an interview that competency has always been a concern in the health care professions, but that it is coming to the forefront under the influence of managed care. Organizations responsible for testing psychiatrists' competency and setting competency standards such as the Accreditation Council for the American College of Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN), have reassessed their policies in recent years, he said.

"The Pew Commission is an important commission, and its work is always worth reading," said Stephen Scheiber, M.D., executive vice president of ABPN. "Our directors also feel that it is important, with all the advances occurring in the field, to have a mechanism in place to make sure our diplomates are keeping up with those advances."

Current competency measurements for psychiatrists include the Psychiatric Residents in Training Exam, tests given by residency training programs, and specialty boards administered by ABPN. Other organizations that are concerned with competency are the Residency Review Committees of ACGME, which do site reviews of residency programs, determine whether a program is accredited, and develop standards for training in psychiatry. Two APA members participate on the Residency Review Committee in Psychiatry.

In the early 1990s ABPN made certification in psychiatry time limited so that all psychiatrists certified from that point on are required to take an exam for recertification every 10 years. Material for these exams is to be based in large part on practice guidelines.

The APA Council on Medical Education and Career Development and the ACGME Resident Review Committee in Psychiatry have recently been working on ways to make sure measures of competency are reasonable, fair, and valid, said Scully. He said there are many issues to consider when creating or evaluating measures of competency. Procedural competencies, he said, are easier to define and measure, while therapeutic competencies are more complex, tricky, and difficult to define and measure. Evaluations of competency should not get stuck in procedure, and they should mean something in terms of taking care of patients, he noted.

Another aspect of competency evaluation that concerns the APA council, said Scully, is the need to use time, energy, and money well.

"Most psychiatrists remain competent over the years. Let's look at the problem areas versus spending a lot of time and effort," he said. "How do we get a measure that is meaningful and worth the time, trouble, money, and energy needed to produce, administer, and score it? We don't want to end up with a bureaucracy."

The Pew commission's recommendations for better defined scopes of practice are important, but scope of practice among health care professionals in particular is a very complex issue, said Scully. This is an ongoing area for negotiations, he said. Definitions won't end the controversy over scope of practice, he noted, adding that it would be more helpful to define the rules of debate, he said.

"Areas of debate should come from science, not economic desperation. For example, the quest for psychologist prescribing privileges is being driven by economics and the fact that there are too many psychologists."

Competency is going to be much talked about in the coming years, said Scully, in relation to not only professional skills and knowledge but also cultural competency. "The whole process is now in flux."