A few years ago, a physician--call him Dr. X--got into serious trouble with his state medical board and found himself headed to Colorado, where a team of doctors would determine whether he was fit to practice medicine.
The doctor had written literally tens of thousands of prescriptions for controlled narcotics, and while there was no evidence that he was using drugs personally, alarmed medical board officials felt compelled to investigate him.
So the medical board sent him, with his permission, to Colorado Personalized Education for Physicians. Aurora, Colo.-based CPEP has been described as everything from a "boot camp" for bad doctors to a "traffic school" for physicians who have made minor mistakes. The facility was established 10 years ago, by a consortium of healthcare associations including the Colorado Medical Society and the University of Colorado Health Sciences Center, and has received funding from players ranging from hospitals and health systems to malpractice insurers.
Martha Illige, M.D., is CPEP's medical director. Over several days of intensive workshops, she says, physician consultants and other professionals gave the suspect doctor a battery of assessments--grilling him on hypothetical cases, simulating interviews with patients, having him review his own charts and testing him on clinical knowledge.
"We found this doctor demonstrated extremely weak medical knowledge, including an inability to recognize when a patient was in danger of dying," Illige says. "And there were other problems: poor judgment, illegible, useless documentation and poor communication skills."
As a result of CPEP's recommendation that the doctor did not demonstrate the ability to care for patients in unsupervised practice, the medical board stripped him of his license.
While CPEP was an early proponent of efforts to red-flag suspicious incidents to prevent accidents and errors, such endeavors now are gathering momentum, fueled by growing concerns about medical errors.
Recently, two leading professional organizations, the Federation of State Medical Boards and the National Board of Medical Examiners, used the Colorado program as a model to create their own national assessment center for physicians, the Institute for Physician Evaluation. IPE also is located in Aurora.
Up to 90% of the 285 physicians who have been through the doors of the Colorado program were referred by hospital-based peer review panels or by a state licensure board; the remaining 10% were often doctors working in rural areas who referred themselves for continuing medical education.
CPEP assesses physicians in four categories: medical knowledge, communication skills, documentation skills and problem solving. The staff writes a report containing a prescription for remediation, outlining the strengths and deficits in the physician's practice area, and offering recommendations for retraining.
The doctor's referring medical board or hospital is responsible for implementing the recommendations, usually through some form of continuing medical education or a mini-residency at an academic medical center.
When the education process, which typically lasts between six and 12 months, is completed, CPEP administers a post-test. CPEP itself has no authority to impose sanctions on any physician.
Such retraining can cost about $5,000, which the physician is responsible for paying. (The initial assessment period costs $7,500, also paid by the physician.)
Elizabeth Korinek, executive director of the Colorado program, says about 15% of the doctors examined "are fine; they have strengths and no significant weaknesses, and we recommend they be allowed to continue working."
For example, a doctor was recently referred by the hospital where he worked, whose administrators had questions about his treatment of a diabetic patient, Illige says. (Due to confidentiality restrictions, most administrators at the education program were unwilling to give specifics on individual physicians.) CPEP staff examined the doctor and found "he had superior medical knowledge with great breadth and depth (and) sound clinical reasons for anything he had done," Illige says. He was sent home with a glowing report.
Another 15% "have global deficits" so great that "we can't help them" and the remaining 70% fall in the middle, Korinek says. "They present a mixture of strengths and weaknesses and need some level of education."
Has CPEP worked? Yes, says Korinek, citing a follow-up study of graduates indicating that 80% had no further problems with peer review, a finding she says represents "a huge benefit to doctors, patients and their communities." Beyond that study, which had a 56% response rate, Korinek has only anecdotal data suggesting the program's success.
The Institute for Physician Evaluation opened April 1 as the first of a planned series of regional assessment centers created by the Federation of State Medical Boards and the National Board of Medical Examiners.
In December 1998, Dale Austin, then-deputy executive vice president of the Euless, Texas-based Federation of State Medical Boards, described to Modern Physician the federation's recently developed guidelines to state medical boards for quality-of-care issues. They included identifying "dyscompetent" physicians, developing new ways of evaluating their skills and creating "disciplinary tracks" to rehabilitate them. But Austin conceded that many of the more than 50 independently functioning state and territorial medical boards are organized differently, and he warned that some might have a "weak link" because of a lack of financial or legislative support.
There was an additional problem with state medical boards, says Korinek. When complaints about physicians did reach them, "There was a tendency to either take extreme measures, like license revocation, or to ignore the problem." Something "in between" was needed, she says.
The federation and its medical examiner partners came up with the idea of regional rehabilitation centers, to which the best expertise, research and assessment methodologies would be available. The institute is modeled after CPEP; in fact, it occupies the same quarters in Aurora. CPEP will continue to exist to help physicians find the rehabilitation and re-education they need, based on the institute's recommendations.
CPEP has, in other words, been reborn as IPE, only this time as a truly national center, with the imprimatur of being sponsored by two of the nation's leading professional associations. The federation's executive director, James Winn, M.D., says the institute will help referred physicians "find training and get back up to speed" after questions about their competence are raised.
Eventually the new institute hopes to serve between 200 and 300 physicians annually. However, Carol Clothier, the institute's assistant vice president for examination services, says the center will probably host only about 90 doctors during its first year. Once it gets up to full speed, possibly in a few years, "We'll think about opening new centers," with the first two envisioned on opposite coasts, in North Carolina and Southern California. If there's enough "buyin on the part of nonstate medical board entities, such as hospitals and other healthcare providers with a peer review process," Clothier adds, IPE centers could mushroom across the country.
As a result, some state medical boards may view IPE as a competitor. According to Winn, only five or six states are large and wealthy enough to have created their own assessment programs similar to IPE, but they include California, whose Physician Assessment Clinical and Educational Program (PACE) started in San Diego in late 1996.
"We had a need for someplace to send doctors who had a competency problem and had gotten into trouble with the (medical) board," explains Dave Thornton, a deputy chief of enforcement at the Medical Board of California.
Thornton says he's not convinced that the new institute offers doctors anything PACE doesn't. "We've looked at (IPE) and compared it to what we have in PACE, and we feel it's better to keep the doctor here locally and go through training by physicians based in California rather than sending them to Colorado."
Says Clothier of existing programs, "Certainly each state medical board has the responsibility to make decisions about the needs of its own physicians, but we would hope they would view ours as the premier service available in the U.S."
The interest in physician competence is taking place against a backdrop of public scrutiny. The number of Americans who die annually due to medical errors may be as high as 98,000, according to a 1999 estimate by the Institute of Medicine. Some experts say that as many as 10% of the country's 756,000 practicing physicians require some form of rehabilitation annually.
Results of a survey released in May by HCPro, a Marblehead, Mass., healthcare consulting firm, found that, of 573 healthcare CEOs, physicians, nursing directors and other professionals polled, 71% of the doctors reported having made at least one medical error, while 98% of the CEOs said that medical errors had occurred at their facility.
Winn acknowledges that IPE is not the ultimate answer to the problem of medical errors. For that, the profession requires "ongoing systems that monitor the practice of physicians in a meaningful way, so if someone slips below the level of standards, intervention can occur." That's a lofty goal, but Winn hopes the new institute at least "gives medical boards a valuable tool, and a stronger hand in determining what kind of intervention is required."
Steven H. Heimoff is an Oakland, Calif.-based healthcare business writer.