Capsule Commentary on Gallagher et al., Internists’ Attitudes About Assessing and Maintaining Clinical Competence

Abstract

The medical profession is self-regulating and board certification is believed, though unproven, to be related to quality of care.1 Since 1990, American Board of Internal Medicine (ABIM) certification is time-limited.2 Internists who want to demonstrate their lifelong learning and continued competence need to recertify every 10 years.1 Gallagher et al.3 ask, “What do internists think about recertification?” Survey respondents agreed that continuous learning is important. Most rely on reading and Continuing Medical Education (CME) programs; only about half had participated in Maintenance of Certification (MOC) activities. All reported a desire for better feedback, and few reported receiving quality feedback on their performance. In this study, the importance attached to feedback correlated with respondents’ beliefs and participation in quality measures (i.e., Board certification, National Committee for Quality Assurance (NCQA) recognition, pay for performance, self-assessment). In their discussion, Gallagher et al. noted that ‘the success of self-regulation ultimately hinges on physicians engaging in self-regulated learning’. This is important, because Bandura’s social cognitive theory states that ‘Evaluative self-reactions cannot be much aroused if one does not have a clear idea of how one is doing’.4 Inadequate feedback may dampen self-directed learning and self-evaluation. While physicians have high motivation to provide exemplary patient care, social cognitive theory suggests that self-efficacy beliefs play a large part in determining self-regulation behaviors. In the absence of absolute measures of competence, we are more likely to evaluate our performance in relation to others. Our appraisal of our own performance is dependent on our personal standards, attained level of performance, and the performance of others. These factors should be considered as specialty boards design MOC activities and feedback. The perception of peers and patients about a physician’s practice is important, and additional comparative information is likely to be helpful. The survey results illustrate that required activities and feedback from ABIM MOC activities are of low value to internists for maintaining their competence, with about half participating. Beyond an educational campaign to promote MOC activities, and improvement in those programs, we need to consider how feedback will motivate self-regulation and self-directed learning. Better means of assessing competence and providing quality feedback relevant to practice are needed.