February 2005
Feature Story

Pathology is one of the few medical specialties that does not require continuing education to maintain certification over time. That will end in 2006 for newly minted practitioners—and perhaps effectively end for all others—when the American Board of Pathology begins issuing time-limited, 10-year certificates.

The goal is to ensure that all board-certified physicians "meet the highest standards of patient care and accountability throughout their careers," says the American Board of Medical Specialties, which launched its Maintenance of Certification, or MOC, initiative in 2000. The ABMS is a 24-organization umbrella group of approved specialty boards that includes the ABP. (Pathologists do have to document continuing education by state licensure requirements, but these are variable and not pathology specific.)

The CAP’s Education Committee has spent the past year working to make pathology-specific the ABMS’ general specification of the competencies needed to maintain certification, and the committee has begun to explore how its education programs will help fill the gaps between what’s offered now and what will be needed.

The College has shared its thinking about the competency categories and specific skills in a paper submitted in January to the Archives of Pathology & Laboratory Medicine, and will begin rolling out new education programs targeted to the competency categories later in the year, starting with its annual meeting curriculum.

The ABMS defined six general competencies integral to quality care: medical knowledge, patient care, interpersonal skills and communication, professionalism, practice-based learning and improvement, and systems-based practice. It specified that four general methods would address these competencies: evidence of professional standing, evidence of lifelong learning in the appropriate categories, evidence of cognitive expertise (recredentialing examination), and evidence of performance in practice. Each specialty board must define what each of these general methods will be for its members. The ABP is doing so now and has indicated that it will collaborate with pathology education providers like the CAP in this effort.

"The American Board of Pathology is looking to pathology education providers to create education to meet the ABMS requirements for lifelong learning. That’s not a simple task," says Elizabeth Hammond, MD, chair of the Education Committee and a pathologist at Intermountain Health Care. First, she says, committee members had to understand what the requirements were, make them concrete in terms of what is required for pathologists, and then develop knowledge and skill statements that adequately specified each competency category.

"The short story of what the College has been doing to address MOC," says Constance Filling, vice president of the CAP Division of Education, "is to identify and proactively start the development of some education programs that are going to meet these needs. But there are steps to do that. It’s not just sitting down one afternoon and saying, ’I think we need this.’"

College staff began by bringing the Education Committee up to speed on the ABMS requirements, including the time frame, implementation plan, and what was expected of specialty societies including the ABP, Filling says.

"The second step was actually getting down to work and saying, ’OK, if ABMS has defined these six general competencies across all medical specialties, we have a responsibility to contribute to defining that specifically for our specialty,’" Filling says. "Or, at least, to understand it for our specialty in such a way that we can identify potential areas of need from an education point of view—so that we can try to offer education programs in those areas."

Pathologists who become board-certified in 2006 and thereafter will need to be recertified within 10 years. They can take the exam, which the ABP is likely to offer twice each year, as soon as eight years out from their certification date. In addition to taking the examination, these pathologists must provide documentation that they have fulfilled continuing education requirements for each of the six ABMS categories to demonstrate the maintenance of their competence.

Those in practice now will have the option to take continuing medical education, as they have previously, says Loretta Morrison, CAP’s director of education design and development, but "for many of the pathologists out there, at least right now, these requirements won’t apply to them unless there’s some change in the thinking."

But that may be from the standpoint of what only the ABP would require. "It is likely that hospitals, payers, and perhaps malpractice insurers will make "maintenance of competence, or eligibility for recertification, a de facto requirement for everyone,"Dr. Hammond says.

According to recent Gallup Organization findings, more than 75 percent of patients surveyed would choose a board-certified physician over a physician who was not board-certified but was recommended by a trusted friend or family member (Brennan TA, et al. The role of physician specialty board certification status in the quality movement. JAMA. 2004;292:1038-1043). Eighty percent of those surveyed would be likely to seek another physician if their current physician’s certification had lapsed. Most patients believe, then, that the quality of health care is closely linked to the competence of physicians as indicated by specialty board certification (Folberg R, et al. Competency-based residency training in pathology: challenges and opportunities. Hum Pathol. 2002;33:3-6). Education committee members realize that insurance companies are likely to follow suit, Dr. Hammond says.

The Centers for Medicare and Medicaid Services is already talking about pay for performance and sponsoring the development of care measures by such agencies as the National Quality Forum. Since almost all physician groups already have requirements for documenting maintenance of competency and maintenance of certification, the CMS is likely to look to this documentation as an added measure. "Pathologists will probably have to show documentation of maintenance of competency requirements to receive compensation for services provided to Medicare patients at some point in the future," Dr. Hammond says. "Our goal is to provide relevant education that is documented as painlessly as possible for pathologists right now, so they will be ready when and if this occurs."

