Introduction

The Physician Reentry into the Workforce Project is a multi-organization, collaborative effort that aims to address the wide range of issues related to physician departure and subsequent reentry into the workforce, specifically clinical practice. This is being accomplished through a number of venues including the development of these Issue Briefs. This issue brief considers two basic questions pertaining to the end results of a reentry program.

At a 2008 Physician Reentry into the Workforce Conference (jointly hosted by the American Academy of Pediatrics and the American Medical Association) physician reentry programs were an important topic. At the close of the extended discussion, several unanswered questions remained. Consequently, the conference participants, were asked via e-mail to share their answers to some of these questions. The responses to two of these questions are provided in this Issue Brief.

What Does Completion of a Reentry Program Mean?

Among the Responses/Perspectives Shared:

“Completion of a reentry program” means that the individual has demonstrated in a practice setting (e.g., a hospital) the American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME) general competencies as they relate to the individual’s specialty practice: patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The competencies of interpersonal and communication skills and, especially, of systems-based practice – which together encompass effective teamwork — can only be fully demonstrated and evaluated within a practice setting. Therefore, the completion of the “program” occurs only after the individual has returned to a practice setting and has demonstrated his/her competence in that setting.

At the very least, completion of a reentry program should mean that someone has gone through some kind of standardized program where one’s needs have been assessed, some training has been provided, and an evaluation has been administered after reentry training. The difficult thing is that reentry is highly variable and individualistic — the reentrant’s needs guide the type of training necessary. Within this flexibility, there is a need for some type of bottom-line, some kind of basic infrastructure that everyone agreed on.

Medical Boards struggle with certifying that reentry candidates are competent to hold a full and unrestricted license to practice medicine. At initial licensure a candidate has completed formal training, rigorous testing and 1 year of post-graduate work. In addition, they have proven to be of good character. For the reentry candidate they are given full credit for their accomplishment which leads to initial licensure, but they must satisfy the Board that they still possess the requisite knowledge base, skill and character to be competent for reinstituting a full and unrestricted license.

A paradigm that would look like the one the AMA recommends for new procedures was suggested. More information on the paradigm can be found at the following URL: http://www.ama- assn.org/ama/pub/category/2939.html.

An undifferentiated certificate of completion from a reentry program is too nonspecific (and therefore unhelpful for those that need to make decisions based on that information, such as state medical boards and hospitals). However, providing a certificate that parallels the AMA system of four levels (for new procedure education) would likely burden the reentry programs with a level of liability that would make the programs uncomfortable in offering such services. There are drawbacks to offering any type of certificate, lest certification imply standardization where no standard currently exists. While there are just a few reentry programs in existence, each has a different approach and uses different tools.

Perhaps a compromise would involve a certificate of completion with designation of the specific types of activities that the reentry physician undertook, for example: didactic learning; shadowing in a clinical setting; direct patient care; etc. It might also be relevant, as was discussed at the conference, to convey if a needs assessment was conducted for the reentering physician before education was initiated.

Will the Physician Get a Certificate That Attests to His or Her Competence, or a Certificate That Acknowledges That He/She Completed the Program?

Among the Answers/Perspectives Shared:

A certificate of completion is probably the most appropriate “end-point,” for all of the good reasons cited by others in this discussion. It seems it is ultimately up to the Medical Boards to determine competence, based on the individual situation. However, having some standard for competence that is agreed-upon by most, if not all, state boards would be very useful.

If a formal reentry education program includes sufficient work in a practice setting, a certificate of “completion” could be given at the end of the program. However, if the formal education program ends after the individual is only prepared to enter a practice setting, then “completion” should only be certified after some experience in the practice setting itself (e.g., after the individual exercises privileges in a hospital). In the latter situation, it is not clear what the value of the certificate would be – the individual has already entered the workforce and is establishing a track record of competence.

The task before us is to develop pathways that lead to certification of competence. There is an opportunity here for academic centers and/or Area Health Education Centers to provide training and certification of community mentors who can make sound assessments of candidates in regard to their competence. Thus, we can develop programs and clinical opportunities throughout our communities that will move us from “certificates of completion” to certification of competence. One could call this a “town and gown” cooperative venture.

The Physician Reentry into the Workforce Project is supported by the American Academy of Pediatrics, Division of Workforce & Medical Education Policy

For each resident/fellow finishing an ACGME-accredited program, the program director is required to provide a summative evaluation that documents the graduate’s performance during the final period of education and verify that he/she has demonstrated sufficient competence during training to enter practice without direct supervision. Perhaps the same thing can be adopted here. It’s a little bit more that a certificate of completion and not exactly a certificate of competence – it is demonstrated competence during training.

