AOA Board approves key changes to education continuum

Streamline osteopathic continuous certification for DOs who are certified by more than one specialty board. Improve the quality and variety of continuing medical education programs offered by AOA-accredited Category 1 sponsors. Enhance communication and teamwork among all parties involved in osteopathic graduate medical education (OGME).

These are among the overarching goals of the AOA’s Education Policy and Procedure Review Committee (EPPRC) III, which submitted 83 recommendations to the AOA Board of Trustees during the Board’s midyear meeting in Scottsdale, Ariz., in late January. (EPPRC III continues the work of EPPRC I and II, which in the early 1990s and in 2000 developed recommendations to improve the AOA’s education enterprise.)

Just as osteopathic physicians take environmental factors and the interrelationship of structure and function into account when treating patients, EPPRC III analyzed all aspects of OGME, board certification and CME to devise a plan to “re-engineer” the training and assessment of DOs from graduation from medical school to retirement. The Board approved 71 of the EPPRC recommendations, and it is reassessing the remaining 12.

“The approval of these recommendations demonstrates the AOA’s ongoing commitment to continuous quality improvement in the AOA Department of Education and other osteopathic educational entities and processes,” says AOA Trustee Robert S. Juhasz, DO, who chairs EPPRC III. “Implementing these recommendations will demonstrate our ability to adapt and change to better serve all osteopathic physicians throughout their careers and the patients they care for.”

Removing kinks from continuous certification

As mandated by the AOA Bureau of Osteopathic Specialists and the AOA Board, each AOA specialty certifying board must develop and implement comprehensive recertification requirements—known as osteopathic continuous certification—by Jan. 1, 2013. A number of EPPRC III recommendations target concerns arising from continuous certification.

Designed to ensure DOs’ ongoing competence by making certification a lifelong process rather than a single event, osteopathic continuous certification will require DOs to do the following:

• Undergo practice performance assessment, as well as cognitive assessment.
• Obtain 120 credits of CME during each of the AOA’s three-year CME cycles, at least 50 credits of which must be in the specialty of board certification.
• Maintain AOA membership. DOs who have lifetime certificates will not need to become recertified, but the AOA will encourage them to do so.

The following approved EPPRC III recommendations address some of the issues posed by continuous board certification:

• Approximately 1,100 DOs—many of whom trained in combined specialty residency programs—hold two or more primary AOA board certifications. If required to participate in separate continuous certification processes, these diplomates might choose to drop all but one of their board certifications to reduce paperwork and expense.

  To avert this possibility, AOA specialty boards should identify commonalities among continuous certification processes, and the Bureau of Osteopathic Specialists should develop a method by which diplomates can fulfill the common recertification requirements of different specialty boards simultaneously. DOs with more than one primary certification will still need to take separate recertification examinations and complete the minimum required CME hours for each specialty.

• Approximately 2,000 AOA board-certified DOs also hold corresponding allopathic certifications through specialty boards approved by the American Board of Medical Specialties (ABMS). To lessen the likelihood that these DOs would drop their AOA certifications to avoid participating in two recertification processes, the Bureau of Osteopathic Specialists should develop a means for DOs who are ABMS diplomates to demonstrate their participation in allopathic maintenance of certification programs to fulfill portions of the osteopathic continuous certification process. In turn, the AOA should request that ABMS certifying boards recognize osteopathic continuous certification as comparable to the allopathic process for DOs seeking recertification by both AOA and ABMS boards.
• Osteopathic continuous certification currently applies only to primary certification, not to certificates of added qualification, even though many board-certified DOs practice mainly in the fields of their added qualifications. The AOA certifying boards should require these diplomates to complete at least 25% of their 50 CME specialty credits in their nonprimary specialties and at least 30% in their primary specialties. In addition, the performance and cognitive assessment for recertification of these DOs should address the added specialties, as well as the primary specialties.
• Nonclinical physicians—those who have no contact with patients—must take part in osteopathic continuous certification. But such DOs would have difficulty participating in the practice performance assessment component. The Bureau of Osteopathic Specialists should develop a policy to exempt nonclinical physicians from the clinical assessment. The certifying boards should have the option of developing nonclinical performance assessments for these DOs in lieu of clinical assessments.

