Understanding and applying the principles of contemporary medical professionalism: illustration of a suggested approach, part 2.

In recent years, formal professionalism education, training, and assessment have been introduced to medical schools and accredited residency training programs. Current constructs of medical professionalism characterize it as a multidimensional competency rather than a trait. Medical professionalism is a belief system for organizing and delivering care, in which group members (medical professionals) promise patients and the public that they will self-regulate (ie, ensure that medical professionals live up to standards of competence and ethical values). Physicians who are good professionals have lapses in professionalism. Responses to professional lapses should focus on remediation. Failure of groups of professionals to enforce the standards and values can convey to patients and the public a lack of trustworthiness and thereby undermine the foundation of professionalism, the social contract. The Physician Charter sets forth the 3 fundamental principles and 10 commitments that offer guidance in some of the most challenging situations. One example is illustrated herein and is continued from Part 1 of this two-part series.

ABR examinations: the why, what, and how.

The American Board of Radiology (ABR) has provided certification for diagnostic radiologists and other specialists and subspecialists for more than 75 years. The Board certification process is a tangible expression of the social contract between the profession and the public by which the profession enjoys the privilege of self-regulation and the public is assured that it can expect medical professionals to put patients' interests first, guarantees the competence of practitioners, and guards the public health. A primary tool used by the ABR in fulfilling this responsibility is the secure proctored examination. This article sets forth seven standards based on authoritative sources in the field of psychometrics (the science of mental measurements), and explains in each case how the ABR implements that standard. Readers are encouraged to understand that, despite the multiple opinions that may be held, these standards developed over decades by experts using the scientific method should be the central feature in any discussion or critique of examinations given for the privilege of professional practice and for safeguarding the public well-being.

ABR examinations: the why, what, and how.

The American Board of Radiology (ABR) has provided certification for diagnostic radiologists and other specialists and subspecialists for more than 75 years. The Board certification process is a tangible expression of the social contract between the profession and the public by which the profession enjoys the privilege of self-regulation and the public is assured that it can expect medical professionals to put patients' interests first, guarantees the competence of practitioners, and guards the public health. A primary tool used by the ABR in fulfilling this responsibility is the secure proctored examination. This article sets forth seven standards based on authoritative sources in the field of psychometrics (the science of mental measurements), and explains in each case how the ABR implements that standard. Readers are encouraged to understand that, despite the multiple opinions that may be held, these standards developed over decades by experts using the scientific method should be the central feature in any discussion or critique of examinations given for the privilege of professional practice and for safeguarding the public well-being.

The American Board of Radiology Holman Research Pathway: 10-year retrospective review of the program and participant performance.

INTRODUCTION: In 1999, the American Board of Radiology (ABR) implemented an innovative training program track in diagnostic radiology (DR) and radiation oncology (RO) designed to stimulate development of a cadre of future academic researchers and educators in the 2 disciplines. The program was designated the Holman Research Pathway (HRP). An in-depth retrospective review of initial certification examination performance, post-training career choices, and academic productivity has not been written. This report represents a 10-year retrospective review of post-training performance of a cohort of trainees who have had sufficient time to complete their training and initial certification process and to enter practice. METHODS AND MATERIALS: All pertinent proceedings of the ABR and Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committees for DR and RO between 1997 and May 2011 were reviewed. Thirty-four HRP candidates who fulfilled the established evaluation criteria were identified, and their ABR data files were analyzed regarding performance on the qualifying and certifying examinations. All candidates were contacted directly to obtain a current curriculum vitae. RESULTS: Twenty candidates in RO and 14 candidates in DR were identifiable for review. All candidates attained initial certification. At the time of analysis, 23 of 33 (66.6%) candidates were employed in full-time academic practice (1 DR candidate remained in a fellowship and was not evaluated regarding employment status). Fifteen of 20 (75%) RO candidates were in faculty positions compared with 7 of 13 (53.8%) DR trainees. Additional academic productivity metrics are reported. CONCLUSIONS: A high percentage of HRP trainees remained in academic practice and demonstrated significant academic productivity as measured by manuscript authorship and research support. Additional time and observation will be needed to determine whether these findings will be sustained by past, current, and future HRP trainees.

Reliability of oral examinations: Radiation oncology certifying examination.

PURPOSE: Oral examinations are used in certifying examinations by many medical specialty boards. They represent daily clinical practice situations more realistically than do written tests or computer-based tests. However, there are repeated concerns in the literature regarding objectivity, fairness, and extraneous factors from interpersonal interactions, item bias, reliability, and validity. In this study, the reliability of oral examination on the radiation oncology certifying examination, which was administered in May of 2010, was analyzed. METHODS AND MATERIALS: One hundred fifty-two candidates rotated though 8 examination stations. Stations consisted of a hotel room equipped with a computer and software that exhibited images appropriate to the content areas. Each candidate had a 25-30 minute face-to-face encounter with an oral examiner who was a content expert in one of the following areas: gastrointestinal, gynecology, genitourinary, lymphoma/leukemia/transplant/myeloma, head/neck/skin, breast, central nervous system/pediatrics, or lung/sarcoma. This type of design is typically referred to as a repeated measures design or a subject by treatment design, although the oral examination was a routine event without any experimental manipulation. RESULTS: The reliability coefficient was obtained by applying Feldt and Charter's simple computational alternative to analysis of variance formulas that yielded KR-20, or Cronbach's coefficient alpha of 0.81. CONCLUSIONS: An experimental design to develop a blueprint in order to improve the consistency of evaluation is suggested.

Introduction to value-based payment modifiers.