Unless the course specifically has tools to measure competence (and these are validated instruments), then the best a course could do would be to present a certificate of completion.

Since content of the programs will vary, as well as local issues regarding medical liability coverage, licensure etc., it should be recommended at a minimum a certificate of completion and encourage more specific recommendations, if possible, based upon participation (e.g., ability to perform certain procedures, do examinations etc.) The best that can be done is to direct someone toward a program that fills their identified needs. On completion, they would receive a certificate of completion. There is no way to measure competence, practice readiness, skill, or judgment. This is an abstract outcome.

One must be cautious not put the “cart before the horse” regarding this matter, in that the field of physician reentry is at an early stage of development, and at a stage in which individuals should be promoting and facilitating outcomes research, rather than focusing on providing certification, of which no one knows the value. It may be advisable to utilize the considerable expertise and experience of the organizational members of the Coalition for Physician Enhancement who are doing this work, many of whom have been doing so for many years.

Examples /Cases Offered

A few respondents to the questions offered examples that illustrated some of the issues raised. The following are from reentry program respondents:

This reentry program has a list of items that a participant is supposed to complete. If they do, the program lists those and certifies that the participant has completed them. Then, if the participant goes beyond that, the program has documentation by faculty that they do. The program puts the faculty remarks in quotations–that is beyond the call of duty. So, in short, the program gives a certificate of completion. It is unlikely that it can do anything more. This program provides a letter of completion. In part, this is to assuage the fears of faculty, who do not want to certify the competence of someone that they have worked with for months, as compared to the years that they have worked with residents before they certify their competence. Competence can only be assessed in a setting where a physician is actually practicing clinical medicine, but how long should they be observed in practice before that assessment can be made?

Another program noted beginning work with a reentry candidate who has been out of practice for more than two years due to a closed head injury. Through the Center for Personalized Education for Physicians (CPEP) this physician has had a full assessment, including knowledge base and clinical skills working with model patients. He will now spend a minimum of 120+ hours under direct clinical supervision, followed by several months of chart review and quality assessment with his faculty mentor. Although the program is with CPEP, the candidate’s reentry agreement is between him and the Medical Board. Although the program will be reporting back to CPEP, the Medical Board will look to the program director’s assessment, along with the CPEP assessment, to fulfill the reentry agreement leading to a full and unrestricted license, i.e. proof of competence.

Related Questions/Issues Raised

The responses above generated other questions/issues such as the following:

Is reentry local? Is it really a hospital credentialing process at its core (the hospitals have the closest look at what and how a physician practices and the ability to get 360 degree evaluations that parallel–to some extent–the process for initial licensure). Some work has been done to provide some standardized and validated “tools” to assist that local credentialing process. Is this reliable enough for Boards of Medicine to use for licensure? In this model, the hospital credentialing would stand in for certificates and other assessments made by distant third parties and meet many of the other guidelines laid out in the American Medical Association Council on Medical Education Report 6.

In response to the question, if this is really a hospital credentialing process, one respondent noted that this is not the answer in most cases, for a variety of reasons: many physicians reenter practice in the outpatient setting only, and do not require hospital credentialing; and most hospitals do not want this responsibility due to liability concerns and the belief that they are not equipped to identify and address educational needs.

If mentoring systems are used for reentry programs, then there is some “faculty development” work to do to be sure that the mentors reliably know how to mentor and assess. Considerable thought will need to be given to decide where those mentoring programs are based. Some are great, but some are dying.

Can there be an agreed-upon curriculum? An agreed-upon set of assessment tools?

Disclaimer: The previous comments have been paraphrased for clarity and concision from responses received from Reentry Conference participants. As such, they are the opinions of those individuals and do not represent the official positions of either the Physician Reentry into the Workforce Project or the American Academy of Pediatrics.

Resources

The Web site at www.physicianreentry.org provides additional information on the Physician Reentry into the Workforce Project. The Web site also contains practical Resources for both physicians seeking to reenter the workforce and others interested in the issue, including employers, educators, regulatory groups, and medical and specialty societies.

Fair Use Policy: Individuals or organizations interested in distributing this Issue Brief or using its content should acknowledge the authorship of the Physician Reentry into the Workforce Project in an appropriate citation.

Suggested Citation: Physician Reentry into the Workforce Project. Issue Brief: Perspectives on Completing a Reentry Program. Elk Grove Village, Ill. American Academy of Pediatrics; 2009.