Creating outcomes-based CME

In response to increased scrutiny by legislative and regulatory agencies and the public, the osteopathic medical profession must develop evidence-based and outcomes-based CME, urges EPPRC III’s report. “CME that demonstrates improved physician performance and, ultimately, measurably improved patient outcomes is the gold standard,” the report states, noting that the osteopathic medical profession must begin to demand this quality of CME from AOA-accredited CME sponsors.

The EPPRC report notes that the AOA Council on Continuing Medical Education and the AOA’s CME staff receive “numerous written and verbal complaints regarding CME” from AOA members. As the report elaborates, “there have been comments that physicians sign in attendance at programs, then leave; that programs are geared to primary care physicians with little attention to other specialists’ needs; that the same speakers continue to present the same programs year after year; that the quality is not at the level it should be.”

To resolve these issues, the AOA Board approved several CME quality initiatives recommended by EPPRC III, including the recommendation that each Category 1 sponsor measure outcomes for at least one of its CME programs in the 2010-12 cycle and one in the 2013-15 cycle. In addition, the EPPRC report urges the Council on Continuing Medical Education to develop incentives for CME sponsors to offer programs that evaluate both physician performance and patient outcomes.

The report also calls on the AOA to encourage health care facilities with AOA-approved GME programs, as well as those accredited by the AOA’s Health Facilities Accreditation Program, to serve as Category 1 sponsors. This recommendation would reverse a policy in effect since 2003 that has prevented health care facilities from becoming AOA Category 1 sponsors. The report explains that many of the increasing number of health care facilities that provide AOA-approved training have indicated that they would like to provide CME to their physician faculties.

To assist DOs who have difficulty attending CME programs in person, Category 1 sponsors should identify opportunities for and overcome barriers to offering CME programs on the Internet, EPPRC III recommended.

Improving OGME communication

The AOA Board referred to the AOA Council on Osteopathic Postdoctoral Training several EPPRC III recommendations related to financing OGME. The most significant of these recommendations would simplify the fee structure for AOA-approved GME programs to make the fees more predictable and restructure the GME approval process to employ independent reviewers. “The council will receive further input from stakeholders during its April meeting and advance modified recommendations to the AOA Board of Trustees for consideration during the Board’s annual meeting in July,” Dr. Juhasz says.

During its midyear meeting, the Board approved the following recommendations on improving OGME communication pending the financial assessment of the referred recommendations:

• The AOA Department of Education should hire information technology staff to streamline communication and regulatory processes in GME, assist with data management so that information can be provided in a more timely manner, and ensure that education information on the AOA’s website is current and accurate.
• The AOA’s IT staff should work with osteopathic postdoctoral training institutions (OPTIs), osteopathic medical schools, osteopathic specialty societies and other parties involved in OGME to ensure compatibility in program software and facilitate communication among those parties.
• The AOA should continue to investigate developing a continuous electronic database on osteopathic interns, residents, fellows and practicing physicians—on the order of e-dossiers or e-portfolios—to assist AOA members in documenting their credentials throughout their careers.
• The AOA should provide opportunities for representatives of AOA bureaus, committees and councils; specialty societies; OPTIs; and GME programs to have meaningful conversations with osteopathic medical students, interns, residents and fellows to address problems and improve program quality. These opportunities could be regularly scheduled meetings during AOA educational conferences, discussion boards set up on the AOA’s website, invitational conferences every few years or a combination of these suggestions.
• OGME information updates should be consolidated in one newsletter that reaches all entities involved in AOA-approved GME.
• Working with the Student Osteopathic Medical Association and the American Association of Colleges of Osteopathic Medicine’s Council of Osteopathic Student Government Presidents, the AOA should develop a universal orientation packet on AOA OGME options and policies. The packet would be given to osteopathic medical students before they decide which internship or residency positions to pursue.

The Board also approved recommendations simplifying the process for obtaining AOA approval for residencies accredited by the Accreditation Council for Graduate Medical Education.

AOA President Karen J. Nichols, DO, praises EPPRC III for the extensive work that it did and for the degree of collaboration required to issue so many significant recommendations. “The immense undertaking was accomplished through excellent teamwork from AOA education bureaus and councils, specialty boards, individual osteopathic physicians and AOA staff,” she notes.