Value-based payment modifiers were legislated by Congress in the 2010 Patient Protection and Affordable Care Act. It is clear in the legislation, and the corresponding proposals published by the secretary of the US Department of Health and Human Services in late 2011, that the intent is to move from paying physicians for reporting to paying physicians for performance. The proposals, developed jointly with CMS, specify that the calculation of payments for performance will be a composite of quality and cost measures. The base year for determining performance benchmarks for the performance measures will be 2013, and the measures will be applied to physician payments on a limited basis beginning in 2015 and to all physician payments by 2017. The role of medical specialty boards, such as the ABR, in the development and deployment of measures is highlighted in this context. CMS's recent conversations with board representatives have indicated their view that the boards' measure development activities are key to increasing physician (especially specialist) participation in the Physician Quality Reporting System to 50% by 2015, from 20% to 30% today. The ABR will continue its past activities in this arena, working with the American Board of Medical Specialties, CMS, and specialty societies, so that ABR diplomates will be able to simultaneously complete their Maintenance of Certification requirements, satisfy the requirements for CMS incentives, and avoid penalties.

Practice analysis: a basis for content validity for american board of radiology examinations in diagnostic radiology.

The ABR performs practice analysis every 3 years, according to its strategic plan, in an effort to strengthen the content validity of its qualifying and certifying examinations as well as its maintenance of certification examinations. A nationwide survey of diagnostic radiologists was conducted in July 2010 for the purpose of determining the critically important and frequently performed activities in 12 clinical categories. The survey instrument was distributed electronically to 17,721 members of the ACR, with a unique identification code for each individual. A 5-point scale was established for both frequency and importance variables. The frequency scale ranged from 1 to 5 as follows: 1 = not applicable, 2 = occasionally, 3 = monthly, 4 = weekly, and 5 = daily. The scale for importance also ranged from 1 to 5: 1 = not applicable, 2 = not important, 3 = somewhat important, 4 = important, and 5 = essential. A total of 2,909 diagnostic radiologists (19.32%) participated. Of these, 2,233 (76.76%) indicated that they spent ≥50% of their time in clinical practice. Because of its brevity of the list of the activities, results for the gastrointestinal category are presented in this article. The list of activities weighted according to importance and frequency is presented in this article and, as illustrated, could become the foundation for developing a more detailed blueprint for the gastrointestinal category certifying examinations in diagnostic radiology. Findings on demographic information are also presented.

American Board of Radiology radiation oncology initial qualifying ("written") examinations.

This report was prepared by those who are closely involved in the radiation oncology initial qualification examinations. The primary purpose of this article is to disseminate information concerning test preparation, test administration, scoring, and reporting processes of the ABR. The authors hope that the information contained in the article will be helpful to radiology residents, program directors, and other interested parties.

American Board of Radiology certifying examination: oral versus computer-based format.

OBJECTIVE: This pilot study of a computer-based examination for primary certification by the American Board of Radiology was designed to acquire comparative data on candidates that were measures of individual performance on the oral examination compared with the computer-based examination. MATERIALS AND METHODS: The pilot computer-based pediatric radiology examination was designed by experienced oral board examiners and the pediatric subspecialty trustees. Images were chosen from the examination repository of the American Board of Radiology. The 20-minute examination was designed to include 8-10 cases with 26-31 scorable units covering all aspects of pediatric radiology. RESULTS: Among the 1,317 candidates taking the oral board examination, 1,048 candidates (79.6%) participated in the voluntary pilot examination. The scores of the two examinations were subjected to statistical analysis. The sensitivity and specificity of the pilot examination were 94.5% and 45.7%. The overall accuracy was 92.8%. Seventy-five candidates (7.2%) who participated in this study received different verdicts on the pilot examination and the pediatric radiology category of the oral examination. Fifty-six of these candidates (5.3%) failed the pilot examination but passed in the oral pediatric radiology category; 19 of the candidates (1.8%) passed the pilot examination but failed the oral pediatric radiology test. Pilot examination scores were higher for candidates who passed the oral pediatric radiology category (median score, 80; interquartile range, 74.1-85.2) than for candidates who failed (median score, 65.4; interquartile range, 58.6-71.0) (p < 0.0001). CONCLUSION: The pediatric pilot examination was useful for differentiating passing candidates from failing candidates when the score in the pediatric radiology category of the oral examination was used as the reference standard. The overall accuracy was 92.8%.

Addressing overutilization in medical imaging.

The growth in medical imaging over the past 2 decades has yielded unarguable benefits to patients in terms of longer lives of higher quality. This growth reflects new technologies and applications, including high-tech services such as multisection computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET). Some part of the growth, however, can be attributed to the overutilization of imaging services. This report examines the causes of the overutilization of imaging and identifies ways of addressing the causes so that overutilization can be reduced. In August 2009, the American Board of Radiology Foundation hosted a 2-day summit to discuss the causes and effects of the overutilization of imaging. More than 60 organizations were represented at the meeting, including health care accreditation and certification entities, foundations, government agencies, hospital and health systems, insurers, medical societies, health care quality consortia, and standards and regulatory agencies. Key forces influencing overutilization were identified. These include the payment mechanisms and financial incentives in the U.S. health care system; the practice behavior of referring physicians; self-referral, including referral for additional radiologic examinations; defensive medicine; missed educational opportunities when inappropriate procedures are requested; patient expectations; and duplicate imaging studies. Summit participants suggested several areas for improvement to reduce overutilization, including a national collaborative effort to develop evidence-based appropriateness criteria for imaging; greater use of practice guidelines in requesting and conducting imaging studies; decision support at point of care; education of referring physicians, patients, and the public; accreditation of imaging facilities; management of self-referral and defensive medicine; and payment reform.