The CAP has developed an education-tracking system that can catalogue the education of individual pathologists. This year, the tracking includes the competency category that the educational offering fulfills. "Pathologists and residents can use this tool to track all of their education, not just that offered by CAP," Dr. Hammond says. (To see and use the tool, visit the section on education at www.cap.org.)

The broad implementation outline from the ABMS contained the six competency categories, a working definition of each, and sketched-out competencies along with specific associated skills. The CAP Education Committee and staff refined the category definitions to make them more specific to pathology and fleshed out and tailored the competencies and associated skills, the CAP’s Morrison says.

"We had a very good starting point from ABMS," she says. "In some cases we saw there was very little change to the definition—it was just adding a word or two. In other cases, and this might have been only one case, we simplified it as well." As for the specifics, she adds, "For each of those competencies, we developed these more targeted and very specific and behavioral knowledge and skill statements—all toward the end goal of making these specific to what a pathologist does."

The 12-person committee first met as a large group, then divided into subcommittees that worked on the respective competency categories. At various points in the process, Filling says, "we asked for input and comments and feedback from targeted individuals outside the committee."

"We spent an awful lot of time doing this, and did a lot of homework," says Education Committee member Peter J. Howanitz, MD, a pathologist at the State University of New York Downstate Medical Center, Brooklyn. "We’ve read a lot of articles and have some imaginative things about how we’re planning to disseminate this information."

What’s resulted to date is a list of 17 competencies and 87 specific skills under five of the six competency categories (excepting medical knowledge, which will divide naturally into subspecialties such as anatomic pathology and clinical pathology and their specific disciplines). For example, under "practice-based learning and improvement," the committee identified three competencies: practice analysis, assimilation of external data, and process and outcome improvement.

And under the latter competency—process and outcome improvement—for example, the committee listed as skills the ability to identify processes requiring improvement, analyze root causes (underlying problems) to appropriately target changes, create a process improvement plan or new process, and measure results or improved outcomes by using statistical tools or external benchmarking or both to demonstrate improvement. (The full set of competencies and knowledge and skills statements for each MOC category is provided in the paper submitted to the Archives of Pathology & Laboratory Medicine.)

"The interesting thing about the ABMS competencies is that they are much broader, across all six of them, than many specialties—certainly pathology—had thought about previously," Filling says. "When you ask pathologists what they need to learn and keep up with, their initial answers would generally be focused within the medical knowledge and patient care areas."

To explore where potential needs might exist, the committee has conducted a survey of nearly 2,500 CAP Fellows, to which about 14 percent responded, the results of which were compiled in fall 2004. Respondents were asked to rate, from a low of one to a high of five, how important each skill was to their overall effectiveness and how proficient they were in performing each.

The survey covered competencies and skills under practice-based learning and improvement, systems-based practice, and patient care; the other three competency categories will be surveyed soon. "They were either areas where we thought the College might be able to provide CME programs relatively quickly and/or where we thought there was very little already available," Filling says.

The largest gaps between the importance and proficiency level of the general competencies, on average, were in the areas of practice economics and practice and system integration. The largest gaps for specific skills were in applying "knowledge of health care trends in economic/strategic decision-making" and applying contracting and negotiating skills.

When it comes time to explore the other three areas, Dr. Howanitz has one prediction on a competency that will rate highly as a need. "Communication, I think, is one of the most important. One of the most important ways we communicate is as teachers," he says. "We’re always asked to teach at every conference, in every department."

While the College hopes its efforts in defining the competency categories and fleshing out the competencies and skills will be helpful to the ABP in setting the requirements for pathologists, that’s not the CAP’s chief aim, Filling says.

"We’re doing this for our own purposes in figuring out what the best thing is for us to do from an education point of view," she says. "We’ve mapped the current curriculum the College has to the MOC categories, based on our best assessment of where they would fit, and identified the areas where we think we have gaps." Adds Dr. Hammond, "Using the information about the gaps in our offerings, we can more carefully select courses for the national meeting and plan other educational offerings that will better suit the needs of our members."

The committee examined courses from the 2004 annual conference to see how and where they would fill the Maintenance of Certification requirements, and they’re doing so in advance for the 2005 conference. "We’re planning to look at what’s offered and work with the speakers," Dr. Howanitz says. "They’re expecting to hear back from the Education Committee about exactly what’s expected of them in the description of their program."

Says Filling: "It’s already having an impact in terms of the kinds of courses we’re selecting. From an education point of view, it’s useful to have things broken into skill- and knowledge-based behavioral statements because then you can identify the purpose of the course and the objectives you want to achieve."

She encourages CAP fellows to send their input to staff or committee members and says surveys of education needs will continue. "It’s our intention to do this on an ongoing basis and to upgrade the competencies with the ABMS and ABP as information becomes available. This isn’t something you do once and you’re done," she says.

Ed Finkel is a writer in Evanston, Ill. Send comments to cfillin@cap.org or to M. Elizabeth Hammond, MD, chair of the Education Committee (elizabeth.hammond@ihc.com).